Injury is an external stressor that often initiates a cycle of decline in many older adults. The influence of physical frailty and cognitive decline on 6-month and 1-year outcomes after injury is ...unreported. We hypothesized that physical frailty and cognitive impairment would be predictive of 6-month and 1-year postinjury function and overall mortality.
The sample involved patients who are 65 years or older admitted to a Level I trauma center between October 2013 and March 2014 with a primary injury diagnosis. Surrogates of 188 patients were interviewed within 48 hours of hospital admission to determine preinjury cognitive and physical frailty impairments using brief screening instruments. Follow-up was completed on 172 patients at 6 months and 176 patients at 1 year to determine posthospitalization status and outcomes. Data analysis involved frequencies, measures of central tendency, χ analyses, linear and logistic regression.
The mean age of the patients was 77 years. The median Injury Severity Score (ISS) was 10. The mechanism of injury involved falls from standing (n = 101, 54%). Preinjury vulnerabilities included cognitive impairment (AD8 Dementia Screen AD8 score ≥ 2, n = 93, 50%) and physical frailty (Vulnerable Elders Survey VES-13 score ≥ 4, n = 94, 50%). Overall, median physical frailty scores did not return to baseline in the majority of survivors at 1 year. Multivariate regression analysis revealed that preinjury cognitive impairment (6 months, AD8, β = -0.20, p = 0.002) and preinjury physical frailty (6 months, Barthel Index, β = 0.60, p < 0.001; 1 year, Barthel Index, β = 0.52, p < 0.001) are independently associated with physical function (frailty). Multivariate logistic regression analysis revealed that age (odds ratio OR, 1.09; 95% confidence interval CI, 1.04-1.14), injury severity (OR, 1.07; 95% CI, 1.02-1.12), and preinjury physical frailty (OR, 1.28; 95% CI, 1.14-1.47) are independently associated with overall mortality at 1 year.
Preinjury physical frailty is the predominant predictor of postinjury functional status and mortality in geriatric trauma patients. Identification of frailty and appropriate follow-up are crucial for decision making by providers, patients, and family caregivers.
Prognostic study, level II.
Fall prevention alarms are commonly used among US hospitals as a fall prevention strategy despite limited evidence of effectiveness. Further, fall prevention alarms are harmful to healthcare staff ...(e.g., alarm fatigue) and patients (e.g., sleep disturbance, mobility restriction). There is a need for research to develop and test strategies for reducing use of fall prevention alarms in US hospitals.
To address this gap, we propose testing the effectiveness and implementation of Alarm with Care, a de-implementation strategy to reduce fall prevention alarm use using a stepped-wedge randomized controlled trial among 30 adult medical or medical surgical units from nonfederal US acute care hospitals. Guided by the Choosing Wisely De-Implementation Framework, we will (1) identify barriers to fall prevention alarm de-implementation and develop tailored de-implementation strategies for each unit and (2) compare the implementation and effectiveness of high- versus low-intensity coaching to support site-specific de-implementation of fall prevention alarms. We will evaluate effectiveness and implementation outcomes and examine the effect of multi-level (e.g., hospital, unit, and patient) factors on effectiveness and implementation. Rate of fall prevention alarm use is the primary outcome. Balancing measures will include fall rates and fall-related injuries. Implementation outcomes will include feasibility, acceptability, appropriateness, and fidelity.
Findings from this line of research could be used to support scale-up of fall prevention alarm de-implementation in other healthcare settings. Further, research generated from this proposal will advance the field of de-implementation science by determining the extent to which low-intensity coaching is an effective and feasible de-implementation strategy.
ClinicalTrials.gov identifier: NCT06089239 . Date of registration: October 17, 2023.
Multidomain activities that incorporate physical, cognitive, and social stimuli can enhance older adults' overall health and quality of life. Several robotic platforms have been developed to provide ...these therapies in a quantifiable manner to complement healthcare personnel in resource-strapped long-term care settings. However, these platforms are primarily limited to one-to-one human-robot interaction (HRI) and thus do not enhance social interaction. In this article, we present a novel HRI framework and a realized platform called socially assistive robotic ( SAR)-Connect to foster robot-mediated social interaction among older adults through carefully designed tasks that also incorporate physical and cognitive stimuli. SAR-Connect seamlessly integrates a humanoid robot with a virtual reality-based activity platform and a multimodal data acquisition module including game interaction, audio, visual, and electroencephalography responses of the participants. Results from a laboratory-based user study with older adults indicates the potential of SAR-Connect that showed this system could 1) involve one or multiple older adults to perform multidomain activities and provide dynamic guidance, 2) engage them in the robot-mediated task and foster human-human interaction, and 3) quantify their social and activity engagement from multiple sensory modalities.
