Individuals Who Developed Delirium While Enrolled in the Hospital Elder Life Program: An Exploratory Study.

Delirium prevention in hospitalized older adults is important due to delirium's high prevalence and negative impact on outcomes. Today, there are evidence-based programs with well-documented effectiveness aimed at preventing delirium, such as the Hospital Elder Life Program (HELP); however, approximately 4% to 5% of patients develop delirium regardless of implemented prevention interventions. It remains unknown why some patients develop delirium. The current retrospective exploratory chart review analyzed 98 records for clinical risk factors and outcomes of patients who developed delirium while enrolled in the HELP. On admission, immobility (86.7%) was the most common risk factor. Patients developed delirium approximately 70 hours after admission. Average length of stay was 8 days. Approximately one half (44.9%) of patients died within 1 year. Immobility (97.7% vs. 77.8%, p = 0.005) and renal disease (52.3% vs. 24.1%, p = 0.008) were more often found in patients who died. This study identifies risk factors that seem to require heightened attention during hospitalization to prevent the negative outcomes associated with delirium in older adults. [Journal of Gerontological Nursing, 49(5), 19-29.].

The Modified and Extended Hospital Elder Life Program: A remote model of care to expand delirium prevention.

BACKGROUND: Delirium is a common complication of hospitalization and is associated with poor outcomes. Multicomponent delirium prevention strategies such as the Hospital Elder Life Program (HELP) have proven effective but rely on face-to-face intervention protocols and volunteer staff, which was not possible due to restrictions during the COVID-19 pandemic. We developed the Modified and Extended Hospital Elder Life Program (HELP-ME), an innovative adaptation of HELP for remote and/or physically distanced applications. METHODS: HELP-ME protocols were adapted from well-established multicomponent delirium prevention strategies and were implemented at four expert HELP sites. Each site contributed to the protocol modifications and compilation of a HELP-ME Operations Manual with standardized protocols and training instructions during three expert panel working groups. Implementation was overseen and monitored during seven learning sessions plus four coaching sessions from January 8, 2021, through September 24, 2021. Feasibility of implementing HELP-ME was measured by protocol adherence rates. Focus groups were conducted to evaluate the acceptability, provide feedback, and identify facilitators and barriers to implementation. RESULTS: A total of 106 patients were enrolled across four sites, and data were collected for 214 patient-days. Overall adherence was 82% (1473 completed protocols/1798 patient-days), achieving our feasibility target of >75% overall adherence. Individual adherence rates ranged from 55% to 96% across sites for the individual protocols. Protocols with high adherence rates included the nursing delirium protocol (96%), nursing medication review (96%), vision (89%), hearing (87%), and orientation (88%), whereas lower adherence occurred with fluid repletion (64%) and range-of-motion exercises (55%). Focus group feedback was generally positive for acceptability, with recommendations that an optimal approach would be hybrid, balancing in-person and remote interventions for potency and long-term sustainability. CONCLUSIONS: HELP-ME was fully implemented at four HELP sites, demonstrating feasibility and acceptability. Testing hybrid approaches and evaluating effectiveness is recommended for future work.

Mobility Action Group: Using Quality Improvement Methods to Create a Culture of Hospital Mobility.

BACKGROUND/OBJECTIVES: To describe the Mobility Action Group (MACT), an innovative process to enhance implementation of hospital mobility programs and create a culture of mobility in acute care. DESIGN: Continuous quality improvement intervention with episodic data review. SETTING: Inpatient units including medical, surgical, and intensive care settings. PARTICIPANTS: A total of 42 hospitals of varying sizes across the United States. INTERVENTIONS: The MACT and Change Package were developed to provide a conceptual framework, road map, and step-by-step guide to enable mobility teams to implement mobility programs successfully and meet their mobilization goals. Participants were encouraged to select two to three change tactics to pursue during the first action cycle and select and implement additional tactics in subsequent cycles. Nine learning sessions were held via webinar from April 27, 2017, to October 5, 2017, during which faculty provided brief presentations, facilitation, and group discussion. MEASUREMENTS: Implementation of programs, walks per day, use of bed and chair alarms, and participant satisfaction. RESULTS: Successful implementation of mobility programs was achieved at most (76%) sites. The proportion of patients who received at least three walks per day increased from 9% to 19%. The proportion of patients who were placed on a bed or chair alarm decreased from 36% to 20%. On average, 69% of participants reported they were "strongly satisfied" with the learning sessions. Most participants found the Change Package (58%) and Toolkit (63%) "very helpful." Since the conclusion of the active initiative, the Change Package has been downloaded 1,200 times. Of those who downloaded it, 48% utilized it to establish a mobility program, and 58% used it at their organization at least once a month. CONCLUSION: The MACT and Change Package provides an innovative approach emphasizing systemwide change that can help catalyze a culture of mobility in hospitals across the nation, improving the quality of care for hospitalized older adults. J Am Geriatr Soc 68:2373-2381, 2020.

