Nurses' experiences of using falls alarms in subacute care: A qualitative study.

Bed and chair alarms have been included in many multifaceted falls prevention interventions. None of the randomised trials of falls alarms as sole interventions have showed significant effect on falls or falls with injury. Further, use of bed and chair alarms did not change patients' fear of falling, length of hospital stay, functional status, discharge destination or health related quality of life. The aim of this study was to explore nurses' experiences of using bed and chair alarms. A qualitative descriptive study using semi-structured interviews with a purposive sample of 12 nurses was conducted on a 32-bed Geriatric Evaluation and Management ward in Melbourne, Australia. Participants were interviewed between 27 January and 12 March 2021.Transcribed audio-recordings of interviews were analysed using inductive thematic analysis. NVIVO 12.6 was used to manage the study data. Three major themes and four subthemes were constructed from the data: i) negative impacts of falls alarms (subthemes: noisy technology, imperfect technology), ii) juggling the safety-risk conflict, and iii) negotiating falls alarm use (subthemes: nurse decision making and falls alarm overuse). Nurses' experience of using falls alarms was predominantly negative and there was tension between falls alarms having limited impact on patient safety and risks associated with their use. Nurses described a need to support nurse decision making related to falls alarms use in practice and policy, and a desire to be empowered to manage falls risk in other ways.

The Association between Psychological Resilience and Driving Behavior among Older Drivers in Australia.

This study compared a sample of Australian drivers aged 77 years and older to participants from an older driver longitudinal cohort study (Ozcandrive) and examined the relationship between resilience and self-reported driving measures within these samples. Using a survey with a subset of questions from Ozcandrive, data were collected from 237 older drivers throughout Australia. The two samples were analyzed for differences in demographics, health, resilience, and self-reported driving behavior. A series of multiple regression models were fit for each driving outcome measure for both samples. The two samples had both similarities and differences, with the largest difference observed for resilience. Strong and consistent associations were found between resilience and driving comfort, abilities, and frequency for the Australian sample. Across samples, resilience remained a significant variable in seven of 10 regression models, more than any other independent variable.

Realist review of interprofessional education for health care students: What works for whom and why.

Interprofessional education (IPE) programs, are complex, logistically challenging, and can be expensive to deliver, but these matters are offset by the perceived benefits of IPE. There is little clarity regarding how IPE contributes to the desirable development of collaborative practitioners. To guide educators in the design of IPE programs there is a need to understand the elements that promote optimal learning. A realist review was conducted to identify the mechanisms and resources that contribute to IPE outcomes. Four databases were searched until April 2020 for empirical studies describing mandatory IPE for pre-registration medical, nursing and other health professional students. Twelve articles met the inclusion criteria. Two novel learning design elements were identified; interdependence, where there is a need for genuine contribution of skills and knowledge from the professions learning together to successfully complete tasks, and embodiment, where through being immersed in an authentic scenario, learners feel what it is like to work in their professions. Other observations supported previous research findings such as the importance of skilled facilitators to promote interaction and reflection. Interprofessional interventions incorporating these specific learning design features seem likely to enhance the impact of IPE, thus making the best use of limited institutional resources and student time.

Integrated Geriatric Assessment and Treatment Effectiveness (INTEGERATE) in older people with cancer starting systemic anticancer treatment in Australia: a multicentre, open-label, randomised controlled trial.

