Alcohol use is associated with intracranial hemorrhage in older emergency department head trauma patients.

Objectives: Falls are common in adults aged 65 years and older and are the leading cause of traumatic brain injuries in this age group. Alcohol use may increase the risk of falls as well as the severity of resultant injuries. The aim of this study was to examine the association between self-reported alcohol use and the prevalence of intracranial hemorrhage (ICH) in this patient group. Methods: This was a secondary analysis of the Geriatric Head Trauma Short Term Outcomes Project (GREAT STOP), a study of older adults with blunt head trauma from a fall. We determined the characteristics of every fall event, including patient demographics and medical history, and clinical signs and symptoms related to head trauma. Self-reported alcohol use was categorized as none, occasionally, weekly, or daily. We defined ICH as any acute ICH detected by computed tomography scan. We evaluated the association between alcohol use frequency and ICH, adjusted for patient factors and head injury risk factors. Results: Of 3128 study participants, 18.2% (n = 567) reported alcohol use: 10.3% with occasional use, 1.9% with weekly use, and 6.0% with daily use. ICH was more common in patients who used alcohol (20.5%, 22.0%, and 25.1% for occasional, weekly, and daily alcohol users, respectively, vs. 12.0% for non-users, p < 0.001). The frequency of alcohol use was independently associated with ICH, adjusted for patient and head injury risk factors. The adjusted odds ratios (with 95% confidence intervals) for occasional, weekly, and daily alcohol users increased from 2.0 (1.5‒2.8) to 2.1 (1.1‒4.1) and 2.5 (1.7‒3.6), respectively, and showed the characteristics of dose‒response effect. Conclusions: Alcohol use in older adult emergency department patients with head trauma is relatively common. Self-reported alcohol use appears to be associated with a higher risk of ICH in a dose-dependent fashion. Fall prevention strategies may need to consider alcohol mitigation as a modifiable risk factor.

Day-to-day variability of stress biomarkers during a music intervention in people living with dementia and their family caregivers.

Examination of the variability of stress biomarkers among people living with dementia and their family caregivers can provide evidence of stress reactions and corresponding self-regulation capacities, but no such research has been conducted to date. The aim of this study was to examine day-to-day variability patterns of salivary biomarkers in dyads of people living with dementia and their family caregivers and to investigate differences in variability patterns between music intervention and control groups. This study involved secondary analysis of data collected during a two-group, non-randomized open trial examining the effects of an 8-week music intervention on physiological stress markers. A total of 5791 salivary samples from 34 dyads were used to analyze the variability of morning and evening cortisol and of morning dehydroepiandrosterone sulfate (DHEA-S). The variability indices employed were the intra- and inter-individual standard deviation, coefficient of variation, and intra-class correlation coefficient. We found that family caregivers in the music intervention group had significantly greater coefficients of variation for all three biomarker endpoints than those in the control group. Our findings provide evidence that stress biomarkers in family caregivers with functional self-regulation capacities may be more likely to respond to music intervention. However, stress biomarkers in people living with dementia may not be responsive to music intervention, possibly due to their dysfunctional self-regulation capacities. Future stress biomarker studies involving dyads of people living with dementia and family caregivers should consider biomarker variability patterns in determining the effectiveness of behavioral interventions.

The Florida Geriatric Head Trauma CT Clinical Decision Rule.

BACKGROUND: Several clinical decision rules have been devised to guide head computed tomography (CT) use in patients with minor head injuries, but none have been validated in patients 65 years or older. We aimed to derive and validate a head injury clinical decision rule for older adults. METHODS: We conducted a secondary analysis of an existing dataset of consecutive emergency department (ED) patients >65 years old with blunt head trauma. The main predictive outcomes were significant intracranial injury and Need for Neurosurgical Intervention on CT. The secondary outcomes also considered in the model development and validation were All Injuries and All Intracranial Injuries. Predictor variables were identified using multiple variable logistic regression, and clinical decision rule models were developed in a split-sample derivation cohort and then tested in an independent validation cohort. RESULTS: Of 5776 patients, 233 (4.0%) had significant intracranial injury and an additional 104 (1.8%) met CT criteria for Need for Neurosurgical Intervention. The best performing model, the Florida Geriatric Head Trauma CT Clinical Decision Rule, assigns points based on several clinical variables. If the points totaled 25 or more, a CT scan is indicated. The included predictors were arrival via Emergency Medical Services (+30 points), Glasgow Coma Scale (GCS) <15 (+20 points), GCS <14 (+50 points), antiplatelet medications (+17 points), loss of consciousness (+16 points), signs of basilar skull fracture (+50 points), and headache (+20 points). Utilizing this clinical decision rule in the validation cohort, a point total ≥25 had a sensitivity and specificity of 100.0% (95% CI: 96.0-100) and 12.3% (95% CI: 10.9-13.8), respectively, for significant intracranial injury and Need for Neurosurgical Intervention. CONCLUSIONS: The Florida Geriatric Head Trauma CT Clinical Decision Rule has the potential to reduce unnecessary CT scans in older adults, without compromising safe emergency medicine practice.

