Does Case-Finding for Admission to Aged Care Rapid Investigation and Assessment Unit for Older Patients Improve Hospital Length of Stay? Evaluation of ARIA Unit.

Introduction: Many older people present to emergency departments annually, often with complex geriatric syndromes, yet current acute care models and traditional admissions process may under-serve their needs. The multidisciplinary Aged Care Rapid Investigation and Assessment (ARIA) Unit seeks to bridge this gap, by actively identifying and assessing patients. Methods: A prospective case-control study was undertaken at a single-centre tertiary referral institution. Patients were eligible for inclusion in ARIA group if admitted to ARIA via case-finding by the geriatrician or Aged Care Services Emergency Team, whilst standard geriatric admissions formed the control group. This study evaluates whether ARIA reduced hospital length-of-stay (LOS) and representation rates. Results: 370 patients were included (185 each arm) with similar baseline demographics, frailty scores, and Charlson Comorbidity Indices. Patients admitted to ARIA had significantly shorter hospital LOS than those via standard pathway (3.3 days [IQR2.2-5.8] vs 7.5 days [IQR4.2-13.7], p < 0.00001). There were no significant differences in 90-day representation rates (n = 66 [35.7%] vs n = 64 [34.6%], p = 0.82). Discussion/Conclusion: Introduction of an ARIA unit with a targeted approach to frontline geriatric services and case-finding is associated with improved LOS of older acute hospital patients. An economical cost analysis of this study would be beneficial in exploring potential financial savings.

Poorer outcomes in patients with early postoperative delirium: 120-day follow-up of the Delirium Reduction by Analgesia Management in Hip Fracture (DRAM-HF) study.

OBJECTIVES: The Delirium Reduction by Analgesia Management-Hip Fracture (DRAM-HF) model of care, which incorporated a multicomponent intervention focussing on perioperative analgesia and medication optimisation, was associated with reduced Day 3 postoperative delirium (POD) amongst hip fracture patients. We investigated whether this effect was seen at 120 days postoperatively. METHODS: We assessed 120-day outcomes in all patients who were included in the DRAM-HF study, by telephone, supplemented by electronic medical records, to include death (primary outcome), residential aged care facility (RACF) residence, patient/carer-reported frailty, hospital readmission and new dementia diagnosis. RESULTS: Amongst 300 patients (mean age 81.1, 70% female, none lost to follow-up), by 120 days, 8% (n = 24) had died; 25% of survivors (n = 68/276) were RACF residents. Twenty-two per cent were readmitted (n = 61/281). A new dementia diagnosis was reported by 6% (n = 17/281). Intervention status in the DRAM-HF trial (intervention/control) was not associated with death by 120 days (OR 0.83, 95% CI 0.36-1.93, p = 0.67) or other outcomes assessed. POD was independently associated with 120-day death (aOR 3.3, 95% CI 1.2-9.2, p = 0.02), RACF residence (aOR 2.2, 95% CI 1.1-4.7, p = 0.03) and patient/carer-reported frailty (aOR 5.6, 95% CI 1.0-30.7, p = 0.05), but not readmission (p = 0.21) or new diagnosis of dementia (p = 0.08). CONCLUSIONS: In this cohort, while the DRAM-HF bundle of care did not influence 120-day outcomes, patients who experienced POD had poorer clinical outcomes 120-day postfracture. Given that delirium was associated with death, RACF residence and frailty, models of care which have the potential to reduce POD may have benefits beyond the acute admission, and further investigation is needed.

Clinical and cost-effectiveness of telehealth for Indigenous and culturally and linguistically diverse (CALD) people: a scoping review.

OBJECTIVES: To examine the modalities and clinical and non-clinical effectiveness of telehealth services available to people from Indigenous and culturally and linguistically diverse backgrounds (CALD). MATERIALS AND METHODS: A scoping review of peer-reviewed publications (2000-2021) on the effectiveness of telehealth interventions for Indigenous and CALD groups based on searches of Medline, CINAHL, and PsycInfo and manual searches from reference lists of captured literature reviews. RESULTS: Of the initial 601 articles, 10 met the inclusion criteria (seven of clinical effectiveness and three of non-clinical effectiveness), with participants from the USA, Australia, New Zealand, and Canada, with sample sizes ranging from 19 to 1,665 participants (overall 327 Indigenous and 2,030 CALD patients). Telehealth was delivered via telephone or by videoconference-with or without data uploads-and follow-up ranging from 6 months to 5 years. DISCUSSION: The findings suggest that telehealth shows some promise in: diabetes, depression, neuro/cognitive assessment, and health program adherence/service utilisation/cost. However, our confidence in the accuracy of the results is undermined by the mixed quality of designs and outcome measurements, and the high risk of bias derived from not proper random selections and small sample sizes. CONCLUSIONS: The available literature suggests acceptable clinical and non-clinical effectiveness of telehealth against usual care in Indigenous and/or CALD groups but methodological limitations diminish their value in informing practice. Therefore, we consider it is premature to use the findings of these primary studies to draw conclusive recommendations about clinical or other effectiveness of telehealth for the two target groups. Further randomised trials with adequate sampling frames and objective outcome assessments are warranted.

