Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of Acute Care for Elders (ACE) in a community hospital

Impact of the End PJ Paralysis interventions on patient health outcomes at the participating hospitals in Alberta, Canada

PURPOSE

Multiple hospitals in Alberta implemented the End PJ Paralysis - a multicomponent inpatient ambulation initiative aimed at preventing the adverse physical and psychological effects patients experience due to low mobility during admission. To inform a scale-up strategy, this study assessed the impact of the initiative based on select process and outcome measures.

MATERIALS AND METHODS

Clinical and administrative data were obtained from the hospital Discharge Abstract Database, Research Electronic Data Capture (Redcaps), and Reporting and Learning System for Patient Safety. The variables explored were length of stay, inpatient falls, discharge disposition, pressure injury, patient ambulation, and patient dressed rates. We then used the Interrupted Time Series design for impact analysis.

RESULTS

The analysis included discharge abstracts for 32,884 patients and the results showed significant improvements in outcomes at the participating units. The length of stay and inpatient falls were reduced immediately by 1.8 days (B2=-1.80, p = 0.044, 95% CI [-3.54, -0.05]), and 2.2 events (B2=-2.22, p = 005, 95% CI [-3.75, -0.69]). The percentage of patients discharged home increased overtime (B2=.39, p=.006, 95% CI [.11, .66]). Mobilization and dressed rates also improved.

CONCLUSIONS

The findings imply the interventions safely mitigated the risk of immobility-induced complications, including deconditioning and hospital-acquired disability.

Clinical Trials for Special Populations: Children, Older Adults, and Rare Diseases

Research cannot maximize population health unless it improves health for all members of the public, including special populations such as children, older adults, and people living with rare diseases. Each of these categories require special considerations when planning and performing clinical trials, and common threads of ethical conduct of research in vulnerable populations appear throughout. In this review, definitions of each of the three categories of special population (children, older adults, and rare diseases) are discussed in terms of US research regulations, the unique challenges to conducting clinical trials for these special populations, critical ethical issues, and opportunities for innovative ways to design and operationalize clinical trials in special populations. Additional critical attention is focused on factors that influence the generalizability of study results to reduce health disparities, as well as the importance of community engagement and advocacy groups that can help to educate potential trial participants of the benefits of clinical trial participation.

Acute Care for Elders and Nurses Improving Care for Health System Elders Models in Acute Care: Are We Still Using These Geriatric Models of Care?

Care models for older adults have been studied for more than 30 years. Several models of care for older adults were created in the acute care setting to prevent hospital-acquired disability and decline-a phenomenon frequently observed among older patients admitted in the acute care setting. The Acute Care for Elders (ACE) model and the Nurses Improving Care for Health System Elders program were 2 such models that sought to improve the quality of care for older adults and reduce their cost for care. Where are they today? Are we still using these care models in the acute care setting?

More than medications: a patient-centered assessment of Parkinson's disease care needs during hospitalization

Background

Parkinson's disease (PD) increases the risk of hospitalization and complications while in the hospital. Patient-centered care emphasizes active participation of patients in decision-making and has been found to improve satisfaction with care. Engaging in discussion and capturing hospitalization experience of a person with PD (PwP) and their family care partner (CP) is a critical step toward the development of quality improvement initiatives tailored to the unique hospitalization needs of PD population.

Objectives

This qualitative study aimed to identify the challenges and opportunities for PD patient-centered care in hospital setting.

Methods

Focus groups were held with PwPs and CPs to capture first-hand perspectives and generate consensus themes on PD care during hospitalization. A semi-structured guide for focus group discussions included questions about inpatient experiences and interactions with the health system and the clinical team. The data were analyzed using inductive thematic analysis.

Results

A total of 12 PwPs and 13 CPs participated in seven focus groups. Participants were 52% female and 28% non-white; 84% discussed unplanned hospitalizations. This paper focuses on two specific categories that emerged from the data analysis. The first category explored the impact of PD diagnosis on the hospital experience, specifically during planned and unplanned hospitalizations. The second category delves into the unique needs of PwPs and CPs during hospitalization, which included the importance of proper PD medication management, the need for improved hospital ambulation protocols, and the creation of disability informed hospital environment specific for PD.

Conclusion

PD diagnosis impacts the care experience, regardless of the reason for hospitalization. While provision of PD medications was a challenge during hospitalization, participants also desired flexibility in ambulation protocols and an environment that accommodated their disability. These findings highlight the importance of integrating the perspectives of PwPs and CPs when targeting patient-centered interventions to improve hospital experiences and outcomes.

The cost-effectiveness of a nursing home-based transitional care unit for increasing the potential for independent living in the community among hospitalized older adults

OBJECTIVE

In Canada, a persistent barrier to achieving healthcare system efficiency has been patient days accumulated by individuals with an alternate level of care (ALC) designation. Transitional care units (TCUs) may address the capacity pressures associated with ALC. We sought to assess the cost-effectiveness of a nursing home (NH) based TCU leveraging existing infrastructure to support a hospitalized older adult's transition to independent living at home.

METHODS

This case-control study included frail, older adults who received care within a function-focused TCU following a hospitalization between 1 March 2018 and 30 June 2019. TCU patients were propensity score matched to hospitalized ALC patients ("usual care"). The primary outcome was days without requiring institutional care six months following discharge, defined as institutional-free days. This was calculated by excluding all days in hospitals, rehabilitation facilities, complex continuing care facilities and NHs. Using the total direct cost of care up to discharge from TCU or hospital, the incremental cost-effectiveness ratio was calculated.

RESULTS

TCU patients spent, on average, 162.0 days institution-free (95% CI: 156.3-167.6d) within six months days post-discharge, while usual care patients spent 140.6 days institution-free (95% CI: 132.3-148.8d). TCU recipients had a lower total cost of care, by CAN$1,106 (95% CI: $-6,129-$10,319), due to the reduced hospital length of stay (mean [SD] 15.6d [13.3d] for TCU patients and 28.6d [67.4d] days for usual care). TCU was deemed the more cost-effective model of care.

LIMITATIONS

The main limitation was the potential inclusion of patients not eligible for SAFE in our usual group. To minimize this selection bias, we expanded the geographical pool of ALC patients to patients with SAFE admission potential in other area hospitals.

CONCLUSIONS

Through rehabilitative and restorative care, TCUs can reduce hospital length of stay, increase potential for independent living, and reduce risk for subsequent institutionalization.

Efficacy of acute care pathways for older patients: a systematic review and meta-analysis

Meeting the needs of acute geriatric patients is often challenging, and although evidence shows that older patients need tailored care, it is still unclear which interventions are most appropriate. The objective of this study is to systematically evaluate the hospital-wide acute geriatric models compared with conventional pathways. The design of the study includes hospital-wide geriatric-specific models characterized by components including patient-centered care, frequent medical review, early rehabilitation, early discharge planning, prepared environment, and follow-up after discharge. Primary and secondary outcomes were considered, including functional decline, activities of daily living (ADL), length-of-stay (LoS), discharge destination, mortality, costs, and readmission. A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A total of 20 studies reporting on 15 trials and acutely admitted patients with an average age of 79, complex conditions and comorbidities to acute geriatric-specific pathways (N = 13,595) were included. Geriatric-specific models were associated with lower costs (weighted mean difference, WMD =  - $174.98, 95% CI = -$332.14 to - $17.82; P = 0.03), and shorter LoS (WMD =  - 1.11, 95% CI =  - 1.39 to - 0.83; P < 0.001). No differences were found in functional decline, ADL, mortality, case fatalities, discharge destination, or readmissions. Geriatric-specific models are valuable for improving patient and system-level outcomes. Although several interventions had positive results, further research is recommended to study hospital-wide geriatric-specific models.

Exercise for acutely hospitalised older medical patients

BACKGROUND

Approximately 30% of hospitalised older adults experience hospital-associated functional decline. Exercise interventions that promote in-hospital activity may prevent deconditioning and thereby maintain physical function during hospitalisation. This is an update of a Cochrane Review first published in 2007.

