Simulation training in non-cancer palliative care for healthcare workers: a systematic review of controlled studies

Background

The need for healthcare workers (HCWs) to have skills and knowledge in non-cancer palliative care has been recognised. Simulation is increasingly being used for palliative care training, offering participants the opportunity to learn in a realistic environment and fully interactive way.

Objective

The aim of this systematic review was to summarise and critically appraise controlled studies on simulation training in non-cancer palliative care for HCWs.

Selection

Medline, CINAHL, PubMed and Cochrane Library databases were searched using palliative care and simulation terms. Randomised controlled trials (RCTs), non-randomised RCTs and controlled before-and-after (CBA) studies were included. Two reviewers independently screened titles and abstracts and undertook full article review using predefined selection criteria. Studies that met the inclusion criteria had data extracted and risk of bias assessed using the Cochrane Effective Practice and Organisation of Care risk of bias criteria.

Findings

Five articles were included: three RCTs and two CBA studies. All studies assessed learners’ palliative care communication skills, most studies evaluated learners’ perception of change in skills and one study assessed impact on patient outcomes and learners’ change in behaviour when applied in practice. There was variation in intervention content, intensity and duration, outcome measures and study design, making it difficult to compare and synthesise results.

Conclusion

There is a paucity of evidence to support simulation training to improve non-cancer palliative care. This review highlights the need for more robust research, including multicentre studies that use standardised outcome measures to assess clinician skills, changes in clinical practice and patient-related outcomes.

Prevalence of sarcopenia as a comorbid disease: A systematic review and meta-analysis

BACKGROUND

Sarcopenia shares risk factors with various other age-related diseases. This meta-analysis aimed to determine the prevalence of sarcopenia as a comorbid disease.

METHODS

Medline, EMBASE and Cochrane databases were searched for articles from inception to 8th June 2018, reporting the prevalence of sarcopenia in individuals with a diagnosis of cardiovascular disease (CVD), dementia, diabetes mellitus or respiratory disease and, if applicable their controls. No exclusion criteria were applied with regards to definition of sarcopenia, individuals' age, study design and setting. Meta-analyses were stratified by disease, definition of sarcopenia and continent.

RESULTS

The 63 included articles described 17,206 diseased individuals (mean age: 65.3 ± 1.6 years, 49.9% females) and 22,375 non-diseased controls (mean age: 54.6 ± 16.2 years, 53.8% females). The prevalence of sarcopenia in individuals with CVD was 31.4% (95% CI: 22.4-42.1%), no controls were available. The prevalence of sarcopenia was 26.4% (95% CI: 13.6-44.8%) in individuals with dementia compared to 8.3% (95% CI: 2.8-21.9%) in their controls; 31.1% (95% CI: 19.8-45.2%) in individuals with diabetes mellitus compared to 16.2% (95% CI: 9.5-26.2%) in controls; and 26.8% (95% CI: 17.8-38.1%) in individuals with respiratory diseases compared to 13.3% (95% CI: 8.3-20.7%) in controls.

CONCLUSIONS

Sarcopenia is highly prevalent in individuals with CVD, dementia, diabetes mellitus and respiratory disease.

Subacute combined degeneration of the spinal cord masking motor neuron disease: a case report

Background

Subacute combined degeneration of the spinal cord is a potentially reversible myelopathy typically associated with vitamin B12 deficiency. There is predominant involvement of spinal cord posterior and lateral tracts, and manifestations include peripheral paraesthesia, impaired proprioception, gait disturbance, neuropathy and cognitive changes. Motor neuron disease (MND) is an unremittingly progressive neurodegenerative disorder involving upper and lower motor neurons with an average prognosis of 2–3 years. The diagnosis is clinical and may be supported by electromyography. A subset of MND occurs concurrently with frontotemporal dementia (FTD-MND) and may be initially misdiagnosed as a primary psychotic disorder.

Case presentation

We describe a 57-year-old Caucasian woman who presented with confusion and dysarthria. Low vitamin B12 levels and MRI findings led to an initial diagnosis of subacute combined degeneration of the spinal cord. Despite treatment, persistent dysarthria and presence of both upper and lower motor neuron signs on clinical examination prompted further assessment. Electromyography supported the diagnosis of MND. Comorbid chronic paranoid schizophrenia complicated the diagnostic process. We discuss overlapping features between B12 deficiency and MND as well as the neuropsychiatric overlap of B12 deficiency, FTD-MND and chronic schizophrenia.