BACKGROUND: The effectiveness of comprehensive geriatric assessment (CGA) in improving health outcomes in cancer settings is unclear. We evaluated whether CGA can improve health-related quality of life (HRQOL) in older people with cancer who are starting systemic anticancer treatment. METHODS: INTEGERATE is a multicentre, open-label, pragmatic, parallel-group, randomised controlled trial that was done at three hospitals in Australia. Participants aged 70 years and older with solid cancer or diffuse large B-cell lymphoma planned for chemotherapy, targeted therapy, or immunotherapy, were randomly assigned (1:1; using a central computer-generated minimisation algorithm with a random element, balancing treatment intent, cancer type, age, sex, and performance status) to receive CGA integrated into oncology care (integrated oncogeriatric care) or usual care only. Group assignment was not concealed from the participants and clinicians. The primary outcome was HRQOL over 24 weeks, assessed at baseline, week 12, week 18, and week 24, using the Elderly Functional Index (ELFI; score range 0-100). Analyses were by intention to treat. The trial is registered with ANZCTR.org.au, ACTRN12614000399695, and is completed. FINDINGS: Between Aug 18, 2014, and Sept 5, 2018, 154 participants were randomly assigned to integrated oncogeriatric care (n=76) or usual care (n=78). 13 participants died by week 12 and 130 (92%) of the remaining 141 participants completed two or more ELFI assessments. Participants assigned to integrated oncogeriatric care reported better adjusted ELFI change scores over 24 weeks compared with those in the usual care group (overall main effect of group: t=2·1, df=213, p=0·039; effect size=0·38), with maximal between-group differences at week 18 (mean difference in change 9·8 [95% CI 2·4-17·2]; p=0·010, corrected p=0·030, effect size=0·48). The integrated oncogeriatric care group also had significantly fewer unplanned hospital admissions at 24 weeks (multivariable-adjusted incidence rate ratio 0·60 [95% CI 0·42-0·87]; p=0·0066). No statistically significant between-group difference was observed in overall survival. INTERPRETATION: CGA led to better quality of life and health-care delivery in older people receiving systemic anticancer treatment. Routine CGA-based interventions should be considered in at-risk older people starting systemic anticancer treatment. FUNDING: National Health and Medical Research Council (Australia), Monash University, and Eastern Health.

Examining the contribution of psychological resilience on self-reported and naturalistic driving behavior of older adults.

INTRODUCTION: This study examined the contribution of psychological resilience on self-reported driving comfort, abilities, and restrictions, and on naturalistic driving (ND) behavior of older adults at two time points, five years apart (N = 111; Male: 65.8%, Mean age = 86.1 years). METHOD: Participants from the Ozcandrive older driver cohort study completed a demographic questionnaire, functional assessments, psychosocial driving questionnaires, and a resilience scale. Participants' vehicles were equipped with a recording device to monitor driving behavior throughout the study. Over 1.7 million kilometers of ND data were analyzed. RESULTS: There was a significant increase in resilience over time, and both self-reported and ND measures revealed reduced driving across five years. Hierarchical regression analyses using age, sex, driving exposure, functional measures, and resilience showed that adding resilience into the models at the final step resulted in statistically significant increases in the amount of variance explained for driving comfort during the day and night, perceived driving abilities, number of trips, trip distance, and proportion of night trips. CONCLUSIONS: This research leveraged the longitudinal nature of the Ozcandrive study to provide the first insights into the role of resilience and ND. The observed patterns of reduced driving, captured by both subjective and objective measures, are suggestive of increased levels of self-regulation. As resilience is associated with adaptive coping skills, older adults with higher resilience may be able to more effectively engage in appropriate coping behaviors with regard to driving behavior, safety, and mobility. PRACTICAL APPLICATIONS: Effective methods of increasing resilience in the context of driving is worthy of future research as it will provide valuable information about how older drivers navigate the process of aging as it relates to driving and may assist stakeholders in developing suitable measures to support older driver safety.

Clinical evaluation of the national hospital-acquired complication programme.