OBJECTIVES

To evaluate the benefits and harms of exercise interventions for acutely hospitalised older medical inpatients on functional ability, quality of life (QoL), participant global assessment of success and adverse events compared to usual care or a sham-control intervention.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was May 2021.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials evaluating an in-hospital exercise intervention in people aged 65 years or older admitted to hospital with a general medical condition. We excluded people admitted for elective reasons or surgery.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our major outcomes were 1. independence with activities of daily living; 2. functional mobility; 3. new incidence of delirium during hospitalisation; 4. QoL; 5. number of falls during hospitalisation; 6. medical deterioration during hospitalisation and 7. participant global assessment of success. Our minor outcomes were 8. death during hospitalisation; 9. musculoskeletal injuries during hospitalisation; 10. hospital length of stay; 11. new institutionalisation at hospital discharge; 12. hospital readmission and 13. walking performance. We used GRADE to assess certainty of evidence for each major outcome. We categorised exercise interventions as: rehabilitation-related activities (interventions designed to increase physical activity or functional recovery, but did not follow a specified exercise protocol); structured exercise (interventions that included an exercise intervention protocol but did not include progressive resistance training); and progressive resistance exercise (interventions that included an element of progressive resistance training).

MAIN RESULTS

We included 24 studies (nine rehabilitation-related activity interventions, six structured exercise interventions and nine progressive resistance exercise interventions) with 7511 participants. All studies compared exercise interventions to usual care; two studies, in addition to usual care, used sham interventions. Mean ages ranged from 73 to 88 years, and 58% of participants were women. Several studies were at high risk of bias. The most common domain assessed at high risk of bias was measurement of the outcome, and five studies (21%) were at high risk of bias arising from the randomisation process. Exercise may have no clinically important effect on independence in activities of daily living at discharge from hospital compared to controls (16 studies, 5174 participants; low-certainty evidence). Five studies used the Barthel Index (scale: 0 to 100, higher scores representing greater independence). Mean scores at discharge in the control groups ranged from 42 to 96 points, and independence in activities of daily living was 1.8 points better (0.43 worse to 4.12 better) with exercise compared to controls. The minimally clinical important difference (MCID) is estimated to be 11 points. We are uncertain regarding the effect of exercise on functional mobility at discharge from the hospital compared to controls (8 studies, 2369 participants; very low-certainty evidence). Three studies used the Short Physical Performance Battery (SPPB) (scale: 0 to 12, higher scores representing better function) to measure functional mobility. Mean scores at discharge in the control groups ranged from 3.7 to 4.9 points on the SPPB, and the estimated effect of the exercise interventions was 0.78 points better (0.02 worse to 1.57 better). A change of 1 point on the SPPB represents an MCID. We are uncertain regarding the effect of exercise on the incidence of delirium during hospitalisation compared to controls (7 trials, 2088 participants; very low-certainty evidence). The incidence of delirium during hospitalisation was 88/1091 (81 per 1000) in the control group compared with 70/997 (73 per 1000; range 47 to 114) in the exercise group (RR 0.90, 95% CI 0.58 to 1.41). Exercise interventions may result in a small clinically unimportant improvement in QoL at discharge from the hospital compared to controls (4 studies, 875 participants; low-certainty evidence). Mean QoL on the EuroQol 5 Dimensions (EQ-5D) visual analogue scale (VAS) (scale: 0 to 100, higher scores representing better QoL) ranged between 48.9 and 64.7 in the control group at discharge from the hospital, and QoL was 6.04 points better (0.9 better to 11.18 better) with exercise. A change of 10 points on the EQ-5D VAS represents an MCID. No studies measured participant global assessment of success. Exercise interventions did not affect the risk of falls during hospitalisation (moderate-certainty evidence). The incidence of falls was 31/899 (34 per 1000) in the control group compared with 31/888 (34 per 1000; range 20 to 57) in the exercise group (RR 0.99, 95% CI 0.59 to 1.65). We are uncertain regarding the effect of exercise on the incidence of medical deterioration during hospitalisation (very low-certainty evidence). The incidence of medical deterioration in the control group was 101/1417 (71 per 1000) compared with 96/1313 (73 per 1000; range 44 to 120) in the exercise group (RR 1.02, 95% CI 0.62 to 1.68). Subgroup analyses by different intervention categories and by the use of a sham intervention were not meaningfully different from the main analyses.

AUTHORS' CONCLUSIONS

Exercise may make little difference to independence in activities of daily living or QoL, but probably does not result in more falls in older medical inpatients. We are uncertain about the effect of exercise on functional mobility, incidence of delirium and medical deterioration. Certainty of evidence was limited by risk of bias and inconsistency. Future primary research on the effect of exercise on acute hospitalisation could focus on more consistent and uniform reporting of participant's characteristics including their baseline level of functional ability, as well as exercise dose, intensity and adherence that may provide an insight into the reasons for the observed inconsistencies in findings.

The current landscape of Acute Care for Elders units in the United States

BACKGROUND

The clinical benefits of Acute Care for Elders (ACE) units have been established for over 25 years. However, how widely disseminated ACE units are in the United States and the degree of fidelity to the key elements of this model of care are unknown. Our objective was to identify all existing ACE units in the United States and to obtain detailed information about variations in implementation.

METHODS

The strategy to identify current ACE units began with online searches and snowball sampling using contacts from professional societies and workgroups. Next, a request for information regarding the existence of ACE units was sent to the remaining US hospitals listed in a national hospital database. An online survey was sent to identified ACE unit contacts to capture information on implementation characteristics and the five key elements of ACE units.

RESULTS

There were 3692 hospitals in the database with responses from 2055 (56%) hospitals reporting the presence or absence of an ACE unit. We identified 68 hospitals (3.3%) with an existing or previous ACE unit. Of these 68 hospitals, 50 (74%) completed the survey and reported that 43 ACE units were currently open and 7 had been closed. Of the 43 currently open ACE units, most are affiliated with an academic hospital and there is variable implementation of each of the five key ACE elements (from 69% to 98%).

CONCLUSIONS

Among the 50 hospitals to complete the survey, 43 current ACE units were identified, with variable fidelity to the key elements. Estimates of prevalence of ACE units and fidelity to key elements are limited by nonresponses to the national survey request by nearly half of hospitals.

Interprofessional collaboration and patient-reported outcomes in inpatient care: a systematic review

BACKGROUND

Interprofessional collaboration (IPC) is seen as the "gold standard" of comprehensive care, but credible evidence concerning the effects on patient-reported outcomes (PRO) is lacking. The aim of this systematic review is to study the effect of IPC on PRO in inpatient care.

METHODS

We systematically searched six electronic databases (PubMed, Web of Science/Social Science Citation Index, CENTRAL (Cochrane Library), Current Contents (LIVIVO), CINAHL, and Embase) for studies published between 1997 and 2021. Additional studies were identified through citation tracking, manually searching the Internet and Google Scholar, and consultation of experts. Risk of bias (RoB) was assessed using the RoB 2 tool for randomized controlled trials (RCTs) and ROBINS-I for non-randomized studies (NRS). The included controlled before-and-after study (CBA) was assessed using both the ROBINS-I and the Effective Practice and Organization of Care (EPOC) quality criteria. Results were synthesized through narrative description, grouping, and thematic analysis of extracted data.

RESULTS

The search yielded 10,213 records, from which 22 studies (16 RCTs, five NRS, and one CBA) fulfilled the inclusion criteria. In all but five studies, RoB was assessed as being high (RoB 2) resp. critical or serious (ROBINS-I). Within these 22 studies, nine inductively derived outcomes were assessed: (i) quality of life, (ii) coping, (iii) functional ability and health status, (iv) psychiatric morbidity, (v) pain, (vi) managing one's own health care, (vii) treatment success, (viii) satisfaction, and (ix) therapeutic relationship. While some studies do not report effect estimates, and some of the reported effects appear to be imprecisely estimated, the overall results indicate that IPC may affect PRO positively across all outcomes.

CONCLUSIONS

Due to high clinical heterogeneity and high RoB, the question whether IPC affects PRO cannot be answered conclusively. Methodically rigorous studies are needed in order to answer the question of effectiveness of IPC.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017073900.