Prescribing Benzodiazepines and Opioids and Clinical Characteristics Associated With 30-Day Hospital Return in Patients Aged ≥75 Years: Secondary Data Analysis.

PURPOSE: The current study compared prevalence of opioid or benzodiazepine (BZD) prescription and co-prescription of opioids and BZD at discharge and return to a community hospital within 30 days, as well as identified clinical characteristics associated with hospital return in patients aged ≥75 years. METHOD: A secondary analysis of a database created during implementation of the Safe Transitions for At Risk Patients program at a 400-bed community teaching hospital in south Florida was conducted. Multivariable logistic regression analyses were performed to identify significant demographic and clinical characteristics associated with return to the hospital within 30 days of discharge. RESULTS: A total of 24,262 participants (52.6% women) with a mean age of 85.3 (SD = 6.42) years were included. More than 20% in each central nervous system prescription group (i.e., opioids only, BZD only, opioids and BZD) returned to the hospital within 30 days of discharge. Demographic and chronic conditions (e.g., congestive heart failure, chronic obstructive pulmonary disease, diabetes) and poly-pharmacy were significant factors of a 30-day return to the hospital. CONCLUSION: Findings highlight the importance of hospital nurses' role in identifying high-risk patients, educating patients and caregivers, monitoring them closely, communicating with primary care physicians and specialists, and conducting intensive follow up via telephone to avoid 30-day rehospitalization. [Journal of Gerontological Nursing, 50(4), 25-33.].

The accuracy of total body weight estimation in adults - A systematic review and meta-analysis.

BACKGROUND: Weight estimation is required in adult patients when weight-based medication must be administered during emergency care, as measuring weight is often impossible. Inaccurate estimations may lead to inaccurate drug doses, which may cause patient harm. Little is known about the relative accuracy of different methods of weight estimation that could be used during resuscitative care. The aim of this study was to evaluate the performance and suitability of existing weight estimation methods for use in adult emergency care. METHODS: A systematic literature search was performed for suitable articles that studied the accuracy of weight estimation systems in adults. The study characteristics, the quality of the studies, the weight estimation methods evaluated, the accuracy data, and any information on the ease-of-use of the method were extracted and evaluated. RESULTS: A total of 95 studies were included, in which 27 different methods of total body weight estimation were described, with 42 studies included in the meta-analysis. The most accurate methods, determined from the pooled estimates of accuracy (the percentage of estimates within 10% of true weight, with 95% confidence intervals) were 3-D camera estimates (88.8% (85.8 to 91.8%)), patient self-estimates (88.7% (87.7 to 89.7%)), the Lorenz method (77.5% (76.4 to 78.6%)) and family estimates (75.0% (71.5 to 78.6%)). However, no method was without significant potential limitations to use during emergency care. CONCLUSION: Patient self-estimations of weight were generally very accurate and should be the method of choice during emergency care, when possible. However, since alternative estimation methods must be available when confused, or otherwise incapacitated, patients are unable to provide an estimate, alternative strategies of weight estimation should also be available.

Characteristics and Correlates of Perceived Physical and Psychological Health Among Family Caregivers Living With Persons With Advanced Dementia.

