Delivering improved patient and system outcomes for hospitalized older adults through an Acute Care for Elders Strategy.

Acute care hospitals are widely recognized as potentially high-risk environments for older adults. In 2010, Mount Sinai Hospital conceived its Acute Care for Elders (ACE) Strategy as a multi-component intervention to improve the care of hospitalized older adults. In order to determine its effectiveness, we conducted a quasi-experimental time series analysis of 12,008 older patients admitted non-electively for acute medical issues over a 6-year period. Despite a 53% increase in annual admissions of older patients between 2009/2010 and 2014/2015, Mount Sinai decreased total lengths of stay and readmissions and reduced the direct cost of care per patient, leading to net savings of CDN$4.2 million in 2014/2015. This article presents Mount Sinai's ACE Strategy and discusses the benefits of implementing integrated evidence-based models across the continuum of care and how it is supporting the implementation of ACE Strategy models of care and care practices across Canada and beyond.

Sport Participation for People with Disabilities: Exploring the Potential of Reverse Integration and Inclusion through Wheelchair Basketball.

Reverse integration is defined as the inclusion of able-bodied people into disability sport. For decades, there have been movements towards integrating people with a disability in mainstream society. There has been a lack of research supporting the movement of able-bodied involvement in disability sport, known as reverse integration. In this study, the real-life experiences and motivations of 11 national wheelchair basketball players (four able-bodied and seven with a disability) were explored, identifying the potential of reverse integration and what influenced the players involvement. Thematic analysis was employed using a deductive approach. The social-relational model was used as a framework to help interpret the findings. The results highlighted that health and social benefits were key factors towards prolonged engagement in wheelchair basketball, and it was reported that reverse integration led to an increased mutual understanding of the impact of (dis)ability. All participants reported positive experiences and supported able-bodied involvement, suggesting that able-bodied players play a key role and help to grow the sport locally. However, involvement of able-bodied players was not supported at international level. This challenges the concept of inclusion at higher level and whether the sport could be more inclusive. These findings could provide direction to coaches and policymakers for developing further inclusive opportunities at all levels. Further research may explore coach education programs and learning experiences of becoming an inclusive coach to ensure coaches know how to create, stimulate and coach in inclusive sport environments.

Reducing unnecessary sedative-hypnotic use among hospitalised older adults.

BACKGROUND: Benzodiazepines and sedative hypnotics (BSH) have numerous adverse effects that can lead to negative outcomes, particularly in vulnerable hospitalised older adults. At our institution, over 15% of hospitalised older adults are prescribed sedative-hypnotics inappropriately. Of these prescriptions, 87% occurred at night to treat insomnia and almost 20% came from standard admission order sets. METHODS: We conducted a time-series study from January 2015 to August 2016 among medical and cardiology inpatients following the implementation in August 2015 of a sedative reduction bundle (education, removal of BSH from available admission order sets and non-pharmacological strategies to improve sleep). Preintervention period was January-July 2015 and postintervention period was August 2015-August 2016. A surgical ward served as control. Primary outcome was the proportion of BSH-naive (not on BSH prior to admission) patients 65 years or older discharged from medical and cardiology wards who were prescribed any new BSH for sleep in hospital. Data were analysed on statistical process control (SPC) p-charts with upper and lower limits set at 3δ using standard rules. Secondary measures included Patient-reported Median Sleep Quality scores and rates of fall and sedating drug prescriptions that may be used for sleep (dimenhydrinate). RESULTS: During the study period, there were 5805 and 1115 discharges from the intervention and control units, respectively. From the mean baseline BSH prescription rate of 15.8%, the postintervention period saw an absolute reduction of 8.0% (95% CI 5.6% to 10.3%; p<0.001). Adjusted for temporal trends, the intervention produced a 5.3% absolute reduction in the proportion of patients newly prescribed BSH (95% CI 5.6% to 10.3%; p=0.002). BSH prescription rates remained stable on the control ward. Patient-reported measure of sleep quality, falls and use of other sedating medications remained unchanged throughout the study duration. CONCLUSION: A comprehensive intervention bundle was associated with a reduction in inappropriate BSH prescriptions among older inpatients.

Effect of a Multimodal Educational Intervention on Use of Urinary Catheters in Hospitalized Individuals.

BACKGROUND/OBJECTIVES: Urinary catheters are frequently used in hospital inpatients despite their association with greater morbidity and mortality. Reducing their unnecessary use can improve patient care. The objective of the current study was to determine the effectiveness of a multimodal nursing and physician education intervention to reduce the unnecessary use of urinary catheters in adult inpatients. DESIGN: Quasi-experimental interrupted time series study. SETTING: General internal medicine and surgical services of a large urban teaching hospital. PARTICIPANTS: Admissions to the services under study during the study period (September 2009 to February 2013) (N = 21,550). INTERVENTION: A multimodal educational intervention incorporating educational posters, small-group teaching sessions, and changes to the hospital's electronic health records and nursing clinical documentation systems were introduced to nurses and physicians. MEASUREMENTS: Mean catheter days per patient (CDPP) and incidence of urinary catheterization, measured at monthly intervals throughout the study period. RESULTS: A decrease in mean CDPP of 5.6 and 6.5 days (P < .001) respectively was observed on the medical and surgical services following the intervention. The monthly incidence of catheterization decreased by 3.0 percentage points on medical units and 6.4 percentage points on surgical units immediately after the intervention, from an average of 14.5% and 15.0%, respectively, before the intervention. Similar degrees of improvement were observed for individuals of all ages, although older adults remained more likely to be catheterized. The effect persisted over nearly 3 years of observed follow-up. CONCLUSIONS: A relatively simple multimodal educational intervention targeting nurses and physicians resulted in a significant and sustained reduction in CDPP and the proportion of participants catheterized.

Do post discharge phone calls improve care transitions? A cluster-randomized trial.

IMPORTANCE: The transition from hospital to home can expose patients to adverse events during the post discharge period. Post discharge care including phone calls may provide support for patients returning home but the impact on care transitions is unknown. OBJECTIVE: To examine the effect of a 72-hour post discharge phone call on the patient's transition of care experience. DESIGN: Cluster-randomized control trial. SETTING: Urban, academic medical center. PARTICIPANTS: General medical patients age 18 and older discharged home after hospitalization. MAIN OUTCOMES AND MEASURES: Primary outcome measure was the Care Transition Measure (CTM-3) score, a validated measure of the quality of care transitions. Secondary measures included self-reported adherence to medication and follow up plans, and 30-day composite of emergency department (ED) visits and hospital readmission. RESULTS: 328 patients were included in the study over an 6-month period. 114 (69%) received a post discharge phone call, and 214 of all patients in the study completed the follow outcome survey (65% response rate). A small difference in CTM-3 scores was observed between the intervention and control groups (1.87 points, 95% CI 0.47-3.27, p = 0.01). Self-reported adherence to treatment plans, ED visits, and emergency readmission rates were similar between the two groups (odds ratio 0.57, 95% CI 0.13-2.45, 1.20, 95% CI 0.61-2.37, and 1.18, 95% CI 0.53-2.61, respectively). CONCLUSIONS AND RELEVANCE: A single post discharge phone call had a small impact on the quality of care transitions and no effect on hospital utilization. Higher intensity post discharge support may be required to improve the patient experience upon returning home. TRIAL REGISTRATION: ClinicalTrials.gov NCT01580774.