Association of frailty and functional recovery in an Acute Care for Elders unit: a prospective observational study

Background

Evidence on the effects of Acute Care for Elders (ACE) units in frail older adults remains limited. Therefore, we aimed to evaluate the effects of the ACE unit on functional outcomes in frail older adults.

Methods

In this prospective observational study, we enrolled 114 consecutive patients aged 65 years and older admitted to the ACE unit for acute medical conditions between October 2019 and September 2020. The FRAIL scale (5-question assessment of fatigue, resistance, aerobic capacity, illnesses, and loss of weight) was used to classify the patients into three groups: robust (score = 0, n = 28), prefrail (score = 1–2, n = 57), and frail (score = 3–5, n = 29). The primary outcome was the activities of daily living (ADL) measured by the Barthel Index at admission and before discharge. Paired sample t-test was employed to determine the difference in ADL. Multiple linear regression analysis, with adjustment for covariates, was conducted to examine the association between frailty status and change in ADL.

Results

Among 114 patients enrolled (mean age, 79.8 ± 8.1 years; mean length of stay, 6.4 ± 5.6 days), 77 (67.5%) were female. ADL at admission (60.3 ± 31.9) and before discharge (83.7 ± 21.6) were significantly different (P < 0.001). After covariates adjustment, a significant association between frailty status and change in ADL was found (prefrail vs. robust: β = 9.0, 95% confidence interval [CI] 0.3–17.6, P = 0.04; frail vs. robust: β = 13.4, 95% CI 2.7–24.0, P = 0.01).

Conclusions

Older adults with frailty experienced functional improvement after admission to the ACE unit. Prefrail and frail groups were associated with a more significant change in ADL between admission and discharge compared to the robust group.

[Effectiveness and efficiency of acute geriatric units: A classic topic revisited]

Previous meta-analyses have shown that the hospital admission of older patients in acute geriatric units (AGU) compared to admission to other conventional units, significantly reduced the risk of functional deterioration during hospitalization, increasing the possibility of returning home, with an added reduction in cost of hospitalization. A new meta-analysis on the subject has recently been published in Age and Aging, which adds six new studies to the five clinical trials analyzed in previous meta-analyses. This article analyzes the results of this new meta-analysis, delving into the characteristics of the new studies included and making some considerations on the implications for care in the future development of AGU.

Effectiveness of acute geriatric unit care on functional decline, clinical and process outcomes among hospitalised older adults with acute medical complaints: a systematic review and meta-analysis

Background

the aim of this systematic review and meta-analysis was to update and synthesise the totality of research evidence on the effectiveness of acute geriatric unit (AGU) care for older adults admitted to hospital with acute medical complaints.

Methods

MEDLINE, CINAHL, CENTRAL and Embase databases were systematically searched from 2008 to February 2022. Screening, data extraction and quality grading were undertaken by two reviewers. Only trials with a randomised design comparing AGU care and conventional care units were included. Meta-analyses were performed in Review Manager 5.4 and the Grading of Recommendations, Assessment, Development and Evaluations framework was used to assess the certainty of evidence. The primary outcome was incidence of functional decline between baseline 2-week prehospital admission status and discharge and at follow-up.

Results

11 trials recruiting 7,496 participants across three countries were included. AGU care resulted in a reduction in functional decline at 6-month follow-up (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.66–0.93; moderate certainty evidence) and an increased probability of living at home at 3-month follow-up (RR 1.06, 95% CI 0.99–1.13; high certainty evidence). AGU care resulted in little or no difference in functional decline at hospital discharge or at 3-month follow-up, length of hospital stay, costs, the probability of living at home at discharge, mortality, hospital readmission, cognitive function or patient satisfaction.

Conclusions

AGU care improves clinical and process outcomes for hospitalised older adults with acute medical complaints. Future research should focus on greater inclusion of clinical and patient reported outcome measures.

Total elbow arthroplasty in elderly trauma patients: adding a new perspective for functional evaluation

PURPOSE

Total elbow arthroplasty (TEA) has evolved over the last years, with satisfactory early results, mainly not only in degenerative arthritis, but also increasingly after trauma. Outcome studies in recently published papers are mainly based on the range of motion (ROM), complication rate as well as patient-reported outcome scales and questionnaires. The purpose of this study was to add a new perspective with the "Purdue Pegboard" skill tests in a homogenous set of elderly trauma patients to contribute to a more precise objective outcome measurement in this specific population.

METHODS

A retrospective review was performed on a consecutive cohort of all patients with age above 60 years that received TEA after trauma. Data from follow-up examinations over a standardized time-schedule within 2 years after TEA were included. Mayo Elbow Performance Score (MEPS), "Disability of Arm, Shoulder and Hand" (DASH) Questionnaire, ROM as well as test-scores using the Pegboard test were evaluated.

RESULTS

Mean age was 76.0 years ± 10.3. Indications for TEA were posttraumatic arthrosis in 68.8% (n = 11) and extensive fractures that could not be reconstructed surgically in 31.3% (n = 5). The mean score of MEPS was 82.81 ± 16.63 and 29.18 ± 12.01 in the DASH. ROM presented with a mean of 109.7° ± 15.4. Patients demonstrated good, but marginally reduced test scores in the Pegboard skill tests in comparison with the healthy reference population. No relevant differences between the arm with and the arm without TEA (0.3 ± 3.6; p = 0.715) were noted after 2 years.

CONCLUSION

In the elderly trauma patient with complex fractures of the elbow, TEA is a good alternative to joint reconstruction using various osteosynthesis techniques. TEA is able to avoid revision surgery after open reduction and internal fixation of complex fractures. In cases of failed reconstruction, it is also a viable secondary procedure in posttraumatic arthrosis. Good outcomes in functionality and dexterity can be achieved. Skill tests like the Purdue Pegboard could add a valuable perspective in assessing functional outcomes after TEA.

Intersectoral Ward Rounds on Patients Admitted to Temporary Twenty-Four-Hour Accommodations in Denmark: Case Study

Introduction:

Temporary twenty-four-hour accommodations (TTAs) are municipal beds for elderly patients discharged from the hospital with acute treatment, care and/or rehabilitation needs that cannot be met in their own homes. TTAs are staffed by nurses and nursing assistants who are not authorized to prescribe or modify medications. At North Zealand Hospital one third of the many readmissions from a TTA within eight days after discharge have been assessed as preventable.

Description:

A hospital-based team rounded on 268 patients at TTAs from May 2017 to October 2019 to promote integrated care. This study aimed to assess the efficacy of the rounding by auditing patient cases. A physician, a nurse, and a pharmacist from the hospital; a general practitioner; and one or two TTA nurses audited 17 cases.

Discussion:

Obtaining access to all electronic patient records and reconstructing information shared across sectors were not feasible in all cases.

Conclusion

Effects of game-based interventions on functional capacity in acutely hospitalised older adults: results of an open-label non-randomised clinical trial

BACKGROUND

Hospitalisation-associated disability due to reduced physical activity levels and prolonged bedrest episodes are highly prevalent in older adults.

OBJECTIVE

To assess the effect of gamified interventions on functional capacity in hospitalised older adults.

METHODS

A three-armed non-randomised controlled trial with two experimental intervention groups and a control group was conducted in a tertiary public hospital in Navarre, Spain. Participants were allocated to a simple gamification group (SGG) (n = 21), a technology-based gamification group (TGG) (n = 23) or a control group (CG) (n = 26). The end points were changes in functional capacity, muscle strength, cognition, mood status and quality of life.

RESULTS

Seventy patients (mean age 86.01 ± 4.27 years old) were included in the study; 29 (41.4%) were women. At discharge, compared to CG, a mean increase of 1.47 points (95%CI, 0.15-2.80 points) and 2.69 points (95%CI, 1.32-4.06 points) was observed (SGG and TGG, respectively) in the SPPB test; as well as an increase of 5.28 points (95%CI, 0.70-9.76 points) in the Barthel Index and 2.03 kg (95%CI, 0.33-3.72 kg) in handgrip strength in the TGG. Regression mediation analyses demonstrated that muscle strength changes (β = 1.30; 95%CI, 0.45-2.14; indirect effect 0.864; 95%CI, 0.09-1.90) significantly mediated the TGG effect on the SPPB score.

