Geriatric CO-mAnagement for Cardiology patients in the Hospital (G-COACH): study protocol of a prospective before-after effectiveness-implementation study

From research to daily clinical practice: implementation of orthogeriatric co-management in the trauma ward

Introduction

Evidence strongly suggests that orthogeriatric co-management improves patient outcomes in frail older patients with a fracture, but evidence regarding how to implement this model of care in daily clinical practice is scarce. In this paper, we first describe the implementation process and selection of implementation strategies for an orthogeriatric co-management program in the traumatology ward of the University Hospitals Leuven in Belgium. Second, we report the results of a multi-method feasibility study. This study (1) measures the fidelity towards the program's core components, (2) quantifies the perceived feasibility and acceptability by the healthcare professionals, and (3) defines implementation determinants.

Methods

Implementation strategies were operationalized based on the Expert Recommendations for Implementing Change (ERIC) guidelines. In the feasibility study, fidelity towards the core components of the program was measured in a group of 15 patients aged 75 years and over by using electronic health records. Feasibility and acceptability as perceived by the involved healthcare professionals was measured using a 15-question survey with a 5-point Likert scale. Implementation determinants were mapped thematically based on seven focus group discussions and two semi-structured interviews by focusing on the healthcare professionals' experiences.

Results

We observed low fidelity towards completion of a screening questionnaire to map the premorbid situation (13%), but high fidelity towards the other program core components: multidimensional evaluation (100%), development of an individual care plan (100%), and systematic follow-up (80%). Of the 50 survey respondents, 94% accepted the program and 62% perceived it as feasible. Important implementation determinants were feasibility, awareness and familiarity, and improved communication between healthcare professionals that positively influenced program adherence.

Conclusions

Fidelity, acceptability, and feasibility of an orthogeriatric co-management program were high as a result of an iterative process of selecting implementation strategies with intensive stakeholder involvement from the beginning.

Clinical trial registration

[https://www.isrctn.com/ISRCTN20491828], International Standard Randomised Controlled Trial Number (ISRCTN) Registry: [ISRCTN20491828]. Registered on October 11, 2021.

Identifying vulnerable older adults at risk for functional decline in cardiac care wards: time to shift the paradigm

OBJECTIVE

To determine whether routine screening with the Flemish version of the Triage Risk Screening Tool (fTRST) is a valid approach to determine which patients on cardiac care wards are at risk for inhospital functional decline and would benefit from geriatric expertise consultation.

METHODS

A secondary data-analysis of the G-COACH before-cohort, describing patient profiles and routine care processes, in 189 older adults on two cardiac care wards in the University Hospitals Leuven between September 2016 and June 2017. Inhospital functional decline was defined as an increase of at least one point on the Katz Index of Activities of Daily Living or death between hospital admission and discharge.

RESULTS

Nine in 10 patients had at least one geriatric syndrome and one-third developed functional decline. Based on the fTRST proposed cut-off of ≥2, 156 (82.5%) patients were at risk for functional decline (sensitivity of 95.2%, specificity of 23.8%, negative predictive value of 90.9% and Area Under the Curve of 0.60). Of the 156 'at risk' patients, 43 (27.6%) received a consultation by the geriatric consultation team after a median of four hospitalization days. A positive fTRST was not significantly related to geriatric consultations (x² = 0.57; p = 0.45).

CONCLUSION

The fTRST has a low discriminative value in identifying older cardiology patients at risk for functional decline. Given the high prevalence of geriatric syndromes, we propose a new paradigm were all older adults on cardiac care wards undergo a needs assessment upon hospital admission.

How to implement geriatric co-management in your hospital? Insights from the G-COACH feasibility study

BACKGROUND

Geriatric co-management is advocated to manage frail patients in the hospital, but there is no guidance on how to implement such programmes in practice. This paper reports our experiences with implementing the 'Geriatric CO-mAnagement for Cardiology patients in the Hospital' (G-COACH) programme. We investigated if G-COACH was feasible to perform after the initial adoption, investigated how well the implementation strategy was able to achieve the implementation targets, determined how patients experienced receiving G-COACH, and determined how healthcare professionals experienced the implementation of G-COACH.

METHODS

A feasibility study of the G-COACH programme was performed using a one-group experimental study design. G-COACH was previously implemented on two cardiac care units. Patients and healthcare professionals participating in the G-COACH programme were recruited for this evaluation. The feasibility of the programme was investigated by observing the reach, fidelity and dose using registrations in the electronic patient record and by interviewing patients. The success of the implementation reaching its targets was evaluated using a survey that was completed by 48 healthcare professionals. The experiences of 111 patients were recorded during structured survey interviews. The experiences of healthcare professionals with the implementation process was recorded during 6 semi-structured interviews and 4 focus groups discussions (n = 27).

RESULTS

The programme reached 91% in a sample of 151 patients with a mean age of 84 years. There was a high fidelity for the major components of the programme: documentation of geriatric risks (98%), co-management by specialist geriatrics nurse (95%), early rehabilitation (80%), and early discharge planning (74%), except for co-management by the geriatrician (32%). Both patients and healthcare professionals rated G-COACH as acceptable (95 and 94%) and feasible (96 and 74%). The healthcare professionals experienced staffing, competing roles and tasks of the geriatrics nurse and leadership support as important determinants for implementation.

CONCLUSIONS

The implementation strategy resulted in the successful initiation of the G-COACH programme. G-COACH was perceived as acceptable and feasible. Fidelity was influenced by context factors. Further investigation of the sustainability of the programme is needed.

