Abstract
Background
Mobility in hospital is important to maintain independence and prevent complications. Our multi-centre study aimed to measure mobility and identify barriers and enablers to ...mobility participation from the older patient’s perspective.
Methods
Mixed methods study including direct observation of adult inpatients on 20 acute care wards in 12 hospitals and semi-structured interviews with adults aged 65 years or older on each of these wards. Interviews were undertaken by trained staff during the inpatient stay. Quantitative data were analysed descriptively. Qualitative data were initially coded deductively using the theoretical domains framework (TDF), with an inductive approach then used to frame belief statements.
Results
Of 10,178 daytime observations of 503 adult inpatients only 7% of time was spent walking or standing. Two hundred older patient interviews were analysed. Most (85%) patients agreed that mobilising in hospital was very important. Twenty-three belief statements were created across the eight most common TDF domains. Older inpatients recognised mobility benefits and were self-motivated to mobilise in hospital, driven by goals of maintaining or recovering strength and health and returning home. However, they struggled with managing pain, other symptoms and new or pre-existing disability in a rushed, cluttered environment where they did not wish to trouble busy staff. Mobility equipment, meaningful walking destinations and individualised programmes and goals made mobilising easier, but patients also needed permission, encouragement and timely assistance.
Conclusion
Inpatient mobility was low. Older acute care inpatients frequently faced a physical and/or social environment which did not support their individual capabilities.
Background/Objectives
Frailty is common in people with heart failure (HF) and associated with poorer outcomes. The aim of this study was to describe the characteristics, exercise participation, and ...outcomes of frail and not‐frail participants enrolled in a randomized trial of exercise training (ET) within a cardiac rehabilitation (CR) program.
Design
Secondary analysis of EJECTION‐HF randomized trial (ACTRN12608000263392).
Setting
Five HF‐specific CR programs in Queensland, Australia.
Participants
Adults recently hospitalized with HF.
Intervention
All participated in CR including home exercise prescription and monitoring; half were randomized to center‐based ET.
Measurements
A frailty index (FI) was constructed at randomization and 6‐month follow‐up. Outcomes included ET attendance, change in 6‐min walk distance (6MWD), improved FI (>0.09 units) at 6 months, achieving physical activity (PA) guidelines at 6 months, and 12 month all‐cause death or readmission.
Results
The FI was measured in 256 participants at randomization: 110 (43%) were not‐frail (FI 0.2 or less), 119 (46%) were frail (FI >0.2 to 0.39), and 27 (11%) were very frail (FI ≥0.4). Frailty was more common with older age, female gender, decompensated HF, worse HF symptoms, and preserved ejection fraction. ET attendance did not differ by frailty group. Participants who were more frail had lower 6WMD at enrollment, but similar improvement over 6 months. Mean FI improved by 0.03 units at 6 months (95% CI 0.02–0.04, p < 0.001). Participants who were more frail had significantly greater improvements in FI compared with not‐frail participants and were often able to achieve PA guidelines, both in intervention and control groups. Neither baseline frailty nor intervention was significantly associated with 12‐month death or readmission.
Conclusion
Frail people with HF participating in CR that includes home and/or center‐based ET often achieve PA guidelines, and some may have meaningful reductions in frailty.
See related editorial by Pandey et al.
A multitude of theories, models and frameworks relating to implementing evidence-based practice in health care exist, which can be overwhelming for clinicians and clinical researchers new to the ...field of implementation science. Clinicians often bear responsibility for implementation, but may be unfamiliar with theoretical approaches designed to inform or understand implementation.
In this article, a multidisciplinary group of clinicians and health service researchers present a pragmatic guide to help clinicians and clinical researchers understand what implementation theories, models and frameworks are; how a theoretical approach to implementation might be used; and some prompts to consider when selecting a theoretical approach for an implementation project. Ten commonly used and highly cited theoretical approaches are presented, none of which have been utilised to their full potential in the literature to date. Specifically, theoretical approaches tend to be applied retrospectively to evaluate or interpret findings from a completed implementation project, rather than being used to plan and design theory-informed implementation strategies which would intuitively have a greater likelihood of success. We emphasise that there is no right or wrong way of selecting a theoretical approach, but encourage clinicians to carefully consider the project's purpose, scope and available data and resources to allow them to select an approach that is most likely to "value-add" to the implementation project.
