IMpleMenting Effective infection prevention and control in ReSidential aged carE (IMMERSE): protocol for a multi-level mixed methods implementation study.

BACKGROUND: Older people living in residential aged care facilities are at high risk of acquiring infections such as influenza, gastroenteritis, and more recently COVID-19. These infections are a major cause of morbidity and mortality among this cohort. Quality infection prevention and control practice in residential aged care is therefore imperative. Although appointment of a dedicated infection prevention and control (IPC) lead in every Australian residential aged care facility is now mandated, all people working in this setting have a role to play in IPC. The COVID-19 pandemic revealed inadequacies in IPC in this sector and highlighted the need for interventions to improve implementation of best practice. METHODS: Using mixed methods, this four-phase implementation study will use theory-informed approaches to: (1) assess residential aged care facilities' readiness for IPC practice change, (2) explore current practice using scenario-based assessments, (3) investigate barriers to best practice IPC, and (4) determine and evaluate feasible and locally tailored solutions to overcome the identified barriers. IPC leads will be upskilled and supported to operationalise the selected solutions. Staff working in residential aged care facilities, residents and their families will be recruited for participation in surveys and semi-structured interviews. Data will be analysed and triangulated at each phase, with findings informing the subsequent phases. Stakeholder groups at each facility and the IMMERSE project's Reference Group will contribute to the interpretation of findings at each phase of the project. DISCUSSION: This multi-site study will comprehensively explore infection prevention and control practices in residential aged care. It will inform and support locally appropriate evidence-based strategies for enhancing infection prevention and control practice.

Evaluation of IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) a staff simulation training intervention to improve palliative care of people with advanced dementia living in nursing homes: a cluster randomised controlled trial.

BACKGROUND: People with dementia have unique palliative and end-of-life needs. However, access to quality palliative and end-of-life care for people with dementia living in nursing homes is often suboptimal. There is a recognised need for nursing home staff training in dementia-specific palliative care to equip them with knowledge and skills to deliver high quality care. OBJECTIVE: The primary aim was to evaluate the effectiveness of a simulation training intervention (IMPETUS-D) aimed at nursing home staff on reducing unplanned transfers to hospital and/or deaths in hospital among residents living with dementia. DESIGN: Cluster randomised controlled trial of nursing homes with process evaluation conducted alongside. SUBJECTS & SETTING: One thousand three hundred four people with dementia living in 24 nursing homes (12 intervention/12 control) in three Australian cities, their families and direct care staff. METHODS: Randomisation was conducted at the level of the nursing home (cluster). The allocation sequence was generated by an independent statistician using a computer-generated allocation sequence. Staff from intervention nursing homes had access to the IMPETUS-D training intervention, and staff from control nursing homes had access to usual training opportunities. The predicted primary outcome measure was a 20% reduction in the proportion of people with dementia who had an unplanned transfer to hospital and/or death in hospital at 6-months follow-up in the intervention nursing homes compared to the control nursing homes. RESULTS: At 6-months follow-up, 128 (21.1%) people with dementia from the intervention group had an unplanned transfer or death in hospital compared to 132 (19.0%) residents from the control group; odds ratio 1.14 (95% CI, 0.82-1.59). There were suboptimal levels of staff participation in the training intervention and several barriers to participation identified. CONCLUSION: This study of a dementia-specific palliative care staff training intervention found no difference in the proportion of residents with dementia who had an unplanned hospital transfer. Implementation of the intervention was challenging and likely did not achieve adequate staff coverage to improve staff practice or resident outcomes. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618002012257 . Registered 14 December 2018.

Accuracy of the Clinical Frailty Scale for perioperative frailty screening: a prospective observational study.