BACKGROUND: The national hospital-acquired complication programme captures complications arising from patient-related and hospital-related factors, but the proportion of the two is unclear. AIM: Health services are encouraged to evaluate data from the national hospital-acquired complications (HAC) programme and identify strategies to mitigate them. METHODS: A retrospective chart review compared HAC extracted from administrative data. The setting was a 430-bed university-affiliated metropolitan hospital. Records from 260 participants with, and 462 without, reported HAC from 2619 multi-day stay adults were reviewed. The main outcome measures were prevalence and positive predictive value (PPV) of HAC methodology. RESULTS: No errors of HAC coding or classification were identified. Four hundred and twenty-three HAC events were reported in 260 records; most commonly delirium (n = 57; 13.4%), pneumonia (n = 46; 10.9%), blood stream infection (n = 39; 9.2%), hypoglycaemia (n = 33; 7.8%) and cardiac arrhythmias (n = 33; 7.8%). One hundred and eight (25.5%) 'HAC' events in 69 separations (95% confidence interval (CI) = 2.05-3.33 per 100 separations) were false positive, and 43 of 462 (95% CI = 6.72-12.22 per 100 separations) were false negative. Prevalence of total (reported plus missing) HAC was 16.06 (95% CI = 14.02-19.52), reported HAC was 9.93 (95% CI = 8.76-11.21), potentially preventable HAC was 1.68 (95% CI = 1.22-2.26) and healthcare errors was 0.31 (95% CI = 0.13-1.30) per 100 separations. PPV of HAC for true clinical events was 0.74 (0.68-0.79), preventable events 0.18 (0.13-0.23) and healthcare error 0.03 (0.01-0.06). CONCLUSIONS: Prevalence of HAC events was higher than expected, but PPV for healthcare errors was low, suggesting provision of care is a less common cause of HAC events than patient factors. HAC may be an indicator of hospital admission complexity rather than HAC.

Factors associated with the decision to prescribe and administer antipsychotics for older people with delirium: a qualitative descriptive study.

OBJECTIVES: To explore factors associated with decision-making of nurses and doctors in prescribing and administering as required antipsychotic medications to older people with delirium. DESIGN: Qualitative descriptive. SETTING: Two acute care hospital organisations in Melbourne, Australia. PARTICIPANTS: Nurses and doctors were invited to participate. Semi-structured focus groups and individual interviews were conducted between May 2019 and March 2020. Interviews were audio-recorded and transcribed verbatim. Data were analysed using thematic analysis. RESULTS: Participants were 42 health professionals; n=25 nurses and n=17 doctors. Themes relating to decisions to use antipsychotic medication were: safety; a last resort; nursing workload; a dilemma to medicate; and anticipating worsening behaviours. Nurses and doctors described experiencing pressures when trying to manage hyperactive behaviours. Safety was a major concern leading to the decision to use antipsychotics. Antipsychotics were often used as chemical restraints to 'sedate' a patient with delirium because nurses 'can't do their job'. Results also indicated that nurses had influence over doctors' decisions despite nurses being unaware of this influence. Health professionals' descriptions are illustrated in a decision-making flowchart that identifies how nurses and doctors navigated decisions regarding prescription and administration of antipsychotic medications. CONCLUSIONS: The decision to prescribe and administer antipsychotic medications for people with delirium is complex as nurses and doctors must navigate multiple factors before making the decision. Collaborative support and multidisciplinary teamwork are required by both nurses and doctors to optimally care for people with delirium. Decision-making support for nurses and doctors may also help to navigate the multiple factors that influence the decision to prescribe antipsychotics.

SARS-CoV-2 seroprevalence in healthcare workers in a tertiary healthcare network in Victoria, Australia.