Mobilizing older adults: A multi-site, exploratory and observational study on patients enrolled in the Hospital Elder Life Program (HELP).

The aim of this study was to explore and describe the characteristics of the Hospital Elder Life Program (HELP) sites and how they mobilize patients with volunteers in the United States and other countries. The purpose was to describe: the number of enrollments, modalities, fall and injury rates, and to identify barriers to mobilization. A survey was distributed to 228 international sites. The responding sites enrolled an average of 53.9 (SD 35.3) patients per month. The majority (76%) reported that mobilization included 'active range of motion exercises' and 'ambulation'. Eighteen percent identified volunteer training, safety and liability concerns as barriers. Falls with injury on HELP units was 0-3%, with an average rate of 0.46 per 1,000 patient days. No patient falls while ambulating with the HELP team and/or volunteers were reported. More research and evidence are needed to further determine barriers and safety of mobilization with the HELP during hospitalization.

Falls and delirium in an acute care setting: A retrospective chart review before and after an organisation-wide interprofessional education.

AIM AND OBJECTIVES: To describe and compare identification of delirium, length of stay and discharge locations in two patient samples of falls, before and after an organisation-wide interprofessional delirium education and practice change along with implementation of a policy. BACKGROUND: Delirium is a common and severe problem for hospitalised patients, with occurrence ranging from 14%-56%, morbidity and mortality from 25%-33%. Recent studies report that 73%-96% of patients who fell during a hospital stay had symptoms of delirium; however, the delirium went undiagnosed and untreated in 75% of the cases. DESIGN: A descriptive, retrospective observational study using a pre/postdesign. METHODS: Two chart reviews were performed on patient falls as identified in the hospital safety reporting system in 2009-2010 (98 fallers) and 2012 (108 fallers). An organisation-wide education was planned and implemented with monitoring of policy compliance. RESULTS: After the education, documentation of the "diagnosis of delirium" and "no evidence of delirium" increased from 14.3%-29.5% and from 27.6%-44.4%. The documentation of "evidence of delirium" decreased significantly from 58.2%-25.9% (p < .001). The confusion assessment method (CAM) identified the diagnosis of delirium at 76% accuracy. The length of stay decreased by 7.3 days. The fall rates in 2011 and 2012 were 3.01 and 2.82 falls per 1,000 patient days and in 2013 decreased to 2.16. CONCLUSION: The results indicate that improving delirium recognition and treatment through interprofessional education can reduce falls and length of stay. RELEVANCE TO CLINICAL PRACTICE: The results demonstrate that when staff learn to prevent, identify, manage and document delirium more accurately the fall rate decreases. The practice change, including the use of CAM, was sustained by continuous auditing including re-education, and the re-enforcement of learning along with the implementation of a policy.

Variations in Hospice Utilization and Length of Stay for Medicare Patients With Melanoma.

CONTEXT: Timely hospice referral is an indicator of high-quality end-of-life care for cancer patients. Variations in patient characteristics associated with hospice utilization and length of stay have been demonstrated in studies of other malignancies but not melanoma. OBJECTIVES: We sought to understand hospice utilization and patient characteristics associated with variability in use for the older melanoma population. METHODS: We used the Surveillance, Epidemiology, and End Results-Medicare database to identify 13,393 melanoma patients aged 65+ years at time of diagnosis between 2000 and 2009, who died by 12/31/10. The primary outcome was enrollment in hospice with secondary outcome of hospice duration. Patient characteristics associated with variations in hospice enrollment were examined. RESULTS: Among 13,393 patients who died with melanoma, 5298 (40%) received hospice care. Of these, 17% were enrolled in hospice for three days or less, while 13% had ≥90 days of hospice care. Despite improvements over time in the proportion of patients who received hospice and those who received at least 90 days of hospice care, late hospice enrollments did not change. Multivariable analysis revealed that patients of older age, with distant disease at time of diagnosis, and residing in rural areas or in census tracts with higher rates of high school completion were more likely to enroll in hospice. CONCLUSION: Rates of hospice enrollment increased over time but remained under accepted quality benchmarks with variations evident in those who receive hospice services. Efforts to increase access to earlier hospice care for all patients dying with melanoma are essential.