Conclusions

Firstly, variability in neurocognitive and imaging manifestations of B12 deficiency can limit delineation of other pathologies. Failure to improve following correction of nutritional deficiencies warrants further investigation for an alternate diagnosis. Secondly, re-evaluation of patients with comorbid mental health conditions is important in reaching timely and accurate diagnoses.

A screen-based simulation training program to improve palliative care of people with advanced dementia living in residential aged care facilities and reduce hospital transfers: study protocol for the IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) cluster randomised controlled trial

Background

Many people with advanced dementia live in residential aged care homes. Care home staff need the knowledge and skills to provide high-quality end-of-life (EOL) dementia care. However, several studies have found EOL dementia care to be suboptimal, and care staff have reported they would benefit from training in palliative care and dementia. Simulation offers an immersive learning environment and has been shown to improve learners’ knowledge and skills. However, there is little research on simulation training for residential care staff.

This article presents the development and evaluation protocol of IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) - a screen-based simulation training program on palliative dementia care, targeted at residential care staff. IMPETUS-D aims to improve the quality of palliative care provided to people living with dementia in residential care homes, including avoiding unnecessary transfers to hospital.

Methods

A cluster RCT will assess the effect of IMPETUS-D. Twenty-four care homes (clusters) in three Australian cities will be randomised to receive either the IMPETUS-D intervention or usual training opportunities (control). The primary outcome is to reduce transfers to hospital and deaths in hospital by 20% over 6-months in the intervention compared to the control group. Secondary outcomes include uptake of goals of care plans over 6 and 12 months, change in staff knowledge and attitudes towards palliative dementia care over 6 months, change in transfers to hospital and deaths in hospital over 12 months. For the primary analysis logistic regression models will be used with standard errors weighted by the cluster effects. A mixed methods process evaluation will be conducted alongside the cluster RCT to assess the mechanisms of impact, the implementation processes and contextual factors that may influence the delivery and effects of the intervention.

Discussion

In Australia, the need for high-quality advanced dementia care delivered in residential aged care is growing. This study will assess the effect of IMPETUS-D a new simulation-based training program on dementia palliative and EOL care. This large multisite trial will provide robust evidence about the impact of the intervention. If successful, it will be distributed to the broader residential care sector.

Trial registration

ANZCTR, ACTRN12618002012257. Registered 14 December 2018.

Introducing Goals of Patient Care in Residential Aged Care Facilities to Decrease Hospitalization: A Cluster Randomized Controlled Trial

OBJECTIVES

The "Goals of Patient Care" (GOPC) process uses shared decision making to incorporate residents' prior advance care planning (ACP) or preferences into medical treatment orders, guiding health care decisions at a time of clinical deterioration should they be unable to voice their opinions. The objective was to determine whether GOPC medical treatment orders were more effective than ACP alone in preventing emergency department (ED) visits (no hospitalization), ED visits (with hospitalization), and deaths outside the residential aged care facility (RACF).

DESIGN

The study was a prospective cluster randomized controlled trial, with the intervention being the completion of GOPC process by a geriatrician, following a shared decision-making process, incorporating ACP documents or residents' preferences.

SETTING AND PARTICIPANTS

The study took place in 6 RACFs in Northern Metropolitan Melbourne, Australia. Eligible participants included all permanent residents in participating RACFs for whom written informed consent could be obtained.

MEASURES

The primary outcome was the effect on ED visits and hospitalizations at 6 months. Secondary outcomes included a difference in hospitalization rates at 3 and 12 months, total hospital bed-days, and in-RACF and in-hospital mortality rates.

RESULTS

More than 75% of residents participated, 181 randomized to Intervention and 145 to Control. The intervention did not result in a statistically significant change at 6 months; however, at 12 months, it reached statistical significance with 40% reduction in ED visits and hospitalizations compared with Control, with an incident rate ratio 0.63 [95% confidence interval (CI) 0.41-0.99, P = .044]. Mortality rates show increased likelihood of dying in the RACF, with statistical significance at 6 months at a relative risk ratio of 2.19 (95% CI 1.16-4.14, P = .016).