BACKGROUND: Healthcare workers (HCW) are exposed to an increased risk of COVID-19 through direct contact with patients and patient environments. We calculated the; seroprevalence of SARS-CoV-2 in HCW at Eastern Health, a tertiary healthcare network in Victoria, and assessed associations with demographics, work location and role. METHODS: A cross-sectional cohort study of HCW at Eastern Health was conducted. Serum was analysed for the presence of antibodies to SARS-CoV-2, and all participants completed; an online survey collecting information on demographics, place of work, role, and exposures; to COVID-19. Seroprevalence was calculated as the proportion participants with SARS-CoV-2; antibodies out of all tested individuals. RESULTS: The crude seroprevalence of SARS-CoV-2 antibodies in this study was 2.17% (16/736). Thirteen of the 16 (81.2%) positive cases had previously been diagnosed with COVID-19 by PCR: the seroprevalence in the group not previously diagnosed with COVID by PCR was 0.42% (3/720). Having direct contact with COVID-19 patients did not increase the likelihood of having positive serology. A prior history of symptoms consistent with COVID-19 was associated with a higher likelihood of having positive serology (OR 17.2, p = 0.006, 95%CI: 2.25-131.55). CONCLUSION: Our calculated seroprevalence of 2.17% is higher than estimated in the general Australian population, but lower than that reported in HCW internationally. The; majority of those with positive serology in our study had previously been diagnosed with COVID-19 by PCR based testing. Seropositivity was not associated with interaction with COVID-19 positive patients, highlighting effective infection prevention and control practices within the workplace.

The Elderly Functional Index (ELFI), a patient-reported outcome measure of functional status in patients with cancer: a multicentre, prospective validation study.

BACKGROUND: Functional assessment of patients with cancer can be challenging and is often undertaken by the clinician with minimal direct input from the patient. We developed and aimed to validate the Elderly Functional Index (ELFI), a composite measure of self-reported functioning in older patients with cancer. METHODS: In this multicentre, prospective validation study, we validated ELFI in adult patients attending five oncology practices in Australia. ELFI is a 12-item composite measure of self-reported functioning derived from functional scales of the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ): physical, role, and social functioning, and mobility. For evaluation of validity and internal consistency, participants self-completed ELFI, cognitive functioning and emotional functioning scales of the EORTC QLQ Core-30, Eastern Cooperative Oncology Group Performance Status (ECOG-PS), instrumental activities of daily living (IADL), and Clinical Frailty Scale (CFS) at baseline. For evaluation of test-retest reliability, participants opted in to repeat ELFI, cognitive functioning scale, emotional functioning scale, and ECOG-PS 1 week later, as well as completing the Global Rating of Change. Internal consistency reliability was assessed using Cronbach's α and test-retest reliability was assessed using intraclass correlation (ICC). We assessed ELFI for convergent and discriminant validity (Spearman's r), known-groups validity (ANOVA), and structural validity (exploratory factor analysis). FINDINGS: Between May 6 and Dec 15, 2017, 877 participants with cancer returned a total of 869 baseline questionnaires and 482 retest questionnaires. 621 (71%) participants (192 [31%] aged ≥70 years) were included in evaluations of validity and internal consistency and 278 (32%) participants (106 [38%] aged ≥70 years) in evaluations of test-retest reliability. ELFI demonstrated excellent internal consistency reliability (Cronbach's α=0·93 for all participants; p<0·0001) and test-retest reliability (overall ICC 0·90, 95% CI 0·87-0·92; p<0·0001). Hypotheses regarding convergent and discriminant validity were confirmed, with all item-scale correlations exceeding 0·40 except for one on the physical functioning scale. ELFI was better than its component scales and other function measures at differentiating between groups with different function and frailty scores (known-groups validity). Exploratory factor analysis provided empirical support to the structural validity of ELFI. Strong correlation was observed between ELFI and its component scales (r ranging from 0·67 to 0·79), ECOG-PS (-0·79), IADL (0·69), and CFS (-0·73). INTERPRETATION: ELFI is a validated and simple person-reported multidimensional measure of functional status, which captures broad dimensions of functioning. ELFI has enhanced statistical efficiency relative to its components, reducing the sample size required to detect a given effect. ELFI could be used as a clinical trial endpoint to assess functional domains of health-related quality of life. FUNDING: National Health and Medical Research Council, Monash University, Eastern Health.

Protocol for a randomised controlled trial evaluating the impact of a community pharmacy discharge medication reconciliation service on unplanned hospital readmissions - The DCMedsRec trial.

