The perspectives of in-hospital healthcare professionals on the timing and collaboration in advance care planning: A survey study.

Background: Hospital admissions are common in the last phase of life. However, palliative care and advance care planning (ACP) are provided late or not at all during hospital admission. Aim: To provide insight into the perceptions of in-hospital healthcare professionals concerning current and ideal practice and roles of in-hospital palliative care and advance care planning. Methods: An electronic cross-sectional survey was send 398 in-hospital healthcare professionals in five hospitals in the Netherlands. The survey contained 48 items on perceptions of palliative care and ACP. Results: We included non-specialists who completed the questions of interest, resulting in analysis of 96 questionnaires. Most respondents were nurses (74%). We found that current practice for initiating palliative care and ACP was different to what is considered ideal practice. Ideally, ACP should be initiated for almost every patient for whom no treatment options are available (96.2%), and in case of progression and severe symptoms (94.2%). The largest differences between current and ideal practice were found for patients with functional decline (Current 15.2% versus Ideal 78.5%), and patients with an estimated life expectancy <1 year (Current 32.6% versus ideal 86.1%). Respondents noted that providing palliative care requires collaboration, however, especially nurses noted barriers like a lack of inter-professional consensus. Conclusions: The differences between current and ideal practice demonstrate that healthcare professionals are willing to improve palliative care. To do this, nurses need to increase their voice, a shared vision of palliative care and recognition of the added value of working together is needed.

Challenges in the implementation and evaluation of a transmural palliative care pathway for acutely hospitalized older adults; lessons from the PalliSupport program: A qualitative process evaluation study.

OBJECTIVES: To improve transmural palliative care for acutely admitted older patients, the PalliSupport transmural care pathway was developed. Implementation of this care pathway was challenging. The aim of this study was to improve understanding why the implementation partly failed. DESIGN: A qualitative process evaluation study. SETTING/PARTICIPANTS: 17 professionals who were involved in the PalliSupport program were interviewed. METHODS: Online semi-structured interviews. Thematic analysis to create themes according to the implementation framework of Grol & Wensing. RESULTS: From this study, themes within four levels of implementation emerged: 1) The innovation: challenges in current palliative care, the setting of the pathway and boost for improvement; 2) Individual professional: feeling (un)involved and motivation; 3) Organizational level: project management; 4) Political and economic level: project plan and evaluation. CONCLUSION AND IMPLICATIONS: We learned that the challenges involved in implementing a transmural care pathway in palliative care should not be underestimated. For successful implementation, we emphasize the importance of creating a program that fits the complexity of transmural palliative care. We suggest starting on a small scale and invest in project management. This could help to involve all stakeholders and anticipate current challenges in palliative care. To increase acceptance, create one care pathway that can start and be used in all care settings. Make sure that there is sufficient flexibility in time and room to adjust the project plan, so that a second pilot study can possibly be performed, and choose a scientific evaluation with both rigor and practical usefulness to evaluate effectiveness.

Medication management during transitions from hospital to home: a focus group study with hospital and primary healthcare providers in the Netherlands.

Background Medication management is jeopardized during a patient's transition from hospital to home. Insight is required from both hospital and primary healthcare providers on how care should be organised to achieve continuity of medication management. Objective This study aimed to identify perspectives of hospital and primary healthcare providers on barriers to the continuity of medication management during a patient's transition from hospital to home and facilitators to overcome these. Setting A qualitative descriptive study was conducted within hospital and primary healthcare settings in the Netherlands. Method Two focus groups were performed with two community care registered nurses, two community pharmacists, four general practitioners, two hospital nurses, two hospital pharmacists, four outpatient pharmacists, two pharmacy technicians, and one physician. A semi-structured interview guide was used to identify perspectives of participants on barriers to continuity of medication management and facilitators to overcome these. Data were analysed following thematic content analysis. Main outcome measure Barriers to the continuity of medication management during a patient's transition from hospital to home would be enumerated, along with facilitators to overcome these barriers. Results Three main themes of barriers and facilitators were identified: (1) healthcare provider collaboration, including the transfer of medication information and effective collaboration; (2) patient's medication use, including information about medication, personalised care, and supervision after discharge; and (3) organisation of healthcare, including the connection between information systems and the supply of medication. Conclusion Barriers and facilitators to continuity of medication management during the transition from hospital to home occur at the provider, patient, and healthcare-system levels. Future interventions should focus on all levels through interprofessional healthcare teams, tailoring care to patient needs, and on the use of a uniform, nationwide patient electronic health record.