PURPOSE: Perioperative frailty increases postoperative complications, mortality, and new functional dependence. Despite this, routine perioperative frailty screening is not widespread. We aimed to assess the accuracy of the Clinical Frailty Scale (CFS) as a screening tool prior to anesthesia, and to determine which health domains are affected by frailty. METHODS: In a prospective, single-centre observational study, we enrolled 218 patients aged ≥ 65 yr undergoing elective and emergency surgery. The screening performance of the CFS was compared with the Edmonton Frail Scale, including the effect in individual frailty domains, and outcomes including discharge location and mortality. RESULTS: The median [interquartile range] age of the enrolled subjects was 74 [69-80] yr and 24% of the patients were frail. The CFS and Edmonton scales were highly correlated (Spearman correlation coefficient, 0.81; 95% confidence interval [CI], 0.77 to 0.86), and in substantial agreement (kappa coefficient, 0.76; 95% CI, 0.70 to 0.81), with an area under the receiver operating characteristic curve of 0.91 (95% CI, 0.86 to 0.94) indicating excellent discrimination for the CFS in predicting frailty status based on the Edmonton scale. Frail patients had higher 30-day mortality (odds ratio, 5.26; 95% CI, 1.28 to 21.62), and were less likely to be discharged home. Frail patients had poorer health throughout frailty domains, including functional dependence (42% of frail vs 4% of non-frail patients; P < 0.001), malnutrition (48% vs 19%, P < 0.001), and poor physical performance (47% vs 7%, P < 0.001). CONCLUSION: The CFS is a valid and accurate tool to screen for perioperative frailty, which encompasses the spectrum of health-related domains.

RéSUMé: OBJECTIF: La fragilité périopératoire augmente les complications postopératoires, la mortalité et une nouvelle dépendance fonctionnelle. Le dépistage de routine de la fragilité périopératoire n'est cependant pas une pratique répandue. Nous avions pour objectif d'évaluer la précision de l'échelle de mesure de fragilité CFS (pour Clinical Frailty Scale) comme outil de dépistage préanesthésique et de déterminer quels domaines de la santé étaient affectés par la fragilité. MéTHODE: Nous avons recruté 218 patients âgés de plus de 65 ans et subissant une chirurgie non urgente ou urgente dans notre étude observationnelle prospective et monocentrique. Les résultats du dépistage de la CFS ont été comparés à l'échelle de fragilité d'Edmonton (Edmonton Frail Scale), y compris en ce qui a trait à l'effet de la fragilité sur les domaines individuels de fragilité et aux résultats tels que la destination au congé et la mortalité. RéSULTATS: L'âge médian [écart interquartile] des patients recrutés était de 74 [69­80] ans et 24 % des patients étaient fragiles. Les échelles CFS et d'Edmonton avaient une forte corrélation (coefficient de corrélation de Spearman, 0,81; intervalle de confiance [IC] 95 %, 0,77 à 0,86) et étaient en accord substantiel (coefficient kappa, 0,76; IC 95 %, 0,70 à 0,81), avec une surface sous la courbe de fonction d'efficacité de l'observateur de 0,91 (IC 95 %, 0,86 à 0,94), indiquant une discrimination excellente de la CFS pour prédire l'état de fragilité fondé sur l'échelle d'Edmonton. Les patients fragiles souffraient d'une mortalité à 30 jours plus élevée (rapport de cotes, 5,26; IC 95 %, 1,28 à 21,62) et il était moins probable qu'ils reçoivent leur congé de l'hôpital à la maison. Les patients fragiles étaient en moins bonne santé dans tous les domaines de fragilité, notamment en dépendance fonctionnelle (42 % des patients fragiles vs 4 % des patients non fragiles; P < 0,001), en malnutrition (48 % vs 19 %, P < 0,001) et en mauvaise performance physique (47 % vs 7 %, P < 0,001). CONCLUSION: L'échelle CFS constitue un outil valable et précis pour dépister la fragilité périopératoire, qui englobe l'éventail des domaines liés à la santé.

Medical student-led patient education prior to hospital discharge improves 1-month adherence rates.

Approximately 40% of patients are non-adherent to their medications. A prospective study of 80 patients evaluated the effectiveness of medical student-led pre-discharge medication education sessions. A significantly greater proportion of patients in the intervention group were adherent to their regular medications at 1 month compared with the control group (76.3% compared to 60.3%, P = 0.037). Medical student-led patient education significantly improved medication adherence rates.

The clinical frailty scale predicts functional decline and mortality when used by junior medical staff: a prospective cohort study.