BACKGROUND: Various factors drive a care setting shift from institutional to home settings for dementia care until the latest stage of the disease, suggesting the critical role of family caregivers living with persons with dementia. OBJECTIVES: This study explored the characteristics and correlates of self-reported overall physical and psychological (ie, depressive symptoms and stress) health among family caregivers living with persons with dementia in Sweden. METHODS: This cross-sectional, descriptive study used baseline data from an existing music-based intervention study of persons with dementia and their family caregivers (N = 76). Multivariable linear regression analyses were performed. RESULTS: On average, caregivers (n = 38; mean age: 74.8 years) were slightly younger than persons with dementia (n = 38; mean age: 78.6 years). Most caregivers were female (n = 24; 63.2%) and spouses or partners of persons with dementia (n = 37; 97.4%). Caregivers' perceived relationship with their family members with dementia was the only factor associated with caregivers' self-reported overall physical health (b = -0.655, p = .046). This suggests caregivers' more frequent feeling of a good relationship with the persons with dementia was linked to better self-rated physical health among family caregivers living with persons with dementia. CONCLUSIONS: This study highlights the importance of family caregivers' perceived relationship with persons with dementia in the context of caregivers' self-reported physical health. Future research is needed to explore the perceived relationship from the perspectives of persons with dementia and the determinants of caregiving dyads' (persons with dementia and family caregivers) perceived relationship with each other.

Lack of patient and primary care physician follow-up in geriatric emergency department patients with head trauma from a fall.

STUDY OBJECTIVE: Falls are the leading cause of injuries in the US for older adults. Follow-up after an ED-related fall visit is essential to initiate preventive strategies in these patients who are at very high risk for recurrent falls. It is currently unclear how frequently follow-up occurs and whether preventive strategies are implemented. Our objective is to determine the rate of follow-up by older adults who sustain a fall related head injury resulting in an ED visit, the rate and type of risk assessment and adoption of preventive strategies. METHODS: This 1-year prospective observational study was conducted at two South Florida hospitals. All older ED patients with an acute head injury due to a fall were identified. Telephone surveys were conducted 14 days after ED presentation asking about PCP follow-up and adoption of fall prevention strategies. Clinical and demographic characteristics were compared between patients with and without follow up. RESULTS: Of 4951 patients with a head injury from a fall, 1527 met inclusion criteria. 905 reported follow-up with their PCP. Of these, 72% reported receiving a fall assessment and 56% adopted a fall prevention strategy. Participants with PCP follow-up were significantly more likely to have a history of cancer or hypertension. CONCLUSION: Only 60% of ED patients with fall-related head injury follow-up with their PCP. Further, 72% received a fall assessment and only 56% adopted a fall prevention strategy. These data indicate an urgent need to promote PCP fall assessment and adoption of prevention strategies in these patients.

Assessing stress using repeated saliva concentration of steroid hormones in dementia care dyads: results from a controlled pilot care music intervention.

Background: Stress-related biomarkers have the potential to provide objective measures of whether interventions directed at people with dementia (PWD) and their family caregivers (FCG) are successful. The use of such biomarkers has been limited by logistical barriers to sample collection. Objective: Explore saliva concentration of steroid hormones in dementia care dyads during a music intervention. Methods: Consecutive PWD attending a memory evaluation center and their FCG were allocated to either an intervention-with-music or a non-intervention control group. All were living at home. Stress biomarkers, salivary cortisol and dehydroepiandrosterone sulfate (DHEA-S) samples were collected by the PWD and their FCG, in the morning and evening, 5 days a week, for 8 consecutive weeks. Biomarker concentrations of the intervention and the control groups were compared at week 8, in an intention-to-treat approach with adjustment for baseline value. Results: Twenty-four PWD in the intervention group and 10 in the control group, and their FCG were included in the analyses. The mean number of morning saliva collections was similar in the intervention and the control groups, ranging from 4.3 to 4.9 per participant weekly during the first 7 weeks, declining to 3.3 during week 8. Median log morning cortisol (pg/mL) among caregivers was lower in the intervention group than in the control group (8.09 vs. 8.57, P = 0.0133). Conclusion: This study demonstrates that music intervention was associated with lower morning saliva cortisol concentrations for FCGs.

Midwife Educators' perceptions of the efficacy of the Objective Structured clinical assessment of life-saving interventions - a qualitative interview study in Bangladesh.