By assisting clinicians and clinical researchers to become confident in selecting and applying theoretical approaches to implementation, we anticipate an increase in theory-informed implementation projects. This then will contribute to more nuanced advice on how to address evidence-practice gaps and ultimately to contribute to better health outcomes.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Frailty: mind the gap Mudge, Alison M; Hubbard, Ruth E
Age and ageing,
07/2018, Letnik:
47, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Abstract
Frailty has become the focus of considerable research interest and media attention over the past 15 years. While it has much to offer geriatric medicine, potential pitfalls also need to be ...acknowledged. The conceptualisation of frailty in very different ways—as a syndrome or a risk state—has created semantic dissonance: the frailest patients by one definition may have early sarcopenia, by another be bedbound and in institutional care. Caution is required in transferring findings between studies enroling these different populations. Furthermore, a yawning gap has emerged between the number of studies reporting the associations of frailty and those investigating interventions such that the empirical benefits of identifying and treating frailty currently remain unclear. Perhaps most importantly, frailty research has evolved with little account of the perspectives and preferences of patients themselves. The label of ‘frail’, being linked to mental or moral weakness, has pejorative implications and care should be taken to avoid the adverse functional effects of negative priming.
Here, we suggest pathways for future studies to provide a stronger evidence base to apply this important concept. This research is essential to avoid frailty becoming the new cloak of ageism, a tool for discrimination and disempowerment applied to the most vulnerable.
OBJECTIVES
To propose a new multicomponent measure of hospital‐associated complications of older people (HAC‐OP) and evaluate its validity in a large hospital sample.
DESIGN
Observational study using ...baseline (pre‐intervention) data from the Collaboration for Hospitalised Elders Reducing the Impact of Stays in Hospital cluster randomized controlled trial.
SETTING
Acute medical and surgical wards in 4 hospitals in Queensland, Australia.
PARTICIPANTS
Individuals aged 65 and older (mean age 76, 48% female) with a hospital stay of 72 hours or longer (N=434).
MEASUREMENTS
We developed a multicomponent measure including 5 well‐recognized hospital‐associated complications of older people: hospital‐associated delirium, functional decline, incontinence, falls, and pressure injuries. To evaluate construct validity, we examined associations with common risk factors (aged ≥75, functional impairment, cognitive impairment, history of falls). To evaluate predictive validity, we examined the association between length of stay, facility discharge, and 6‐month mortality and any HAC‐OP and total number of HAC‐OP.
RESULTS
Overall, 192 (44%) participants had 1 or more HAC‐OP during their admission. Any HAC‐OP was strongly associated with the proposed shared risk factors, and there was a strong and graded association between HAC‐OP and length of stay (9.1±7.4 days for any HAC‐OP vs 6.8 ±4.1 days with none, p < .001), facility discharge (59/192 (31%) vs 27/242 (11%), p < .001) and 6‐month mortality (26/192 (14%) vs 17/242 (7%), p = .02).
CONCLUSION
This study provides evidence of construct and predictive validity of the proposed measure of HAC‐OP as a potential outcome measure for research investigating and improving hospital care of older people. J Am Geriatr Soc 67:352–356, 2019.
High-quality, efficient health care for older patients is a priority for health care systems. Acute Care for Elders units improve outcomes but there is a need for generalizable models of care that ...adopt the principles pioneered in these units. This report describes Eat Walk Engage, a collaborative care model on a general medical ward in Brisbane, Australia. The model focused on early mobilization, feeding assistance, and cognitive stimulation. Using the Promoting Action on Research Implementation in Health Services implementation framework, the facilitation team enabled the clinical team to recognize barriers and develop solutions. Challenges included unclear responsibility, workload concerns, and risk aversion. Implementation strategies included engaging champions, education, audit and feedback, task delineation and delegation, improving physical resources, and workforce redesign. During the first 18 months, audits showed improved nursing documentation in targeted domains and improved performance of mobilizing and cognitive strategies; length of stay for older inpatients fell by 3 days on the intervention ward.
Older inpatients are at high risk of hospital-associated complications, particularly delirium and functional decline. These can be mitigated by consistent attention to age-friendly care practices ...such as early mobility, adequate nutrition and hydration, and meaningful cognitive and social activities. Eat Walk Engage is a ward-based improvement programme theoretically informed by the i-PARIHS framework which significantly reduced delirium in a four-hospital cluster trial. The objective of this process evaluation was to understand how Eat Walk Engage worked across trial sites.
Prospective multi-method implementation evaluation on medical and surgical wards in four hospitals implementing Eat Walk Engage January 2016-May 2017. Using UK Medical Research Council guidance, this process evaluation assessed context, implementation (core components, implementation strategies and improvements) and mechanisms of impact (practice changes measured through older person interviews, structured mealtime observations and activity mapping) at each site.
The four wards had varied contextual barriers which altered dynamically with time. One ward with complex outer organisational barriers showed poorer implementation and fewer practice changes. Two experienced facilitators supported four novice site facilitators through interactive training and structured reflection as well as data management, networking and organisational influence. Novice site facilitators used many implementation strategies to facilitate 45 discrete improvements at individual, team and system level. Patient interviews (42 before and 38 after implementation) showed better communication about program goals in three sites. Observations of 283 meals before and 297 after implementation showed improvements in mealtime positioning and assistance in all sites. Activity mapping in 85 patients before and 111 patients after implementation showed improvements in cognitive and social engagement in three sites, but inconsistent changes in mobility. The improvements in mealtime care and cognitive and social engagement are plausible mediators of reduced delirium observed in the trial. The lack of consistent mobility improvements may explain why the trial did not show reduction in functional decline.
