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Young AM, Byrnes A, Mahoney D, Power G, Cahill M, Heaton S, McRae P, Mudge A, Miller E. Exploring hospital mealtime experiences of older inpatients, caregivers and staff using photovoice methods. J Clin Nurs 2024; 33:1906-1920. [PMID: 38284486 DOI: 10.1111/jocn.17009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/05/2023] [Accepted: 01/07/2024] [Indexed: 01/30/2024]
Abstract
AIM To gather and understand the experience of hospital mealtimes from the perspectives of those receiving and delivering mealtime care (older inpatients, caregivers and staff) using photovoice methods to identify touchpoints and themes to inform the co-design of new mealtime interventions. METHODS This study was undertaken on acute care wards within a single metropolitan hospital in Brisbane, Australia in 2019. Photovoice methods involved a researcher accompanying 21 participants (10 older patients, 5 caregivers, 4 nurses and 2 food service officers) during a mealtime and documenting meaningful elements using photographs and field notes. Photo-elicitation interviews were then undertaken with participants to gain insight into their experience. Data were analysed using inductive thematic analysis, involving a multidisciplinary research team including a consumer. RESULTS Themes were identified across the three touchpoints: (1) preparing for the meal (the juggle, the anticipation), (2) delivering/receiving the meal (the rush, the clutter and the wait) and (3) experiencing the meal (the ideal, pulled away and acceptance). Despite a shared understanding of the importance of meals and shared vision of 'the ideal' mealtime, generally this was a time of tension, missed cares and dissatisfaction for staff, patients and caregivers. There was stark contrast in some aspects of mealtime experience, with simultaneous experiences of 'the rush' (staff) and 'the wait' (patients and caregivers). There was an overwhelming sense of acceptance and lack of control over change from all. CONCLUSIONS This study identified themes during hospital mealtimes which have largely gone unaddressed in the design of mealtime interventions to date. This research may provide a framework to inform the future co-design of mealtime interventions involving patients, caregivers and multidisciplinary staff, centred around these key touchpoints. PRACTICE IMPLICATIONS Mealtimes are experienced differently by patients, caregivers, nurses and food service officers across three key touchpoints: preparing for, delivering/receiving and experiencing the meal. Improving mealtime experiences therefore necessitates a collaborative approach, with co-designed mealtime improvement programs that include specific interventions focusing each touchpoint. Our data suggest that improvements could focus on reducing clutter, clarifying mealtime roles and workflows and supporting caregiver involvement. IMPACT What problem did the study address? Mealtimes are the central mechanism to meet patients' nutritional needs in hospital; however, research consistently shows that many patients do not eat enough to meet their nutritional requirements and that they often do not receive the mealtime assistance they require. Interventions to improve hospital mealtimes have, at best, shown only modest improvements in nutritional intake and mealtime care practices. Gaining deeper insight into the mealtime experience from multiple perspectives may identify new opportunities for improvement. What were the main findings? Patients, caregivers and staff have shared ideals of comfort, autonomy and conviviality at mealtimes, but challenges of complex teamwork and re-prioritisation of mealtimes in the face of prevailing power hierarchies make it difficult to achieve this ideal. There are three discrete touchpoints (preparing for, delivering/receiving and experiencing the meal) that require different approaches to improvement. Our data suggests a need to focus improvement on reducing clutter, clarifying mealtime roles and workflows and supporting caregivers. Where and on whom will the research have an impact? The research provides a framework for multidisciplinary teams to begin co-designing improvements to mealtime care to benefit patients, caregivers and staff, while also providing a method for researchers to understand other complex care situations in hospital. REPORTING METHOD This manuscript is written in adherence with the Standards for Reporting Qualitative Research. PATIENT OR PUBLIC CONTRIBUTION Patients and caregivers were involved in the conception and design of the study through their membership of the hospital mealtime reference group. A consumer researcher (GP) was involved in the team to advise on study conduct (i.e. recruitment methods and information), data analysis (i.e. coding transcripts), data interpretation (i.e. review and refinement of themes) and manuscript writing (i.e. review and approval of final manuscript).
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Affiliation(s)
- Adrienne M Young
- Dietetics and Food Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Centre for Health Services Research, the University of Queensland, Brisbane, Queensland, Australia
- Nutrition Research Collaborative, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Angela Byrnes
- Dietetics and Food Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Nutrition Research Collaborative, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Danielle Mahoney
- Dietetics and Food Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Psychology, the University of Queensland, Brisbane, Queensland, Australia
| | - Gary Power
- Consumer Representative Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Margaret Cahill
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Sarah Heaton
- Speech Pathology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Prue McRae
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Alison Mudge
- Centre for Health Services Research, the University of Queensland, Brisbane, Queensland, Australia
- Nutrition Research Collaborative, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Evonne Miller
- School of Design, Queensland University of Technology, Brisbane, Queensland, Australia
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Valkenet K, McRae P, Reijneveld E, Jans M, Bor P, van Delft L, Young DL, Veenhof C. Inpatient physical activity across a large university city hospital: a behavioral mapping study. Physiother Theory Pract 2024; 40:153-160. [PMID: 36036375 DOI: 10.1080/09593985.2022.2112116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 08/03/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Physical inactivity is common during hospitalization. Physical activity has been described in different inpatient populations but never across a hospital. PURPOSE To describe inpatient movement behavior and associated factors throughout a single university hospital. METHODS A prospective observational study was performed. Patients admitted to clinical wards were included. Behavioral mapping was undertaken for each participant between 9AM and 4PM. The location, physical activity, daily activity, and company of participants were described. Barriers to physical activity were examined using linear regression analyses. RESULTS In total, 345 participants from 19 different wards were included. The mean (SD) age was 61 (16) years and 57% of participants were male. In total, 65% of participants were able to walk independently. On average participants spent 86% of observed time in their room and 10% of their time moving. A physiotherapist or occupational therapist was present during 1% of the time, nursing staff and family were present 11% and 13%, respectively. Multivariate regression analysis showed the presence of an intravenous line (p = .039), urinary catheter (p = .031), being female (p = .034), or being dependent on others for walking (p = .016) to be positively associated with the time spent in bed. Age > 65, undergoing surgery, receiving encouragement by a nurse or physician, reporting a physical complaint or pain were not associated with the time spent in bed (P > .05). CONCLUSION As family members and nursing staff spend more time with patients than physiotherapists or occupational therapists, increasing their involvement might be an important next step in the promotion of physical activity.
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Affiliation(s)
- Karin Valkenet
- Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Research Group Innovation of Mobility Care, University of Applied Sciences Utrecht, Expertise Center Innovation of Care, Utrecht, Netherlands
| | - Prue McRae
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Elja Reijneveld
- Research Group Innovation of Mobility Care, University of Applied Sciences Utrecht, Expertise Center Innovation of Care, Utrecht, Netherlands
| | - Marielle Jans
- Institute of Mobility Studies, University of Applied Sciences Utrecht, Utrecht, Netherlands
| | - Petra Bor
- Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Lotte van Delft
- Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Daniel L Young
- Department of Physical Therapy, University of Nevada, Las Vegas, Nevada, NV, USA
| | - Cindy Veenhof
- Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Research Group Innovation of Mobility Care, University of Applied Sciences Utrecht, Expertise Center Innovation of Care, Utrecht, Netherlands
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Harvey G, Collyer S, McRae P, Barrimore SE, Demmitt C, Lee-Steere K, Nolan B, Mudge AM. Navigating the facilitation journey: a qualitative, longitudinal evaluation of 'Eat Walk Engage' novice and experienced facilitators. BMC Health Serv Res 2023; 23:1132. [PMID: 37864161 PMCID: PMC10588033 DOI: 10.1186/s12913-023-10116-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/04/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND The Promoting Action on Research Implementation in Health Services (PARIHS) and integrated-PARIHS (i-PARIHS) frameworks position facilitation as an overarching strategy to enable implementation. In the revised i-PARIHS framework, facilitation is operationalised through a multi-level model with novice, experienced and expert facilitators working together in a network structure to build facilitation knowledge and skills along a continuum. To date, there has been limited evaluation of this facilitation model in practice, which is the aim of the study reported here. METHODS A descriptive, qualitative longitudinal study was undertaken to track a team of four novice and two experienced facilitators involved in facilitating the implementation of an intervention known as 'Eat Walk Engage' to improve multidisciplinary team delivery of age-friendly care principles in hospital. Over an 18-month period, repeat interviews were conducted to explore the learning, development, and evolving roles of novice facilitators and the roles of the experienced facilitators in providing support and mentoring. Interview data were analysed using a descriptive qualitative approach and findings were interpreted in collaboration with the participating facilitators. RESULTS The findings demonstrated experiential learning in both the novice and experienced facilitator groups as they enacted their roles in practice. The novice facilitators progressively transitioned to becoming more experienced facilitators and the experienced facilitators became increasingly expert, in line with the i-PARIHS concept of a facilitation journey from novice to expert. Strategies to support this development included a staggered approach to learning, regular meetings between the experienced and novice facilitators, reflective writing and informal peer support and networking. However, the roles were not without challenge and these challenges changed over time, from a more specific focus on the demands of the facilitator role to concerns about embedding and sustaining improvements in practice. CONCLUSIONS Within a network of peers and a mentored relationship with more experienced facilitators, individuals who are new to an implementation facilitator role can transition along a continuum to become experienced facilitators. Building implementation facilitation capability in this way takes time and requires tailored support and mentorship using a mix of structured and flexible approaches incorporating opportunities for reflection to support individual and group learning.