INTRODUCTION: Objective Structured Clinical Assessment (OSCA) is a way of evaluating students or clinicians in how they are carrying out their duties. The aim of this study was to examine how midwifery educators in Bangladesh perceived using OSCA as an assessment device in midwifery education for student performance in life-saving midwifery interventions. METHOD: Individual interviews were conducted with 47 academic midwives and clinical midwives using purposive sampling at 38 education institutions in Bangladesh. Content analysis inspired by Elo and Kyngas was used to analyze the data. RESULTS: The ability of students to perform effectively in the OSCA-evaluated simulation of life-saving skills was related to the educators' understanding of the concept of midwifery. The overarching main category of this study showed that for midwifery educators to be able to effectually teach professional, evidence-based midwifery, they need to be able to synthesize the delivery of practical and theoretical skills with pedagogical skills and knowledge. To implement the OSCA tool more effectively, midwifery educators need to understand the underpinning principles of midwifery values and philosophy including leadership, ownership, responsibility, and personal engagement. CONCLUSION: There is potential to improve the efficacy of using OSCA to deliver the teaching of life-saving skills. Team sessions with midwives and physicians aiming to practice teamwork and role divisions in life-saving interventions are recommended.

In-home online music-based intervention for stress, coping, and depression among family caregivers of persons with dementia: A pilot study.

Little is known about how music affects family caregivers who provide care to persons with dementia at home. We examined the effects of an 8-week online music-based intervention on self-reported stress, coping, and depression among dementia family caregivers. Mann-Whitney U test and Wilcoxon signed-ranked tests were performed to examine between- and within-group differences between intervention (n = 24) and comparison (n = 11) groups from baseline to post-test. The coping subscale yielded a significant difference between the groups at post-test (U=76.50, Z=-1.978, p=0.048), indicating the intervention group had better coping than the comparison group at post-test. Significant within-group differences in overall stress (Z=-2.200, p=0.028) and coping subscale (Z=-1.997, p=0.046) in the comparison group at post-test suggest that overall stress and coping were maintained throughout the study in the intervention group, whereas the comparison group had higher overall stress and lower coping at post-test. Our in-home music-based intervention showed potential benefits for dementia family caregivers.

The Feasibility and Acceptability of In-Home Saliva Collection for Stress in Persons With Dementia and Their Family Caregivers.

BACKGROUND: Although increasing attention is being paid to cortisol and the sulfated form of dehydroepiandrosterone (DHEA-S) as stress biomarkers, the feasibility of saliva collection of such biomarkers has yet to be investigated among dementia care dyads (persons with dementia [PWD] and family caregivers) living in a home setting. We explored the feasibility and acceptability of in-home saliva collection for cortisol and DHEA-S as stress biomarkers among dementia care dyads. METHODS: Dementia care dyads were recruited from a memory evaluation center. After pre-evaluation and education sessions, participants collected their saliva 3 times a day, 5 days a week, for 8 consecutive weeks. We calculated frequency counts and percentages to assess enrollment rate, retention rate, the completion rate of saliva collection, and valid samples of cortisol and DHEA-S. Independent samples t-tests were performed to compare mean differences in the total number of collected samples and valid samples between PWD and family caregivers at each time point of saliva collection. RESULTS: A total of 46 dyads were referred to this study; 32 dyads (69.6%) agreed to participate, and 26 started collecting saliva. Twenty-four dyads (75%) completed 8 weeks of saliva collection. There were no significant differences (p > 0.05) in the number of collected samples and valid samples between PWD and caregiver participants. CONCLUSION: This study supports the feasibility of in-home saliva collection for stress biomarker assay and the need for further investigation into self-administered collection of stress biomarkers with a particular focus on dementia care dyads living at home.

The use of saliva steroids (cortisol and DHEA-s) as biomarkers of changing stress levels in people with dementia and their caregivers: A pilot study.

The rationale was to explore the efficacy/sensitivity of using morning and evening cortisol levels as biomarkers for stress reduction in persons with dementia (PWDs) and their family caregivers (FCGs) participating in a music intervention program. Thirty-two PWD and their FGC were recruited to an 8-week, home-based music intervention program. Daily home-based collection of saliva samples took place at bedtime and upon awakening. Cortisol was analyzed in the morning and evening saliva samples and DHEA-s in the morning samples. Trends over 40 workdays (15-40 observations per subject) were assessed using linear regression analysis. Twenty-three PWD (72% of invited, 16 men and 7 women, age 69-93) and 24 caregivers (75%, 8 men and 16 women, age 37-90) completed the intervention for at least 6 weeks and were included in the analysis. One-fourth of the PWD and FCG had decreasing evening cortisol, accompanied by decreasing morning cortisol levels. In one-fourth of the participants the ratio between cortisol and DHEA-S in the morning samples was improved, indicating improved balance between energy mobilization and regeneration. Several participants showed no significant endocrine change. There was a statistically significant (two-sided test) correlation within the PWD-caregiver dyads in evening cortisol trend and a statistically significant decrease (two-sided test) in the morning-evening cortisol slope for the FCG group. Reduction in stress, as measured by evening cortisol, was observed in a substantial number of the participants. Recording endocrine stress is helpful for the unbiased assessment of the intervention.