CONCLUSIONS

The TGG intervention programme may provide significant benefits in physical and muscle function over usual care and seems to reverse the functional decline frequently associated with acute hospitalisation in older adults.

Changing Hospital Care For Older Adults: The Case for Geriatric Hospitals in the United States

Hospital care of frail older adults is far from optimal. Although some geriatric models of care have been shown to improve outcomes, the effect size is small and models are difficult to fully implement, sustain and replicate. The two root causes for these shortcomings are competing interests (high revenue generating diseases, procedures and surgeries) and current hospital cultures (for example a culture of safety that emphasizes bed alarms and immobility rather than frequent ambulation). Geriatric hospitals would be hospitals completely dedicated to the care of frail older patients, a group which is most vulnerable to the negative consequences of a hospitalization. They would differ from a typical adult hospital because they could implement evidence based principles of successful geriatric models of care on a hospital wide basis, which would make them sustainable and allow for scaling up of proven outcomes. Innovative structural designs, unachievable in a typical adult hospital, would enhance mobility while maintaining safety. Financial viability and stability would be a challenge but should be feasible, likely through affiliation with larger health care systems with other hospitals because of cost savings associated with geriatric models of care (decreased length of stay, increased likelihood of discharge home, without increasing costs).

The Effectiveness of Multicomponent Functional Maintenance Initiatives for Acutely Hospitalized Older Adults: A Systematic Review and Meta-analysis

BACKGROUND AND PURPOSE

To evaluate the effectiveness of multicomponent functional maintenance initiatives (MFMIs) on functional outcomes and adverse events associated with functional decline among acutely hospitalized older adults.

DATA SOURCES

Studies were sourced from OVID Medline, PubMed, Embase, CINAHL, the Cochrane Library, and PEDro databases from inception to April 15, 2020, and their bibliographies.

STUDY SELECTION

Randomized controlled trials were included if they investigated multicomponent interventions comprising more than one nonpharmacological intervention targeting physical functional decline and another shared risk factor for geriatric syndromes in acutely hospitalized medical or nonelective surgical patients 65 years and older.

DATA EXTRACTION

Two reviewers independently assessed for eligibility, extracted data, and conducted risk of bias assessments.

DATA SYNTHESIS

Eight studies involving 5534 patients were included. Multicomponent functional maintenance initiatives did not appear to confer significant effects on functional status, length of stay, or 30-day hospital readmissions; however, clinical heterogeneity limited meta-analysis for some specific functional outcomes. Patients who did not receive MFMIs were more likely to be discharged to a nursing staff facility (odds ratio = 1.53; 95% confidence interval, 1.23 to 1.90). No effect of MFMI on all-cause mortality was observed, and adverse events were rare and unlikely attributed to nonpharmacological interventions.

CONCLUSIONS

Data from a small number of studies suggest MFMIs reduce the likelihood of discharge to a nursing staff facility in acutely hospitalized older adults; however, this effect may not be driven via improvements in physical function. Standardized evaluation methods to determine MFMI effectiveness appear indicated to assist decision-making regarding their implementation in clinical practice.

Patient-Centeredness in Older Adults With Multimorbidity: Results of an Online Expert Delphi Study

BACKGROUND AND OBJECTIVES

Older adults suffering from multimorbidity represent a priority target group for patient-centeredness (PC). We aimed to investigate the transferability of an existing integrated model of PC comprising 15 dimensions on the care of older adults with multimorbidity from an expert perspective.

RESEARCH DESIGN AND METHODS

A total of 242 experts were invited to participate in a 2-round online Delphi study. In round 1, they were asked to (a) individually rate relevance and clarity of the dimensions, (b) add missing dimensions, and (c) prioritize the dimensions. In round 2, experts received results of round 1 and were asked to rerate their ratings.

RESULTS

Forty-eight experts participated in round 1 and 39 in round 2. Ten dimensions were rated as sufficiently relevant and clear, including one new dimension ("prognosis and life expectancy, burden of treatment"). Four dimensions were rated as relevant but insufficiently clear. One dimension failed to reach our validation threshold on both criteria. The 5 dimensions rated as most important were: "patient as a unique person," "clinician-patient communication," "patient involvement in care," "physical, cognitive, and emotional support," and "involvement of family and friends."

DISCUSSION AND IMPLICATIONS

The experts' ratings were higher regarding relevance than regarding clarity, which emphasizes the still existing conceptual uncertainty of PC. Our results give further directions regarding the operationalization of PC in older adults with multimorbidity, which is essential for its implementation in routine care. Further refined using focus groups with geriatric patients, our adapted model serves as a basis for a systematic review of assessment instruments.

The Aging Muscle in Experimental Bed Rest: A Systematic Review and Meta-Analysis

Background: Maintaining skeletal muscle mass and function in aging is crucial for preserving the quality of life and health. An experimental bed rest (BR) protocol is a suitable model to explore muscle decline on aging during inactivity. Objective: The purpose of this systematic review and meta-analysis was, therefore, to carry out an up-to-date evaluation of bed rest, with a specific focus on the magnitude of effects on muscle mass, strength, power, and functional capacity changes as well as the mechanisms, molecules, and pathways involved in muscle decay. Design: This was a systematic review and meta-analysis study. Data sources: We used PubMed, Medline; Web of Science, Google Scholar, and the Cochrane library, all of which were searched prior to April 23, 2020. A manual search was performed to cover bed rest experimental protocols using the following key terms, either singly or in combination: "Elderly Bed rest," "Older Bed rest," "Old Bed rest," "Aging Bed rest," "Aging Bed rest," "Bed-rest," and "Bedrest". Eligibility criteria for selecting studies: The inclusion criteria were divided into four sections: type of study, participants, interventions, and outcome measures. The primary outcome measures were: body mass index, fat mass, fat-free mass, leg lean mass, cross-sectional area, knee extension power, cytokine pattern, IGF signaling biomarkers, FOXO signaling biomarkers, mitochondrial modulation biomarkers, and muscle protein kinetics biomarkers. Results: A total of 25 studies were included in the qualitative synthesis, while 17 of them were included in the meta-analysis. In total, 118 healthy elderly volunteers underwent 5-, 7-, 10-, or 14-days of BR and provided a brief sketch on the possible mechanisms involved. In the very early phase of BR, important changes occurred in the skeletal muscle, with significant loss of performance associated with a lesser grade reduction of the total body and muscle mass. Meta-analysis of the effect of bed rest on total body mass was determined to be small but statistically significant (ES = -0.45, 95% CI: -0.72 to -0.19, P < 0.001). Moderate, statistically significant effects were observed for total lean body mass (ES = -0.67, 95% CI: -0.95 to -0.40, P < 0.001) after bed rest intervention. Overall, total lean body mass was decreased by 1.5 kg, while there was no relationship between bed rest duration and outcomes (Z = 0.423, p = 672). The meta-analyzed effect showed that bed rest produced large, statistically significant, effects (ES = -1.06, 95% CI: -1.37 to -0.75, P < 0.001) in terms of the knee extension power. Knee extension power was decreased by 14.65 N/s. In contrast, to other measures, meta-regression showed a significant relationship between bed rest duration and knee extension power (Z = 4.219, p < 0.001). Moderate, statistically significant, effects were observed after bed rest intervention for leg muscle mass in both old (ES = -0.68, 95% CI: -0.96 to -0.40, P < 0.001) and young (ES = -0.51, 95% CI: -0.80 to -0.22, P < 0.001) adults. However, the magnitude of change was higher in older (MD = -0.86 kg) compared to younger (MD = -0.24 kg) adults. Conclusion: Experimental BR is a suitable model to explore the detrimental effects of inactivity in young adults, old adults, and hospitalized people. Changes in muscle mass and function are the two most investigated variables, and they allow for a consistent trend in the BR-induced changes. Mechanisms underlying the greater loss of muscle mass and function in aging, following inactivity, need to be thoroughly investigated.