Video-based tools to enhance nurses' geriatric knowledge: A development and pilot study.

BACKGROUND: The need for health care professionals with geriatric knowledge is expected to increase due to aging of society. Educational tools that fit the specific learning styles of nurses and nursing students might be useful for this. Serioussoap.nl (available in Dutch and English) is an educational tool that integrates video-based gaming and storytelling, and it might be an effective way to improve the geriatric knowledge of nurses or nursing students. OBJECTIVES: To investigate the effect of Serioussoap.nl on the geriatric knowledge of nurses and nursing students, and to evaluate its usability. DESIGN: We conducted a development and an explorative pilot study, using a pretest posttest quantitative design to investigate the effect of Serioussoap.nl on geriatric knowledge. A qualitative approach was used to evaluate its usability. PARTICIPANTS AND SETTING: Three vocational nursing schools (n = 119 second/third year students), one baccalaureate nursing university (n = 77 first year vocational nurses) and one home-care organization (n = 44 vocational nurses) in the Netherlands participated in the quantitative study, and 94 vocational students participated in the qualitative study. METHODS: We measured the effect on geriatric knowledge with the Knowledge of Older People Questionnaire (KOP-Q, score 0-30). The qualitative study included observations of 94 participants while they played Serioussoap.nl, four semi-structured focus groups and eleven individual interviews. RESULTS: The study demonstrated a significant increase of geriatric knowledge of 7.8% (+2.3 score on the KOP-Q, 95% Confidence Interval (1.4-3.2, p < 0.001). The qualitative data showed that Serioussoap.nl contributed to the reflective learning-style and enhanced meaningful learning. CONCLUSION: Serioussoap.nl increased the students' geriatric knowledge and was perceived as a suitable and effective educational tool for vocational nursing students and nurses.

Recommendations of older adults on how to use the PROM 'TOPICS-MDS' in healthcare conversations: A Delphi study.

In shared decision making, the exploration of preferred personal health outcomes is important. Patient-reported outcome measures (PROMs) provide input for discussions between patients and healthcare professionals. The Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS) PROM is a multidimensional questionnaire on the physical and mental health and wellbeing of older adults. This study investigates how the TOPICS-MDS could be used in individual healthcare conversations. We explored views of older adults regarding 1) whether the health domains they want to discuss are included in the TOPICS-MDS and 2) the comprehensibility of the TOPICS-MDS for healthcare conversations with older adults. A three-round Delphi study was conducted. A total of 57 older adults participated in the study, the mean (SD) age was 71.5 (8.5) years, and 78.9% of the participants were female. The participants were divided into four panels based on educational level and cultural background. We used online questionnaires and focus groups. Consensus was pre-defined to be the point when ≥75% of the participants agreed that a domain was important or very important (scored on a 5-point Likert scale). The inter-expert agreement was computed for Round 1 and 3 with Kendall's W. Round 2 was a focus-group. Qualitative data were analyzed by content analysis. Older adults considered 'functional limitations', 'emotional wellbeing', 'social functioning' and 'quality of life' to be important domains of the TOPICS-MDS to discuss in healthcare conversations. The participants added 'coping with stress', 'dealing with health conditions and the effects on life' as extra domains for healthcare conversations. Challenges regarding the comprehensibility of the TOPICS-MDS included difficult words and lengthy or sensitive questions. Questions that included multiple topics were difficult to understand. The TOPICS-MDS covers the domains of life that older adults value as important to discuss with healthcare professionals, and two additional domains were identified. For older adults with a low level of education or a culturally diverse background, the TOPICS-MDS needs to be adjusted for comprehensibility.

Readmission and mortality in patients ≥70 years with acute myocardial infarction or heart failure in the Netherlands: a retrospective cohort study of incidences and changes in risk factors over time.