Abstract
Background
Hospital falls remain common and approximately 30% of falls in hospital result in injury. The aims of the study were the following: (i) to identify the association between fall ...interventions present at the time of the injurious fall and injurious faller characteristics and (ii) to identify the association between fall preventive interventions present at the time of the injurious fall and the injurious fall circumstances.
Methods
Secondary data analysis of deidentified case series of injurious falls across 24 acute medical/surgical units in the United States. Variables of interest were falls prevention interventions (physical therapy, bed alarm, physical restraint, room change, or a sitter) in place at the time of fall. Data were analyzed using logistic regression and hazard ratios.
Results
There were 1,033 patients with an injurious fall, occurrence peaked between Day 1 and Day 4, with 46.8% of injurious falls having occurred by Day 3 of admission. Injurious fallers with a recorded mental state change 24 hours prior to the fall were more likely to have a bed alarm provided (adjusted odds ratio OR 2.56, 95% confidence interval CI 1.61, 4.08) and receive a physical restraint as fall prevention interventions (adjusted OR 6.36, 95% CI 4.35, 9.30). Injurious fallers restrained fell later (stay Day 6) than those without a restraint (stay Day 4) (p = .007) and had significantly longer lengths of stay (13 days vs 9 days).
Conclusions
On medical/surgical units, injurious falls occur early following admission suggesting interventions should be commenced immediately. Injurious fallers who had a physical restraint as an intervention had longer lengths of stay.
The aging population with its concomitant medical conditions, physical and cognitive impairments, at a time of strained resources, establishes the urgent need to explore advanced technologies that ...may enhance function and quality of life. Recently, robotic technology, especially socially assistive robotics has been investigated to address the physical, cognitive, and social needs of older adults. Most system to date have predominantly focused on one-on-one human robot interaction (HRI). In this paper, we present a multi-user engagement-based robotic coach system architecture (ROCARE). ROCARE is capable of administering both one-on-one and multi-user HRI, providing implicit and explicit channels of communication, and individualized activity management for long-term engagement. Two preliminary feasibility studies, a one-on-one interaction and a triadic interaction with two humans and a robot, were conducted and the results indicated potential usefulness and acceptance by older adults, with and without cognitive impairment.
Broad-scale adoption of spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) into everyday practice has been slow, and uncertainty exists regarding what factors facilitate or ...impede their routine delivery.
What patient, practice, and pharmacologic factors are associated with SAT and SBT performance and to what extent do they predict overall SAT/SBT performance?
This secondary analysis used data collected from a national quality improvement collaborative composed of 68 diverse ICUs. Adults with critical illness adults who received mechanical ventilation and/or continuously infused sedative medications were included. We performed mixed-effects logistic regression modeling, created receiver operating characteristic curves, and calculated the area under the curve (AUC).
Included in the SAT and SBT analysis were 4,847 and 4,938 patients, respectively. In multivariable models controlling for admitting patient characteristics, factors independently associated with higher odds of a next-day SAT and SBT included physical restraint use (adjusted odds ratio AOR, 1.63; 95% CI, 1.42-1.87; AOR, 1.83; 95% CI, 1.60-2.09), documented target sedation level (AOR, 1.68; 95% CI, 1.41-2.01; AOR, 1.46; 95% CI, 1.24-1.72), more frequent level of arousal assessments (AOR, 1.22; 95% CI, 1.03-1.43; AOR, 1.32; 95% CI, 1.13-1.54), and dexmedetomidine administration (AOR, 1.23; 95% CI, 1.05-1.45; AOR, 1.52; 95% CI, 1.27-1.80). Factors independently associated with lower odds of a next-day SAT and SBT included deep sedation/coma (AOR, 0.69; 95% CI, 0.60-0.80; AOR, 0.33; 95% CI, 0.28-0.37) and benzodiazepine (AOR, 0.83; 95% CI, 0.72-0.95; AOR, 0.67; 95% CI, 0.59-0.77) or ketamine (AOR, 0.34; 95% CI, 0.16-0.71; AOR, 0.40; 95% CI, 0.18-0.88) administration. Models incorporating admitting, daily, and unit variations displayed moderate discriminant accuracy in predicting next-day SAT (AUC, 0.73) and SBT (AUC, 0.72) performance.