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Affiliation(s)
- Gillian Harvey
- Caring Futures Institute, Flinders University, Adelaide, Australia.
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Australia.
| | - Sarah Collyer
- Caring Futures Institute, Flinders University, Adelaide, Australia
| | - Prue McRae
- Royal Brisbane and Women's Hospital Department of Internal Medicine and Aged Care, Brisbane, Australia
- Queensland University of Technology Institute of Health and Biomedical Innovation, Brisbane, Australia
| | | | - Camey Demmitt
- Caboolture Hospital, Caboolture, Queensland, Australia
| | - Karen Lee-Steere
- Royal Brisbane and Women's Hospital Department of Internal Medicine and Aged Care, Brisbane, Australia
- University of Queensland Faculty of Health and Behavioural Sciences, Brisbane, Australia
| | | | - Alison M Mudge
- Royal Brisbane and Women's Hospital Department of Internal Medicine and Aged Care, Brisbane, Australia
- University of Queensland Faculty of Medicine, Brisbane, Australia
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Young A, Kozica-Olenski S, Mallan K, McRae P, Treleaven E, Walsh Z, Mudge A. Developing and validating a novel staff questionnaire to identify barriers and enablers to nutrition and mealtime care on hospital wards. Nutr Diet 2023; 80:389-398. [PMID: 37169361 DOI: 10.1111/1747-0080.12815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 04/12/2023] [Accepted: 04/21/2023] [Indexed: 05/13/2023]
Abstract
AIMS Improving hospital nutrition and mealtime care is complex and often requires multifaceted interventions and implementation strategies to change how staff, wards and systems operate. This study aimed to develop and validate a staff questionnaire to identify multilevel barriers and enablers to optimal nutrition and mealtime care on hospital wards, to inform and evaluate local quality improvement. METHODS Literature review, multidisciplinary focus groups and end-user testing informed questionnaire development and establishment of content and face validity. To determine the construct validity, the questionnaire was administered to ward staff working in five wards across two facilities (acute hospital, rehabilitation unit). Exploratory factor analysis was used to estimate the number of factors and to guide decisions about whether to retain or reject individual items. Scale reliability was assessed using Cronbach's alpha. RESULTS The questionnaire was completed by 138 staff, with most respondents being nurses (57%) and working in the acute care facility (76%). Exploratory factor analysis supported construct validity of four of the original seven subscales. The final questionnaire consisted of 17 items and 4 sub sub-scales related to (1) Personal Staff Role; (2) Food Service; (3) Organisational Support, and (4) Family Involvement; each sub-scale demonstrated good reliability with Cronbach's alpha values all >0.70. CONCLUSION This novel and brief questionnaire shows good reliability and preliminary evidence of construct validity in this small sample. It provides a potentially useful instrument to identify barriers and enablers to nutrition and mealtime care from the staff perspective and inform where improvement efforts should be focused.
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Affiliation(s)
- Adrienne Young
- Dietetics and Food Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Centre for Health Services Research, University of Queensland, Brisbane, Queensland, Australia
| | - Samantha Kozica-Olenski
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Monash Centre for Health Research and Implementation, Monash University, Melbourne, Victoria, Australia
| | - Kimberley Mallan
- School of Behavioural and Health Sciences, Australian Catholic University, Brisbane, Queensland, Australia
| | - Prue McRae
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Elise Treleaven
- Dietetics and Food Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Zoe Walsh
- Nutrition and Dietetics, Community and Oral Health Metro North Health, Melbourne, Victoria, Australia
| | - Alison Mudge
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Greater Brisbane Medical School, University of Queensland, Brisbane, Queensland, Australia
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Byrnes A, McRae P, Mudge AM. 'Life is about movement-everything that is alive moves': a mixed methods study to understand barriers and enablers to inpatient mobility from the older patient's perspective. Age Ageing 2023; 52:afad111. [PMID: 37463284 PMCID: PMC10353760 DOI: 10.1093/ageing/afad111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Indexed: 07/20/2023] Open
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.
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Affiliation(s)
- Angela Byrnes
- Eat Walk Engage Program, Metro North Health, Herston, QLD, Australia
- Internal Medicine Research Unit, Royal Brisbane and Women’s Hospital, Herston, QLD, Australia
- Department of Nutrition and Dietetics, Royal Brisbane and Women’s Hospital, Herston, QLD, Australia
| | - Prue McRae
- Eat Walk Engage Program, Metro North Health, Herston, QLD, Australia
- Internal Medicine Research Unit, Royal Brisbane and Women’s Hospital, Herston, QLD, Australia
| | - Alison M Mudge
- Address correspondence to: Alison M. Mudge, Eat Walk Engage Program, 6th floor block 7, Royal Brisbane and Women’s Hospital, Butterfield St, Herston, 4029 QLD, Australia. Tel: 61736460854.
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Mudge AM, McRae P, Young A, Blackberry I, Lee-Steere K, Barrimore S, Quirke T, Harvey G. Implementing a ward-based programme to improve care for older inpatients: process evaluation of the cluster randomised CHERISH trial. BMC Health Serv Res 2023; 23:668. [PMID: 37344776 DOI: 10.1186/s12913-023-09659-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 06/06/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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. TRIAL REGISTRATION The CHERISH trial was prospectively registered with the ANZCTR ( http://www.anzctr.org.au ): ACTRN12615000879561.
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Affiliation(s)
- Alison M Mudge
- Royal Brisbane and Women's Hospital Department of Internal Medicine and Aged Care, Herston, Australia.
- Queensland University of Technology Institute of Health and Biomedical Innovation, Kelvin Grove, Australia.