INTRODUCTION: A substantial proportion of hospital admissions and readmissions are directly attributable to preventable medication-related harm. Interventions that reduce these harms could avert significant suffering and healthcare costs. OBJECTIVES: The Discharge Medications Reconciliation (DCMedsRec) trial will evaluate a structured medication reconciliation service by community pharmacists post hospital discharge on the risk of 30-day unplanned readmission. Electronic access to the Hospital Discharge Summary via My Health Record will underpin this service. METHODS: DCMedsRec is a non-blinded randomised controlled trial of an intervention by community pharmacists within 30 days of hospital discharge in Melbourne, Australia. Patients discharged from hospital will be assessed by a hospital pharmacist for trial eligibility. If eligible, patients will be randomised to either a control or intervention group by sequentially marked sealed envelopes. Intervention patients receive an invitation to the DCMedsRec service at a participating community pharmacy, who will be reimbursed. Control patients will receive usual care. A Number Needed to Treat of 20 will require 293 DCMedsRec interventions to achieve 80% power. With a predicted 30% uptake, a minimum sample of 977 in the intervention arm is required. OUTCOMES: The primary outcome will be the rate of 30-day unplanned hospital readmission in intervention (DCMedsRec) versus usual care groups. Secondary analyses will evaluate the economic impact of the intervention and a qualitative thematic analysis of the experience and value of the service for both patients and service providers (community pharmacists). ANALYSIS: An intention-to-treat analysis will be used to assess intervention efficacy and results will be reported using risk ratios with 95% confidence intervals. Cost-effectiveness analysis will compare within-trial costs and outcomes of the DCMedsRec versus usual care from a health-system perspective. TRIAL REGISTRATION AND FUNDING: This trial is registered with the Australian and New Zealand Clinical Trials Register and funded by the Australian Digital Health Agency.

Sarcopenia in women with hip fracture: A comparison of hormonal biomarkers and their relationship to skeletal muscle mass and function.

OBJECTIVES: Sarcopenia is a decline in skeletal muscle mass and function. It is associated with adverse outcomes and increased mortality. Sarcopenia is also reported to be prevalent in the hip fracture population. Our aims in this study are to compare the hormonal profile in women with hip fracture to controls, and to assess the relationship between hormonal biomarkers to skeletal muscle mass and function in these women. METHODS: A cross sectional study was performed enrolling women above age 60 years old with hip fracture as a study group. For comparison healthy women from the community were recruited. Peripheral blood samples were obtained for analysis of hormonal profiles. Measures of skeletal muscle mass and function by muscle area on computed tomography, dual energy X-ray absorptiometry, bioelectrical impedance analysis, and grip strength was performed. RESULTS: A high proportion of sarcopenic individuals were detected in the hip fracture group (60%). Women with hip fracture compared to controls were older (P = 0.073), had lower serum albumin levels (P < 0.001), serum insulin-like growth factor-1 (IGF-1) (P < 0.001), insulin-like growth factor binding protein -3 (IGFBP-3) (P < 0.001), free testosterone levels (P = 0.001), and impaired beta cell function by homeostasis model assessment (HOMA beta) (P = 0.038). CONCLUSIONS: There is a high proportion of sarcopenic individuals in the hip fracture group. Lowered serum levels of IGF-1 and IGFBP-3, HOMA beta cell function, and free testosterone levels were detected in this group and may serve as potential biomarkers of sarcopenia.

Gastrointestinal bleeding risk with rivaroxaban vs aspirin in atrial fibrillation: A multinational study.