Nursing home performance in a trial to reduce hospitalizations: Implications for future trials.

BACKGROUND: Experience in trials of implementing quality improvement (QI) programs in nursing homes (NHs) has been variable. Understanding the characteristics of NHs that demonstrate improvements during these trials is critical to improving NH care. DESIGN: Secondary analysis of a randomized controlled trial of implementation of a QI program to reduce hospital transfers. PARTICIPANTS: Seventy-one NHs that completed the 12-month trial INTERVENTION: Implementation included distance-learning strategies, involvement of a champion, regular submission of data on hospitalizations and root cause analyses of transfers, and training, feedback and support. MEASUREMENTS: Primary outcomes included all-cause and potentially avoidable hospitalizations and emergency department (ED) visits per 1000 NH resident days, and the percentage of residents readmitted in 30-days. We compared multiple other variables that could influence effective program implementation in NHs in the highest versus lowest quartile of changes in the primary outcomes. RESULTS: The 18 high-performing NHs had significant reductions in hospitalization and ED visits, whereas the 18 NHs in the low-performing group had increases. The difference in changes in each outcome varied between a reduction of 0.75 and 2.30 events relative to a NH with a census of 100; the absolute difference in 30-day readmissions was 19%. None of the variables we examined reached significance after adjustment for multiple comparisons between the groups. There was no consistent pattern of differences in nonprofit status, nursing staffing, and quality ratings. CONCLUSION: Our experience and reviews of other NH trials suggest that key factors contributing to successful implementation QI programs in NHs remain unclear. To improve NH care, implementation trials should account for intervention fidelity and factors that have not been examined in detail, such as degree and nature of leadership support, financial and regulatory incentives, quality measures, resident and family perspectives, and the availability of onsite high-quality medical care and support of the medical director.

Adherence to care transitions recommendations among high-risk hospitalized older patients.

BACKGROUND/OBJECTIVES: Evidence on the effectiveness of inpatient hospital geriatric consultation is scant, and it is unknown whether adherence to specific recommendations will improve care and patient outcomes. This study was conducted to provide insights from a quality improvement project that may help guide further improvements in the effectiveness of these consultations made as a component of a care transitions program (CTP). DESIGN: Secondary analysis of the implementation of a multicomponent CTP for high-risk hospitalized patients aged 75 and older. SETTING: A 400-bed community teaching hospital. PARTICIPANTS: Two hundred and two patients admitted to non-ICU beds who met high-risk criteria. INTERVENTION: Inpatient comprehensive geriatric consultation including care transition recommendations, telephone and in-person follow-up weekly for 4 weeks after discharge, and collaboration with post-acute organizations and primary care and specialist physicians to implement recommendations. MEASUREMENTS: Primary outcomes for this analysis was 30-day hospital readmissions and adherence to transition of care recommendations. RESULTS: The 142 patients with at least one post-discharge visit received 936 care transition recommendations. Overall, 663 (71%) of the 936 care transition recommendations were adhered to (71%). The adherence rate was lower in the 22 patients who were readmitted to the hospital within 30 days (63%) compared to 72% adherence in the 120 patients who were not readmitted. This was not a statistically significant difference, and there were no significant differences in the number and percent adherence in any recommendation category between the two groups. CONCLUSION: We found adherence to just over two-thirds of care transition recommendations, similar to a small number of other studies. We did not find a relationship between the number of recommendations and adherence to them with 30-day readmissions to the hospital. Future studies of CTPs should consider several strategies may enhance geriatric consultation care transitions recommendations and adherence to them, and improve patient outcomes.

Thirty-Day Hospital Readmissions in a Care Transitions Program for High-Risk Older Adults.