- University of Queensland Faculty of Medicine, Brisbane, Australia.
| | - Prue McRae
- Royal Brisbane and Women's Hospital Department of Internal Medicine and Aged Care, Herston, Australia
- Queensland University of Technology Institute of Health and Biomedical Innovation, Kelvin Grove, Australia
| | - Adrienne Young
- University of Queensland Faculty of Medicine, Brisbane, Australia
- Royal Brisbane and Women's Hospital Department of Nutrition and Dietetics, Herston, Australia
| | - Irene Blackberry
- LaTrobe University John Richards Centre for Rural Ageing Research, Wodonga, Australia
| | - Karen Lee-Steere
- Royal Brisbane and Women's Hospital Department of Internal Medicine and Aged Care, Herston, Australia
- University of Queensland Faculty of Health and Behavioural Sciences, Brisbane, Australia
| | | | - Tara Quirke
- Consumer Advocate Dementia Training Australia, Brisbane, Australia
| | - Gillian Harvey
- Queensland University of Technology Institute of Health and Biomedical Innovation, Kelvin Grove, Australia
- Flinders University College of Nursing and Health Sciences, Bedford Park, Australia
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Mudge AM, McRae P, Banks M, Blackberry I, Barrimore S, Endacott J, Graves N, Green T, Harvey G, Hubbard R, Kurrle S, Lim WK, Lee-Steere K, Masel P, Pandy S, Young A, Barnett A, Inouye SK. Effect of a Ward-Based Program on Hospital-Associated Complications and Length of Stay for Older Inpatients: The Cluster Randomized CHERISH Trial. JAMA Intern Med 2022; 182:274-282. [PMID: 35006265 PMCID: PMC8749692 DOI: 10.1001/jamainternmed.2021.7556] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- Alison M Mudge
- Internal Medicine and Aged Care Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia.,School of Clinical Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Prue McRae
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia.,Eat Walk Engage Program, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Merrilyn Banks
- Nutrition and Dietetics Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Irene Blackberry
- John Richards Centre for Rural Ageing Research, La Trobe Rural Health School, La Trobe University, Melbourne, Victoria, Australia
| | - Sally Barrimore
- Department of Nutrition and Dietetics, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - John Endacott
- Geriatrics Department, Nambour Hospital, Nambour, Queensland, Australia
| | - Nicholas Graves
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia.,Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Theresa Green
- School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, Queensland, Australia.,STARS Research and Education Alliance, Metro North Health Surgical Treatment and Rehabilitation Service, Brisbane, Queensland, Australia
| | - Gill Harvey
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia.,College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Ruth Hubbard
- Centre for Research in Geriatric Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Sue Kurrle
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Wen Kwang Lim
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Aged Care Services, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Karen Lee-Steere
- Eat Walk Engage Program, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Phil Masel
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Shaun Pandy
- Department of Internal Medicine, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Adrienne Young
- Nutrition and Dietetics Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Adrian Barnett
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sharon K Inouye
- Marcus Institute for Ageing Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Abstract
Physical activity behaviour has not been previously described in hospitalised adults with burn injuries. This prospective, cross-sectional study used a standardised behavioural mapping protocol to observe patient behaviour related to physical activity over a 12-hour period on one weekday in a quaternary referral specialist burn centre. Structured observations were recorded for each of four domains: 1) patient location, 2) position, 3) activity performed and 4) the presence of others. Observations were summarised across all participants as median (IQR) proportion of time. Participants (n=17) were predominantly male (82%) with a mean age of 44.3 (SD 15.2) years, a mean burn size of 34.9% (SD 26.7) total body surface area and a median hospital length of stay of 18 (IQR 6-49) days at time of observation. Participants spent a median of 83% (IQR 73-93) of time in their bedroom, 92% (IQR 68-97) of time in or on their bed and a median of 5% (IQR 3-13) of time mobilising. Exercise accounted for 10% (IQR 8-17) of activity related observations. A median of 68% (IQR 39-83) of time was spent alone. Results suggest time spent engaging in physical activity is low. Further studies are required to investigate motivators and barriers to performing physical activity in this population. This will consequently inform the development and implementation of appropriate strategies to improve physical activity behaviour in this cohort.
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Affiliation(s)
- Anita Plaza
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, Australia.,Professor Stuart Pegg Adult Burn Centre, Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, Australia
| | - Julie Adsett
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, Australia
| | - Angela Byrnes
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, Australia
| | - Prue McRae
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, Australia
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Mudge AM, Lee-Steere K, Treleaven E, Cahill M, Finnigan S, McRae P. Cognitive impairment in older hospital inpatients: prevalence, care needs and carer perceptions. AUST HEALTH REV 2021; 46:244-250. [PMID: 34856117 DOI: 10.1071/ah20286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 04/15/2021] [Indexed: 11/23/2022]
Abstract
ObjectivesThe aim of this study was to describe the prevalence of cognitive impairment in hospital inpatients, the associated need for assistance with activities of daily living (ADL) and carer perceptions of hospital care.MethodsA prospective cross-sectional observational study was conducted in a large metropolitan teaching hospital in Brisbane, Australia. Participants were inpatients aged ≥65 years and their carers. Cognitive impairment was measured by clinician auditors using the validated 4 'A's test (4AT), with a score >0 indicating cognitive impairment (1-3, probable dementia; >3, probable delirium). The need for supervision and/or assistance with ADL was recorded from daily nursing documentation. Carers were invited to complete a brief questionnaire.ResultsIn all, 92 of 216 older inpatients (43%) had cognitive impairment, including 52 (24%) with probable delirium. The need for supervision and/or assistance with ADL increased significantly with 4AT score. Fifty-two carers of patients with cognitive impairment reported feeling welcome and that care was safe. They identified opportunities for better information, greater support and more inclusion of carers.ConclusionsCognitive impairment is common in older inpatients and is associated with increased care needs. Workforce planning and health professional training need to acknowledge the needs of patients with cognitive impairment. There are opportunities for greater support and more involvement of carers.What is known about the topic?Cognitive impairment due to delirium and dementia increases with age, and is common in older medical and surgical inpatients. However, cognitive impairment remains under-recognised by healthcare staff. Australian guidelines now recommend routine screening using valid tools, and including carers, when appropriate, when assessing, caring for and communicating with people with cognitive impairment.What does this paper add?This cross-sectional study using the validated 4AT showed 43% of hospital inpatients aged ≥65 years had cognitive impairment. Participants with cognitive impairment had higher care needs and much longer hospitalisations. Carers of people with cognitive impairment reported unmet information needs in hospital and had limited involvement in assessment and care.What are the implications for practitioners?Cognitive impairment is common in older inpatients. Hospitals and healthcare professionals must be prepared and equipped to recognise cognitive impairment, and address the accompanying patient and carer needs.
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Affiliation(s)
- Alison M Mudge
- Internal Medicine Research Unit, Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
| | - Karen Lee-Steere
- Internal Medicine Research Unit, Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
| | - Elise Treleaven
- Internal Medicine Research Unit, Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
| | - Margaret Cahill
- Internal Medicine Research Unit, Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
| | - Simon Finnigan
- Centre for Functioning and Health Research, Metro South Hospitals and Health Service, Buranda, Qld, Australia
| | - Prue McRae
- Internal Medicine Research Unit, Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
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10
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Mudge AM, McRae P, Donovan PJ, Reade MC. Multidisciplinary quality improvement programme for older patients admitted to a vascular surgery ward .. Intern Med J 2021; 50:741-748. [PMID: 32537917 DOI: 10.1111/imj.14400] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 06/01/2019] [Accepted: 06/03/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Older vascular surgical patients are at high risk of hospital-associated complications and prolonged stays. AIMS To implement a multidisciplinary co-management model for older vascular patients and evaluate impact on length of stay (LOS), delirium incidence, functional decline, medical complications and discharge destination. METHODS Prospective pre-post evaluation of a quality improvement intervention, enrolling pre-intervention (August 2012-January 2013) and post-intervention cohort (September 2013-March 2014). Participants were consenting patients aged 65 years and over admitted to the vascular surgical ward of a metropolitan teaching hospital for at least 3 days. Intervention was physician-led co-management plus a multidisciplinary improvement programme targeting delirium and functional decline. Primary outcomes were LOS, delirium and functional decline. Secondary outcomes were medical complications and discharge destination. Process measures included documented consultation patterns. Administrative data were also compared for all patients aged 65 and older for 12 months pre- and post-intervention. RESULTS We enrolled 112 participants pre-intervention and 123 participants post-intervention. LOS was reduced post-intervention (geometric mean 7.6 days vs 9.3 days; ratio of geometric means 0.82 (95% confidence interval CI0.68-1.00), P = 0.04). There was a trend to less delirium (18 (14.6%) vs 24 (21.4%), P = 0.17) and functional decline (18 (14.6%) vs 27 (24.3%), P = 0.06), with greatest reductions in the urgently admitted subgroup. Administrative data showed reduced median LOS (5.2 days vs 6 days, P = 0.03) and greater discharge home (72% vs 50%, P < 0.01). CONCLUSIONS Physician-led co-management plus a multidisciplinary improvement programme may reduce LOS and improve functional outcomes in older vascular surgical patients.
