Reforming allied health service provision in residential aged care to improve the rehabilitation reach: a feasibility study.

Objective My Therapy is an allied health guided, co-designed rehabilitation self-management program for residents of aged care facilities. This study aimed to determine the feasibility of implementing My Therapy in a residential aged care setting. Methods This observational study was conducted on a 30-bed wing, within a 90-bed metropolitan residential aged care facility, attached to a public health service, in Victoria, Australia. Staff and resident data were collected prospectively over 6 weeks (staff focus groups, patient surveys, and audits) to evaluate the feasibility domains of acceptability , reach and demand , practicality , integration , limited efficacy testing and adaptations . Results Twenty-six residents and five allied health staff (physiotherapy and occupational therapy) participated. My Therapy was acceptable to residents (survey) and staff (focus groups). Via initial My Therapy discussions between the resident and the therapists, to determine goals and resident preferences, My Therapy reached 26 residents (n = 26/26, 100% program reach ), with 15 residents subsequently receiving a rehabilitation program (n = 15/26, 58% program demand ). The remaining 11 residents did not participate due to resident preference or safety issues (n = 11/26, 42%). Collecting physical function outcome measures for limited efficacy testing was practical , and the cost of My Therapy was AUD$6 per resident per day, suggesting financial integration may be possible. Several adaptations were required, due to limited allied health staff, complex resident goal setting and program co-design. Conclusion My Therapy has the potential to improve the rehabilitation reach of allied health services in residential aged care. While introducing this low-cost intervention is feasible, adaptations were required for successful implementation.

Pharmacist-led medication review in a residential in-reach service leads to deprescribing.

OBJECTIVE: To examine the effect of a pharmacist-led medication review on deprescribing medications in a Residential In-Reach (RIR) service which provides acute care substitution to residential aged care residents. METHODS: A pre-post observational study was conducted. Patient characteristics and admission and discharge medications were collected over two 3-month phases before (prephase) and after (postphase) the introduction of a pharmacist who performed a comprehensive medication review and provided deprescribing recommendations. The Screening Tool of Older Persons' Prescriptions (STOPP) version 2 was used to identify potentially inappropriate medications (PIMs). The Drug Burden Index (DBI) was used to measure cumulative anticholinergic and sedative medication burden. Outcome of deprescribing was measured by the reduction in the number of PIMs, DBI scores and proportion of polypharmacy from admission to discharge. RESULTS: The prephase included 59 patients (mean age 87.3 years, 63% female), and the postphase included 88 patients (mean age 87.3 years, 63% female). There was a significant reduction in the mean number of PIMs (pre +0.05 ± 2.59 vs. post -0.78 ± 2.32, p = 0.04) and median DBI (pre -0.004 ± 0.17 vs. post -0.07 ± 0.2, p = 0.03) in postphase compared to prephase. The proportion of polypharmacy at discharge was reduced in the postphase (pre-100% vs. post-90%, p = 0.01). The most deprescribed PIMs as measured by STOPP in postphase were drugs without indication, cardiovascular system drugs and gastrointestinal system drugs. CONCLUSIONS: The introduction of a pharmacist-led medication review in RIR service was associated with a significant reduction in the mean number of PIMs, median DBI and polypharmacy. Future studies are needed to determine whether deprescription is sustained to examine correlations to long-term patient outcomes.

Telehealth consultation before inter-hospital transfer after falls in a subacute hospital (the PREVENT-2 study).

OBJECTIVE: Inter-hospital transfers are increasingly common due to the regionalisation of healthcare, but are associated with patient discomfort, high costs and adverse events. The aim of the present study was to evaluate the effectiveness of a trauma outreach service for preventing inter-hospital transfers to a major trauma centre. METHODS: This was an observational pre- and post-intervention study over a 12-month period from 1 October 2020 to 30 September 2021. Eligible patients sustained a fall at Caulfield Hospital, a subacute care hospital specialising in community services, rehabilitation, geriatric medicine and aged mental health. The intervention was delivery of site-specific education at Caulfield Hospital and a trauma outreach service by specialist trauma clinicians at The Alfred Hospital who provided remote assessment, assisted with clinical management decisions and advised on appropriateness of transfer. RESULTS: The present study included 160 patients in the pre-intervention phase and 203 after the intervention. The primary outcome of transfer occurred in 19 (11.9%) patients in the pre-intervention phase and 4 (2.0%) in the post-intervention phase (P < 0.001). In the subgroup of patients without pelvis or long bone fractures, pre-intervention transfer occurred for 17 (10.9%) patients and post-intervention transfer occurred for 4 (2.0%) patients (P < 0.001). CT imaging was performed for 54 (33.8%) patients in the pre-intervention and 45 (22.2%) patients in the post-intervention group (P = 0.014). CONCLUSIONS: Telehealth consultation with a trauma specialist was associated with significant reduction of inter-hospital transfers, and significant reduction of CT imaging. This supports continuation of the service with scope for expansion and evaluation of patient-centred outcomes.

Nursing perspectives on reducing sedentary behaviour in sub-acute hospital settings: A mixed methods study.