CONCLUSIONS AND IMPLICATIONS

In the RACF population, GOPC medical treatment orders were more effective than ACP alone for decreasing hospitalization and likelihood of dying outside the RACF. GOPC should be considered by both RACF staff and health services to decrease hospitalization and in-hospital mortality.

Obesity in older adults: Effect of degree of weight loss on cardiovascular markers and medications

Obesity worsens the age-related tendency towards cardiovascular disease and diabetes. Older adults are vulnerable to medication adverse effects. Intentional weight loss in older adults with obesity has been shown to improve cardiovascular and glycaemic markers. The effect of rapid weight loss induced by very-low-calorie diets (VLCDs) on these markers has not been evaluated in this group. In this 12-week study, participants were randomized to one of healthy eating, hypocaloric diet or VLCD, all combined with three times weekly exercise (Ex/HE, Ex/Diet, Ex/VLCD, respectively). The effects of these interventions on weight, blood pressure, lipids, glucose and HbA_1c , inflammatory markers and cardiovascular and diabetes medication changes were measured. Weight loss was 3.7%, 5.1% and 11.1% in Ex/HE, Ex/Diet and Ex/VLCD, respectively. There were significant improvements in HbA_1c in all groups, but by the greatest degree in Ex/VLCD (0.18 ± 0.07%, 0.18 ± 0.06% and 0.59 ± 0.13%, respectively). Similar patterns were seen in total cholesterol (0.13 ± 0.15, 0.21 ± 0.11 and 0.53 ± 0.13 mmol/L, respectively, P = .047), triglycerides (0.35 ± 0.13, 0.20 ± 0.10 and 0.51 ± 0.09 mmol/L, respectively, P = .011) and systolic blood pressure (9 ± 2, 2 ± 3 and 14 ± 3 mmHg respectively, P = .025). There were no between-group differences in fasting glucose, high-density lipoprotein (HDL) cholesterol, LDL-C and inflammatory markers. Reductions in anti-hypertensive or diabetes medication were made in 4/29, 7/36 and 16/37 participants in Ex/HE, Ex/Diet and Ex/VLCD, respectively (P = .017). Significant weight loss achieved with a VLCD gave rise to improvements in multiple cardiovascular risk markers, despite reduction in medication. Weight loss is an under-utilized method of cardiovascular risk management in this group.

Sarcopenia and its association with falls and fractures in older adults: A systematic review and meta-analysis

Sarcopenia is a potentially modifiable risk factor for falls and fractures in older adults, but the strength of the association between sarcopenia, falls, and fractures is unclear. This study aims to systematically assess the literature and perform a meta-analysis of the association between sarcopenia with falls and fractures among older adults. A literature search was performed using MEDLINE, EMBASE, Cochrane, and CINAHL from inception to May 2018. Inclusion criteria were the following: published in English, mean/median age ≥ 65 years, sarcopenia diagnosis (based on definitions used by the original studies' authors), falls and/or fractures outcomes, and any study population. Pooled analyses were conducted of the associations of sarcopenia with falls and fractures, expressed in odds ratios (OR) and 95% confidence intervals (CIs). Subgroup analyses were performed by study design, population, sex, sarcopenia definition, continent, and study quality. Heterogeneity was assessed using the I² statistics. The search identified 2771 studies. Thirty-six studies (52 838 individuals, 48.8% females, and mean age of the study populations ranging from 65.0 to 86.7 years) were included in the systematic review. Four studies reported on both falls and fractures. Ten out of 22 studies reported a significantly higher risk of falls in sarcopenic compared with non-sarcopenic individuals; 11 out of 19 studies showed a significant positive association with fractures. Thirty-three studies (45 926 individuals) were included in the meta-analysis. Sarcopenic individuals had a significant higher risk of falls (cross-sectional studies: OR 1.60; 95% CI 1.37-1.86, P < 0.001, I²  = 34%; prospective studies: OR 1.89; 95% CI 1.33-2.68, P < 0.001, I²  = 37%) and fractures (cross-sectional studies: OR 1.84; 95% CI 1.30-2.62, P = 0.001, I²  = 91%; prospective studies: OR 1.71; 95% CI 1.44-2.03, P = 0.011, I²  = 0%) compared with non-sarcopenic individuals. This was independent of study design, population, sex, sarcopenia definition, continent, and study quality. The positive association between sarcopenia with falls and fractures in older adults strengthens the need to invest in sarcopenia prevention and interventions to evaluate its effect on falls and fractures.