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Affiliation(s)
- Alison M Mudge
- Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Prue McRae
- Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Peter J Donovan
- Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Michael C Reade
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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11
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Mudge AM, Young A, McRae P, Graham F, Whiting E, Hubbard RE. Qualitative analysis of challenges and enablers to providing age friendly hospital care in an Australian health system. BMC Geriatr 2021; 21:147. [PMID: 33639854 PMCID: PMC7913259 DOI: 10.1186/s12877-021-02098-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 01/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With ageing global populations, hospitals need to adapt to ensure high quality hospital care for older inpatients. Age friendly hospitals (AFH) aim to establish systems and evidence-based practices which support high quality care for older people, but many of these practices remain poorly implemented. This study aimed to understand barriers and enablers to implementing AFH from the perspective of key stakeholders working within an Australian academic health system. METHODS In this interpretive phenomenenological study, open-ended interviews were conducted with experienced clinicians, managers, academics and consumer representatives who had peer-recognised interest in improving care of older people in hospital. Initial coding was guided by the Promoting Action on Research Implementation in Health Services (PARIHS) framework. Coding and charting was cross checked by three researchers, and themes validated by an expert reference group. Reporting was guided by COREQ guidelines. RESULTS Twenty interviews were completed (8 clinicians, 7 academics, 4 clinical managers, 1 consumer representative). Key elements of AFH were that older people and their families are recognized and valued in care; skilled compassionate staff work in effective teams; and care models and environments support older people across the system. Valuing care of older people underpinned three other key enablers: empowering local leadership, investing in implementation and monitoring, and training and supporting a skilled workforce. CONCLUSIONS Progress towards AFH will require collaborative action from health system managers, clinicians, consumer representatives, policy makers and academic organisations, and reframing the value of caring for older people in hospital.
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Affiliation(s)
- Alison M Mudge
- Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, Australia. .,University of Queensland School of Clinical Medicine, Brisbane, Australia.
| | - Adrienne Young
- Department of Nutrition and Dietetics, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Prue McRae
- Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Frederick Graham
- Department of Internal Medicine, Princess Alexandra Hospital, Brisbane, Australia
| | | | - Ruth E Hubbard
- Centre for Research in Geriatric Medicine, The University of Queensland, Brisbane, Australia
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12
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Kozica-Olenski S, Treleaven E, Hewitt M, McRae P, Young A, Walsh Z, Mudge A. Patient-reported experiences of mealtime care and food access in acute and rehabilitation hospital settings: a cross-sectional survey. J Hum Nutr Diet 2021; 34:687-694. [PMID: 33491875 DOI: 10.1111/jhn.12854] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 12/08/2020] [Accepted: 12/14/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Nutrition and mealtime interventions can improve nutritional intake amongst hospital inpatients; however, patient-reported experience is rarely considered in their development and evaluation. The present study aimed to measure patient-reported food and mealtime experience to evaluate and inform continuous quality improvement of hospital nutrition care. METHODS A cross-sectional survey with inpatients in seven acute care and rehabilitation wards was conducted. A 27-item validated questionnaire measured five domains of patient experience: food choices, organisational barriers, feeling hungry, physical barriers to eating and food quality. Responses were summarised descriptively and compared between settings (acute versus rehabilitation), patient demographics (age, gender) and time in hospital. RESULTS Responses from 143 participants (mean age 67 years, 57% male, 28% rehabilitation, median 6 days into hospitalisation) showed that 10% or fewer respondents reported difficulties with food choices, feeling hungry or food quality. The most common difficulties were opening packets (36%), insufficient menu information provided (29%), being interrupted by staff when eating (28%), being disturbed when eating (27%), being in an uncomfortable position when eating (24%) and difficulty reaching food (21%). There were no significant differences in domain patterns by sex, age group or time in hospital. Organisational barriers were reported less frequently amongst rehabilitation participants compared to acute care (P = 0.01). CONCLUSIONS This survey highlights areas of positive patient-reported experience with nutrition care and suggests that local improvement efforts should focus on physical assistance needs and organisational barriers, especially in acute care wards. The questionnaire may be useful for informing and evaluating systematic nutrition care improvements.
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Affiliation(s)
- S Kozica-Olenski
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - E Treleaven
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,Nutrition and Dietetics, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - M Hewitt
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,Mater Health, Brisbane, QLD, Australia
| | - P McRae
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - A Young
- Nutrition and Dietetics, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Z Walsh
- Nutrition and Dietetics, Brighton Health Campus, Brighton, QLD, Australia
| | - A Mudge
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
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13
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Wu Y, Smits EJ, Window P, Beningfield A, Johnston V, McRae P. Mobility levels of acute medical patients: Is behavioural mapping comparable to accelerometry? Clin Rehabil 2020; 35:595-605. [PMID: 33203223 DOI: 10.1177/0269215520970341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To (1) determine agreement between behavioural mapping and accelerometry for measuring mobility levels in an acute medical inpatient setting and to (2) explore and compare the required resources and costs for both methods. DESIGN Observational cross-sectional study. SETTING Tertiary referral teaching hospital in Brisbane, Australia. SUBJECTS Adult patients admitted to two acute medical wards. MAIN MEASURES Mobility levels were recorded by behavioural mapping, and thigh and chest-worn accelerometers (ActivPAL). The level of agreement between the two methods was evaluated using the Intraclass Correlation Coefficients for each mobility level (i.e. lying, sitting, upright, standing and walking). RESULTS Nineteen patients (10 male (53%); mean(SD) age of 72(14) years) were included in the agreement analysis. The Intraclass Correlation Coefficients were high for 'lying' (ICC = 0.87), 'sitting' (ICC = 0.84) and 'upright' (ICC = 0.93), indicating good to excellent agreement between the two methods. For these mobility levels, mean differences between the two methods were small (<2%), with large standard deviations (up to 18%). Agreement was poor for 'standing' (ICC = 0.00) and 'walking' (ICC = 0.35). Both methods were labour-intensive, with labour costs of A$1,285/€798 (34 hours) for behavioural mapping and A$1,055/€655 (28 hours) for accelerometry. No further costs were involved in behavioural mapping, but clinical backfill was required. Accelerometry involved a financial investment for accelerometers (A$11,100/€6,894 for 22 ActivPAL devices). CONCLUSION Agreement between behavioural mapping and accelerometry was good for measuring 'lying', 'sitting' and 'upright', but poor for 'standing' and 'walking' in an acute inpatient setting. Both behavioural mapping and accelerometry were labour-intensive, with high costs for the accelerometry equipment.
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Affiliation(s)
- Yizhou Wu
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Esther J Smits
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Peter Window
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Alice Beningfield
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Venerina Johnston
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Prue McRae
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Brisbane, Australia
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14
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Hunter SC, Kim B, Mudge A, Hall L, Young A, McRae P, Kitson AL. Experiences of using the i-PARIHS framework: a co-designed case study of four multi-site implementation projects. BMC Health Serv Res 2020; 20:573. [PMID: 32576197 PMCID: PMC7310499 DOI: 10.1186/s12913-020-05354-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/24/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework is an implementation framework that has been developed and refined over the last 20 years. Its underlying philosophy is that implementing research into healthcare practice is complex, unpredictable and non-linear which therefore requires a flexible and responsive approach to implementation. Facilitation is recognized as the central ingredient of this approach, and i-PARIHS now provides a Facilitation Guide with associated tools. This multiple case study of four implementation projects explored how the i-PARIHS framework has been practically operationalized by diverse implementation project teams. METHODS A co-design approach was used to elicit the experiences of four implementation project teams who used the i-PARIHS framework to guide their implementation approach. We conducted the established co-design steps of (i) setting up for success, (ii) gathering the experience, and (iii) understanding the experience. In particular we explored teams' approaches to setting up their projects; why and how they used the i-PARIHS framework and what they learnt from the experience. RESULTS We found both commonalities and differences in the use of i-PARIHS across the four implementation projects: (i) all the projects used the Facilitation Checklist that accompanies i-PARIHS as a starting point, (ii) the projects differed in how facilitation was carried out, (iii) existing tools were adapted for distinct phases: pre-implementation, during implementation, and post-implementation stages; and (iv) project-specific tools were often developed for monitoring implementation activities and fidelity. CONCLUSIONS We have provided a detailed overview of how current users of i-PARIHS are operationalising the framework, which existing tools they are using or adapting to use, and where they have needed to develop new tools to best utilise the framework. Importantly, this study highlights the value of existing tools from the published i-PARIHS Facilitation Guide and provides a starting point to further refine and add to these tools within a future Mobilising Implementation of i-PARIHS (or "Mi-PARIHS") suite of resources. Specifically, Mi-PARIHS might include more explicit guidance and/or tools for developing a structured implementation plan and monitoring fidelity to the implementation plan, including recording how strategies are tailored to an evolving context.