Falls in A Tertiary Care Hospital-Association With Delirium: A Replication Study.

BACKGROUND: Delirium has been previously implicated as a risk factor for patient falls. This is a replication study of a 2009 investigation examining the prevalence of diagnosed and undiagnosed delirium in patients who fell during their hospital stay. OBJECTIVE: To determine the prevalence of delirium at our institution and to examine the relationship of falls with delirium, advanced age, and hospital procedures. METHOD: Using the data collection tool developed for the 2009 study, the authors performed a retrospective review of records of 99 patients who fell during their inpatient stay. Similar information was gathered on patient demographics, fall date, fall location, hospital service type, discharge disposition, diagnosis of delirium (DD), synonyms used to describe delirium, metabolic derangements, and surgeries or procedures performed. Data were collected on the day of admission, day of the fall, and 2 days before the fall. RESULTS: Falls in the general hospital were associated with delirium (73% of subjects had evidence or a DD at the time of their fall), advanced age (64.5% were older than 70 years), and specific procedures and surgeries. CONCLUSION: As identified in the previous study, improving delirium recognition and treatment may reduce the number of patient falls and promote more favorable outcomes such as reduced length of stay, fewer discharges to intermediate care facilities, and prevention of fall injuries. A comprehensive fall risk assessment that includes a delirium detection tool would improve the sensitivity and specificity of these instruments to detect those at greatest risk.

The role of clinical nurse specialists in the implementation and sustainability of a practice change.

AIM: This project's purpose was to promote and sustain a practice change focusing on delirium utilising the clinical nurse specialist (CNS) in a leadership role. BACKGROUND: Delirium is an altered state of consciousness accompanied by an acute change in cognition that tends to have a fluctuating course. Delirium is strongly associated with negative outcomes and is often unrecognised. METHOD: A policy was implemented stating that the RNs will screen patients for delirium with the confusion assessment method (CAM). Interdisciplinary delirium education was offered prior to the practice change and repeated at 3, 6 and 12 months after implementation. The documentation, completion and CAM accuracy screening were determined by the CNS. RESULTS: The CAM documentation and completion audit goal was met and sustained by week 21, and screenings were accurate 83% of the time. CONCLUSIONS: The CNS has an opportunity to take a leadership role when instituting an innovative practice change. Successful implementation of a new practice requires that patient care units are divided into cohorts with systematic roll-out of the initiative. IMPLICATIONS FOR NURSING MANAGEMENT: In addition to leadership, CNS availability on the patient care units is imperative to staff acceptance and sustainability of a practice change.

Decisions about medication use and cancer screening across age groups in the United States.

OBJECTIVE: To describe decision process and quality for common cancer screening and medication decisions by age group. METHODS: We included 2941 respondents to a national Internet survey who made at least one decision about colorectal, breast, and prostate cancer screening, blood pressure or cholesterol medications. Respondents were queried about decision processes. RESULTS: Across the five decisions considered, decision process scores were similar (and generally low) across age groups for medication and cancer screening, indicating that all groups had poor involvement in medical decision making. Overall knowledge scores were low across age groups, with elderly (75+) having slightly higher knowledge about medications vs. younger respondents. Elderly respondents reported similar goals and concerns when making decisions, though placed greater importance of having peace of mind from a normal result for cancer screening vs. younger respondents. CONCLUSION: Across age groups, respondents reported poor decision processes about common medications and cancer screening, despite little evidence of benefit for some interventions (cancer screening, cholesterol lowering medicines in low risk elderly) and possibility of harm in the elderly. PRACTICE IMPLICATIONS: Particular care should be taken to help patients understand both benefit and risk of screening tests and routine medications.

Intraperitoneal chemotherapy among women in the Medicare population with epithelial ovarian cancer.