Feasibility, satisfaction, acceptability and safety of telehealth for First Nations and culturally and linguistically diverse people: a scoping review.

OBJECTIVES: The COVID-19 pandemic has highlighted the importance of access to telehealth as an alternative model of service during social restrictions and for urban and remote communities alike. This study aimed to elucidate whether First Nations and culturally and linguistically diverse (CALD) patients also benefited from the resource before or during the pandemic. STUDY DESIGN: This study was a scoping review. METHODS: A scoping review of MEDLINE, CINAHL and PsycINFO databases from 2000 to 2021 was performed. Paired authors independently screened titles, abstracts and full texts. A narrative synthesis was undertaken after data extraction using a standard template by a team including First Nations and CALD researchers. RESULTS: Seventeen studies (N = 4,960 participants) mostly qualitative, covering First Nations and CALD patient recipients of telehealth in the United States, Canada, Australia, and the Pacific Islands, met the inclusion criteria. Telehealth was perceived feasible, satisfactory, and acceptable for the delivery of health screening, education, and care in mental health, diabetes, cancer, and other chronic conditions for remote and linguistically isolated populations. The advantages of convenience, lower cost, and less travel promoted uptake and adherence to the service, but evidence was lacking on the wider availability of technology and engagement of target communities in informing priorities to address inequalities. CONCLUSIONS: Further studies with larger samples and higher level evidence methods involving First Nations and CALD people as co-designers will assist in filling the gap of safety and cultural competency.

Identifying the needs of our older community-based patients in the COVID era: A telephone survey.

Background: Older people's vulnerability during a pandemic may extend to social connectedness, access to healthcare, and information delivery. We sought to identify whether and how older community-based patients are maintaining connections and accessing information during COVID-19. Methods: We administered a telephone questionnaire to all patients (or carer/proxy answering 'on patient's behalf') who previously attended our Geriatric Medicine clinic, May-December 2019. Results: Response rate was 58.8% (151/257), carer respondents comprising 23.8% (36/151). Mean patient age was 81.8 years (SD 8.6); 59.6% were female, 15.2% lived alone. English was the preferred language for 72.9% (110/151). Almost half (46.4%, 70/151) felt COVID-related restrictions had impacted them. Thirty-eight percent (58/151) reported feelings of social isolation, most (38/58) reporting this new since COVID. Nonetheless, 92.1% (139/151) reported maintaining social connections, all with family (139/139), less often with friends (69.8%, 97/139). COVID-related information sources included television 68.9% (104/151), family/friends (54.3%), healthcare providers (24.5%), and written sources (21.2%, 32/151); 12.6% used online resources. Increasing age lowered likelihood of accessing online information, while having smartphone/computer increased. Most (82.6%) believed their healthcare needs were being met, and 76.1% had accessed their GP, 87% (100/115) in-person. Only 33.1% (50/151) agreed telehealth acceptable, more often those with smartphone/computer (OR 2.15, p=0.04). Conclusions: Interventions to reduce isolation and optimize connectedness and healthcare- despite physical distancing- are important during COVID-19. During a rapidly evolving pandemic, healthcare delivery and information provision to our older population is likely best served by a multifaceted approach which acknowledges identified preferences, practices and barriers.

Delirium Reduction by Analgesia Management in Hip Fracture surgery (DRAM-HF): Exploration of perceived facilitators and barriers.

OBJECTIVES: In tandem with the implementation of a multidisciplinary protocol which was successful in reducing delirium after hip fracture surgery (DRAM-HF), we sought to investigate enablers and barriers to same. METHODS: Single-centre, prospective, before-and-after questionnaire targeted at health-care professionals involved in DRAM-HF. We assessed respondent-reported enablers and barriers to the multidisciplinary protocol, using 0-100 agreement scales and free-text responses. RESULTS: A total of 134 preintervention and 124 postintervention responses were collated (out of 200, response rates 67% and 62%, respectively). Preintervention support for DRAM-HF was 100% (n = 130) and postintervention 95.9% (n = 116). Study design was well received with a mean score of 76.7 (SD 19.7) for being easy to understand. Support for additional computer alert systems was also high (mean 73.6, SD 23.9). Free-text responses emphasised the need for integration of ward pharmacists into medication optimisation (n = 31) and upskilling nurse practitioners (n = 23). CONCLUSION: Whilst generally supported, DRAM-HF implementation may be streamlined by optimising electronic delivery, offering targeted education and expanding roles.