OBJECTIVES: To describe the causes of 30-day hospital readmissions among high-risk older adults during implementation of a multicomponent care transitions program. DESIGN: Secondary analysis of data from the evaluation of a multicomponent care transitions program for hospitalized high-risk older adults. SETTING: A 400-bed community teaching hospital. PARTICIPANTS: Patients aged 75 and older admitted to non-intensive care unit beds who met specific criteria for high risk of complications and hospital readmissions. The intervention group included 202 patients, of whom 37 were readmitted to the hospital as an inpatient or on observation status within 30 days of discharge. MEASUREMENTS: Root-cause analyses on each readmission were conducted by hospital physicians and post-acute care (PAC) organization staff. Additional data were collected by trained project staff using the medical record and postdischarge telephone or in-person follow-up visits. These data were reviewed and adjudicated among the authors, and each readmission was rated with unanimous agreement as "preventable," "possibly preventable," or "not preventable." RESULTS: No significant differences were found in demographic and clinical characteristics of intervention patients readmitted versus those not readmitted. A higher proportion of the 37 patients who were readmitted did not have a postdischarge visit than the 165 patients who were not readmitted (15 [41%] vs 45 [27%]; P = .11). Among the 37 readmissions, 14 (38%) were rated as not preventable, 14 (38%) as possibly preventable, and 9 (24%) as preventable. Readmissions were rated as preventable or possibly preventable for a variety of reasons that provide insight into how care transitions programs for high-risk older adults might be made more effective. CONCLUSION: Root-cause analyses of hospital readmissions among high-risk older adults by hospital physicians and PAC providers can identify strategies that might enhance the effectiveness of care transitions interventions in this complex population. J Am Geriatr Soc 68:1307-1312, 2020.

Evaluation of a Multicomponent Care Transitions Program for High-Risk Hospitalized Older Adults.

OBJECTIVES: To test the effectiveness of a multicomponent care transition intervention targeted at hospitalized patients, aged 75 years and older, at high risk for hospital readmissions, return emergency department (ED) visits, and related complications. DESIGN: Implementation as a quality improvement program with propensity-matched preintervention and concurrent comparison groups over a 12-month period. SETTING: A 400-bed community teaching hospital. PARTICIPANTS: Patients, aged 75 years and older, admitted to non-intensive care unit beds who met specific high-risk criteria. The intervention group included 202 patients, and the concurrent and preintervention comparison groups included 4142 and 4592 patients, respectively. MEASUREMENTS: Primary outcomes were 30-day hospital readmissions and returns to the ED; 7-day readmissions and ED visits were secondary measures. RESULTS: Among the 202 patients enrolled in the "Safe Transitions for At-Risk Patients" ("STAR") program, 37 (18.3%) were readmitted within 30 days, in contrast to 14.3% and 14.6% in the concurrent and preintervention comparison groups, respectively. Rates for 30-day return ED visits that did not result in hospitalization were 10.9% in the intervention group, and 7.2% and 7.9% in the comparison groups. STAR patients had greater 30-day ED use than patients in the preintervention comparison group (5.0 percentage points; 95% confidence interval = 0.8-9.3 percentage points; P = .020). Implementation challenges included suboptimal involvement of the participating hospital and post-acute care organizations and a relatively high proportion of patients who did not receive the intervention as planned, despite agreeing to participate before leaving the hospital. CONCLUSION: A multicomponent care transitions intervention targeting high-risk patients, aged 75 years and older, admitted to a community teaching hospital was not effective in reducing 30- or 7-day readmissions or return ED visits. Our implementation experience offers many lessons for future programs for similar high-risk geriatric populations. J Am Geriatr Soc 67:2634-2642, 2019.

Management of Acute Changes in Condition in Skilled Nursing Facilities.

OBJECTIVES: To describe the presentation and management of acute changes in condition in skilled nursing facilities (SNFs) during implementation of a program designed to reduce unnecessary emergency department visits and hospitalizations. DESIGN: Secondary analysis of data from a randomized controlled trial involving 264 SNFs. PARTICIPANTS: One hundred thirty-three of the 264 participating SNFs that provided data on acute changes in condition: 55 in the intervention group, 78 in the control group. INTERVENTIONS: During a 12-month period, intervention SNFs received training and support for implementation of the Interventions to Reduce Acute Care Transfers program. Control SNFs were offered training and implementation support after the end of the 12-month trial. MEASURES: Project champions used a structured online tool to describe acute changes in condition that did not result in a hospital transfer within 72 hours of the change. RESULTS: Most of the 7,689 episodes of acute change in condition reported involved multiple changes that were not disease specific. Ten percent resulted in hospital transfer between 72 hours and 7 days after the change. Five acute changes had odds ratios for transfer greater than 2 (mental status change, abnormal vital signs, bleeding, shortness of breath, and unresponsiveness). Most transfers were for reasons other than the initial change in condition. CONCLUSIONS: A wide variety of acute changes in condition can be managed in SNFs without hospital transfer. Most of these changes are nonspecific and multiple, and when they are associated with hospital transfer, the reasons for the transfer are most often different from the initial acute change in condition. These data highlight the multifactorial nature of acute changes in condition in the SNF population and suggest that disease-specific protocols and assessment tools may not be the most appropriate approach to managing acute changes in condition in the SNF setting. J Am Geriatr Soc 66:2259-2266, 2018.