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Affiliation(s)
- S C Hunter
- College of Nursing and Health Sciences, Flinders University, Sturt Road, Bedford Park, Adelaide, SA, 5042, Australia.
- Caring Futures Institute, Flinders University, Adelaide, SA, Australia.
| | - B Kim
- Centre for Healthcare Organization and Implementation Research, U.S. Department of Veterans Affairs, Boston, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - A Mudge
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia
| | - L Hall
- School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - A Young
- Nutrition and Dietetics, Royal Brisbane and Women's Hospital, QLD, Brisbane, Australia
- School of Exercise and Nutrition Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - P McRae
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - A L Kitson
- College of Nursing and Health Sciences, Flinders University, Sturt Road, Bedford Park, Adelaide, SA, 5042, Australia
- Caring Futures Institute, Flinders University, Adelaide, SA, Australia
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15
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Lee-Steere K, Liddle J, Mudge A, Bennett S, McRae P, Barrimore SE. "You've got to keep moving, keep going": Understanding older patients' experiences and perceptions of delirium and nonpharmacological delirium prevention strategies in the acute hospital setting. J Clin Nurs 2020; 29:2363-2377. [PMID: 32220101 DOI: 10.1111/jocn.15248] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/17/2020] [Accepted: 03/12/2020] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To explore older inpatients' experiences and perceptions of delirium and nonpharmacological delirium prevention strategies (NDPS). BACKGROUND Delirium is a distressing and serious complication in hospitalised older adults. NDPS (supporting nutrition, mobility and cognitive participation) have strong supporting evidence. Few studies have explored older inpatients' perspectives of these strategies. This information may assist staff to better support patient participation in NDPS. DESIGN Qualitative study using an interpretive descriptive (ID) methodological approach to explore older patient's experience of delirium and NDPS. METHODS Structured interviews of inpatients aged over 65 years across 6 medical and surgical wards explored patients' experiences and perceptions of delirium and prevention activities related to nutrition, mobility and cognition; and barriers and enablers to participation. Reporting used COREQ. RESULTS Twenty-three participants were included (12 male, 11 reported delirium experience). Participants reported a range of physiological, emotional and psychological responses to delirium, hearing about delirium was different to experiencing it. Most participants were aware of the benefits of maintaining nutrition and hydration, physical activity and cognitive engagement in hospital. Barriers included poor symptom control, inflexible routines and inconsistent communication, whilst enablers included access to equipment, family involvement, staff encouragement and individual goals. These were organised into themes: outlook, feeling well enough, hospital environment, feeling informed and listened to, and support networks. CONCLUSION A more patient-centred approach to delirium prevention requires consideration of older people's values, needs, preferences and fit within the hospital environment and routines. Feeling informed, listened to and receiving support from staff and family carers can improve older inpatients' engagement in NPDS to prevent delirium in hospital. RELEVANCE TO CLINICAL PRACTICE Nurses are ideally placed to improve patient participation in NDPS through holistic assessment and care, addressing symptoms, providing clear information about delirium and delirium prevention, and facilitating family carer support and patient interactions.
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Affiliation(s)
- Karen Lee-Steere
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia.,Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jacki Liddle
- ARC Centre of Excellence for the Dynamics of Language, School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, QLD, Australia
| | - Alison Mudge
- Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Queensland University of Technology, Brisbane, QLD, Australia.,School of Clinical Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Sally Bennett
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Prue McRae
- Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Sally E Barrimore
- Nutrition and Dietetics Department, The Prince Charles Hospital, Brisbane, QLD, Australia
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16
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Mudge AM, Bew P, Smith S, McRae P. Staff knowledge, attitudes and behaviours related to mobilisation in a rehabilitation setting: Short report of a multidisciplinary survey. Australas J Ageing 2020; 39:225-229. [PMID: 32279415 DOI: 10.1111/ajag.12793] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 02/25/2020] [Accepted: 02/27/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Regular mobilising is important in inpatient rehabilitation, but objective measurements show low patient mobility. We sought to understand multidisciplinary staff perspectives on barriers and enablers to mobility in a rehabilitation setting. METHODS A validated barriers survey (standardised score 0-100, higher representing greater barriers) was distributed to 99 clinical staff on two wards at a single rehabilitation facility. RESULTS The survey was completed by 83 staff (52 nurses, 25 allied health professionals, 4 therapy assistants and 2 medical officers) and identified barriers in behaviour (mean 39, SD 11), attitudes (mean 34, SD 12) and knowledge (mean 23, SD 18). Prominent perceived barriers were nursing workload, unclear responsibility for mobilising, risk of staff injury, patient motivation and family participation; perceived enablers were good knowledge, positive outcome expectations and team communication. CONCLUSIONS These barriers can inform locally tailored strategies to improve rehabilitation patient mobility.
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Affiliation(s)
- Alison M Mudge
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia
| | - Paul Bew
- Brighton Health Campus, Brisbane, Qld, Australia
| | - Simon Smith
- Institute for Social Science Research, The University of Queensland, Brisbane, Qld, Australia
| | - Prue McRae
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia
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17
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Kozica-Olenski S, McRae P, Bew P, Mudge A. 'I will walk out of here': Qualitative analysis of older rehabilitation patients' perceptions of mobility. Australas J Ageing 2020; 39:209-216. [PMID: 32096895 DOI: 10.1111/ajag.12777] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/14/2020] [Accepted: 01/14/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To understand the motivation of older rehabilitation inpatients for mobilisation, and identify barriers and enablers to greater mobilisation. METHODS Qualitative semi-structured interviews were conducted with older rehabilitation inpatients. All interviews were audio-taped, transcribed verbatim and analysed using thematic and inductive techniques. RESULTS From 23 interviews, we found that older patients strongly value mobilisation during rehabilitation admission, to get better and maintain identity, personhood and meaningful connections. At the patient level, mobilisation was impacted by patient's confidence, family support and symptom management. At the organisational level, barriers to mobilisation included lack of timely staff support, inflexible routines, limited social opportunities, lack of physical resources, and poor communication. CONCLUSIONS Recognising and understanding motivators, enablers and barriers to mobilising during subacute hospitalisation of older patients is an essential step towards developing and implementing successful strategies to promote greater mobilisation. Addressing mobilisation barriers requires a multifaceted approach at the patient and organisational level.
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Affiliation(s)
- Samantha Kozica-Olenski
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
| | - Prue McRae
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
| | - Paul Bew
- Brighton Health Campus, Brighton, Qld, Australia
| | - Alison Mudge
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
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18
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McRae P, Bew P, Smith S, Mudge A. An observational study of physical, cognitive and social activities in rehabilitation inpatients. Australas J Ageing 2020; 39:217-224. [PMID: 32096897 DOI: 10.1111/ajag.12785] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 02/02/2020] [Accepted: 02/06/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To describe patient behaviour related to mobility in a rehabilitation inpatient setting and compare intensive and Transition Care Program (TCP, slow-stream rehabilitation) models. METHODS Prospective cross-sectional design including weekday and weekend sampling in two rehabilitation wards (one intensive and one TCP) in a publicly funded facility. A single trained observer undertook behavioural mapping, observing patient location, mobility, activity and company on all inpatients 8 am-4 pm using a structured 2-minute observation protocol. Observations were summarised and compared between wards. RESULTS We observed 74 inpatients on a Tuesday and 77 on a Sunday. Participants spent 7% (median) of daytime standing or walking. They spent 62%-87% in their room, 22%-40% sleeping or resting and 74%-86% alone. The only significant difference between wards was time spent off ward on Tuesday. Activity was lower on Sunday. CONCLUSIONS Time spent in physical, cognitive and social activities is low in inpatient rehabilitation and TCP wards.