Experiences of Pulmonary Rehabilitation in People Living with Chronic Obstructive Pulmonary Disease and Frailty. A Qualitative Interview Study

Rationale: People living with both chronic obstructive pulmonary disease (COPD) and frailty have high potential to benefit from pulmonary rehabilitation but face challenges completing programs. However, research to understand ways to optimize participation in this group is lacking.

Objectives: To explore the experiences, needs, and preferences of people with COPD and frailty referred for outpatient pulmonary rehabilitation.

Methods: Semistructured interviews with people with COPD and physical frailty, purposively sampled by age, living status, level of frailty, and completion of pulmonary rehabilitation. Thematic analysis with a critical realist perspective was used, involving relevant stakeholders with clinical, academic, and lived experience for interpretive rigor.

Results: Nineteen people with COPD and frailty were interviewed, with a median age of 78 years (range, 58–88). Nine did not complete their pulmonary rehabilitation program. Four themes were identified: striving to adapt to multidimensional loss, tensions of balancing support with independence, pulmonary rehabilitation as a challenge worth facing, and overcoming unpredictable disruptions to participation. Participants described constantly adapting to their changing health and resulting multidimensional losses (e.g., functional abilities, relationships, confidence). This involved traversing between independence and seeking support, set against a mismatch between their needs and what support is available. People with COPD and frailty can be highly motivated to participate in pulmonary rehabilitation, despite the physical and mental demands it entails, and report a range of benefits. Yet in the context of changeable health, they must often overcome multiple unpredictable disruptions to completing rehabilitation programs. Participant determination and flexibility of services can facilitate ongoing attendance, but for some, these unpredictable disruptions erode their motivation to attend.

Conclusions: People with COPD and frailty experience accumulating, multidimensional loss. This group are motivated to complete pulmonary rehabilitation but often require additional support and flexibility owing to fluctuating and unpredictable health. Person-centered approaches should be considered to minimize disruptive health events and support pulmonary rehabilitation participation and completion. Service adaptations could allow more flexibility to meet the changing needs of this group and enable communication around how pulmonary rehabilitation might align with their priorities.

Home hospital as a disposition for older adults from the emergency department: Benefits and opportunities

The $1 trillion industry of acute hospital care in the United States is shifting from inside the walls of the hospital to patient homes. To tackle the limitations of current hospital care in the United States, on November 25, 2020, the Center for Medicare & Medicaid Services announced that the acute hospital care at home waiver would reimburse for "home hospital" services. A "home hospital" is the home-based provision of acute services usually associated with the traditional inpatient hospital setting. Prior work suggests that home hospital care can reduce costs, maintain quality and safety, and improve patient experiences for select acutely ill adults who require hospital-level care. However, most emergency physicians are unfamiliar with the evidence of benefits demonstrated by home hospital services, especially for older adults. Therefore, the lead author solicited narrative inputs on this topic from selected experts in emergency medicine and home hospital services with clinical experience, publications, and funding on home hospital care. Then we sought to identify information most relevant to the practice of emergency medicine. We outline the proven and potential benefits of home hospital services specific to older adults compared to traditional acute care hospitalization with a focus on the emergency department.

Optimizing hospital-to-home transitions for older persons in rural communities: a participatory, multimethod study protocol

BACKGROUND

Transitional care involves time-limited interventions focusing on the continuity of care from hospital to home, to optimize patient functioning and management. Providing interventions, as part of transitional care, that optimize the functioning of older people with dementia is critical due to the small window of opportunity in which they can return to their baseline levels of functioning. Yet prior research on transitional care has not included interventions focused on functioning and did not target older people with dementia in rural communities, limiting the applicability of transitional care to this population. Accordingly, the goal of this study is to align hospital-to-home transitional care with the function-related needs of older people with dementia and their family-caregivers in rural communities.

METHODS

In this multimethod study, two phases of activities are planned in rural Ontario and Nova Scotia. In phase I, a purposive sample of 15-20 people with dementia and 15-20 family-caregivers in each province will rate the acceptability of six evidence-based interventions and participate in semi-structured interviews to explore the interventions' acceptability and, where relevant, how to improve their acceptability. Acceptable interventions will be further examined in phase II, in which a purposive sample of healthcare providers, stratified by employment location (hospital vs. homecare) and role (clinician vs. decision-maker), will (1) rate the acceptability of the interventions and (2) participate in semi-structured focus group discussions on the facilitators and barriers to delivering the interventions, and suggestions to enable their incorporation into rural transitional care. Two to three focus groups per stratum (8-10 healthcare providers per focus group) will be held for a total of 8-12 focus groups per province. Data analysis will involve qualitative content analysis of interview and focus group discussions and descriptive statistics of intervention acceptability ratings.

DISCUSSION

Findings will (1) include a set of acceptable interventions for rural transitional care that promote older patients' functioning and family-caregivers' ability to support patients' functioning, (2) identify resources needed to incorporate the interventions into rural transitional care, and (3) provide high-quality evidence to inform new transitional care practices and policies and guide future research.

Characteristics and outcomes of mechanically ventilated elderly patients in the absence of an end-of-life care policy: a retrospective study from Bahrain

BACKGROUND

Globally, the percentage of elderly patients has been increasing, leading to a higher demand for healthcare resources and intensive care. Bahrain has a majority Muslim population and Islam governs most policies, including end-of-life care. All patients at our institute receive full resuscitative measures regardless of the prognosis, leading to a high number of mechanically ventilated patients.

OBJECTIVES

Assess characteristics, outcomes, theoretical costs, and use of antibiotics in critically ill elderly patients requiring mechanical ventilation.

DESIGN

Retrospective.

SETTING

Intensive care unit and general ward of a tertiary medical care center.

PATIENTS AND METHODS

We studied all elderly patients (≥60 years old) admitted under general medicine in the period of January to June 2018 who needed intensive care and were intubated.

MAIN OUTCOME MEASURES

The duration of mechanical ventilation, theoretical costs, antibiotic usage.

SAMPLE SIZE

140 patients.

RESULTS

Of 140 patients, 136 died (97%) and half of the deaths (n=69, 50.7%) occurred within the first 24 hours of intubation. Sixty-nine (79.3%) of the patients on short-term ventilation (≤96 hours) died within 24 hours of intubation, while the four survivors were on long-term ventilation (>96 hours) (P<.001). All the nonsurviving patients (n=136) were on antimicrobial therapy, mostly for hospital-acquired infections. The median (interquartile range) APACHE II score was relatively high at 28.0 (8.0) with significantly higher scores in the early mortality group compared to the late mortality group (30 [10] vs 26 [7], P=.013) and higher scores in the short-term vs long-term ventilation group (29 [10] vs 26 [7], P=.029). The median theoretical cost per patient in the early and late mortality groups was USD 10 731 and USD 30 660, respectively (P<.001).

CONCLUSIONS

Given that less than 3% of patients had a favorable outcome, 50% of the cases died within 24 hours after intubation, hospital costs and antimicrobial use were high, the current policy of "full resuscitative measures for all" should be revised. We suggest implementing an end-of-life care policy, since the goal of resuscitation is to reverse premature death, not prolong the dying process.

LIMITATIONS

Small sample size and absence of long-term follow-up. Theoretical costs were used as no direct calculated costs were available in our hospital.

CONFLICT OF INTEREST

None.

Effectiveness of comprehensive geriatric assessment intervention on quality of life, caregiver burden and length of hospital stay: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Comprehensive geriatric assessment (CGA) interventions can improve functional ability and reduce mortality in older adults, but the effectiveness of CGA intervention on the quality of life, caregiver burden, and length of hospital stay remains unclear. The study aimed to determine the effectiveness of CGA intervention on the quality of life, length of hospital stay, and caregiver burden in older adults by conducting meta-analyses of randomised controlled trials (RCTs).

METHODS

A literature search in PubMed, Embase, and Cochrane Library was conducted for papers published before February 29, 2020, based on inclusion criteria. Standardised mean difference (SMD) or mean difference (MD) with 95% confidence intervals (CIs) was calculated using the random-effects model. Subgroup analyses, sensitivity analyses, and publication bias analyses were also conducted.