PURPOSE: Comparative gastrointestinal bleeding (GIB) risk between rivaroxaban and low-dose aspirin is unknown in patients with atrial fibrillation (AF). This study investigated GIB risk with rivaroxaban vs aspirin among two separate AF cohorts in Hong Kong and the United Kingdom, using a common protocol approach. METHODS: This was a population-based cohort study using separate data from the Clinical Data Analysis and Reporting System (CDARS) of the Hong Kong Hospital Authority (2010-2018) and The Health Improvement Network (THIN) database in the United Kingdom (2011-2017). Patients with AF newly prescribed aspirin or rivaroxaban were included. Cox proportional hazards regression was used to compare GIB risks for rivaroxaban vs aspirin, accounting for confounders using propensity score fine stratification approach. RESULTS: In CDARS, 29 213 patients were included; n = 1052 (rivaroxaban), n = 28 161 (aspirin). Crude GIB event rates per 100 patient-years in CDARS were 3.0 (aspirin) and 2.6 (rivaroxaban). No difference in GIB risk was observed between rivaroxaban and aspirin overall (HR = 1.04, 95%CI = 0.76-1.42), and in dose-stratified analyses (HR = 1.21, 95%CI = 0.84-1.74 [20 mg/day]; HR = 0.80, 95%CI = 0.44-1.45 [≤15 mg/day]). In THIN, 11 549 patients were included, n = 3496 (rivaroxaban) and n = 8053 (aspirin). Crude GIB event rates were 1.3 (aspirin) and 2.4 (rivaroxaban) per 100 patient-years. No difference in GIB risk was observed between rivaroxaban and aspirin overall (HR = 1.40, 95%CI = 1.00-1.98) and low-dose rivaroxaban (≤15 mg/day) (HR = 1.00, 95%CI = 0.56-1.30), but increased GIB risk was observed for rivaroxaban 20 mg/day vs aspirin (HR = 1.57, 95%CI = 1.08-2.29). CONCLUSION: In patients with AF, GIB risk was comparable between aspirin and rivaroxaban ≤15 mg/day. GIB risk for rivaroxaban 20 mg/day vs aspirin remains uncertain and warrants further investigation.

Understanding the patient experience of early unplanned hospital readmission following acute care discharge: a qualitative descriptive study.

OBJECTIVES: To understand from a patient and carer perspective: (1) what features of the discharge process could be improved to avoid early unplanned hospital readmission (within 72 hours of acute care discharge) and (2) what elements of discharge planning could have enhanced the discharge experience. DESIGN: A qualitative descriptive design was used. Study data were collected using semi-structured interviews that were transcribed verbatim and analysed using inductive thematic analysis. Data related to participant characteristic were collected by medical record audit and summarised using descriptive statistics. SETTING: Three acute care hospitals from one health service in Australia. PARTICIPANTS: Patients who had an early unplanned hospital readmission and/or their carers, if present during the interviews and willing to participate, with patient permission. FINDINGS: Thirty interviews were conducted (23 patients only; 6 patient and carer dyads; 1 carer only). Five themes were constructed: 'experiences of care', 'hearing and being heard', 'what's wrong with me', 'not just about me' and 'all about going home'. There was considerable variability in patients' and carers' experiences of hospital care, discharge processes and early unplanned hospital readmission. Features of the discharge process that could be improved to potentially avoid early unplanned hospital readmission were better communication, optimal clinical care including ensuring readiness for discharge and shared decision-making regarding discharge timing and goals on returning home. The discharge experience could have been enhanced by improved communication between patients (and carers) and the healthcare team, not rushing the discharge process and a more coordinated approach to patient transport home from hospital. CONCLUSIONS: The study findings highlight the complexities of the discharge process and the importance of effective communication, shared decision-making and carer engagement in optimising hospital discharge and reducing early unplanned hospital readmissions.

Safety and Effectiveness of Direct Oral Anticoagulants vs Warfarin in People With Atrial Fibrillation and Dementia.