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Affiliation(s)
- Prue McRae
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
| | - Paul Bew
- Brighton Health Campus, Brisbane, Qld, Australia
| | - Simon Smith
- Institute for Social Science Research, The University of Queensland, Brisbane, Qld, Australia
| | - Alison Mudge
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
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19
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Mudge AM, McRae P, Hubbard RE, Peel NM, Lim WK, Barnett AG, Inouye SK. Hospital-Associated Complications of Older People: A Proposed Multicomponent Outcome for Acute Care. J Am Geriatr Soc 2018; 67:352-356. [PMID: 30423197 DOI: 10.1111/jgs.15662] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 09/14/2018] [Accepted: 09/22/2018] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Alison M Mudge
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Prue McRae
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ruth E Hubbard
- Centre for Research in Geriatric Medicine, University of Queensland, Brisbane, Queensland, Australian
| | - Nancye M Peel
- Centre for Research in Geriatric Medicine, University of Queensland, Brisbane, Queensland, Australian
| | - Wen Kwang Lim
- Royal Melbourne Hospital, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Adrian G Barnett
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sharon K Inouye
- Institute for Aging Research, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts
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Young A, Mudge A, McRae P, Banks M. FUNCTIONAL DECLINE IN ACUTE CARE ENVIRONMENTS. Innov Aging 2017. [DOI: 10.1093/geroni/igx004.2507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- A. Young
- Nutrition and Dietetics, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia,
- Queensland University of Technology, Brisbane, Queensland, Australia,
| | - A.M. Mudge
- Queensland University of Technology, Brisbane, Queensland, Australia,
- Internal Medicine and Aged Care, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - P. McRae
- Internal Medicine and Aged Care, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - M. Banks
- Nutrition and Dietetics, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia,
- Queensland University of Technology, Brisbane, Queensland, Australia,
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Affiliation(s)
- A.M. Mudge
- Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia,
- Queensland Insitute of Technology, Brisbane, Queensland, Australia
| | - P. McRae
- Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia,
| | - K. Lee-Steere
- Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia,
| | - M. Cahill
- Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia,
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Mudge AM, Banks MD, Barnett AG, Blackberry I, Graves N, Green T, Harvey G, Hubbard RE, Inouye SK, Kurrle S, Lim K, McRae P, Peel NM, Suna J, Young AM. CHERISH (collaboration for hospitalised elders reducing the impact of stays in hospital): protocol for a multi-site improvement program to reduce geriatric syndromes in older inpatients. BMC Geriatr 2017; 17:11. [PMID: 28068906 PMCID: PMC5223473 DOI: 10.1186/s12877-016-0399-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 12/15/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Older inpatients are at risk of hospital-associated geriatric syndromes including delirium, functional decline, incontinence, falls and pressure injuries. These contribute to longer hospital stays, loss of independence, and death. Effective interventions to reduce geriatric syndromes remain poorly implemented due to their complexity, and require an organised approach to change care practices and systems. Eat Walk Engage is a complex multi-component intervention with structured implementation, which has shown reduced geriatric syndromes and length of stay in pilot studies at one hospital. This study will test effectiveness of implementing Eat Walk Engage using a multi-site cluster randomised trial to inform transferability of this intervention. METHODS A hybrid study design will evaluate the effectiveness and implementation strategy of Eat Walk Engage in a real-world setting. A multisite cluster randomised study will be conducted in 8 medical and surgical wards in 4 hospitals, with one ward in each site randomised to implement Eat Walk Engage (intervention) and one to continue usual care (control). Intervention wards will be supported to develop and implement locally tailored strategies to enhance early mobility, nutrition, and meaningful activities. Resources will include a trained, mentored facilitator, audit support, a trained healthcare assistant, and support by an expert facilitator team using the i-PARIHS implementation framework. Patient outcomes and process measures before and after intervention will be compared between intervention and control wards. Primary outcomes are any hospital-associated geriatric syndrome (delirium, functional decline, falls, pressure injuries, new incontinence) and length of stay. Secondary outcomes include discharge destination; 30-day mortality, function and quality of life; 6 month readmissions; and cost-effectiveness. Process measures including patient interviews, activity mapping and mealtime audits will inform interventions in each site and measure improvement progress. Factors influencing the trajectory of implementation success will be monitored on implementation wards. DISCUSSION Using a hybrid design and guided by an explicit implementation framework, the CHERISH study will establish the effectiveness, cost-effectiveness and transferability of a successful pilot program for improving care of older inpatients, and identify features that support successful implementation. TRIAL REGISTRATION ACTRN12615000879561 registered prospectively 21/8/2015.
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Affiliation(s)
- Alison M Mudge
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, Australia.
| | - Merrilyn D Banks
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, Australia
| | - Adrian G Barnett
- Institute of Health and Biomedical Innovation and School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - Irene Blackberry
- John Richards Initiative, Australian Institute of Primary Care and Ageing, La Trobe University, Albury-Wodonga, Australia
| | - Nicholas Graves
- Institute of Health and Biomedical Innovation and School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - Theresa Green
- School of Nursing, Queensland University of Technology, Brisbane, Australia
| | | | - Ruth E Hubbard
- Centre for Research in Geriatric Medicine, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Sharon K Inouye
- Harvard Medical School, Beth Israel Deaconess Medical Centre, Institute for Aging Research, Hebrew Senior Life, Boston, USA
| | - Sue Kurrle
- Cognitive Decline Partnership Centre, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Kwang Lim
- Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Prue McRae
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, Australia
| | - Nancye M Peel
- Centre for Research in Geriatric Medicine, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Jessica Suna
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, Australia
| | - Adrienne M Young
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, Australia
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Mudge AM, McRae P, McHugh K, Griffin L, Hitchen A, Walker J, Cruickshank M, Morris NR, Kuys S. Poor mobility in hospitalized adults of all ages. J Hosp Med 2016; 11:289-91. [PMID: 26797978 DOI: 10.1002/jhm.2536] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 11/19/2015] [Accepted: 12/04/2015] [Indexed: 11/12/2022]
Abstract
Low levels of activity in hospital inpatients contribute to functional decline. Previous studies have shown low levels of activity in older inpatients, but few have investigated younger inpatients (aged <65 years). This observational study measured activity in older (aged ≥65 years) and younger hospital inpatients on 3 wards (medical, surgical, oncology) in a major teaching hospital in Brisbane, Australia, as part of a quality-improvement intervention to enhance mobility. Using structured behavioral mapping protocols, participants were observed for 2-minute intervals throughout 4, 4-hour daytime observation periods. The proportion of time spent at different activity levels was calculated for each participant, and time spent standing, walking or wheeling was compared between age group and wards. There were 3272 observations collected on 132 participants (median, 30 per patient; range, 9-35). The most time was spent lying in bed (mean 57%), with 9% standing or walking. There were significant differences among wards, but no difference between older and younger subgroups. Low mobility is common in adult inpatients of all ages. Behavioral mapping provided measures suitable for use in quality improvement.