Orthostatic hypotension and cognition in older adults: A systematic review and meta-analysis

BACKGROUND

Orthostatic hypotension (OH) is common in older adults with reported prevalence rates of 5-40%. A direct link between OH and cognitive performance has been proposed due to impaired vascular autoregulation.

AIM

To systematically assess the literature of the association between OH and cognitive performance in older adults.

METHODS

Literature search of MEDLINE, Embase, Cochrane Central Register of Controlled Trials and PsycINFO from inception to May 2017. Studies were included if OH and cognition were assessed in subjects of mean or median age ≥65 years. Risk of bias was assessed with the Newcastle Ottawa Scale.

RESULTS

Of 3266 studies screened, 32 studies (22 cross-sectional; 10 longitudinal) reporting data of 28,980 individuals were included. OH prevalence ranged from 3.3% to 58%. Of the 32 studies, 18 reported an association between OH and worse cognitive performance and 14 reported no association. Mini Mental State Examination (MMSE) was the most commonly used cognitive assessment tool. Studies using more than one cognitive assessment tool were more likely to find an association between OH and worse cognition. OH was significantly associated with a lower MMSE mean score (mean difference - 0.51 (95% CI: -0.85, -0.17, p = 0.003)) and an increased risk of cognitive impairment (OR 1.19 (95% CI, 1.00-1.42, p = 0.048)).

CONCLUSIONS

OH is common in older populations and is associated with worse cognition expressed as lower MMSE scores. Use of MMSE alone as a cognitive assessment tool may underestimate the association. It is yet unclear whether the association between OH and worse cognitive performance is causative.

Lower Skeletal Muscle Mass at Admission Independently Predicts Falls and Mortality 3 Months Post-discharge in Hospitalized Older Patients

Background

Approximately 10% of older adults are annually admitted to a hospital. Hospitalization is associated with a higher risk of falls and mortality after discharge. This study aimed to identify predictors at admission for falls and mortality 3 months post-discharge in hospitalized older patients.

Methods

The Evaluation of Muscle parameters in a Prospective cohort of Older patients at clinical Wards Exploring Relations with bed rest and malnutrition (EMPOWER) study is an observational, prospective longitudinal inception cohort of 378 patients aged 70 years and older who were subsequently admitted to a tertiary hospital (the Netherlands). Potential predictors for falls and mortality 3 months post-discharge were tested using univariate and multivariate logistic regression analyses and included the following domains: demographic (age, sex, living independently), lifestyle (alcohol, smoking), nutrition (SNAQ score), muscle mass (absolute, relative), physical function (handgrip strength, Katz ADL score), cognition (six-item cognitive impairment test score), and disease (medications, diseases).

Results

The mean age was 79.6 years (standard deviation 6.23) and 50% were male. Within 3 months post-discharge, 19% reported a fall and 13% deceased. Univariate predictors for falls were higher age, lower absolute muscle mass and higher six-item cognitive impairment test score. Lower absolute muscle mass independently predicted falls post-discharge (multivariate). Univariate predictors for mortality were higher age, male sex, no current alcohol use, higher SNAQ score, lower absolute and higher relative muscle mass, higher Katz ADL score and higher number of diseases. Male sex, higher SNAQ score, and lower absolute muscle mass independently predicted mortality post-discharge (multivariate).

Conclusions

In hospitalized older adults, muscle mass should be measured to predict future outcome. Future intervention studies should investigate if increasing muscle mass prevent short-term falls and mortality.

Improving the utility of multisource feedback for medical consultants in a tertiary hospital: a study of the psychometric properties of a survey tool