OBJECTIVES: To determine the risk of first unplanned all-cause readmission and mortality of patients ≥70 years with acute myocardial infarction (AMI) or heart failure (HF) and to explore which effects of baseline risk factors vary over time. METHODS: A retrospective cohort study was performed on hospital and mortality data (2008) from Statistics Netherlands including 5,175 (AMI) and 9,837 (HF) patients. We calculated cumulative weekly incidences for first unplanned all-cause readmission and mortality during 6 months post-discharge and explored patient characteristics associated with these events. RESULTS: At 6 months, 20.4% and 9.9% (AMI) and 24.6% and 22.4% (HF) of patients had been readmitted or had died, respectively. The highest incidences were found in week 1. An increased risk for 14-day mortality after AMI was observed in patients who lived alone (hazard ratio (HR) 1.57, 95% confidence interval (CI) 1.01-2.44) and within 30 and 42 days in patients with a Charlson Comorbidity Index ≥3. In HF patients, increased risks for readmissions within 7, 30 and 42 days were found for a Charlson Comorbidity Index ≥3 and within 42 days for patients with an admission in the previous 6 months (HR 1.42, 95% CI 1.12-1.80). Non-native Dutch HF patients had an increased risk of 14-day mortality (HR 1.74, 95% CI 1.09-2.78). CONCLUSION: The risk of unplanned readmission and mortality in older AMI and HF patients was highest in the 1st week post-discharge, and the effect of some risk factors changed over time. Transitional care interventions need to be provided as soon as possible to prevent early readmission and mortality.

The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality.

BACKGROUND: After hospitalization for cardiac disease, older patients are at high risk of readmission and death. Although geriatric conditions increase this risk, treatment of older cardiac patients is limited to the management of cardiac diseases. The aim of this study is to investigate if unplanned hospital readmission and mortality can be reduced by the Cardiac Care Bridge transitional care program (CCB program) that integrates case management, disease management and home-based cardiac rehabilitation. METHODS: In a randomized trial on patient level, 500 eligible patients ≥ 70 years and at high risk of readmission and mortality will be enrolled in six hospitals in the Netherlands. Included patients will receive a Comprehensive Geriatric Assessment (CGA) at admission. Randomization with stratified blocks will be used with pre-stratification by study site and cognitive status based on the Mini-Mental State Examination (15-23 vs ≥ 24). Patients enrolled in the intervention group will receive a CGA-based integrated care plan, a face-to-face handover with the community care registered nurse (CCRN) before discharge and four home visits post-discharge. The CCRNs collaborate with physical therapists, who will perform home-based cardiac rehabilitation and with a pharmacist who advices the CCRNs in medication management The control group will receive care as usual. The primary outcome is the incidence of first all-cause unplanned readmission or mortality within 6 months post-randomization. Secondary outcomes at three, six and 12 months after randomization are physical functioning, functional capacity, depression, anxiety, medication adherence, health-related quality of life, healthcare utilization and care giver burden. DISCUSSION: This study will provide new knowledge on the effectiveness of the integration of geriatric and cardiac care. TRIAL REGISTRATION: NTR6316 . Date of registration: April 6, 2017.

Hip Fractures in Older Patients: Trajectories of Disability after Surgery.

BACKGROUND: Hip fracture in older patients often lead to permanent disabilities and can result in mortality. OBJECTIVE: To identify distinct disability trajectories from admission to one-year post-discharge in acutely hospitalized older patients after hip fracture. DESIGN: Prospective cohort study, with assessments at admission, three-months and one-year post-discharge. SETTING AND PARTICIPANTS: Patients ≥ 65 years admitted to a 1024-bed tertiary teaching hospital in the Netherlands. METHODS: Disability was the primary outcome and measured with the modified Katz ADL-index score. A secondary outcome was mortality. Latent class growth analysis was performed to detect distinct disability trajectories from admission and Cox regression was used to analyze the effect of the deceased patients to one-year after discharge. RESULTS: The mean (SD) age of the 267 patients was 84.0 (6.9) years. We identified 3 disability trajectories based on the Katz ADL-index score from admission to one-year post-discharge: 'mild'- (n=54 (20.2%)), 'moderate'- (n=110 (41.2%)) and 'severe' disability (n=103 (38.6%)). Patients in all three trajectories showed an increase of disabilities at three months, in relation to baseline and 80% did not return to baseline one-year post-discharge. Seventy-three patients (27.3%) deceased within one-year post-discharge, particularly in the 'moderate'- (n=22 (8.2%)) and 'severe' disability trajectory (n=47 (17.6%)). CONCLUSIONS: Three disability trajectories were identified from hospital admission until one-year follow-up in acutely hospitalized older patients after hip fracture. Most patients had substantial functional decline and 27% of the patient's deceased one-year post-discharge, mainly patients in the 'moderate'- 'and severe' disability trajectories.