TRIAL REGISTRATION

ISRCTN22096382 (21/05/2020).

Geriatric co-management for cardiology patients in the hospital: A quasi-experimental study

BACKGROUND/OBJECTIVES

Older patients admitted to cardiac care units often suffer functional decline. We evaluated whether a nurse-led geriatric co-management program leads to better functional status at hospital discharge.

DESIGN

A quasi-experimental before-and-after study was performed between September 2016 and December 2018, with the main endpoint at hospital discharge and follow-up at 6 months.

SETTING

Two cardiac care units of the University Hospitals Leuven.

PARTICIPANTS

One hundred and fifty-one intervention and 158 control patients aged 75 years or older admitted for acute cardiovascular disease or transcatheter aortic valve implantation.

INTERVENTION

A nurse from the geriatrics department performed a comprehensive geriatric assessment within 24 h of admission. The cardiac care team and geriatrics nurse drafted an interdisciplinary care plan, focusing on early rehabilitation, discharge planning, promoting physical activity, and preventing geriatric syndromes. The geriatrics nurse provided daily follow-up and coached the cardiac team. A geriatrician co-managed patients with complications.

MEASUREMENTS

The primary outcome was functional status measured using the Katz Index for independence in activities of daily living (ADL; one-point difference was considered clinically relevant). Secondary outcomes included the incidence of ADL decline and complications, length of stay, unplanned readmissions, survival, and quality of life.

RESULTS

The mean age of patients was 85 years. Intervention patients had better functional status at hospital discharge (8.9, 95% CI = 8.7-9.3 versus 9.5, 95% CI = 9.2-9.9; p = 0.019) and experienced 18% less functional decline during hospitalization (25% vs. 43%, p = 0.006). The intervention group experienced significantly fewer cases of delirium and obstipation during hospitalization, and significantly fewer nosocomial infections. At 6-month follow-up, patients had significantly better functional status and quality of life. There were no differences regarding length of stay, readmissions, or survival.

CONCLUSION

This first nurse-led geriatric co-management program for frail patients on cardiac care units was not effective in improving functional status, but significantly improved secondary outcomes.

Physician's feedback on a clinical pharmacy program on geriatric wards

OBJECTIVES

As clinical pharmacy (CP) services can improve drug use and clinical outcome in older inpatients, a dedicated CP program was installed at the geriatric wards of an academic hospital. The aim of this study was to evaluate and potentially improve the CP program, by obtaining physician's feedback.

METHODS

An anonymous e-questionnaire was sent to all physicians who were active between October 2014 and March 2018 on the acute geriatric wards (80 beds) of the University Hospitals Leuven, Belgium. Thematic content analysis was applied. Six themes were defined: satisfaction with the service, time allocation of the clinical pharmacists, content and clinical relevance of pharmaceutical interventions, communication, time savings for the treating physician and future perspectives.

RESULTS

A total of 45 physicians (59%) completed the e-questionnaire. All respondents were satisfied with the content of the provided pharmaceutical recommendations. A minority (44%) found that a 0.8 full-time equivalent clinical pharmacist presence was sufficient in terms of the expected workload. The provided CP interventions improved quality of care according to 38 (84%) physicians. Oral and written communication were considered necessary by 89% and 82% of physicians, respectively. On average, an estimated 30 minutes physician time (IQR: 15-60) per patient was saved as a result of the program. The majority (87%) preferred clinical pharmacist presence for discharge support in all geriatric patients.

CONCLUSION

Physician's satisfaction with the CP service was very high. CP services in geriatric inpatients were perceived to be clinically relevant as well as time-saving by the involved physicians.

Importance of Geriatric Syndrome Screening within 48 Hours of Hospitalization for Identifying Readmission Risk: A Retrospective Study in an Acute-Care Hospital

BACKGROUND

Given the association between geriatric syndrome and hospital readmission, we evaluated the suitability of geriatric syndrome screening for care (GSC) in identifying readmission risk and suggested the appropriate time for GSC.

METHODS

GSC considering cognitive impairment, depression, polypharmacy (five or more medications), functional mobility, dysphagia, malnutrition, pain, and incontinence was performed among 2,663 general ward inpatients aged 65 years or older within 48 hours after admission and again before discharge between November 2016 and October 2017. From each patient, fall events, pressure ulcers, potentially inappropriate medication use, and delirium were assessed at admission. Patients were divided into two groups on the basis of readmission within 1 year after the first admission. According to the screening period (at admission and before discharge) and in-hospital decline, we applied receiver operating characteristic curve analysis to compare the prevalence of clinical concerns between the readmission and no-readmission groups. We also used multiple logistic regression analysis to evaluate the risk of readmission according to the presence of geriatric syndrome and clinical outcomes.

RESULTS

The 782 readmitted patients (29.4%) showed a higher rate of poor GSC than those who were not readmitted. Polypharmacy at admission was significantly correlated with readmission risk (area under the receiver operating characteristic curve=0.602). Fall events (odds ratio [OR]=4.36; 95% confidence interval [CI], 2.36-8.05), urinary incontinence (OR=4.21; 95% CI, 3.28-5.39), and depressive mood (OR=3.88; 95% CI, 2.69-5.59) at admission were risk factors for readmission.

CONCLUSION

Geriatric syndromes assessed by GSC at admission was associated with an increased risk of readmission.