The Aging, Community and Health Research Unit Community Partnership Program (ACHRU-CPP) for older adults with diabetes and multiple chronic conditions: study protocol for a randomized controlled trial.

BACKGROUND: Older adults (≥65 years) with diabetes and multiple chronic conditions (MCC) (> 2 chronic conditions) experience reduced function and quality of life, increased health service use, and high mortality. Many community-based self-management interventions have been developed for this group, however the evidence for their effectiveness is limited. This paper presents the protocol for a randomized controlled trial (RCT) comparing the effectiveness and implementation of the Aging, Community and Health Research Unit-Community Partnership Program (ACHRU-CPP) to usual care in older adults with diabetes and MCC and their caregivers. METHODS: We will conduct a cross-jurisdictional, multi-site implementation-effectiveness type II hybrid RCT. Eligibility criteria are: ≥65 years, diabetes diagnosis (Type 1 or 2) and at least one other chronic condition, and enrolled in a primary care or diabetes education program. Participants will be randomly assigned to the intervention (ACHRU-CPP) or control arm (1:1 ratio). The intervention arm consists of home/telephone visits, monthly group wellness sessions, multidisciplinary case conferences, and system navigation support. It will be delivered by registered nurses and registered dietitians/nutritionists from participating primary care or diabetes education programs and program coordinators from community-based organizations. The control arm consists of usual care provided by the primary care setting or diabetes education program. The primary outcome is the change from baseline to 6 months in mental functioning. Secondary outcomes will include, for example, the change from baseline to 6 months in physical functioning, diabetes self-management, depressive symptoms, and cost of use of healthcare services. Analysis of covariance (ANCOVA) models will be used to analyze all outcomes, with intention-to-treat analysis using multiple imputation to address missing data. Descriptive and qualitative data from older adults, caregivers and intervention teams will be used to examine intervention implementation, site-specific adaptations, and scalability potential. DISCUSSION: An interprofessional intervention supporting self-management may be effective in improving health outcomes and client/caregiver experience and reducing service use and costs in this complex population. This pragmatic trial includes a scalability assessment which considers a range of effectiveness and implementation criteria to inform the future scale-up of the ACHRU-CPP. TRIAL REGISTRATION: Clinical Trials.gov Identifier NCT03664583 . Registration date: September 10, 2018.

Critical care in the emergency department: an assessment of the length of stay and invasive procedures performed on critically ill ED patients.

INTRODUCTION: Critically ill patients commonly present to the ED and require aggressive resuscitation. Patient transfer to an ICU environment in an expedient manner is considered optimal care. However, this patient population may remain in the ED for prolonged periods of time. The goal of this study is to describe the ED length of stay, and the invasive procedures performed in critically ill ED patients. METHODS: This is a retrospective medical record review of all patients who presented to the study center over a 1 year period. Patient demographic data, in addition to the times of ED presentation and ICU admission were recorded. Invasive procedures performed in the pre-hospital, ED and the initial 24 hours of ICU care were also recorded. RESULTS: Overall, 178 patients' required direct admission to an ICU from the ED, with a mortality rate of 21.9%. The median LOS in the ED for critically ill patients requiring ICU admission was 4.9 h (mean 6.5 h, range 1.4-28.2 h). Seventy percent of patients (125,178, 70.2%) required endotracheal intubation with the majority (118/125, 94.4%) being performed in the ED (80/125, 64.0%) or the prehospital setting (38/125, 30.4%). Central venous access was obtained in 56/178 patients (31.5%), with 17.9% (10/56) completed in the ED. Similarly, arterial catheters were inserted in 99/178 patients (55.6%) with 14.1% (14/99) inserted in the ED. CONCLUSION: Critically ill patients are managed in the emergency department for a significant length of time. Although the majority of airway intervention occurs in the prehospital setting and ED, relatively few patients undergo invasive procedures while in the emergency department.