BACKGROUND: Increasing frailty is associated with risk of mortality and functional decline in hospitalized older adults, but there is no consensus on the best screening method for use by non-geriatricians. The objective of this study is to determine whether the clinical frailty scale (CFS) can be used to identify patient baseline frailty status in the acute general medical setting when used by junior medical staff using information obtained on routine clinical assessment. METHODS: This was a prospective cohort study in an acute general medical unit. All patients aged 65 and over admitted to a general medical unit during August and September 2013 were eligible for the study. CFS score at baseline was documented by a member of the treating medical team. Demographic information and outcomes were obtained from medical records. The primary outcomes were functional decline and death within three months. RESULTS: Frailty was assessed in 95 % of 179 eligible patients. 45 % of patients experienced functional decline and 11 % died within three months. 40 % of patients were classified as vulnerable/mildly frail, and 41 % were moderately to severely frail. When patients in residential care were excluded, increasing frailty was associated with functional decline (p = 0.011). Increasing frailty was associated with increasing mortality within three months (p = 0.012). CONCLUSIONS: A high proportion of eligible patients had the frailty measure completed, demonstrating the acceptability of the CFS to clinicians. Despite lack of training for medical staff, increasing frailty was correlated with functional decline and mortality supporting the validity of the CFS as a frailty screening tool for clinicians.

Hospitalized Patients with Delirium and 28-Day Unplanned Hospital Readmissions: A Longitudinal Retrospective Cohort Study.

OBJECTIVE: To establish the predictors of 28-day unplanned hospital readmissions (28D-UHR) in older adults (aged >65 years) with delirium during index hospital admission. DESIGN: Retrospective longitudinal cohort study. SETTING AND PARTICIPANTS: 1634 patients (aged >65 years) admitted to a Melbourne quaternary hospital with delirium during index admission. METHODS: Delirium during hospital admission was defined by the inclusion of one of the following International Classification of Diseases, Tenth Revision, codes F05.0, F05.1, F05.8, or F05.9 in the hospital medical discharge summary. Descriptive statistics were obtained for baseline characteristics. Multivariate logistic regression model was developed to assess predictors of 28D-UHR. RESULTS: A total of 1634 patients with delirium during their inpatient admission were included, with 9.8% (160 patients) incidence of 28D-UHR. For patients who were readmitted, a shorter length of stay [odds ratio (OR) 0.98, 95% CI 0.96-0.99], higher number of medications on discharge from index admission (OR 1.10, 95% CI 1.06-1.14), and residing in a nursing home preadmission (OR 1.35, 95% CI 1.04-1.75) were associated with 28D-UHR. CONCLUSIONS AND IMPLICATIONS: This study found that nursing home residence pre index admission, shorter length of stay (LOS), and polypharmacy were predictors of 28D-UHR. Further research into strategies to minimize 28D-UHR is required. Exploration of predischarge pharmacy-driven deprescribing programs and hospital-based postdischarge support for nursing home staff are important areas for future intervention.

Assessing infection prevention and control programs in residential aged care in Australia: A multi-methods cross-sectional study.

AIM: To assess infection prevention and control programs in residential aged care facilities. METHODS: A cross-sectional survey and structured interviews from 10 residential aged care facilities in Victoria, Australia, were used. Infection prevention and control nurse leads from each facility completed a purpose-built survey based on best practice infection prevention control program core components, including staff training, policies and procedures, governance, and surveillance. Follow-up interviews with residential aged care staff, residents and family visitors were carried out to elaborate and verify survey data. RESULTS: Surveys from all 10 facilities were received and 75 interviews carried out. All facilities had an infection prevention and control lead nurse who had undergone additional training, and 60% of facilities had an infection prevention and control lead position description. All facilities had a committee to oversee their infection prevention and control program, and all had policies and procedures for standard and transmission-based precautions. One facility did not have a policy on healthcare-associated infection surveillance, and two facilities did not have an antimicrobial stewardship policy. All facilities provided staff training in hand hygiene and personal protective equipment use, but not all routinely assessed competency in these. CONCLUSIONS: The residential aged care facilities' infection prevention and control programs were generally in a strong position, although there were some areas that require improvement. Further assessment of the quality of infection prevention and control program components, such as content of education and training, and policies and procedures, and ongoing evaluation of programs is recommended. Geriatr Gerontol Int 2024; 24: 358-363.