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Affiliation(s)
- Alison M Mudge
- Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- University of Queensland School of Medicine, Brisbane, Queensland, Australia
| | - Prue McRae
- University of Queensland School of Medicine, Brisbane, Queensland, Australia
- Safety and Quality Unit, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Kirstie McHugh
- School of Allied Health Sciences, Griffith University, Brisbane, Queensland, Australia
| | - Lauren Griffin
- School of Allied Health Sciences, Griffith University, Brisbane, Queensland, Australia
| | - Andrew Hitchen
- School of Allied Health Sciences, Griffith University, Brisbane, Queensland, Australia
| | - James Walker
- School of Allied Health Sciences, Griffith University, Brisbane, Queensland, Australia
| | - Mark Cruickshank
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Norman R Morris
- School of Allied Health Sciences, Griffith University, Brisbane, Queensland, Australia
- Griffith Health Institute, Brisbane, Queensland, Australia
| | - Suzanne Kuys
- School of Allied Health Sciences, Griffith University, Brisbane, Queensland, Australia
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Young A, Allia A, Jolliffe L, de Jersey S, Mudge A, McRae P, Banks M. Assisted or Protected Mealtimes? Exploring the impact of hospital mealtime practices on meal intake. J Adv Nurs 2016; 72:1616-25. [PMID: 26996998 DOI: 10.1111/jan.12940] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2016] [Indexed: 11/30/2022]
Abstract
AIMS To evaluate the impact of mealtime practices (meal time preparation, assistance and interruptions) on meal intake of inpatients in acute hospital wards. BACKGROUND It is common for patients to eat poorly while in hospital, related to patient and illness factors and possibly mealtime practices. Few studies have quantified the impact of mealtime practices on the meal intake of hospital patients. DESIGN Cross-sectional study. METHODS Structured observations were conducted at 601 meals across four wards (oncology, medical and orthopaedic and vascular surgical) during 2013. Each ward was observed by two dietitians and/or nurses for two breakfasts, lunches and dinners over 2 weeks. Data were collected on patient positioning, mealtime assistance, interruptions and meal intake (visual estimate of plate waste). Associations between mealtime practices and 'good' intake (prospectively defined as ≥75% of meal) were identified using chi-squared tests. RESULTS Sitting up for the meal was associated with good intake, compared with lying in bed. Timely mealtime assistance (within 10 minutes) was associated with good intake, compared with delayed or no assistance. Mealtime interruptions had no impact on intake. Forty percent of patients (n = 241) ate half or less of their meal, with 10% (n = 61) eating none of the meal provided. CONCLUSION Timely mealtime assistance and positioning for the meal may be important factors that facilitate intake among hospital patients, while mealtime interruptions appeared to have no impact on intake. To improve intake of older inpatients, mealtime programmes should focus on 'assisted mealtimes' rather than only Protected Mealtimes.
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Affiliation(s)
- Adrienne Young
- Nutrition and Dietetics, Royal Brisbane and Women's Hospital, Queensland, Australia.,School of Exercise and Nutrition Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Amy Allia
- Nutrition and Dietetics, Royal Brisbane and Women's Hospital, Queensland, Australia.,Nutrition and Dietetics, Mater Health Services, Brisbane, Queensland, Australia
| | - Lisa Jolliffe
- Nutrition and Dietetics, Royal Brisbane and Women's Hospital, Queensland, Australia.,Community Services, Weipa Integrated Health Service, Queensland, Australia
| | - Susie de Jersey
- Nutrition and Dietetics, Royal Brisbane and Women's Hospital, Queensland, Australia.,School of Exercise and Nutrition Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Alison Mudge
- Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Prue McRae
- Safety and Quality Unit, Royal Brisbane and Women's Hospital, Queensland, Australia
| | - Merrilyn Banks
- Nutrition and Dietetics, Royal Brisbane and Women's Hospital, Queensland, Australia.,Queensland University of Technology, Brisbane, Queensland, Australia
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25
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Chari SR, McRae P, Stewart MJ, Webster J, Fenn M, Haines TP. Point prevalence of suboptimal footwear features among ambulant older hospital patients: implications for fall prevention. AUST HEALTH REV 2015; 40:399-404. [PMID: 26456639 DOI: 10.1071/ah14168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 08/17/2015] [Indexed: 11/23/2022]
Abstract
Objective The aim of the present study was to establish the point prevalence of 'suboptimal' features in footwear reported to have been used by older hospital patients when ambulating, and to explore underpinning factors for their choice of footwear. Method A cross-sectional investigation was undertaken on 95 of 149 eligible in-patients across 22 high fall-risk wards in a large metropolitan hospital in Brisbane, Australia. Results Over 70% of participants experienced an unplanned admission. Although most participants had access to some form of footwear in hospital (92%), nearly all reported ambulating in footwear with 'suboptimal' features (99%). Examples included slippers (27%), backless slippers (16%) or bare feet (27%). For patients who ambulated in bare feet, only one-third reported 'lack of access to footwear' as the primary cause, with others citing foot wounds, pain, oedema and personal choice as the main reason for bare foot ambulation. Conclusions Admitted patients frequently use footwear with 'suboptimal' features for ambulation in hospital. While some footwear options (for example well-fitting slippers) could be suited for limited in-hospital ambulation, others are clearly hazardous and might cause falls. Since footwear choices are influenced by multiple factors in this population, footwear education strategies alone may be insufficient to address the problem of hazardous footwear in at-risk patients. Footwear requirements may be more effectively addressed within a multidisciplinary team approach encompassing foot health, mobility and safety. What is known about the topic? Accidental falls while ambulating are an important health and safety concern for older people. Because certain footwear characteristics have been negatively linked to posture and balance, and specific footwear types linked to falls among seniors, the use of footwear with fewer suboptimal characteristics is generally recommended as a means of reducing the risk of falling. While footwear usage and choices have been explored in older people in the community and in residential care settings, there is little comparable data on acutely unwell older hospital patients. What does this paper add? This paper provides prevalence data on the use of footwear with suboptimal characteristics among ambulant older hospital patients, and identifies concurrent factors that may be relevant to patient footwear choices. What are the implications for practitioners? Pain, foot pathology and a desire to retain independence are important concerns for hospitalised patients and are likely to influence their choice of footwear used to ambulate with. Pragmatic team-based approaches that remain sensitive to key patient concerns may be more successful in optimising patient footwear usage than footwear education strategies alone.
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Affiliation(s)
- Satyan R Chari
- Safety and Quality Unit, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Level 7, Block 7, Herston, Qld 4029, Australia
| | - Prue McRae
- Safety and Quality Unit, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Level 7, Block 7, Herston, Qld 4029, Australia. Present Address: Internal Medicine Research Unit, 7th Floor, UQ Health Sciences Building, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Herston, Qld 4029, Australia. Email
| | - Matthew J Stewart
- Department of Physiotherapy, Allied Health Services, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Ned Hanlon Building, Herston, Qld 4029, Australia. Email
| | - Joan Webster
- Centre for Clinical Nursing, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Herston, Qld 4029, Australia. Email
| | - Mary Fenn
- Patient Flow Unit, Lower Ground Floor, Ned Hanlon Building, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Herston, Qld 4029, Australia. Email
| | - Terry P Haines
- Southern Clinical School, Physiotherapy Department, Monash University, Frankston, Vic. 3199, Australia. Email
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Chari S, McRae P, Varghese P, Ferrar K, Haines TP. Predictors of fracture from falls reported in hospital and residential care facilities: a cross-sectional study. BMJ Open 2013; 3:bmjopen-2013-002948. [PMID: 23906949 PMCID: PMC3733318 DOI: 10.1136/bmjopen-2013-002948] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Fall-related fractures are associated with substantial human and economic costs. An improved understanding of the predictors of fall-related fractures in healthcare settings would be useful in developing future interventions. The objective of this study was to identify such predictors by exploring associations between fall-related factors and fracture outcomes through logistic regression analysis of routinely collected fall incident data. DESIGN Retrospective cross-sectional study. SETTING 197 public healthcare facilities in Queensland, Australia. PARTICIPANTS We included data from incident reports completed after falls among admitted adult hospital patients (n=24 218 falls, 229 fractures) and aged-care residents (n=8980 falls, 74 fractures) between January 2007 and November 2009. PRIMARY AND SECONDARY OUTCOMES The outcomes of interest were fall-related predictors of fracture. RESULTS Hospital patients who reported to have been screened for their risk of falling at admission were less likely to fracture after a fall (OR: 0.60, 95% CI 0.41 to 0.89) than those who had not been screened. Further, falls from standing (OR: 2.08, 95% CI 1.22 to 3.55) and falls while walking (OR: 1.86, 95% CI 1.32 to 2.62) were associated with higher fracture odds than falls during other activities. In line with these results, falls while reaching in standing (OR: 3.51, 95% CI 1.44 to 8.56) and falls while walking (OR: 2.11, 95% CI 1.24 to 3.58) were also predictive of fracture in the adjusted residential care model. CONCLUSIONS Our findings indicate that screening of hospital patients for their risk of falling may contribute towards the prevention of fall-related injury. Falls from upright postures appear to be more likely to result in fractures than other falls in healthcare settings. Further prospective research is warranted.