AIM AND OBJECTIVES: To determine the factors influencing nurses' decisions and capacity to reduce sedentary behaviour in hospital inpatients in sub-acute hospital settings. BACKGROUND: Sedentary behaviour in hospital inpatients is a complex issue that can be resistant to resolution. There is little research investigating factors influencing nurses' promotion of reduced levels of sedentary behaviour in sub-acute hospital settings. DESIGN: An explanatory sequential design was employed, comprising quantitative and qualitative phases. METHODS: An online survey was conducted with a convenience sample of 138 nurses from five Australian states. Logistic regression modelling identified demographic and behavioural characteristics of nurses who often encouraged patients to reduce their sedentary behaviour. In-depth interviews were conducted with 11 ward nurses and nurse managers, with the content subjected to thematic analysis. STROBE and GRAMMS checklists were employed. RESULTS: Nurses recognised their role in promoting reduced sedentary behaviour but faced a range of personal and organisational barriers in achieving this outcome for patients. Few nurses were aware of national physical activity and sedentary behaviour guidelines. Five themes emerged from interviews (nursing role, care challenges, expectations of advocates, teamwork and improving the experience). Overall, many nurses experienced a lack of agency in promoting reduced sedentary behaviour and cognitive dissonance in feeling unable to undertake this role. CONCLUSIONS: The results of this study are significant in confirming that reducing sedentary behaviour in hospital inpatients is influenced by a range of complex and multi-level factors. There is a fundamental need for organisational and clinical leadership in building a culture and climate in which staff feel empowered to promote reduced sedentary behaviour in their patients. RELEVANCE TO CLINICAL PRACTICE: The results of this study highlight the importance of taking action to reduce sedentary behaviour in sub-acute hospital settings. A co-design approach to developing interventions in local health services is warranted.

Evaluation of a dedicated outpatient hip fracture clinic.

OBJECTIVES: There is a lack of guidance on how to manage the multiple post-discharge issues of older people following minimal trauma hip fracture. We developed a geriatrician-staffed outpatient service for people aged ≥65 years admitted with a hip fracture who were not discharged to a nursing home. We aimed to evaluate the potential benefits of the addition of a dedicated hip fracture follow-up clinic by measuring the actions performed by such a clinic. METHODS: We evaluated the potential benefit of the clinic through a retrospective review of the medical records of all those referred to the clinic over a 2-year period. RESULTS: A total of 80 people were provided a clinic appointment, with 43 (54%) attending. The median age of clinic attendees was 81 years. A total of 40/43 (93%) of attendees received inpatient rehabilitation in a sub-acute facility before discharge. At the dedicated outpatient clinic, multiple issues were identified and managed including further fall reduction strategies (n = 12), commencement of anti-resorptive medications (n = 11) and medication deprescribing (n = 11). CONCLUSIONS: We found that the introduction of a dedicated hip fracture outpatient clinic identified and managed a broad range of issues. It is unclear if these needs would have been met by previously existing services. Further work is required to clarify whether managing these issues translates into improved patient outcomes and whether a dedicated clinic is a cost-effective practice of achieving this.

Redundancy within hospital-related harm prediction tools.

The predictive ability and efficiency of inpatient harm screening tools is unclear. We performed a retrospective analysis of approximately 25 000 people admitted to our hospital in 2019. We found that the discriminatory ability of the harm screening tools was at best moderate and could be attributed to one or two questions that overlapped with each other in the harm they predicted.

Electronic Medication Management System Introduction and Deprescribing Practice in Post-Acute Care.

OBJECTIVE: To determine the effect of introducing an electronic medication management system (EMMS) on deprescribing practice in a post-acute hospital setting. DESIGN: This study used a before-after study design. SETTING AND PARTICIPANTS: This study examined the admission and discharge medications prescribed to patients admitted to an Australian post-acute hospital before and after the introduction of an EMMS. METHODS: Data were collected over a 1-month period before and after the introduction of an EMMS and included summary measures of drug burden including Potentially Inappropriate Medications and the Drug Burden Index. We calculated and compared admission and discharge medication prescription as well as change in medication use before and after the introduction of an EMMS. RESULTS: Medication prescription data were available for 121 people before and 107 people after EMMS introduction. In both phases, when compared with admission, those discharged were prescribed fewer medications (mean reduction pre-EMMS = 2.9, P < .001, post-EMMS = 2.6, P < .001), fewer Potentially Inappropriate Medications (mean reduction pre-EMMS = 0.4, P < .001, post-EMMS = 0.6, P < .001) and had lower Drug Burden Index (mean reduction pre-EMMS = 0.1, P < .001, post-EMMS = 0.2, P < .001). The degree of reduction in each measure was similar before and after EMMS introduction. CONCLUSIONS AND IMPLICATIONS: The introduction of an EMMS did not affect deprescribing practice in a post-acute hospital setting. Future work is required to explore the potential for clinical decision support within an EMMS to further improve the safety and effectiveness of deprescribing within post-acute care.

Examination of risk scores to better predict hospital-related harms.

BACKGROUND: Many hospitals use predictive scores to identify a person's risk of inpatient falls, pressure injury and malnutrition despite evidence of limited predictive accuracy. AIM: To examine whether we could improve predictive accuracy by generating a score combining all components of currently used tools. METHODS: We performed a retrospective, cross-validation study in a single sub-acute (geriatrics and rehabilitation) hospital, extracting data regarding hospital risk scores, and incidence of falls, pressure injury and malnutrition from January 2014 to June 2016. The sample was randomly halved into training and testing data sets. For each harm outcome, model fit was examined using area under receiver operating characteristic curves (AUC) and proportions of people reclassified based on a combined score were calculated. Secondary analyses explored the predictive performance of individual question-responses. RESULTS: Data were available for 4487 admissions (median age 83.0 years). A total of 667 (15%) people had at least one fall, 499 (11%) had at least one pressure injury and 20 (0.4%) malnutrition. The currently used tools had, at best, moderate ability to predict risk of harm outcomes (AUC 0.56-0.73). Testing of the combined score models resulted in minimal change in AUC (<5.1%) and did not add value to risk category reclassification. Most of the predictive ability of the currently used tools relied on the performance of two individual question-responses. CONCLUSION: Combining scores or reducing to two-item question-responses did little to change predictive accuracy. This study highlights the limitations of hospital harm predictive scores and emphasises the importance of rigorous testing of predictive scores.