BACKGROUND: Intraperitoneal combined with intravenous chemotherapy (IV/IP) for primary treatment of epithelial ovarian cancer results in a substantial survival advantage for women who are optimally debulked surgically, compared with standard IV only therapy (IV). Little is known about the use of this therapy in the Medicare population. METHODS: We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify 4665 women aged 66 and older with epithelial ovarian cancer diagnosed between 2005-2009, with their Medicare claims. We defined receipt of any IV/IP chemotherapy when there was claims evidence of any receipt of such treatment within 12 months of the date of diagnosis. We used descriptive statistics to examine factors associated with treatment and health services use. RESULTS: Among 3561 women with Stage III or IV epithelial ovarian cancer who received any chemotherapy, only 124 (3.5%) received IV/IP chemotherapy. The use of IV/IP chemotherapy did not increase over the period of the study. In this cohort, younger women, those with fewer comorbidities, whites, and those living in Census tracts with higher income were more likely to receive IV/IP chemotherapy. Among women who received any IV/IP chemotherapy, we did not find an increase in acute care services (hospitalizations, emergency department visits, or ICU stays). CONCLUSION: During the period between 2005 and 2009, few women in the Medicare population living within observed SEER areas received IV/IP chemotherapy, and the use of this therapy did not increase. We observed marked racial and sociodemographic differences in access to this therapy.

Mobilization of ventilated older adults.

BACKGROUND: Recent studies of ventilated, critically ill patients have shown early mobilization to be safe and resulting in better functional outcomes at discharge but have not focused on older adults. OBJECTIVES: The objectives of this pilot study were to examine the feasibility of and to describe functional outcomes associated with providing early mobilization to critically ill, older adult patients. METHODS: This is a prospective cohort study that took place in the medical and surgical intensive care units of a tertiary, academic medical center. Participants were aged 65 years or older, were on mechanical ventilation for 72 or more hours, and had a preadmission Barthel Index score of 70 or greater. Patients with an open ventriculostomy, continuous hemodialysis, or hospitalization of 7 or more days prior to intubation were excluded. A standardized early mobilization protocol was applied by a trained physical and occupational therapist to eligible participants according to previously published guidelines. Demographic information, hospitalization data, RAND 36-Item Short Form Health Survey (SF-36), and Barthel Index scores from preadmission, hospital discharge, and 30-day follow-up were collected. RESULTS: Patients who survived to hospital discharge compared with nonsurvivors were similar in their admission and hospital stay demographics. Survivors reported significantly higher functioning than nonsurvivors on preadmission functional status on both the physical functioning and general health RAND SF-36 subscales. Nonsurvivors reported significantly lower physical functioning, general health, vitality, and mental health on preadmission function when compared with the published normative RAND SF-36 data for patients aged 75 years and older. Patients who did survive hospitalization reported significantly more bodily pain at 30-day follow-up than the published normative data. Patients met criteria for therapy 92% of planned interventions, 99% of those sessions were completed, and adverse events occurred in less than 1% of interventions. CONCLUSION: Overall results indicate the feasibility and safety of implementing an early mobilization program to critically ill older adult patients.

Disparities in hospice care among older women dying with ovarian cancer.

BACKGROUND: Timely hospice referral is an essential component of quality end-of-life care, although a growing body of research suggests that for patients with various types of cancer, hospice referrals often occur very late in the course of care, and are marked by sociodemographic disparities. However, little is known about the ovarian cancer patient population specifically. We examined the extent and timing of hospice referrals in ovarian cancer patients over age 65, and the factors associated with these outcomes. METHODS: We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify 8211 women aged 66+ with ovarian cancer who were diagnosed between 2001 and 2005 and died by December 31, 2007. We excluded women who were not eligible for Medicare A continuously during the 6 months prior to death. Outcomes studied included overall hospice use in the last 6 months of life and late hospice enrollment, defined as within 3 days of death. We examined variations in these two measures based on year of diagnosis and sociodemographic characteristics (age, race, marital status, rural residence, income, education) and type of Medicare received (fee-for-service vs. managed care). RESULTS: Among 8211 women in the cohort who died from ovarian cancer, 39.7% never received hospice care (3257/8211). Overall hospice care increased over the period of observation, from 49.7% in 2001 to 63.6% [corrected] in 2005, but the proportion of women receiving hospice care within 3 days of death did not improve. Among those who received hospice care, 11.2% (556/4954) and 26.2% (1299/4954) received such care within 3 and 7 days of death, respectively. A higher proportion of black women (46.5% vs. 38.4% among whites), women in the lowest income group (42.8% vs. 37.0% in the highest income group), and those receiving fee-for-service Medicare (41.3% vs.33.5% for women in managed care) never received hospice care. In multivariable models, factors associated with lack of hospice care included age younger than 80 years (OR 1.27, 95% CI 1.15-1.40), non-white race (OR 1.44, 95% CI 1.26-1.65), low income (OR 1.17, 95% CI 1.04-1.32) and enrollment in fee-for-service Medicare compared with managed care (OR 1.39, 95% CI 1.24-1.56). CONCLUSION: More older women with ovarian cancer are receiving hospice care over time, however, a substantial proportion receive such care very near death, and sociodemographic disparities in hospice care exist. Our data also support the need to target lower-income and minority women in efforts to increase optimally timed hospice referrals in this population. Our finding that ovarian cancer patients enrolled in managed care plans were more likely to receive hospice care suggests the importance of health care system factors in the utilization of hospice services.