Patterns of use of near-infrared spectroscopy in neonatal intensive care units: international usage survey.

AIM: To assess uptake and applications of near-infrared spectroscopy (NIRS) by neonatal intensive care units (NICUs). METHODS: A pre-piloted online questionnaire was distributed in May 2015 to 12 perinatal societies in Asia, Europe, Australasia, North America and Middle East for dissemination to NICUs. Questions surveyed demographics, NIRS research/clinical applications, usage frequency, training approaches and target infant populations. RESULTS: In total, 255 responses from 235 NICUs were obtained. Of these, 85 (36%) owned a NIRS device. Australian and New Zealand NICUs were more likely to own NIRS technology than Asian (OR 1.12, 95% CI: 0.38-3.37) and North American (OR 2.63, 95% CI: 1.07-6.45) NICUs. A total of 69 (71%) used NIRS within clinical or mixed clinical-research settings, however routine reliance for management and prognostication was low (9% and 3%, respectively). Of those without NIRS technology, 96 (64%) had no acquisition intentions. The main limiting factors were controversial evidence on efficacy (59%) and financial considerations (50%). About 51% of respondents received in-house NIRS training and 32% had access to written guidelines. CONCLUSION: There is considerable geographical variation in NIRS usage in NICUs that is, on the whole, limited by consumer perception of lack of evidence for its clinical utility. This knowledge gap should be addressed by future research.

Cerebral oxygenation as measured by near-infrared spectroscopy in neonatal intensive care: correlation with arterial oxygenation.

AIM: To assess correlation between cerebral oxygenation (rScO2 ), as measured by near-infrared spectroscopy (NIRS), and arterial oxygenation (PaO2 ), as measured by arterial blood gases, in preterm neonates. METHODS: Preterm neonates <37 weeks gestation with an indwelling arterial vascular catheter were recruited between April and August 2015 from the neonatal intensive care unit of the Royal Hospital for Women, Randwick NSW, Australia. The NIRS sensor was placed on the frontolateral aspect of the head prior to arterial gas sampling. NIRS, blood gas and clinical observation data were analysed using mixed linear modelling. RESULTS: Twenty-two neonates between 24 and 31 weeks gestation (mean 27.6 weeks) were recruited, and 75 readings obtained. No significant correlation was identified between cerebral oxygenation (rScO2 ) and arterial oxygenation (PaO2 ) (p = 0.37). There was also no significant correlation between rScO2 and clinically relevant parameters of SaO2 (p = 0.06), SpO2 (p = 0.44) and PaCO2 (p = 0.79). CONCLUSION: This study did not demonstrate any correlation between NIRS values and arterial oxygenation in clinically stable preterm infants. These results highlight some of the difficulties in clinical interpretation of NIRS values in neonatal intensive care, and further evaluation is needed to determine the applicability of NIRS to management of preterm infants.

Clinicians in 25 countries prefer to use lower levels of oxygen to resuscitate preterm infants at birth.

AIM: This study determined current international clinical practice and opinions regarding initial fractional inspired oxygen (FiO2 ) and pulse oximetry (SpO2 ) targets for delivery room resuscitation of preterm infants of less than 29 weeks of gestation. METHODS: An online survey was disseminated to neonatal clinicians via established professional clinical networks using a web-based survey programme between March 9 and June 30, 2015. RESULTS: Of the 630 responses from 25 countries, 60% were from neonatologists. The majority (77%) would target SpO2 between the 10th to 50th percentiles values for full-term infants. The median starting FiO2 was 0.3, with Japan using the highest (0.4) and the UK using the lowest (0.21). New Zealand targeted the highest SpO2 percentiles (median 50%). Most respondents agreed or did not disagree that a trial was required that compared the higher FiO2 of 0.6 (83%), targeting the 50th SpO2 percentile (60%), and the lower FiO2 of 0.21 (80%), targeting the 10th SpO2 percentile (78%). Most (65%) would join this trial. Many considered that evidence was lacking and further research was needed. CONCLUSION: Clinicians currently favour lower SpO2 targets for preterm resuscitation, despite acknowledging the lack of evidence for benefit or harm, and 65% would join a clinical trial.

Video analysis tool system: implementation and evaluation of use with clinical nursing assessments of older adults.