There are a number of modifiable factors associated with SAT/SBT performance that are amenable to the development and testing of implementation interventions.
Abstract
Objective
To describe nurses’ preferences for the design of a probability-based clinical decision support (PB-CDS) tool for in-hospital clinical deterioration.
Methods
A convenience sample ...of bedside nurses, charge nurses, and rapid response nurses (n = 20) from adult and pediatric hospitals completed participatory design sessions with researchers in a simulation laboratory to elicit preferred design considerations for a PB-CDS tool. Following theme-based content analysis, we shared findings with user interface designers and created a low-fidelity prototype.
Results
Three major themes and several considerations for design elements of a PB-CDS tool surfaced from end users. Themes focused on “painting a picture” of the patient condition over time, promoting empowerment, and aligning probability information with what a nurse already believes about the patient. The most notable design element consideration included visualizing a temporal trend of the predicted probability of the outcome along with user-selected overlapping depictions of vital signs, laboratory values, and outcome-related treatments and interventions. Participants expressed that the prototype adequately operationalized requests from the design sessions.
Conclusions
Participatory design served as a valuable method in taking the first step toward developing PB-CDS tools for nurses. This information about preferred design elements of tools that support, rather than interrupt, nurses’ cognitive workflows can benefit future studies in this field as well as nurses’ practice.
•Intensive care units use a breadth of strategies when implementing the ABCDEF bundle.•There may be an overreliance on readily available educational strategies.•End-users provide insight to bundle ...implementation needs, challenges, and success.
Intensive care unit (ICU) clinicians struggle to routinely implement the ICU Liberation bundle (ABCDEF bundle). As a result, critically ill patients experience increased risk of morbidity and mortality. Despite extensive research related to the barriers and facilitators of bundle use, little is known regarding which implementation strategies are used to facilitate its adoption and sustainability.
To identify implementation strategies used to increase adoption of the ABCDEF bundle and how those strategies are perceived by end-users (i.e., ICU clinicians) related to their helpfulness, acceptability, feasibility, and cost.
We conducted a national, cross-sectional survey of ICU clinicians from the 68 ICU sites that previously participated in the Society of Critical Care Medicine's ICU Liberation Collaborative. The survey was structured using the 73 Expert Recommendations for Implementing Change (ERIC) implementation strategies. Surveys were delivered electronically to site contacts.
Nineteen ICUs (28%) returned completed surveys. Sites used 63 of the 73 ERIC implementation strategies, with frequent use of strategies that may be readily available to clinicians (e.g., providing educational meetings or ongoing training), but less use of strategies that require changes to well-established organizational systems (e.g., alter incentive allowance structure). Overall, sites described the ERIC strategies used in their implementation process to be moderately helpful (mean score >3<4 on a 5-point Likert scale), somewhat acceptable and feasible (mean score >2<3), and either not-at-all or somewhat costly (mean scores >1<3).
Our results show a potential over-reliance on accessible strategies and the possible benefit of unused ERIC strategies related to changing infrastructure and utilizing financial strategies.
Objectives
To determine the proportion of variation in long‐term fall rates attributable to variability between rather than within hospital units and to identify unit‐ and hospital‐level ...characteristics associated with persistently low‐ and high‐fall units.
Design
Retrospective study of administrative data on inpatient falls. Eighty low‐fall and 74 high‐fall units were identified based on monthly rankings of fall rates. Unit‐ and hospital‐level characteristics of these units were compared.
Setting
U.S. general hospitals participating in the National Database of Nursing Quality Indicators.
Participants
Nonsubspecialty medical units (n = 800) with 24 consecutive months of falls data.
Measurements
Monthly self‐reported unit fall rates (falls per 1,000 patient‐days).
Results
An estimated 87% of variation in 24‐month fall rates was due to between‐unit differences. With the exception of patient‐days, a proxy for unit bed size, low‐ and high‐fall units did not differ on nurse staffing or any other unit or hospital characteristic variable.
Conclusion
There are medical units with persistently low and persistently high fall rates. High‐fall units had higher patient volume, suggesting patient turnover as a variable for further study. Understanding additional factors underlying variability in long‐term fall rates could lead to sustainable interventions for reducing inpatient falls.
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