Objective The aim of this study was to investigate the psychometric properties of a multisource review survey tool for medical consultants in an Australian health care setting. Methods Two sets of survey data from a convenience sample of medical consultants were analysed using SPSS, comprising self-assessment data from 73 consultants and data from 734 peer reviewers. The 20-question survey consisted of three subscales, plus an additional global question for reviewers. Analysis included the reliability coefficient (α) of the scale and the three subscales, inter-rater reliability or agreement and validity of the model, correlation between the single global question, the total performance score and the three survey subfactors (Pearson's), interrater agreement (rWG(J)), the optimal number of peer reviewers required and model-based reliability (ρ). Results The global question, total performance score and the three subfactors were strongly correlated (general scale r=0.81, clinical subscale r=0.78, humanistic subscale r =0.74, management subscale r=0.75; two-tailed P<0.01 for all). The scale showed very good internal consistency, except for the five-question management subscale. Model-based reliability was excellent (ρ=0.93). Confirmatory factor analysis showed the model fit using the 20-item scale was not satisfactory (minimum discrepancy/d.f.=7.70; root mean square error of approximation=0.10; comparative fit index=0.79; Tucker-Lewis index=0.76). A modified 13-item model provided a good fit. Using the 20-item scale, a 99% level of agreement could be achieved with eight to 10 peer reviewers; for the same level of agreement, the number of reviewers increased to >10 using a revised 13-item scale. Conclusions Overall, the 20-item multisource review survey tool showed good internal consistency reliability for both self and peer ratings; however, further investigation using a larger dataset is needed to analyse the robustness of the model and to clarify the role that a single global question may play in future multisource review processes. What is known about the topic? Defining and measuring skills and behaviours that reflect competence in the health setting have proven to be complex, and this has resulted in the development of specific multisource feedback surveys for individual medical specialities. Because little literature exists on multisource reviews in an Australian context, a pilot study of a revised survey tool was undertaken at an Australian tertiary hospital. What does this paper add? The aim of this study was to investigate the psychometric properties of a generic tool (used across specialities) by assessing the validity, reliability and interrater reliability of the scale and to consider the contribution of a single global question to the overall multisource feedback process. This study provides evidence of the validity and reliability of the survey tool under investigation. The strong correlation between the global item, the total performance score and the three subfactors suggests that this is an area requiring further investigation to determine the role that a robust single global question like this may play in future multisource review surveys. Our five-question management skills subscale provides answers to questions relevant to the specific organisation surveyed, and we anticipate that it may serve to stimulate further exploration in this area. What are the implications for practitioners? The survey tool may provide a valid and reliable basis for performance review of medical consultants in an Australian healthcare setting.

Hospital-Associated Complications of Older People: A Proposed Multicomponent Outcome for Acute Care

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.

Do health assets have a protective effect for hospitalized frail older adults?

BACKGROUND

Although increasing frailty is predictive of increased mortality and length of stay for hospitalized older adults, this approach ignores health assets that individuals can utilize to recover following hospital admission.

AIM

To examine whether health assets mitigate the effect of frailty on outcomes for older adults admitted to hospital.

DESIGN

Patients of 1418 aged ≥ 70 years admitted to 11 hospitals in Australia were evaluated at admission using the interRAI assessment system for Acute Care, which surveys a large number of domains, including cognition, communication, mood and behaviour, activities of daily living, continence, nutrition, skin condition, falls and medical diagnosis.

METHODS

The data set was interrogated for potential health assets and a multiple logistic regression adjusted for frailty index, age and gender as covariates was performed for the outcomes mortality, length of stay, re-admission and new need for residential care.

RESULTS

Inpatient mortality was 3% and 4.5% of patients died within 28 days of discharge. Median length of stay was 7 days (IQR 4-11). In multivariate analysis that includes frailty, being able to walk further [OR 0.08 (0.01-0.63)], ability to leave the house [OR 0.35 (0.17-0.74)] and living alone [OR 0.28 (0.10-0.79)] were protective against mortality. The presence of a support person was associated with a decreased length of stay [OR 0.14 (0.08-0.25)].

CONCLUSION

The inclusion of health assets in predictive models can improve prognostication and highlights potential interventions to improve outcomes for hospitalized older adults.

Using technology to support care in gestational diabetes mellitus: Quantitative outcomes of an exploratory randomised control trial of adjunct telemedicine for gestational diabetes mellitus (TeleGDM)

AIMS

The increasing incidence and prevalence of gestational diabetes mellitus (GDM) on a background of limited resources calls for innovative approaches healthcare provision. Our aim was to explore the effects of telemedicine supported GDM care on a range of health service utilisation and maternal and foetal outcomes.

METHODS

An exploratory randomised controlled trial of adjunct telemedicine support in the management of insulin-treated GDM compared to usual care control. Outcomes included health service use, maternal and foetal clinical outcomes as well as costs. Groups were compared on outcomes and Poisson and Cox regression analysis were performed for predictors of health service utilisation, glycaemic control and costs.