A multi-level enabling facilitation approach supported adaptive implementation to varied contexts to support mechanisms of impact which partly achieved the programme goals. Contexts changed over time, suggesting the need for adequate time and continued facilitation to embed, enhance and sustain age-friendly practices on acute care wards and optimise outcomes.
The CHERISH trial was prospectively registered with the ANZCTR ( http://www.anzctr.org.au ): ACTRN12615000879561.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
IMPORTANCE: Hospital-associated complications of older people (HAC-OPs) include delirium, hospital-associated disability, incontinence, pressure injuries, and falls. These complications may be ...preventable by age-friendly principles of care, including early mobility, good nutrition and hydration, and meaningful cognitive engagement; however, implementation is challenging. OBJECTIVES: To implement and evaluate a ward-based improvement program (“Eat Walk Engage”) to more consistently deliver age-friendly principles of care to older individuals in acute inpatient wards. DESIGN, SETTING, AND PARTICIPANTS: This cluster randomized CHERISH (Collaboration for Hospitalised Elders Reducing the Impact of Stays in Hospital) trial enrolled 539 consecutive inpatients aged 65 years or older, admitted for 3 days or more to study wards, from October 2, 2016, to April 3, 2017, with a 6-month follow-up. The study wards comprised 8 acute medical and surgical wards in 4 Australian public hospitals. Randomization was stratified by hospital, providing 4 clusters in intervention and in control groups. Statistical analysis was performed from August 28, 2018, to October 17, 2021, on an intention-to-treat basis. INTERVENTION: A trained facilitator supported a multidisciplinary work group on each intervention ward to improve the care practices, environment, and culture to support key age-friendly principles. MAIN OUTCOMES AND MEASURES: Primary outcomes were incidence of any HAC-OP and length of stay. Secondary outcomes were incidence of individual HAC-OPs, facility discharge, 6-month mortality, and all-cause readmission. Outcomes were analyzed at the individual level, adjusted for confounders and clustering. RESULTS: A total of 265 participants on 4 intervention wards (124 women 46.8%; mean SD age, 75.9 7.3 years) and 274 participants on 4 control wards (145 women 52.9%; mean SD age, 78.0 8.2 years) were enrolled. The composite primary outcome of any HAC-OP occurred for 115 of 248 intervention participants (46.4%) and 129 of 249 control participants (51.8%) (intervention group: adjusted odds ratio, 1.07; 95% CI, 0.71-1.61). The median length of stay was 6 days (IQR, 4-9 days) for the intervention group and 7 days (IQR, 5-10 days) for the control group (adjusted hazard ratio, 0.96; 95% credible interval, 0.80-1.15). The incidence of delirium was significantly lower for intervention participants (adjusted odds ratio, 0.53; 95% CI, 0.31-0.90). There were no significant differences in other individual HAC-OPs, facility discharge, mortality, or readmissions. CONCLUSIONS AND RELEVANCE: The Eat Walk Engage program did not reduce the composite primary outcome of any HAC-OP or length of stay, but there was a significant reduction in the incidence of delirium. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12615000879561
Abstract Objective Although several validated nutritional screening tools have been developed to “triage” inpatients for malnutrition diagnosis and intervention, there continues to be debate in the ...literature as to which tool/tools clinicians should use in practice. This study compared the accuracy of seven validated screening tools in older medical inpatients against two validated nutritional assessment methods. Methods This was a prospective cohort study of medical inpatients at least 65 y old. Malnutrition screening was conducted using seven tools recommended in evidence-based guidelines. Nutritional status was assessed by an accredited practicing dietitian using the Subjective Global Assessment (SGA) and the Mini-Nutritional Assessment (MNA). Energy intake was observed on a single day during first week of hospitalization. Results In this sample of 134 participants (80 ± 8 y old, 50% women), there was fair agreement between the SGA and MNA (κ = 0.53), with MNA identifying more “at-risk” patients and the SGA better identifying existing malnutrition. Most tools were accurate in identifying patients with malnutrition as determined by the SGA, in particular the Malnutrition Screening Tool and the Nutritional Risk Screening 2002. The MNA Short Form was most accurate at identifying nutritional risk according to the MNA. No tool accurately predicted patients with inadequate energy intake in the hospital. Conclusion Because all tools generally performed well, clinicians should consider choosing a screening tool that best aligns with their chosen nutritional assessment and is easiest to implement in practice. This study confirmed the importance of rescreening and monitoring food intake to allow the early identification and prevention of nutritional decline in patients with a poor intake during hospitalization.
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