RESULTS

A total of 28 RCTs were included. Overall, the intervention components common in different CGA intervention models were interdisciplinary assessments and team meetings. Meta-analyses showed that CGA interventions improved the quality of life of older people (SMD = 0.12; 95% CI = 0.03 to 0.21; P = 0.009) compared to usual care, and subgroup analyses showed that CGA interventions improved the quality of life only in participants' age > 80 years and at follow-up ≤3 months. The change value of quality of life in the CGA intervention group was better than that in the usual care group on six dimensions of the 36-Item Short-Form Health Survey questionnaire (SF-36). Also, compared to usual care, the CGA intervention reduced the caregiver burden (SMD = - 0.56; 95% CI = - 0.97 to - 0.15, P = 0.007), but had no significant effect on the length of hospital stay.

CONCLUSIONS

CGA intervention was effective in improving the quality of life and reducing caregiver burden, but did not affect the length of hospital stay. It is recommended that future studies apply the SF-36 to evaluate the impact of CGA interventions on the quality of life and provide supportive strategies for caregivers as an essential part of the CGA intervention, to find additional benefits of CGA interventions.

Preliminary data demonstrate the Geriatric Surgery Verification program reduces postoperative length of stay

OBJECTIVES/BACKGROUND

The Geriatric Surgery Verification (GSV) Program promotes clinical standards aimed to optimize the quality of surgical care delivered to older adults. The purpose of this study was to determine if preliminary implementation of the GSV Program standards improves surgical outcomes.

DESIGN

Prospective study with cohort matching.

SETTING

Data from a single institution compared with a national data set cohort.

PARTICIPANTS

All patients aged ≥75 years undergoing inpatient operations between January 2018 and December 2019 were included. Cohort matching by age and procedure code was performed using a national data set.

MEASUREMENTS

Baseline pre- and intraoperative characteristics prospectively recorded using Veterans Affairs Surgical Quality Improvement Program (VASQIP) variable definitions. Postoperative outcomes were recorded including complications as defined by VASQIP, 30-day mortality, and length of stay.

RESULTS

A total of 162 patients participated in the GSV program, and 308 patients comprised the matched comparison group. There was no difference in postoperative occurrence of one or more complications (p = 0.81) or 30-day mortality (p = 0.61). Patients cared for by the GSV Program had a reduced postoperative length of stay (median 4 days [range 1,31] vs. 5 days [range 1,86]; p < 0.01; and mean 5.4 ± 4.8 vs. 8.8 ± 11.8 days; p < 0.01) compared with the matched cohort. In a multivariable regression model, the GSV Program's reduced length of stay was independent of other associated covariates including age, operative time, and comorbidities (p < 0.01).

CONCLUSION

Preliminary implementation of the GSV Program standards reduces length of stay in older adults undergoing inpatient operations. This finding demonstrates both the clinical and financial value of the GSV Program.

Adherence to care transitions recommendations among high-risk hospitalized older patients

BACKGROUND/OBJECTIVES

Evidence on the effectiveness of inpatient hospital geriatric consultation is scant, and it is unknown whether adherence to specific recommendations will improve care and patient outcomes. This study was conducted to provide insights from a quality improvement project that may help guide further improvements in the effectiveness of these consultations made as a component of a care transitions program (CTP).

DESIGN

Secondary analysis of the implementation of a multicomponent CTP for high-risk hospitalized patients aged 75 and older.

SETTING

A 400-bed community teaching hospital.

PARTICIPANTS

Two hundred and two patients admitted to non-ICU beds who met high-risk criteria.

INTERVENTION

Inpatient comprehensive geriatric consultation including care transition recommendations, telephone and in-person follow-up weekly for 4 weeks after discharge, and collaboration with post-acute organizations and primary care and specialist physicians to implement recommendations.

MEASUREMENTS

Primary outcomes for this analysis was 30-day hospital readmissions and adherence to transition of care recommendations.

RESULTS

The 142 patients with at least one post-discharge visit received 936 care transition recommendations. Overall, 663 (71%) of the 936 care transition recommendations were adhered to (71%). The adherence rate was lower in the 22 patients who were readmitted to the hospital within 30 days (63%) compared to 72% adherence in the 120 patients who were not readmitted. This was not a statistically significant difference, and there were no significant differences in the number and percent adherence in any recommendation category between the two groups.

CONCLUSION

We found adherence to just over two-thirds of care transition recommendations, similar to a small number of other studies. We did not find a relationship between the number of recommendations and adherence to them with 30-day readmissions to the hospital. Future studies of CTPs should consider several strategies may enhance geriatric consultation care transitions recommendations and adherence to them, and improve patient outcomes.

Rural Perceptions of Acute Care at Home: A Qualitative Analysis

PURPOSE

Hospital-level care at home in urban areas delivers low-cost, high-quality care. Few have attempted to deliver home hospital care in a rural environment, where traditional hospitals are often less equipped to deliver high-quality care. Little is known about rural clinicians' and patients' perceptions regarding rural home hospital care and how the urban model might be adapted to fit rural circumstances.

METHODS

We conducted semistructured qualitative interviews in the United States with a national purposive sample of practicing rural clinicians, a focus group with clinicians who care for rural patients, and interviews with rural patients. We coded these qualitative data into domains and subdomains.

FINDINGS

We identified 4 domains: (1) current state of rural health care, (2) attitudes toward rural home hospital, (3) perceived barriers to implementing rural home hospital, and (4) perceived facilitators to implementing rural home hospital. Participants expressed challenges with current rural health care, including inefficient care coupled with poor access. Most felt rural home hospital care could offer benefits, including comfort, timeliness, and downstream outcomes such as readmission rate reduction. Rural patients were open to receiving acute care in their homes. Potential barriers included geographic accessibility, Internet connectivity, rural hospital politics, the culture of hospitalization, and the availability of skilled human resources.

CONCLUSIONS

Significant interest and optimism exist surrounding rural home hospital despite perceived barriers. Designing for and testing adaptations to the urban model will likely optimize benefits and minimize threats to a potential intervention.

Acute care for elderly patients in a functional impairment prevention unit

AIM

To determine whether the care of patients with moderate dependency who were hospitalised in a functional impairment prevention unit (FIPU) was superior to that of a conventional unit (CU) in terms of functional impairment and mean stay.

METHODS

We conducted a single-centre, retrospective, controlled intervention study that compared acute treatment in an FIPU and in conventional wards. The study included 466 elderly patients with moderate dependence (Barthel index, 30-70) and older than 75 years. Of these, 280 were included in the intervention group and 186 in the control group. The primary outcomes were loss of functionality attributable to the hospitalisation (measured by the loss of ambulation and urinary continence) and differences in the length of stay.

RESULTS

The patients hospitalised in the FIPU showed less functional impairment as determined by the loss of urinary continence (2.1% of the FIPU patients vs. 9.7% of the CU patients; p<.01) and the loss of walking ability (2.1% vs. 25.3%; p<.01). The patients hospitalised in the FIPU had a shorter mean stay (7.4 vs. 8.5 days; p<.05), with 1 day less of stay than the CU patients.

CONCLUSION

The acute care of elderly patients with moderate dependency in an FIPU was independently associated with less functional decline and shorter stays.

Effects of a nursing care program focused on basic self-care in older acute medical in-patients: a randomized controlled trial

Background

Acute illness and hospitalization are often associated with decreased independence in basic activities of daily living. The aim of this study was to test the hypothesis that a nursing care program focused on basic self-care (N_BSC) improves functional outcomes in older patients admitted to an acute medical unit.

Methods

This was a 2-group randomized controlled trial with repeated measures: 182 older patients admitted to an acute medical unit were randomly allocated to the usual care group (n = 91) and intervention group (n = 91). The intervention consisted of nursing care centered on basic self-care that includes promotion of daily walking and all daytime meals seated, out of bed. The main outcome was changes in the number of independent basic activities of daily living (BADL) from 2 weeks before admission (baseline) to discharge.