Completion of adjuvant chemotherapy and use of health services for older women with epithelial ovarian cancer.

PURPOSE: This analysis identifies factors associated with completion of adjuvant chemotherapy for patients with ovarian cancer and subsequent use of health services. PATIENTS AND METHODS: We used the Surveillance, Epidemiology, and End Results (SEER) -Medicare database to identify 4,617 women age 65 years or older with ovarian cancer diagnosed from 2001 to 2005. By using multivariable analyses with completion of chemotherapy as the outcome of interest, we describe factors associated with completion of treatment, including age, race, marital status, comorbidities, and sociodemographic factors. Use of health services was captured from Medicare claims. RESULTS: Among 4,617 patients with untreated ovarian cancer, 1,329 (28.8%) received no chemotherapy, 1,139 (24.7%) received a partial course of chemotherapy, and 2,149 (46.5%) completed chemotherapy. Women age 75 years or older were at greater risk of incomplete chemotherapy versus women age 65 to 74 years (odds ratio [OR], 1.64; 95% CI, 1.33 to 2.04). Having two or more comorbidities was also significantly associated with incomplete chemotherapy (OR, 1.83; 95% CI, 1.34 to 2.50). Among women who received either a partial or complete course of chemotherapy, we did not find an increase in use of health services (hospitalizations, emergency department visits, or physician visits) for the oldest women (age 80 years or older) compared with younger women. CONCLUSION: There is considerable room for improvement in helping older patients with ovarian cancer initiate and complete chemotherapy. The oldest women who completed chemotherapy in this study did not use health services more than younger women did. Treatment teams for older patients with ovarian cancer should include expertise in geriatric assessment, should carefully identify medical and psychosocial barriers to completing treatment, and should support patients throughout treatment.

Nonpharmacological management of agitation in hospitalized patients: a pilot study.

This article reports on the use of Simple Pleasures interventions to minimize agitation in hospitalized patients with late-stage dementia. The pilot project was not able to demonstrate statistical significance; however, the positive response to the education and provision of interventions has led to a hospital-wide dissemination of the interventions in the form of an activity box. No adverse effects of the interventions were found, and some patients experienced a significant decrease in agitation and use of sedative medications after exposure to the interventions. Hospital lengths of stay were shorter than expected and may also have been influenced by the intervention.

Assessing the appropriate use of metformin in an inpatient setting and the effectiveness of two pharmacy-based measures to improve guideline adherence.

OBJECTIVE: To demonstrate the level of compliance to metformin-prescribing guidelines and to evaluate the effectiveness of 2 pharmacy-based interventions. METHODS: Retrospective chart review of all inpatients who had received at least 2 doses of metformin while hospitalized. Two cohorts of patients had chart audits-one group (group A) hospitalized between March and August of 2003 (487 patients) and one group (group B) hospitalized between August of 2005 and January of 2006 (370 patients). In December of 2003, the pharmacy inserted a safety alert in the electronic ordering system and mailed a printed safety alert to all clinical staff outlining the contraindications and precautions concerning metformin use. RESULTS: More than two-thirds (69.3%) of the charts reviewed demonstrated that metformin was used in accordance with the prescribing guidelines. Surgical procedures, intravenous contrast use, and elevated serum creatinine levels accounted for the greatest percentage of guideline violations. The prescribing guidelines were violated 27.4% (47/137 charts) of the times in group A and 34.3% (40/146 charts) of the times in group B. CONCLUSIONS: The significance of this study is that metformin is often given in spite of the presence of contraindications to its use. Two pharmacy interventions were ineffective in decreasing the guideline violation frequency in a group of patients who were prescribed the drug.