Postoperative B-type natriuretic peptide for prediction of major cardiac events in patients undergoing noncardiac surgery: systematic review and individual patient meta-analysis.

BACKGROUND: It is unclear whether postoperative B-type natriuretic peptides (i.e., BNP and N-terminal proBNP) can predict cardiovascular complications in noncardiac surgery. METHODS: The authors undertook a systematic review and individual patient data meta-analysis to determine whether postoperative BNPs predict postoperative cardiovascular complications at 30 and 180 days or more. RESULTS: The authors identified 18 eligible studies (n = 2,051). For the primary outcome of 30-day mortality or nonfatal myocardial infarction, BNP of 245 pg/ml had an area under the curve of 0.71 (95% CI, 0.64-0.78), and N-terminal proBNP of 718 pg/ml had an area under the curve of 0.80 (95% CI, 0.77-0.84). These thresholds independently predicted 30-day mortality or nonfatal myocardial infarction (adjusted odds ratio [AOR] 4.5; 95% CI, 2.74-7.4; P < 0.001), mortality (AOR, 4.2; 95% CI, 2.29-7.69; P < 0.001), cardiac mortality (AOR, 9.4; 95% CI, 0.32-254.34; P < 0.001), and cardiac failure (AOR, 18.5; 95% CI, 4.55-75.29; P < 0.001). For greater than or equal to 180-day outcomes, natriuretic peptides independently predicted mortality or nonfatal myocardial infarction (AOR, 3.3; 95% CI, 2.58-4.3; P < 0.001), mortality (AOR, 2.2; 95% CI, 1.67-86; P < 0.001), cardiac mortality (AOR, 2.1; 95% CI, 0.05-1,385.17; P < 0.001), and cardiac failure (AOR, 3.5; 95% CI, 1.0-9.34; P = 0.022). Patients with BNP values of 0-250, greater than 250-400, and greater than 400 pg/ml suffered the primary outcome at a rate of 6.6, 15.7, and 29.5%, respectively. Patients with N-terminal proBNP values of 0-300, greater than 300-900, and greater than 900 pg/ml suffered the primary outcome at a rate of 1.8, 8.7, and 27%, respectively. CONCLUSIONS: Increased postoperative BNPs are independently associated with adverse cardiac events after noncardiac surgery.

Exploratory and confirmatory factor analysis of the questionnaire on Palliative Care for Advanced Dementia (qPAD) using a large sample of staff from Australian residential aged care homes.

BACKGROUND: The Questionnaire on Palliative Care for Advanced Dementia (qPAD) is increasingly being used to assess residential aged care workers' knowledge and attitudes about palliative care for people with dementia. The qPAD developers performed an exploratory factor analysis and assessed the internal consistency using a small sample. AIM: The aim of this study was to further assess the structural validity of the qPAD using a large sample of qPAD responses from staff who work in residential aged care homes in Australia. METHODS: Data from 727 care staff who participated in an Australian dementia palliative care training project were used for exploratory factor analyses, assessment of internal consistency, and confirmatory factor analysis of the knowledge test and attitude scale components of the qPAD. RESULTS: The exploratory factor analysis of the knowledge test produced a four-factor solution. One item loaded weakly, and four items had cross-loadings. Factor labels for the knowledge test were difficult to define. Factor analysis of the attitude scale produced a three-factor structure with good internal consistency-Feeling valued and part of the care team (α = 0.88), Family and team engagement (α = 0.75) and Perceptions and beliefs (α = 0.83). Confirmatory factor analysis indicated improvements in model fit were needed for both the knowledge test and attitude scale. CONCLUSION: The findings of this factor analysis differed from the original study. The attitude scale produced a three-factor structure, but the knowledge test requires further development due to weak and cross-loadings of several items, inadequate internal consistency of factors and poor model fit.

Development of a Frailty Index from Routine Hospital Data in Perioperative and Critical Care.