Results

There was significant effect of the N_BSC on the outcomes. Changes from baseline to discharge in the number of independent BADL differ significantly between the intervention and usual care group. Intervention group patients were discharged with a superior functional status than usual care group. On discharge they were able to perform independently 2.93 BADL, whereas usual care patients performed independently 1.90 BADL (P < .001).

Conclusions

N_BSC for hospitalized older adults was feasible and program participants were discharged with better functional status than a clinically similar comparison group. N_BSC could be readily adapted for use in other hospitals and warrants further evaluation as a potential new tool for improving outcomes for hospitalized older patients.

A Case-Control Study of the Sub-Acute Care for Frail Elderly (SAFE) Unit on Hospital Readmission, Emergency Department Visits and Continuity of Post-Discharge Care

OBJECTIVES

In Canada, alternate-level-of-care (ALC) beds in hospitals may be used when patients who do not require the intensity of services provided in an acute care setting are waiting to be discharged to a more appropriate care setting. However, when there is a lack of care options for patients waiting to be discharged, it contributes to prolonged hospital stays and bottlenecks in the health care system manifested as "hallway medicine." We examined the effectiveness of a function-focused transitional care program, the Sub-Acute care for Frail Elderly (SAFE) Unit, in reducing the length of stay (LOS) in hospital, as well as post-discharge acute care use and continuity of care.

DESIGN

Case-control study.

SETTING AND PARTICIPANTS

A 450-bed nursing home located in Ontario, Canada, where the SAFE Unit is based. The study population included frail, older patients aged 60 years and older who received care in the SAFE Unit between March 1, 2018, and February 28, 2019 (n = 153) to controls comprising of other hospitalized patients (n = 1773).

METHODS

We linked facility-level to provincial health administrative databases on hospital admissions and emergency department (ED) visits, and the Ontario Health Insurance Plan claims database for physician billings to investigated the LOS during the index hospitalization, 30-day odds of post-discharge ED visits, hospital readmission, and follow-up with family physicians.

RESULTS

SAFE patients had a median hospital LOS of 13 days [interquartile range (IQR): 8-19 days], with 75% having fewer than 1 day in an ALC bed. In comparison, the median LOS in the control group was 15 days (IQR: 10-24 days), with one-third of those days spent in an ALC bed (median: 5 days, IQR: 3-10 days). SAFE patients were more likely (64.1%) to be discharged home than control patients (46.3%). Both groups experienced similar 30-day odds of ED visits, hospital readmission and follow-up with a family physician.

CONCLUSIONS AND IMPLICATIONS

Frail older individuals in the SAFE Unit experienced shorter hospital stays, were less likely to be discharged to settings other than home and had similar 30-day acute care outcomes as control patients post-discharge.

Perioperative Care Strategy for Older Adults

Geriatric patients are not just older adult patients. Aging brings about unique physiologic, psychological, and sociologic changes within individuals. Recognition of these unique characteristics and measuring for their impact; instituting mitigating strategies; using age-specific anesthetic measures; and performing a systematic, algorithmic care model in the postoperative period overseen by a multidisciplinary team brings about enhanced outcomes and improved quality of care for this expanding group of patients.

Interventions for reducing hospital-associated deconditioning: A systematic review and meta-analysis

PURPOSE

To determine the effectiveness of hospital-based interventions designed to reduce Hospital-Associated Deconditioning (HAD) for people in inpatient hospital settings.

MATERIALS & METHODS

Systematic literature search of published and unpublished databases was conducted from (inception to 01 June 2020). Randomised and non-randomised controlled trials investigating the effectiveness of enhanced inpatient programmes aimed to reduce HAD in adults admitted to a hospital ward were included. Evidence was appraised using the Cochrane Risk of Bias tool and outcomes evaluated against the GRADE criteria. Where appropriate, data were pooled in meta-analyses and presented as risk difference (RD) or standardised mean difference with 95 % confidence intervals (CI).

RESULTS

Seven studies recruiting 12,597 participants (7864 enhanced programmes; 4349 usual care) were included. There was low-quality evidence for reduced risk of decline in physical performance for those in the enhanced programmes compared to usual care (RD: -0.04; 95 % CI: -0.08 to -0.01; N = 2085). There was low- or very-low quality evidence reporting no benefit of enhanced programmes for mobility on discharge, length of hospital stay, hospital readmission, and mortality within the first three-months post-admission (p > 0.05). There was low-quality evidence that nursing home placement and mortality at 12-months was superior through enhanced inpatient programmes compared to usual care.

CONCLUSION

Enhanced inpatient programmes targeted at HAD may offer benefit over usual care for some outcomes. There remain uncertainty in relation to how applicable the findings are to non-North American countries, which elements of an enhanced programme are most important to reduce HAD, and longer-term sequelae.

The Patient-Centered Approach: A Review of the Literature and Its Application for Acoustic Neuromas

Patient-centered care is defined as "care that is consistent with and respects the values, needs, and wishes of patients" and is best achieved when clinicians involve patients and their support system in health care discussions and decisions. While this approach has been well established and supported in more general medical specialties, such as primary care, that may encompass a more holistic approach, it has rarely been described in surgical disciplines. Acoustic neuromas (ANs) can be unique among other skull base and intracranial pathologies, in that the management of these tumors can vary from patient to patient depending on various factors. Moreover, typical options, including observation, radiation, and surgery, may often have equipoise for some patients and their tumors. Therefore, a patient-centered approach, strongly guided by the expertise of experienced skull base surgeons, may likely be the most appropriate type of care for patients with ANs. Herein, we review the documented use of patient-centered care in other aspects of medicine, propose the benefits of this approach for patients with ANs, and provide ways this can be better implemented in practice.

Care Transitions in the Psychiatric Hospital: Focus on Older Adults

Patients undergoing a care transition are vulnerable to duplication of services, conflicting care recommendations, and errors in medication reconciliation. Older adults may be more vulnerable to care transitions given their relatively higher medical burden, cognitive impairment, and frequent polypharmacy. In this Treatment in Geriatric Mental Health: Research in Action article, we first present the results of a quality improvement study examining the frequency of care transitions to and from the medical hospital among patients admitted to a university-affiliated psychiatric hospital. Among a sample of 50 geriatric adults and 50 nongeriatric adults admitted to the psychiatric hospital, we tallied the number of care transitions to and from the medical hospital. We found that the geriatric cohort was significantly more likely to experience this type of care transition (p = 0.012, Fisher's exact test) compared to the nongeriatric cohort. In the second part of this article, we use a clinical vignette to illustrate the types of medical errors that can occur as a vulnerable and frail older adult moves between acute psychiatric and medical settings. Finally, we list provider-level and systems-level evidence-based recommendations for how care of the patient in the vignette could be improved. The quality improvement study and clinical vignette demonstrate how older adults are at greater risk for care transitions to and from the acute medical setting during psychiatric hospitalization, and that creative solutions are required to improve outcomes.

Augmented exercise in hospital improves physical performance and reduces negative post hospitalization events: a randomized controlled trial

BACKGROUND

To measure the effects of an augmented prescribed exercise programme versus usual care, on physical performance, quality of life and healthcare utilisation for frail older medical patients in the acute setting.

METHODS

This was a parallel single-blinded randomised controlled trial. Within 2 days of admission, older medical inpatients with an anticipated length of stay ≥3 days, needing assistance/aid to walk, were blindly randomly allocated to the intervention or control group. Until discharge, both groups received twice daily, Monday-to-Friday half-hour assisted exercises, assisted by a staff physiotherapist. The intervention group completed tailored strengthening and balance exercises; the control group performed stretching and relaxation exercises. Length of stay was the primary outcome measure. Blindly assessed secondary measures included readmissions within 3 months, and physical performance (Short Physical Performance Battery) and quality of life (EuroQOL-5D-5 L) at discharge and at 3 months. Time-to-event analysis was used to measure differences in length of stay, and regression models were used to measure differences in physical performance, quality of life, adverse events (falls, deaths) and negative events (prolonged hospitalisation, institutionalisation).