RESULTS

95 participants were recruited (intervention n = 61, control n = 34). There were no differences between the groups in number of face-to-face appointments (median (IQR) intervention = 8(7), control = 8(6), p = 0.843), rates of caesareans, macrosomia, large for gestational age, special care nursery admission or newborn birth-weight. The intervention had no impact on total (IRR = 1.04, p = 0.596) or face-to-face (IRR = 1.09, p = 0.257) clinic appointments or service provider costs. Participants receiving the intervention reached optimum glycaemic control quicker: mean (SD) 4.3(4.2) weeks vs. 7.6(4.5) weeks, p = 0.0001). Telemedicine was a significant predictor of better glycaemic control (HR = 1.71(95%CI: 1.11, 2.65, p = 0.015).

CONCLUSIONS

Telemedicine support for GDM care showed no impact on service utilisation and costs. The intervention produced similar GDM clinical outcomes as usual care and posed no added risk to clinical quality of care. The intervention may be associated with fewer insulin dose titrations and participants achieved optimum glycaemic control sooner.

Validation of the health assets index in the Australian inpatient setting: a multicentre prospective cohort protocol study

INTRODUCTION

It is well known that frail older adults are at increased risk for mortality and functional decline on admission to hospital. Systematic review demonstrates that health assets are associated with improved outcomes for hospitalised older adults. The health assets index (HAI) has been developed to measure health assets in the hospital setting. A protocol has been developed to determine the predictive validity of the HAI for frail older adults.

METHODS AND ANALYSIS

The HAI was developed based on a systematic review and secondary analysis of the interRAI-Acute Care (interRAI-AC) dataset. A pilot study was undertaken to refine the tool.The validation study will be a multicentre prospective cohort. Participants will be adults aged 70 years and older with an unplanned admission to hospital. Frailty, illness severity and demographic data will also be recorded. The primary outcomes are mortality at 28 days postdischarge and functional decline at the time of discharge from hospital. The primary hypothesis is that a higher score on the HAI will mitigate the effects of frailty for hospitalised older adults. The secondary outcomes to be recorded are length of stay, readmission at 28 days and functional status at 28 days postdischarge. The correlation between HAI and frailty will be explored. A multivariate analysis will be undertaken to determine the relationship between the HAI and the outcomes of interest.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from Austin Health Human High Risk Ethics Committee. The results will be disseminated in peer-reviewed journals and research conferences. This study will determine whether the HAI has predictive validity for mortality and functional decline for hospitalised, frail older adults.

Reliability of an Online Geriatric Assessment Procedure Using the interRAI Acute Care Assessment System

OBJECTIVES

To determine whether geriatric triage decisions made using a comprehensive geriatric assessment (CGA) performed online are less reliable than face-to-face (FTF) decisions.

DESIGN

Multisite noninferiority prospective cohort study. Two specialist geriatricians assessed individuals sequentially referred for an acute care geriatric consultation. Participants were allocated to one FTF assessment and an additional assessment (FTF or online (OL)), creating two groups-two FTF (FTF-FTF, n = 81) or online and FTF (OL-FTF, n = 85).

SETTING

Three acute care public hospitals in two Australian states.

PARTICIPANTS

Admitted individuals referred for CGA.

INTERVENTION

Nurse-administered CGA, based on the interRAI Acute Care assessment system accessed online and other online clinical data such as pathology results and imaging enabling geriatricians to review participants' information and provide input into their care from a distance.

MEASUREMENTS

The primary decision subjected to this analysis was referral for permanent residential care. Geriatricians also recorded recommendations for referrals and variations for medication management and judgment regarding prognosis at discharge and after 3 months.

RESULTS

Overall percentage agreement was 88% (n = 71) for the FTF-FTF group and 91% (n = 77) for the OL-FTF group. The difference in agreement between the FTF-FTF and OL-FTF groups was -3%, indicating that there was no difference between the methods of assessment. Judgements made regarding diagnoses of geriatric syndromes, medication management, and prognosis (with regard to hospital outcome and location at 3 months) were found to be equally reliable in each mode of consultation.

CONCLUSION

Geriatric assessment performed online using a nurse-administered structured CGA system was no less reliable than conventional assessment in making clinical triage decisions.

