A mixed methods rapid evaluation investigating the use of pulse oximetry in care homes across England to manage residents with COVID-19 and long-term health conditions

Background and rationale

The majority of people living in care homes in England are over the age of 80, most have multiple long-term health conditions, and the majority are affected by physical disability and/or cognitive impairment. These factors explain, in part, the vulnerability to COVID-19 of older people living in care homes. Across England care homes are facing the increased burden of treating and monitoring residents with COVID-19, which is made difficult by the complexity of care residents require, regional disparities in integrated working alongside primary, community and secondary care teams, and an over-stretched workforce.

There is emerging evidence that using pulse oximetry, a non-invasive and painless test that measures a person’s oxygen saturation level, in community settings can accurately predict outcomes for individuals who have tested positive for COVID-19 with regard to mortality and intensive care unit (ICU) admission.

A number of models of care using pulse oximetry with people in their own homes were set up and implemented across primary and secondary care in England during the first wave of the pandemic (April to September 2020) which led to the national roll-out of COVID Oximetry @ Home; a service that involves pulse oximetry and the remote monitoring of patients with coronavirus symptoms. A mixed-methods evaluation of the COVID Oximetry @ Home programme is also being undertaken by the BRACE and RSET evaluation teams in parallel to this study with a number of outputs already published.

Despite this, little is known about the use of pulse oximetry and remote monitoring for COVID-19 in care homes. Despite the growing evidence base and policy guidance on the implementation and delivery of pulse oximetry and remote monitoring services across the wider health sector, there is limited UK government guidance for care home staff when managing COVID-19 in a care home environment.

It is to be hoped that with the roll-out of coronavirus vaccination, and the prioritisation of care home residents, the incidence of COVID-19 among care home residents will fall to low levels from mid-2021 onwards. Pulse oximetry will remain potentially valuable, however, for monitoring residents of care homes who do contract COVID-19 or its variants, or have other conditions for which hypoxia is a possible consequence, for example chronic obstructive pulmonary disease (COPD) and asthma.

This rapid evaluation will examine the views of care home staff and primary, community and secondary care staff to determine how pulse oximetry is currently being used and in which circumstances, including any facilitators or barriers, and how its use might be best supported by primary, community and secondary care teams. Lessons learned from this evaluation will be transferable to patients and residents living with a range of long-term health conditions, and may provide useful learning for remote health monitoring within social care more generally.

Aims

In view of the gaps in evidence we have identified through our scoping work and engagement with relevant grey and published literature, our rapid evaluation will seek to answer questions concerned with the use of pulse oximetry in managing COVID-19 and other health conditions in a range of care home settings across England. In particular, we will explore the views of care home staff and primary, community, and secondary care staff in relation to the use of pulse oximetry when managing COVID-19 in the care home environment.

Evaluation questions In order to address our aim, the study seeks to answer the following evaluation questions:

EQ1: When and how is pulse oximetry being employed in care homes for managing the health care of residents with COVID-19 and other health conditions? EQ1.1: Which care home staff are involved in the set-up, delivery, and monitoring of pulse oximetry in care homes?

EQ1.2: What support are care homes receiving from primary, community, and secondary care NHS teams with regard to the use of pulse oximetry; is that support appropriate; and are there any weaknesses in providing that support that might be rectified?

EQ2: What are the perceived benefits to residents (e.g. health-related outcomes, satisfaction with care received, hospital admission avoidance, impact on perceived anxiety) of using pulse oximetry in their care home?

EQ3: What are the experiences of staff using oximetry in care homes, including barriers and enablers and lessons learnt? EQ3.1: What training have care home staff received to deliver pulse oximetry in a range of care home settings? EQ3.2: What impact has the use of pulse of oximetry had on care home staff well-being and confidence?

EQ3.3: What are the challenges faced by care home staff in delivering pulse oximetry and associated monitoring?

EQ4: What are the views of senior care home staff and managers on the guidance and resource necessary to support and sustain the use of pulse oximetry in care homes?

EQ5: What are the experiences of the primary, community, and secondary care healthcare staff involved, of supporting the use of pulse oximetry in care homes, including where relevant as part of the national COVID Oximetry @ Home service? Design and methods Our evaluation comprises four work packages (WP):

• WP1: Scoping: interviews with key NHS leaders, care association directors and care home managers, engaging with relevant literature, co-designing the study approach and research questions with members from a user involvement group.

• WP2: A national online survey of care homes in England examining the application of pulse oximetry in care homes. Including analysis of data and testing findings with members from a user involvement group.

• WP3: Qualitative case studies by means of in-depth interviews with care home managers and staff, and with primary, community and secondary care healthcare staff who support care homes, at six purposively selected case study sites; including analysis of data and testing findings with members from a user involvement group.

• WP4: Synthesis, reporting and dissemination. Dissemination and outputs We anticipate disseminating the findings of this evaluation project in a number of ways, including:

• A slide set, supported by infographics, summarising the overall findings of the rapid evaluation to stakeholders across the NHS and the care home sector, but may be of particular interest to: NHS England and Improvement’s Older People and Person-Centred Integrated Care workstream and People Receiving Social Care workstream, the NHS COVID Oximetry @ Home programme (and various national and regional learning networks e.g. the Communities of Practice group, COVID Oximetry @ Home Learning Network), the National Care Association, the National Care Forum, the Nursing Homes Association, the Care Quality Commission, and the Enabling Research in Care Homes (ENRICH) NIHR Clinical Research Network.

• One or more papers published in high quality, peer-reviewed, academic journals.

• Publication of an article in primary and social care professional press such as Pulse, Health Services Journal, GP Online, or Care Management Matters.

• Oral and/or poster conference presentation(s) such as at the British Journal of General Practice (BJGP) conference, the Society for Academic Primary Care (SAPC) conference, Health Services Research UK, Future of Care conference, and the National Care Forum conference

• Disseminating findings through BRACE and RSET networks, national care home associations, the appropriate NHS and social care channels, and utilising the assistance of our user development group, the BRACE Health and Care Panel and BRACE Steering Group, and RSET Stakeholder Advisory Board. Given the impact of our findings on care home residents and their families, we will also disseminate to patients, carers and the organisations that represent them.

We will work closely with National Voices as well as the Social Care Institute for Excellence and their membership community to do this.

• A final report submitted to the National Institute for Health Research, Health Services and Delivery Research Programme, to be published in the National Institute for Health Research Journals Library. Study timeline

The study will take place over five months (January 2021 to May 2021 inclusive), assuming access to case study sites and the timely securing of necessary ethical approvals. Funding

This project is funded by NHS England and Improvement through the Health Services and Delivery Research evaluation team funded by the National Institute for Health Research (RSET Project no. 16/138/17; BRACE Project no. 16/138/31).