BACKGROUND/OBJECTIVES: Frailty is common in surgical and intensive care unit (ICU) populations, yet it is not routinely measured. Frailty indices are able to quantify this condition across a range of health deficits. We aimed to develop a frailty index (FI) from routinely collected hospital data in a surgical and ICU population. DESIGN: Prospective observational single-center cohort study. SETTING: Tertiary referral metropolitan Australian hospital. PARTICIPANTS: A total of 336 individuals aged 65 and older undergoing surgery or aged 50 and older admitted to the ICU. MEASUREMENTS: Routine admission health data were used to derive an FI comprising 36 health deficits. We examined the FI correlation with existing frailty tools (Clinical Frailty Scale [CFS] and Edmonton Frail Scale [EFS]) and assessed its predictive ability for negative outcomes including 30-day mortality. RESULTS: Median FI was .17 (interquartile range [IQR]) = .10-.24) for ICU patients and .17 (IQR = .11-.25) for surgical patients; maximum FI was .58, and 25% (95% confidence interval [CI] = 10.4-29.6) of patients overall were diagnosed with frailty (FI score ≥.25). Correlation was strong between the FI and the EFS: ρ = .76 (95% CI = .70-.83) for ICU patients and .71 (95% CI = .64-.78) for surgical patients, and the CFS was .77 (95% CI = .70-.84) for ICU patients and .72 (95% CI = .65-.79) for surgical patients. The FI had good discriminative ability for prediction of 30-day mortality in ICU patients (multivariate odds ratio for each increase in FI of .1 = 2.04 [95% CI = 1.19-3.48]), comparable with the performance of the Acute Physiology and Chronic Health Evaluation III score (ICU patients) and the Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity score (surgical patients). CONCLUSION: It is feasible to construct an FI from hospital admission data in a cohort of critically ill and surgical patients.

Contributors to frailty in critical illness: Multi-dimensional analysis of the Clinical Frailty Scale.

PURPOSE: Frailty in critical illness is common and associated with poor outcomes, however little is known about contributing factors. We compared the Clinical Frailty Scale (CFS) with a multi-dimensional validated tool, the Edmonton Frail Scale (EFS), and investigated which health domains are affected by frailty in ICU. MATERIALS AND METHODS: This prospective cohort study enrolled patients aged ≥50 years admitted between February-June 2017, comparing the CFS and EFS using Spearman correlation and Kappa coefficients, assessing frailty status across health domains, and examining outcomes including mortality. RESULTS: One hundred and sixty patients were enrolled, 33.8% were frail. Frail patients had greater in-hospital and 6-month mortality [25.9% vs. 8.5%; adjusted OR (95% CI) = 3.31 (1.17, 9.39), p = .024; and 40.4% vs. 17.3%; OR (95% CI) = 2.84 (1.18, 6.83), p = .020 respectively]. CFS and EFS scales were highly correlated [Spearman correlation coefficient = 0.85 (95% CI 0.81-0.88)], with high agreement [kappa coefficient = 0.78 (95% CI: 0.68-0.88)]. Frail patients had worse health status across the spectrum of frailty domains, in particular functional dependence, malnutrition, and prior hospital admissions. CONCLUSIONS: Frailty in the critically ill affects a range of health deficits, adequately measured via the CFS.

Protocol for a prospective observational study to develop a frailty index for use in perioperative and critical care.

INTRODUCTION: Frailty is of increasing importance to perioperative and critical care medicine, as the proportion of older patients increases globally. Evidence continues to emerge of the considerable impact frailty has on adverse outcomes from both surgery and critical care, which has led to a proliferation of different frailty measurement tools in recent years. Despite this, there remains a lack of easily implemented, comprehensive frailty assessment tools specific to these complex populations. Development of a frailty index using routinely collected hospital data, able to leverage the automated aspects of an electronic medical record, would aid risk stratification and benefit clinicians and patients alike. METHODS AND ANALYSIS: This is a prospective observational study. 150 intensive care unit (ICU) patients aged ≥50 years and 200 surgical patients aged ≥65 years will be enrolled. The primary objective is to develop a frailty index. Secondary objectives include assessing its ability to predict in-hospital mortality and/or discharge to a new non-home location; the performance of the frailty index in predicting postoperative and ICU complications, as well as health-related quality of life at 6 months; to compare the performance of the frailty index against existing frailty measurement and risk stratification tools; and to assess its modification by patients' health assets. ETHICS AND DISSEMINATION: This study has been approved by the Melbourne Health Human Research Ethics Committee(20 January 2017, HREC/16/MH/321). Dissemination will be via international and national anaesthetic and critical care conferences, and publication in the peer-reviewed literature.