[10 tips for improving patient handovers from hospital to other health care settings]. / 10 tips voor een goede transmurale overdracht.

When patients are transferred from the hospital to other health care settings, responsibility for the patient is transferred from the treating physician, nurse, paramedic or pharmacist at the hospital to the next health care provider. Good patient handovers from hospital to other healthcare settings are essential to ensure continuity of care. However, handovers are often delayed or incomplete and the patient is barely involved in her or his own transfer. Risks related to an incomplete handover may be considerable. More than half of the preventable adverse events that occur after discharge are attributable to ineffective communication between hospital and other healthcare providers. Through the implementation of some adjustments, the discharge process can become a point of focus during a patient's hospital stay. Examples to improve patient handovers are standardizing the discharge process and the content of patient handovers, planning a target discharge date, starting the collection of transfer data on time and involving the patient in her or his transfer.

Minimal Important Change and Minimal Detectable Change in Activities of Daily Living in Community-Living Older People.

OBJECTIVE: To estimate the minimal important change (MIC) and the minimal detectable change (MDC) of the Katz-activities of daily living (ADL) index score and the Lawton instrumental activities of daily living (IADL) scale. DESIGN: Data from a cluster-randomized clinical trial and a cohort study. SETTING: General practices in the Netherlands. PARTICIPANTS: 3184 trial participants and 51 participants of the cohort study with a mean age of 80.1 (SD 6.4) years. MEASUREMENTS: At baseline and after 6 months, the Katz-ADL index score (0-6 points), the Lawton IADL scale (0-7 points), and self-perceived decline in (I)ADL were assessed using a self-reporting questionnaire. MIC was assessed using anchor-based methods: the (relative) mean change score; and using distributional methods: the effect size (ES), the standard error of measurement (SEM), and 0.5 SD. The MDC was estimated using SEM, based on a test-retest study (2-week interval) and on the anchor-based method. RESULTS: Anchor-based MICs of the Katz-ADL index score were 0.47 points, while distributional MICs ranged from 0.18 to 0.47 points. Similarly, anchor-based MICs of the Lawton IADL scale were between 0.31 and 0.54 points and distributional MICs ranged from 0.31 to 0.77 points. The MDC varies by sample size. For the MIC to exceed the MDC at least 482 patients are needed. CONCLUSION: The MIC of both the Katz-ADL index and the Lawton IADL scale lie around half a point. The certainty of this conclusion is reduced by the variation across calculational methods.

Determinants of health-related quality of life in older patients after acute hospitalisation.

BACKGROUND: To assess the association between demographics, comorbidity, geriatric conditions, and three health-related quality of life (HRQOL) outcomes one year after acute hospitalisation in older patients. METHODS: A prospective cohort study conducted between 2006 and 2009 with one-year follow-up in 11 medical wards at two university hospitals and one teaching hospital in the Netherlands. Participants were 473 patients of 65 years and older, acutely hospitalised for more than 48 hours. Demographics, Charlson Comorbidity Index (CCI), and data on 18 geriatric conditions were collected at baseline. At baseline and 12 months post-admission, the EuroQol-5D was administered. Based on a population-derived valuation (Dutch EuroQol-5D tariff), utilities (range -0.38-1.00) were determined, which were used to calculate quality-adjusted life years (QALY) over one year (max QALY score 1). The EuroQol-5D visual analogue scale (VAS) (range 0-100) was also used. Linear regression analyses were performed to explore the association between the independent variables and the three HRQOL outcomes. RESULTS: CCI was most consistently significantly associated with HRQOL outcomes: Beta -0.05 (95% CI -0.06--0.03) for utility, -0.04 (95% CI -0.05-0.03) for QALY, -1.03 (95% CI -2.06-0.00) for VAS, p < 0.001, < 0.001, 0.05, respectively). Baseline utility was significantly associated with one-year utility (beta 0.25, 95% CI 0.11-0.39, p < 0.01) and QALY (beta 0.31, 95% CI 0.17-0.45, p < 0.001). The number of geriatric conditions at baseline was more strongly associated with one-year utility than any individual geriatric condition. CONCLUSION: Less comorbidity, better utility and less geriatric conditions at baseline were associated with better HRQOL one year after acute hospitalisation in older patients.

