Effect of a Ward-Based Program on Hospital-Associated Complications and Length of Stay for Older Inpatients

Abstract

Hospital-associated complications of older people (HAC-OPs) include delirium, hospital-associated disability, incontinence, pressure injuries, and falls. These complications may be preventable by age-friendly principles of care, including early mobility, good nutrition and hydration, and meaningful cognitive engagement; however, implementation is challenging.OBJECTIVES To implement and evaluate a ward-based improvement program ("Eat Walk Engage") to more consistently deliver age-friendly principles of care to older individuals in acute inpatient wards.DESIGN, SETTING, AND PARTICIPANTS This cluster randomized CHERISH (Collaboration for Hospitalised Elders Reducing the Impact of Stays in Hospital) trial enrolled 539 consecutive inpatients aged 65 years or older, admitted for 3 days or more to study wards, from October 2, 2016, to April 3, 2017, with a 6-month follow-up. The study wards comprised 8 acute medical and surgical wards in 4 Australian public hospitals. Randomization was stratified by hospital, providing 4 clusters in intervention and in control groups. Statistical analysis was performed from August 28, 2018, to October 17, 2021, on an intention-to-treat basis.INTERVENTION A trained facilitator supported a multidisciplinary work group on each intervention ward to improve the care practices, environment, and culture to support key age-friendly principles.MAIN OUTCOMES AND MEASURES Primary outcomes were incidence of any HAC-OP and length of stay. Secondary outcomes were incidence of individual HAC-OPs, facility discharge, 6-month mortality, and all-cause readmission. Outcomes were analyzed at the individual level, adjusted for confounders and clustering.RESULTS A total of 265 participants on 4 intervention wards (124 women [46.8%]; mean [SD] age, 75.9 [7.3] years) and 274 participants on 4 control wards (145 women [52.9%]; mean [SD] age, 78.0 [8.2] years) were enrolled. The composite primary outcome of any HAC-OP occurred for 115 of 248 intervention participants (46.4%) and 129 of 249 control participants (51.8%) (intervention group: adjusted odds ratio, 1.07; 95% CI, 0.71-1.61). The median length of stay was 6 days (IQR, 4-9 days) for the intervention group and 7 days (IQR, 5-10 days) for the control group (adjusted hazard ratio, 0.96; 95% credible interval, 0.80-1.15). The incidence of delirium was significantly lower for intervention participants (adjusted odds ratio, 0.53; 95% CI, 0.31-0.90). There were no significant differences in other individual HAC-OPs, facility discharge, mortality, or readmissions. CONCLUSIONS AND RELEVANCEThe Eat Walk Engage program did not reduce the composite primary outcome of any HAC-OP or length of stay, but there was a significant reduction in the incidence of delirium.

Association of Interprofessional Discharge Planning Using an Electronic Health Record Tool With Hospital Length of Stay Among Patients with Multimorbidity

“… 19 While our findings validate results from a previous meta-analysis 3 showing that LOS was reduced for medical patients who were allocated to a discharge planning program, other investigations found no or even an increasing effect on LOS among unselected medical patients. 6 , 34 Interventions in smaller and more selected patient populations, such as in those with heart failure, were more likely to be successful in reducing LOS. 35 To increase reach, however, this study included a broad and heterogeneous population of medically complex patients with multiple acute and chronic morbidities.…”

“…As in other countries, this raised safety concerns. 4 Several approaches have been developed to optimize LOS, some focusing on aspects of patient management, such as clinical care, 5,6 and others targeting staffing models 7,8 and logistics of care coordination (eg, discharge planning and application of interprofessional care). 3,[9][10][11] Nevertheless, hospital discharge planning procedures have not been widely standardized, carrying the risk of poor communication, delayed assessments for postacute care demands, medication errors, or unprepared patient discharges.…”

Eat Walk Engage: Enabling acute care teams to deliver consistent fundamentals of care for older people

“…It was initially developed and evaluated through pre-post studies on a medical and a vascular surgical ward in a major metropolitan teaching hospital in Brisbane, Australia, which showed improved care processes and team communication, reduced length of stay and increased discharge home (Mudge et al, 2015(Mudge et al, , 2020. The program was then tested in a cluster randomized trial across four hospitals that confirmed the model was scalable and demonstrated a significant reduction in delirium (Mudge et al, 2022). This led to government funding to scale up across 17 metropolitan and regional publicly funded hospitals throughout Queensland since mid-2019.…”

Tom Nolan's research reviews—20 January 2022

“…When talking through these options with them, we often cite the risk of adverse events from hospital admission (hospital acquired infections, pressure sores, deconditioning, and so on) as one good reason to stay at home. A cluster randomised controlled trial of a structured, ward based, improvement programme called “Eat Walk Engage” sought to reduce hospital acquired complications among older people 1. No reduction in hospital associated complications was observed between patients on the four wards that received the intervention (aimed at improving nutrition, hydration, mobility, and cognitive and social engagement) and the four control wards.…”