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Affiliation(s)
- Satyan Chari
- Falls Prevention, Safety and Quality Unit, Royal Brisbane and Women's Hospital, Queensland Health, Australia
- Queensland Health Office of Health and Medical Research (OHMR)
- Department of Physiotherapy, Monash University, Melbourne, Queensland, Australia
- Queensland Falls Injury Prevention Collaborative
| | - Prue McRae
- Falls Prevention, Safety and Quality Unit, Royal Brisbane and Women's Hospital, Queensland Health, Australia
- Queensland Falls Injury Prevention Collaborative
| | - Paul Varghese
- Queensland Falls Injury Prevention Collaborative
- Geriatric Assessment and Rehabilitation Unit, Princess Alexandra Hospital, Queensland Health, Australia
- School of Medicine, University of Queensland, St Lucia, Australia
| | - Kaye Ferrar
- Patient Safety Centre, Queensland Health, Australia
| | - Terry P Haines
- Department of Physiotherapy, Southern Physiotherapy Clinical School, Monash University, Melbourne, Queensland, Australia
- Allied Health Research Unit, Southern Health, Cheltenham, Australia
- School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, Australia
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Webster J, Courtney M, Marsh N, Gale C, Abbott B, Mackenzie-Ross A, McRae P. The STRATIFY tool and clinical judgment were poor predictors of falling in an acute hospital setting. J Clin Epidemiol 2009; 63:109-13. [PMID: 19398296 DOI: 10.1016/j.jclinepi.2009.02.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2008] [Revised: 10/21/2008] [Accepted: 02/10/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To compare the effectiveness of the STRATIFY falls tool with nurses' clinical judgments in predicting patient falls. STUDY DESIGN AND SETTING A prospective cohort study was conducted among the inpatients of an acute tertiary hospital. Participants were patients over 65 years of age admitted to any hospital unit. Sensitivity, specificity, and positive predictive value (PPV) and negative predictive values (NPV) of the instrument and nurses' clinical judgments in predicting falls were calculated. RESULTS Seven hundred and eighty-eight patients were screened and followed up during the study period. The fall prevalence was 9.2%. Of the 335 patients classified as being "at risk" for falling using the STRATIFY tool, 59 (17.6%) did sustain a fall (sensitivity=0.82, specificity=0.61, PPV=0.18, NPV=0.97). Nurses judged that 501 patients were at risk of falling and, of these, 60 (12.0%) fell (sensitivity=0.84, specificity=0.38, PPV=0.12, NPV=0.96). The STRATIFY tool correctly identified significantly more patients as either fallers or nonfallers than the nurses (P=0.027). CONCLUSION Considering the poor specificity and high rates of false-positive results for both the STRATIFY tool and nurses' clinical judgments, we conclude that neither of these approaches are useful for screening of falls in acute hospital settings.
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Affiliation(s)
- Joan Webster
- Centre for Clinical Nursing, Royal Brisbane and Women's Hospital, Brisbane, Queensland 402, Australia.
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Webster J, Courtney M, O'Rourke P, Marsh N, Gale C, Abbott B, McRae P, Mason K. Should elderly patients be screened for their 'falls risk'? Validity of the STRATIFY falls screening tool and predictors of falls in a large acute hospital. Age Ageing 2008; 37:702-6. [PMID: 18703523 DOI: 10.1093/ageing/afn153] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Joan Webster
- Centre for Clinical Nursing, Royal Brisbane and Women's Hospital, Herston, QLD 4029, Australia. joan
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Shansky RM, Glavis-Bloom C, Lerman D, McRae P, Benson C, Miller K, Cosand L, Horvath TL, Arnsten AFT. Estrogen mediates sex differences in stress-induced prefrontal cortex dysfunction. Mol Psychiatry 2004; 9:531-8. [PMID: 14569273 DOI: 10.1038/sj.mp.4001435] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Many anxiety disorders, as well as major depressive disorder (MDD), are at least twice as prevalent in women as in men, but the neurobiological basis of this discrepancy has not been well studied. MDD is often precipitated by exposure to uncontrollable stress, and is frequently characterized by abnormal or disrupted prefrontal cortex (PFC) function. In animals, exposure to stress has been shown to cause PFC dysfunction, but sex differences in this effect have not been investigated. The present study tested male and female rats on a PFC-dependent working memory task after administration of FG7142, a benzodiazepine inverse agonist that activates stress systems in the brain. Female rats were impaired by lower doses than males during proestrus (high estrogen), but not during estrus (low estrogen). Similarly, ovariectomized females showed increased stress sensitivity only after estrogen replacement. These results suggest that estrogen amplifies the stress response in PFC, which may increase susceptibility to stress-related disorders.
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Affiliation(s)
- R M Shansky
- Department of Neurobiology, Yale University School of Medicine, New Haven, CT 06520-8001, USA.
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Abstract
The Greater Bilby has shown a rapid decline in range during this century and now occupies only a small isolated area in south-western Queensland (QLD) and a larger, but mostly low-density area in the north-western deserts of the Northern Territory (NT) and Western Australia (WA). We have examined variation in the control region of mitochondrial DNA (mtDNA) and at nine microsatellite loci in order to investigate the extent of current and historical subdivision across the species range, and to provide a preliminary assessment of genetic structuring and mating system on a finer scale within the QLD population. Both mtDNA and microsatellite loci had substantial variation within and among populations, with mtDNA divergence being greater between QLD and NT than between NT and WA. The QLD population had two unique and divergent mtDNA lineages, but there was no evidence for strong phylogeographical structure across the range. The available evidence suggests that the bilby should be considered as a single Evolutionarily Significant Unit consisting of multiple Management Units. Augmentation of the remnant QLD population from the NT does not appear necessary at this stage, at least not on genetic grounds. Finer-scale analysis of microsatellite variation for two QLD colonies revealed a deficiency of heterozygotes and significantly greater relatedness within than between colonies. However, structuring was observed only for males; relatedness values for females did not depart from those expected under panmixia. Parentage exclusion analysis for one colony allowed the construction of a partial pedigree which indicated strong polygyny, with one male fathering all but one of the eight offspring assigned. The extent to which fine-scale genetic structuring and differences between sexes is due to sex-biased dispersal vs. effects of mating system remain to be determined.
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Affiliation(s)
- C Moritz
- Centre for Conservation Biology, University of Queensland, Australia.
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Southgate R, McRae P, Atherton R. Trapping Techniques and a Pen Design for The Greater Bilby Macrotis lagotis. Aust Mammalogy 1995. [DOI: 10.1071/am95101] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
A case is described in which computerized tomography scanning aided in a prompt diagnosis and assessment of an intravenous catheter-induced septic thrombus. Computerized tomography scanning detected gas bubbles within the thrombus, which extended from the right subclavian vein into the superior vena cava, and retrograde propagation of the thrombus into the right internal jugular vein. Computerized tomography scanning also helped in the assessment of the amount of deep tissue swelling present and the competence of the upper respiratory tract.
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Affiliation(s)
- T Khor
- Department of Urology and Radiology, Perth, Western Australia
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Abstract
Clam enterocystoplasty has proved to be the most effective treatment for severe detrusor instability resistant to conservative treatment (Bramble, 1982; Mundy and Stephenson, 1985). More recently it has become the procedure of choice in patients with neuropathic bladders with hyper-reflexia or severely impaired compliance, provided that the bladder is of reasonable size and that gross fibrosis and/or diverticular formation of the bladder wall has not occurred. Fifty-nine patients have undergone the clam procedure as part or all of their reconstruction in the past 4 years. Although uncontrolled incontinence was the commonest indication, impaired renal function was the indication in 14 patients and need for undiversion in seven. Currently all but four are voiding satisfactorily or are on intermittent self-catheterisation, though six have significant stress incontinence. The clam procedure is easier, quicker and as satisfactory as substitution cystoplasty in selected cases.
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Affiliation(s)
- P McRae
- Department of Urology, Royal Infirmary, Cardiff
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