RESULTS

Of the 199 patients allocated, 190 patients' (aged 80 ± 7.5 years) data were analysed. Groups were comparable at baseline. In intention-to-treat analysis, length of stay did not differ between groups (HR 1.09 (95% CI, 0.77-1.56) p = 0.6). Physical performance was better in the intervention group at discharge (difference 0.88 (95% CI, 0.20-1.57) p = 0.01), but lost at follow-up (difference 0.45 (95% CI, - 0.43 - 1.33) p = 0.3). An improvement in quality of life was detected at follow-up in the intervention group (difference 0.28 (95% CI, 0.9-0.47) p = 0.004). Overall, fewer negative events occurred in the intervention group (OR 0.46 (95% CI 0.23-0.92) p = 0.03).

CONCLUSION

Improvements in physical performance, quality of life and fewer negative events suggest that this intervention is of value to frail medical inpatients. Its effect on length of stay remains unclear.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02463864, registered prospectively 26.05.2015.

Improving Geriatric Care Processes on Two Medical-Surgical Acute Care Units: A Pilot Study

The Acute Care for Elders (ACE) Unit model improves cognitive and functional outcomes for hospitalized elders but reaches a small proportion of patients. To disseminate ACE Unit principles, we piloted the "Virtual ACE Intervention" that standardizes care processes for cognition and function without daily geriatrician oversight on two non-ACE units. The Virtual ACE Intervention includes staff training on geriatric assessments for cognition and function and on nurse-driven care algorithms. Completion of the geriatric assessments by nursing staff in patients aged 65 years and older and measures of patient mobility and prevalence of an abnormal delirium screening score were compared preintervention and postintervention. Postintervention, the completion of the assessments for current functional status and delirium improved (62.5% vs. 88.5%, p < .001) and (4.2% vs. 96.5%, p < .001). In a subsample analysis, in the postintervention period, more patients were up to the chair in the past day (36.4% vs. 63.5%, p = .04) and the prevalence of an abnormal delirium screening score was lower (13.6% vs. 4.8%, p = .16). The Virtual ACE Intervention is a feasible model for disseminating ACE Unit principles to non-ACE Units and may lead to increased adherence to care processes and improved clinical outcomes.

High-risk medication in community care: a scoping review

PURPOSE

To review the international literature related to high-risk medication (HRM) in community care, in order to (1) define a definition of HRM and (2) list the medication that is considered HRM in community care.

METHODS

Scoping review: Five databases were systematically searched (MEDLINE, Scopus, CINAHL, Web Of Science, and Cochrane) and extended with a hand search of cited references. Two researchers reviewed the papers independently. All extracted definitions and lists of HRM were subjected to a self-developed quality appraisal. Data were extracted, analysed and summarised in tables. Critical attributes were extracted in order to analyse the definitions.

RESULTS

Of the 109 papers retrieved, 36 met the inclusion criteria and were included in this review. Definitions for HRM in community care were used inconsistently among the papers, and various recurrent attributes of the concept HRM were used. Taking the recurrent attributes and the quality score of the definitions into account, the following definition could be derived: "High-risk medication are medications with an increased risk of significant harm to the patient. The consequences of this harm can be more serious than those with other medications". A total of 66 specific medications or categories were extracted from the papers. Opioids, insulin, warfarin, heparin, hypnotics and sedatives, chemotherapeutic agents (excluding hormonal agents), methotrexate and hypoglycaemic agents were the most common reported HRM in community care.

CONCLUSION

The existing literature pertaining to HRM in community care was examined. The definitions and medicines reported as HRM in the literature are used inconsistently. We suggested a definition for more consistent use in future research and policy. Future research is needed to determine more precisely which definitions should be considered for HRM in community care.

Prosthetic rehabilitation of the geriatric oncologic rhinectomy patient utilizing a craniofacial implant-retained nasal prosthesis

This clinical report describes the expeditious treatment of a geriatric patient with squamous cell carcinoma of the nose treated with total rhinectomy, craniofacial implant placement, and a nasal prosthesis.

An Innovation Center Model to Transform Health Systems to Improve Care of Older Adults

The US population is aging faster than at any other time in our history. This growth, coupled with a slow adaptive health policy framework, is creating an urgent need to reengineer and improve the quality, safety, and cost-effectiveness of health systems to meet the needs of older adults and embrace the success we have achieved with longevity. Without rapid adoption of evidence-based models that are known to improve safety and health outcomes, we significantly jeopardize the lives of thousands of older adults receiving care under our current health systems' processes and models. This article describes an innovation and operations infrastructure that was successfully tested in two independent and geographically distinct community health systems. This operations and implementation framework can be scaled and used to accelerate the changes needed to improve care for older adults in health systems throughout the United States. J Am Geriatr Soc 68:15-22, 2019.

Development of a longlist of healthcare quality indicators for physical activity of patients during hospital stay: a modified RAND Delphi study

OBJECTIVE

To develop a longlist of healthcare quality indicators for the care of hospitalised adults of all ages with (or at risk of) low physical activity during the hospital stay.

DESIGN

A modified RAND/UCLA Appropriateness Method Delphi study.

SETTING AND PARTICIPANTS

Participants were physical therapists, nurses and managers working in Dutch university medical centres.

METHODS

The current study consisted of three phases. Phase I was a systematic literature search for quality indicators and relevant domains. Phase II was a survey among healthcare professionals to collect additional data. Phase III consisted of three consensus rounds. In round 1, experts rated the relevance of the potential indicators online (Delphi). The second round was a face-to-face expert panel meeting managed by an experienced moderator. Acceptability, feasibility and validity of the quality indicators were discussed by the panel members. In round 3, the panel members rated the relevance of the potential indicators that were still under discussion.

RESULTS

The search retrieved 1556 studies of which 53 studies were assessed full text. Data from 17 studies were included in a first draft longlist of indicators. Eighteen nurses and one physical therapist responded to the survey and added data for a second draft of the longlist. Experts constructed the final longlist of 23 indicators in three consensus rounds. Seven domains were identified: 'Policy', 'Attitude and education', 'Equipment and support', 'Evaluation', 'Information', 'Patient-tailored physical activity plan' and 'Outcome measure'.

CONCLUSION AND IMPLICATIONS

The healthcare quality indicators developed in this study could help to grade, monitor and improve healthcare for hospitalised adults of all ages with (or at risk of) low physical activity during the hospital stay. Future research will focus on the psychometric quality of the indicators and selection of key performance indicators.

An Acute Care for Elders Quality Improvement Program for Complex, High-Cost Patients Yields Savings for the System

BACKGROUND

Acute Care for Elders (ACE) programs improve outcomes for older adults; however, little is known about whether impact varies with comorbidity severity.

OBJECTIVE

To describe differences in hospital-level outcomes between ACE and routine care across various levels of comorbidity burden.

DESIGN

Cross-sectional quality improvement study.

SETTING

A 716-bed teaching hospital.

PARTICIPANTS

Medical inpatients aged ≥70 years hospitalized between September 2014 and August 2017.

INTERVENTION

ACE care, including interprofessional rounds, geriatric syndromes screening, and care protocols, in an environment prepared for elders MEASUREMENTS: Total cost, length of stay (LOS), and 30-day readmissions. We calculated median differences for cost and LOS between ACE and usual care and explored variations across the distribution of outcomes at the 25th, 50th, 75th and 90th percentiles. Results were also stratified across quartiles of the combined comorbidity score.

RESULTS

A total of 1,429 ACE and 10,159 non-ACE patients were included in this study. The mean age was 81 years, 57% were female, and 81% were white. ACE patients had lower costs associated with care ranging from $171 at the 25th percentile to $3,687 at the 90th percentile, as well as lower LOS ranging from 0 days at the 25th percentile to 1.9 days at the 90th percentile. After stratifying by comorbidity score, the greatest differences in outcomes were among those with higher scores. There was no difference in 30-day readmission between the groups.

CONCLUSION

The greatest reductions in cost and LOS were in patients with greater comorbidity scores. Risk stratification may help hospitals prioritize admissions to ACE units to maximize the impact of the more intensive intervention.