Implementation of 'Goals of Patient Care' medical treatment orders in residential aged care facilities: protocol for a randomised controlled trial

INTRODUCTION

Systematic reviews demonstrate that advance care planning (ACP) has many positive effects for residents of aged care facilities, including decreased hospitalisation. The proposed Residential Aged Care Facility (RACF) 'Goals of Patient Care' (GOPC) form incorporates a resident's prior advance care plan into medical treatment orders. Where none exists, it captures residents' preferences. This documentation helps guide healthcare decisions made at times of acute clinical deterioration.

METHODS AND ANALYSIS

This is a mixed methods study. An unblinded cluster randomised controlled trial is proposed in three pairs of RACFs. In the intervention arm, GOPC forms will be completed by a doctor incorporating advance care plans or wishes. In the control arm, residents will have usual care which may include an advance care plan. The primary hypothesis is that the GOPC form is superior to standard ACP alone and will lead to decreased hospitalisation due to clearer documentation of residents' medical treatment plans. The primary outcome will be an analysis of the effect of the GOPC medical treatment orders on emergency department attendances and hospital admissions at 6 months. Secondary outcome measurements will include change in hospitalisation rates at 3 and 12 months, length of stay and external mortality rates among others. Qualitative interviews, 12 months post GOPC implementation, will be used for process evaluation of the GOPC and to evaluate staff perceptions of the form's usefulness for improving communication and medical decision-making at a time of deterioration.

DISSEMINATION

The results will be disseminated in peer review journals and research conferences. This robust randomised controlled trial will provide high-quality data about the influence of medical treatment orders that incorporate ACP or preferences adding to the current gap in knowledge and evidence in this area.

TRIAL REGISTRATION NUMBER

ACTRN12615000298516, Results.

Medication adherence 1 month after hospital discharge in medical inpatients

BACKGROUND

The rate of medication non-adherence has been consistently reported to be between 20 and 50%. The majority of available data comes from international studies, and we hypothesised that a similar rate of adherence may be observed in Australian patients.

AIMS

To determine the rate of adherence to medications after discharge from acute general hospital admission and identify factors that may be associated with non-adherence.

METHODS

A prospective cohort study of 68 patients, comparing admission and discharge medication regimens to self-reported regimens 30-40 days after discharge from hospital. Patients were followed up via telephone call and univariate and multivariate binary logistic regression used to determine patient factors associated with non-adherence.

RESULTS

In all, 27 of 68 patients (39.7%) were non-adherent to one or more regular medications at follow up. Intentional and unintentional non-adherence contributed equally to non-adherence. Using multivariate analysis, presence of a carer responsible for medications was associated with significantly lower non-adherence (odds ratio (OR) 0.20 (0.05-0.83), P = 0.027) when adjusted for age, co-morbidities, chemist blister pack and total number of discharge medications.

CONCLUSIONS

Non-adherence to prescription medications is suboptimal and consistent with previous overseas studies. Having a carer responsible for medications is associated with significantly lower rates of non-adherence. Understanding patients' preferences and involving them in their healthcare may reduce intentional non-adherence.

Arrythmogenic Right Ventricular Dysplasia

A 10-year-old well and asymptomatic female was referred for screening of acute right ventricular dilatation (ARVD) as she had an elder brother diagnosed with ARVD whom died of sudden cardiac death. Electrocardiography (ECG), transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (CMR) were performed. Results of these investigations were suggestive of ARVD. Despite being a rare cardiac disease and largely unrecognised in children and young adult population, ARVD is an important cause of ventricular arrhythmias in this group of patients and is one of the causes of sudden cardiac death (SCD) in this population.

Stenting of vertical vein in an infant with obstructed supracardiac total anomalous pulmonary venous drainage

A 1.7 kg infant with obstructed supracardiac total anomalous pulmonary venous drainage (TAPVD) presented with severe pulmonary hypertension secondary to vertical vein obstruction. The child, in addition, had a large omphalocele that was being managed conservatively. The combination of low weight, unoperated omphalocele, and severe pulmonary hypertension made corrective cardiac surgery very high-risk. Therefore, transcatheter stenting of the stenotic vertical vein, as a bridge to corrective surgery was carried out. The procedure was carried out through the right internal jugular vein (RIJ). The stenotic segment of the vertical vein was stented using a coronary stent. After procedure, the child was discharged well to the referred hospital for weight gain and spontaneous epithelialization of the omphalocele. Stenting of the vertical vein through the internal jugular vein can be considered in very small neonates as a bridge to repair obstructed supracardiac total anomalous venous drainage.