The implementation of a comprehensive discharge bundle to improve the discharge process: a quasi-experimental study.

BACKGROUND: Hospitalised patients are especially vulnerable in times of transitions in care. Structured discharge planning might improve patient outcomes. We implemented and assessed the effect of a multidisciplinary discharge bundle to reduce 30-day readmission. METHODS: A pre-post-test design study with a follow-up of one month at four internal medicine wards in a Dutch university teaching hospital. Eligible patients were 18 years and older, acutely admitted and hospitalised for at least 48 hours. The discharge bundle consisted of (1) planning the date of discharge within 48 hours after admission, (2) a discharge checklist, (3) a personalised patient discharge letter, and (4) multidisciplinary patient education. The primary outcome measure was unplanned 30-day readmission. RESULTS: Participants in the post-test group (n = 204) did not have a lower rate of unplanned hospital readmission than those receiving usual care (n = 224) (12.9 vs. 13.2%, p = 0.93). The medical discharge summaries were sent to the general practitioner faster in the post-test period (median of 14 days pre-test vs. 5 days post-test, p < 0.001) and this group also had a trend towards a longer time to first readmission (14 vs. 10 days, p = 0.06). Patient satisfaction was high in both groups (7.5 and 7.4 points, (p = 0.49)). CONCLUSIONS: The comprehensive discharge bundle was not effective in reducing the rate of readmission and increasing patient satisfaction, but medical discharge summaries were sent faster to the general practitioner and a trend to a longer time to readmission was present.

[Co-morbidity in acutely hospitalised older patients as a risk factor for death in hospital or within 3 months after discharge]. / Comorbiditeit bij acuut opgenomen oudere patiënten als risicofactor voor sterfte in het ziekenhuis of binnen 3 maanden na ontslag.

OBJECTIVE: To study the presence of co-morbidity and delirium and to determine whether these factors are predictors of hospital and shortterm mortality in elderly patients acutely admitted to a department of internal medicine. DESIGN: Prospective cohort study. METHOD: Social and demographic data as well as data on their physical and cognitive limitations were collected from consecutive patients of 65 years and older who were hospitalised in the period from I December 2002 to 30 June 2005 in the Academic Medical Centre in Amsterdam, the Netherlands. Co-morbidity and ICD diagnosis were determined on discharge from the hospital. Three months after discharge the patients' circumstances were assessed. RESULTS: A total of 461 patients, 195 men and 266 women with an average age of 78.2 years (SD: 7.8), were included. Of these patients, 132 (28.6%) had cognitive impairment and the mean number of limitations with regard to the activities of daily living (ADL) was 5.48 (10.4%) patients died in hospital and another 74 patients (16.1%) had died 3 months after discharge. The only independent predictor of hospital mortality was delirium at admission (OR: 2.28; 95% CI: 1.23-4.21). Independent risk factors for mortality within 3 months after discharge were: delirium at admission (OR: 2.20; 95% CI: 1.12-4.31), pre-admission ADL limitations (OR: 1.11; 95% CI: 1.02-1.21), a diagnosed malignancy (OR: 5.96; 95% CI: 2.45-14-52), and a higher Charlson co-morbidity index (OR: 1.19; 95% CI: 1.04-1-34). CONCLUSION: At discharge from the hospital, the risk of death within 3 months after discharge in acutely hospitalised patients of 65 years and older was determined by a combination of delirium at admission, pre-admission ADL limitations, a malignancy, and co-morbidity. These results can be used to identify elderly patients who might benefit from comprehensive geriatric assessment during hospitalisation and from a well-prepared discharge planning that takes their co-morbidity into consideration.