OBJECTIVE: To determine risks of embolic events, bleeding, and mortality with direct oral anticoagulants (DOACs) vs warfarin in people with atrial fibrillation (AF) and dementia. DESIGN: New-user retrospective cohort study using The Health Improvement Network database. SETTING AND PARTICIPANTS: A population-based sample comprising people with AF and dementia prescribed DOACs or warfarin from August 2011 to September 2017. METHODS: Risk of ischemic stroke (IS), ischemic stroke/transient ischemic attack/systemic embolism (IS/TIA/SE), all-cause mortality, intracranial bleeding (ICB), gastrointestinal bleeding (GIB), and other bleeding were compared for DOACs vs warfarin using propensity score-adjusted Poisson regression. Incidence rate ratios (IRRs) and absolute risk differences (ARDs) were calculated. RESULTS: Overall, 2399 people with AF and dementia initiated DOACs (42%) or warfarin (58%). Before propensity score adjustment, patients who initiated DOACs were older and had more comorbidities. After adjustment, DOAC initiators demonstrated similar risks of IS, TIA, or SE; IS alone; and other bleeding but reduced ICB risk (IRR 0.27, 95% CI 0.08, 0.86; ARD -5.2, 95% CI -6.5, -1.0, per 1000 person-years) compared with warfarin. Increased risk of GIB (IRR 2.11, 95% CI 1.30, 3.42; ARD 14.8, 95% CI 4.0, 32.4, per 1000 person-years) and all-cause mortality (IRR 2.06, 95% CI 1.60, 2.65; ARD 53.0, 95% CI 30.2, 82.8, per 1000 person-years) were observed in DOAC initiators compared with warfarin. CONCLUSIONS AND IMPLICATIONS: Among people with AF and dementia, initiating treatment with DOACs compared with warfarin was associated with similar risks of IS, TIA, or SE and IS alone. DOAC-treated patients demonstrated reduced ICB risk but increased GIB and all-cause mortality risks. We cannot exclude the possible impact of residual confounding from channeling of DOACs toward older and sicker people, particularly for the outcome of all-cause mortality. Further safety data are urgently needed to confirm findings.

Direct supervision of physiotherapists improves compliance with clinical practice guidelines for patients with hip fracture: a controlled before-and-after study.

Purpose: To determine if the addition of direct supervision to usual clinical supervision practice of physiotherapists can improve compliance with clinical practice guidelines and post-surgical outcomes for inpatients with hip fracture.Methods: A controlled before-and-after study was conducted on two acute orthopedic wards. Junior and mid-level physiotherapists on one ward were provided with direct supervision during their post-operative management of patients with hip fracture. Physiotherapists on the comparison ward received usual reflective supervision. The primary outcome was patient compliance with the hip fracture guideline to mobilize on the day following surgery. Secondary patient outcomes included physical function on the fifth post-operative day.Results: Data were collected from 290 patients with acute hip fracture. Patients at the direct supervision site were more likely to mobilize on the day after surgery [OR 3.14, 95% confidence interval (CI) 1.41-7.01; p = 0.005] and by the second post-operative day (OR 4.62, 95% CI 2.31-9.23; p < 0.001) compared to patients at the comparison site. Patients walked further on the fifth post-operative day (p < 0.001) with less assistance from therapists (p = 0.044).Conclusions: The addition of direct supervision improved physiotherapists' compliance with hip fracture guidelines and walking endurance and independence in hospitalized patients with hip fracture.Implications for rehabilitationThe addition of a direct supervision model, where physiotherapists are directly observed in their management of patients with hip fracture, to usual practice supervision improved early mobilization of patients with hip fractureDirect supervision appears to be an effective guideline implementation strategy that can improve care and outcomes for hospitalized patients with hip fracture.

Evaluation of a method to estimate the point prevalence of cognitive impairment and delirium in a multi-campus Australian health service.

OBJECTIVE: To design, test (pilot) and implement a study to estimate the point prevalence of cognitive impairment (CI) and delirium in a multi-site health service. METHODS: Clinicians were trained to use the 4 A's Test (4AT) to screen for cognitive impairment and delirium, and the 3-minute Diagnostic Interview for the Confusion Assessment Method (3D-CAM) to detect delirium in those with abnormal 4AT results. Outcomes of interest were as follows: (a) rates of cognitive impairment and delirium and (b) feasibility of the approach measured by participation rate, "direct survey activity" time, cost and surveyor preparation. RESULTS: The rates of cognitive impairment and delirium were 43.8% (245/559) and 16.3% (91/559), respectively. 90.5% (563/622) of eligible adult patients from 25 acute and subacute wards were seen. "Direct survey activities" averaged 14 minutes (range 2-45) and cost $11.48 per patient. Training evaluation indicated additional education in the 4AT and 3D-CAM was needed. CONCLUSION: Health services could use this streamlined, inexpensive method to estimate the point prevalence of cognitive impairment and delirium.