Frailty indexes in perioperative and critical care: A systematic review.

BACKGROUND/OBJECTIVES: Frail patients are increasingly presenting for both perioperative and intensive care, highlighting the need for simple, valid and scaleable frailty measurement. Frailty indexes comprehensively assess a range of deficits in health, and can incorporate routinely collected data. The purpose of this systematic review was to evaluate the effect of frailty indexes on surgical and intensive care risk stratification and patient outcomes (mortality, complications, length of stay, and discharge location). METHODS: A prospectively registered systematic review was performed. MEDLINE, EMBASE, and CINAHL were searched to identify studies enrolling adult surgical or intensive care patients which used a frailty index. Included studies were those published subsequent to 1990, of any study design, which utilised a frailty index consisting of ≥30 health deficits. Primary outcome was mortality; secondary outcomes were complications, length of stay (LOS) and discharge location. Study and frailty index quality were critically appraised by three independent reviewers, with findings narratively described. RESULTS: 2026 articles were screened, from which nine prospective and four retrospective cohort studies (enrolling 2539 patients) were included. Frailty prevalence ranged between 19-62%; frailty indexes identified patients at risk of increased death [mortality rates ranging between 1.9-73.1%; reported odds ratios (ORs) for death ranging between 1.76-3.09 for frail vs. non-frail patients], surgical complications (ORs = 1.67-4.4), increased LOS, and discharge to residential care (ORs = 1.9-3.64). The term "frailty index" was found to be applied to a number of alternative measurement scales. CONCLUSION: Frail patients are at significantly increased risk in critical illness and the perioperative period. Better standardisation of frailty indexes is recommended.

Additional exercise does not change hospital or patient outcomes in older medical patients: a controlled clinical trial.

QUESTION: What are the effects of additional exercise on hospital and patient outcomes for acutely-hospitalised older medical patients? DESIGN: Controlled clinical trial. PARTICIPANTS: 236 Patients aged 65 or older admitted to an acute care hospital with a medical illness between October 2002 and July 2003. INTERVENTION: The experimental group received usual care plus an individually tailored exercise program administered twice daily from hospital admission to discharge. The control group received usual care only. OUTCOME MEASURES: The primary outcome was discharge destination. Secondary outcomes were measures of activity limitation (Barthel Index, Timed Up and Go, Functional Ambulation Classification), length of stay, and adverse events. RESULTS: There was no significant effect of the additional exercise program on any outcome. There were no significant differences between groups for the proportion of the patients discharged to home (RR 0.99, 95% CI 0.86 to 1.14) or inpatient rehabilitation (RR 0.76, 95% CI 0.30 to 1.51) or for measures of activity limitation at hospital discharge. A one day difference in length of stay was identified between groups but this difference was not significant (p = 0.45). There were no significant differences between groups for adverse events: 28-day readmission (RR 1.10, 95% CI 0.65 to 1.86), patient mortality (RR 1.15, 95% CI 0.16 to 8.0), intensive care admission (RR 0.16, 95% CI 0.01 to 3.13) and falls (RR 0.69, 95% CI 0.17 to 2.81). CONCLUSION: Additional physiotherapy intervention during hospitalisation did not significantly improve hospital or patient outcomes.

Good quality of life outcomes after treatment of prosthetic joint infection with debridement and prosthesis retention.