The purpose of this project was to implement and evaluate the Video Analysis Tool (VAT) system, a tool for capturing and analyzing video evidence of students' clinical performance. Through the VAT system, nursing student dyads from 4 universities used a video camera, a computer, and a tripod in the residences of older adults to record interactions and psychosocial assessments of older adult clients. Using their recordings to compare their clinical activities with predefined clinical objectives derived from gerontological nursing standards, they made video clips of their assessments to demonstrate the required outcomes. Use of the VAT system received positive evaluations from students, faculty, and residents in multiple clinical sites. The process has significant implications for assessing clients and health care providers in their interactions in a variety of settings, including on home visits. It has additional applications for documenting performance measures of nurses and team members as they provide client care.

Physical activity, hormone replacement therapy, and the presence of coronary calcium in midlife women.

BACKGROUND: Atherosclerotic calcification is a risk factor for cardiovascular events, independent of other traditional risk factors. Studies of the relation of menopausal hormone therapy to cardiovascular events have had inconsistent results, and often have been confounded by lifestyle behaviors and the "healthy user" effect. The authors evaluated the cross-sectional association of hormone therapy use with the presence and severity of atherosclerosis in postmenopausal women, independent of lifestyle factors, including diet and physical activity levels. METHODS: The authors consecutively enrolled postmenopausal asymptomatic women who were referred for coronary artery calcium scanning to measure cardiovascular risk. After consent was obtained, women were interviewed prior to their cardiac scan about cardiac risk factors, hormone therapy use, menopausal status, diet, and physical activity. Coronary artery calcium prevalence was defined as any calcification present (score >0). RESULTS: Of the 544 enrolled women aged 50-80 years, 252 (46.3%) were hormone therapy users. Hormone therapy users had a significantly lower prevalence of any coronary artery calcium (defined as coronary artery calcium score >0; 37%), than non-users (50%, p = 0.04), as well as significantly lower mean calcium scores (p = 0.02). Multiple logistic regression models demonstrated a significantly reduced odds of coronary artery calcium in hormone therapy users compared to non-users with an adjusted odds ratio of 0.58 (p = 0.04), adjusting for traditional cardiac risk factors and body mass index. Women who reported consuming a vegetarian or a high-protein diet had almost two-fold odds of coronary artery calcium compared with women who reported regular, mixed, or low-fat, low-salt diets (OR = 1.78, p = 0.02). Severity of coronary artery calcium was less with increasing levels of physical activity, and a significant association was observed between physical activity and hormone therapy use (adjusted OR = 4.05, p = 0.03), independent of coronary artery calcium severity. CONCLUSION: This cross-sectional study demonstrated a protective association of hormone therapy with the presence and severity of coronary artery calcium. Although a strong relationship was observed between hormone therapy and physical activity, their complex interplay may affect mechanistic biochemical and physiological processes that have yet to be clearly delineated. Thus, physical activity and diet should be taken into account in prospective studies of the relation of hormone therapy use to coronary artery calcium.

Effects of hormone replacement on progression of coronary calcium as measured by electron beam tomography.

PURPOSE: The recent Women's Health Initiative (WHI) results have demonstrated that combined estrogen plus progestin imparts a small but significant increase in cardiovascular risk and breast cancer among asymptomatic women. However, the effect and potential benefit of unopposed estrogen is not as clear. We sought to evaluate the progression of subclinical atherosclerosis in postmenopausal women using no hormone replacement therapy (HRT), combined therapy, and estrogen alone in an observational study. METHODS: Postmenopausal women without symptoms or known coronary heart disease (CHD) were evaluated at our center for follow-up of coronary calcification. Patients were physician referred and underwent two consecutive electron beam tomography scans at least 1 year apart. All women fitting the study criteria were asked to participate, and those who consented were included. Demographic data, risk factors for CHD, HRT, and other medication use were collected by interview. RESULTS: The study included 177 asymptomatic women. Calcium progression was 14.6%+/-21% in women taking any hormone therapy (n=97). Annual calcium progression rates in nonusers (n=80) was 22.3%+/-32%. Relative to the nonuser group, HRT treatment inhibited the progression of atherosclerosis by 35% (p=0.01). This effect was independent of age, risk, cardiovascular factors, statin use, or baseline CAC score. Thirty-five of the 97 women (36%) were taking estrogen plus progestin, with an annual increase in calcium scores of 24%+/-23%, similar to the non-HRT women (22%). Those women taking estrogen replacement only (n=62) was 63% lower (9%+/-22%). CONCLUSIONS: This is an observational study, and the results are in accordance with the recently published WHI study, demonstrating no benefit of estrogen plus progestin compared with no therapy. However, women taking unopposed estrogen demonstrated a significant slowing of subclinical atherosclerosis compared with non-HRT and estrogen plus progestin.