Delirium management: Let's get physical? A systematic review and meta-analysis.

OBJECTIVE: To investigate whether physical training (alone or in a multi-component intervention) is effective in preventing delirium or improving outcomes for adult patients with delirium in the hospital setting. METHODS: A systematic review, qualitative synthesis and meta-analysis of randomised controlled trials identified by searches of electronic databases, combining key concepts of delirium and physical training (the target intervention). Outcomes were incidence of delirium (for prevention trials) and delirium duration, delirium severity and hospital outcomes (for management trials). RESULTS: Seven trials were included, five of which were multi-component. The odds of developing delirium were lower for patients who received physical training compared with a control intervention [odds ratio 0.46 (95% confidence interval 0.32-0.65), P < 0.01] (moderate-quality evidence). There was insufficient evidence to draw conclusions about managing established delirium. CONCLUSIONS: Strategies incorporating physical training appear to prevent delirium in the hospital setting. More research is required regarding management of established delirium.

Factors associated with unplanned readmissions in a major Australian health service.

Objective The aim of the present study was to gain an understanding of the factors associated with unplanned hospital readmission within 28 days of acute care discharge from a major Australian health service. Methods A retrospective study of 20575 acute care discharges from 1 August to 31 December 2015 was conducted using administrative databases. Patient, index admission and readmission characteristics were evaluated for their association with unplanned readmission in ≤28 days. Results The unplanned readmission rate was 7.4% (n=1528) and 11.1% of readmitted patients were returned within 1 day. The factors associated with increased risk of unplanned readmission in ≤28 days for all patients were age ≥65 years (odds ratio (OR) 1.3), emergency index admission (OR 1.6), Charlson comorbidity index >1 (OR 1.1-1.9), the presence of chronic disease (OR 1.4) or complications (OR 1.8) during the index admission, index admission length of stay (LOS) >2 days (OR 1.4-1.8), hospital admission(s) (OR 1.7-10.86) or emergency department (ED) attendance(s) (OR 1.8-5.2) in the 6 months preceding the index admission and health service site (OR 1.2-1.6). However, the factors associated with increased risk of unplanned readmission ≤28 days changed with each patient group (adult medical, adult surgical, obstetric and paediatric). Conclusions There were specific patient and index admission characteristics associated with increased risk of unplanned readmission in ≤28 days; however, these characteristics varied between patient groups, highlighting the need for tailored interventions. What is known about the topic? Unplanned hospital readmissions within 28 days of hospital discharge are considered an indicator of quality and safety of health care. What does this paper add? The factors associated with increased risk of unplanned readmission in ≤28 days varied between patient groups, so a 'one size fits all approach' to reducing unplanned readmissions may not be effective. Older adult medical patients had the highest rate of unplanned readmissions and those with Charlson comorbidity index ≥4, an index admission LOS >2 days, left against advice and hospital admission(s) or ED attendance(s) in the 6 months preceding index admission and discharge from larger sites within the health service were at highest risk of unplanned readmission. What are the implications for practitioners? One in seven discharges resulted in an unplanned readmission in ≤28 days and one in 10 unplanned readmissions occurred within 1 day of discharge. Although some patient and hospital characteristics were associated with increased risk of unplanned readmission in ≤28 days, statistical modelling shows there are other factors affecting the risk of readmission that remain unknown and need further investigation. Future work related to preventing unplanned readmissions in ≤28 days should consider inclusion of health professional, system and social factors in risk assessments.