Degree of Implementation of the Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement Program Associated with Number of Hospitalizations.

OBJECTIVES: To determine whether degree of implementation of the Interventions to Reduce Acute Care Transfers (INTERACT) program is associated with number of hospitalizations and emergency department (ED) visits of skilled nursing facility (SNF) residents. DESIGN: Secondary analysis from a randomized controlled trial. SETTING: SNFs from across the United States (N=264). PARTICIPANTS: Two hundred of the SNFs from the randomized trial that provided baseline and intervention data on INTERACT use. INTERVENTIONS: During a 12-month period, intervention SNFs received remote training and support for INTERACT implementation; control SNFs did not, although most control facilities were using various components of the INTERACT program before and during the trial on their own. MEASUREMENTS: INTERACT use data were based on monthly self-reports for SNFs randomized to the intervention group and pre- and postintervention surveys for control SNFs. Primary outcomes were rates of all-cause hospitalizations, potentially avoidable hospitalizations (PAHs), ED visits without admission, and 30-day hospital readmissions. RESULTS: The 65 SNFs (32 intervention, 33 control) that reported increases in INTERACT use had reductions in all-cause hospitalizations (0.427 per 1,000 resident-days; 11.2% relative reduction from baseline, p<.001) and PAHs (0.221 per 1,000 resident-days; 18.9% relative reduction, p<.001). The 34 SNFs (12 intervention, 22 control) that reported consistently low or moderate INTERACT use had statistically insignificant changes in hospitalizations and ED visit rates. CONCLUSION: Increased reported use of core INTERACT tools was associated with significantly greater reductions in all-cause hospitalizations and PAHs in both intervention and control SNFs, suggesting that motivation and incentives to reduce hospitalizations were more important than the training and support provided in the trial in improving outcomes. Further research is needed to better understand the most effective strategies to motivate SNFs to implement and sustain quality improvement programs such as INTERACT.

Evaluation of Nursing Facility Resident Safety During Implementation of the INTERACT Quality Improvement Program.

BACKGROUND: Medicare incentivizes the reduction of hospitalizations of nursing facility (NF) residents. The effects of these incentives on resident safety have not been examined. OBJECTIVE: Examine safety indicators in NFs participating in a randomized, controlled trial of the INTERACT Quality Improvement Program. DESIGN: Secondary analysis of a randomized trial in which intervention NFs exhibited a statistically nonsignificant reduction in hospitalizations. SETTING: NFs with adequate on-site medical, radiography, laboratory, and pharmacy services, and capability for online training and data input were eligible. PARTICIPANTS: 264 NFs randomized into intervention and comparison groups stratified by previous INTERACT use and self-reported hospital readmission rates. INTERVENTION: NFs randomized to the intervention group received INTERACT materials, access to online training and a series of training webinars, feedback on hospitalization rates and root-cause analysis data, and monthly telephonic support. MEASURES: Minimum data set (MDS) data for unintentional weight loss, malnutrition, hip fracture, pneumonia, wound infection, septicemia, urinary tract infection, and falls with injury for the intervention year and the year prior; unintentional weight loss, dehydration, changes in rates of falls, pressure ulcers, severe pain, and unexpected deaths obtained from the NFs participating in the intervention through monthly telephone calls. RESULTS: No adverse effects on resident safety, and no significant differences in safety indicators between intervention and comparison group NFs were identified, with 1 exception. Intervention NFs with high levels of INTERACT tool use reported significantly lower rates of severe pain. CONCLUSIONS/IMPLICATIONS: Resident safety was not compromised during implementation of a quality improvement program designed to reduce unnecessary hospitalization of NF residents.