Patients treated for early prosthetic joint infection (PJI) with surgical debridement and prosthesis retention have a rate of successful infection eradication that is similar to patients treated with the traditional approach of prosthesis exchange. It is therefore important to consider other outcomes after prosthetic joint infection treatment that may influence management decisions, such as quality of life (QOL). Our aim was to describe infection cure rates and quality of life for patients with prosthetic joint infection treated with debridement and prosthesis retention and to determine if treatment with this approach was a risk factor for poor quality of life outcomes. Prospectively collected pre and post-arthroplasty data were available for 2,134 patients, of which PJI occurred in 41. For patients treated for prosthetic joint infection, the 2-year survival free of treatment failure was 87% (95%CI 84-89). Prosthetic joint infection cases treated with debridement and retention had a similar improvement from pre-arthroplasty to 12-months post-arthroplasty as patients without PJI in QOL according to the SF-12 survey. Prosthetic joint infection treated with debridement and retention was not a risk factor for poor quality of life on univariate or multivariate analysis. Prosthetic joint infection treated with debridement and prosthesis retention results in good cure rates and quality of life. Further studies are required that directly compare quality of life for different surgical approaches for prosthetic joint infection to better inform management decisions. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:898-902, 2016.

People aged over 75 in atrial fibrillation on warfarin: the rate of major hemorrhage and stroke in more than 500 patient-years of follow-up.

OBJECTIVES: To determine the incidence of major hemorrhage and stroke in people aged 76 and older with atrial fibrillation on adjusted-dose warfarin who had been recently been admitted to hospital. DESIGN: A retrospective observational cohort study. SETTING: A major healthcare network involving four tertiary hospitals. PARTICIPANTS: Two hundred thirty-five patients aged 76 and older admitted to a major healthcare network between July 1, 2001, and June 30, 2002, with atrial fibrillation on warfarin were enrolled. MEASUREMENTS: Information regarding major bleeding episodes, strokes, and warfarin use was obtained from patients, relatives, primary physicians, and medical records. RESULTS: Two hundred twenty-eight patients (42% men) with a mean age of 81.1 (range 76-94) were included in the analysis. Total follow-up on warfarin was 530 years (mean 28 months). There were 53 major hemorrhages, for an annual rate of 10.0%, including 24 (45.3%) life-threatening and five (9.4%) fatal bleeds. The annual stroke rate after initiation of warfarin was 2.6%. CONCLUSION: The rate of major hemorrhage was high in this old, frail group, but excluding fatalities, resulted in no long-term sequelae, and the stroke rate on warfarin was low, demonstrating how effective warfarin treatment is.

Care coordination in the Emergency Department: improving outcomes for older patients.

This study aimed to evaluate the effectiveness of the care coordination (CC) program operating in the Emergency Department (ED) of The Northern Hospital in improving outcomes for older people and reducing ED admissions and re-presentations. This was achieved by comparing admissions from ED to wards pre and post commencement of the CC program, and measuring patient health-related quality of life pre and post CC intervention. Patient readmission rates and staff and patient satisfaction with the service were also investigated. Results indicate a statistically significant reduction in the proportion of patients admitted from the ED to a ward since the inception of the program, a significant difference in the mean-related quality of life scores before and after intervention by care coordination, and staff and patient satisfaction with the service. The readmission data collected in the present evaluation will serve as a baseline measure for future evaluations.

An enhanced exercise and cognitive programme does not appear to reduce incident delirium in hospitalised patients: a randomised controlled trial.

OBJECTIVE: To determine if a programme of progressive resistance exercise, mobilisation and orientation, in addition to usual care, was superior to usual care alone in the prevention of incident delirium in older hospitalised patients. DESIGN: A randomised controlled trial. SETTING: The study was performed at a secondary referral hospital in Melbourne, Australia between May 2005 and December 2007. PARTICIPANTS: 648 consecutive medical inpatients aged 65 years or older who had been in hospital for less than 48 h and who did not have delirium. INTERVENTION: Participants were randomly allocated to a twice-daily programme of progressive resistance exercise tailored to individual ability, mobilisation and orientation in addition to usual care or to usual care alone. MEASUREMENTS: Delirium was measured using the Confusion Assessment Method at baseline and every 48 h until discharge. Secondary outcome measures were severity and duration of delirium, discharge destination and length of stay. RESULTS: Delirium occurred in 4.9% (95% CI 2.3% to 7.3%) of the intervention group (15/305) and in 5.9% (20/339; 95% CI 3.8% to 9.2%) of the group receiving usual care. No difference was observed between groups (χ(2); p=0.5). The intervention had no effect on delirium duration, severity, discharge destination or length of stay. CONCLUSION: A programme of progressive resistance exercise and orientation was not effective in reducing incident delirium in hospitalised elderly patients.