Internal Medicine and Aged Care Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia.
JAMA Intern Med. 2022 Mar 1;182(3):274-282. doi: 10.1001/jamainternmed.2021.7556.
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.
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.
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.
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.
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.
The 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.
anzctr.org.au Identifier: ACTRN12615000879561.
重要性：老年人医院相关并发症（HAC-OPs）包括谵妄、医院相关性残疾、失禁、压疮和跌倒。通过实施以老年人为中心的护理原则，包括早期活动、良好的营养和水分摄入、以及有意义的认知参与，可以预防这些并发症；然而，实施具有挑战性。
目的：实施并评估一项基于病房的改进计划（“Eat Walk Engage”），以便更一致地为急性住院病房的老年人提供以老年人为中心的护理原则。
设计、地点和参与者：这项多中心、随机对照试验（CHERISH 试验）纳入了 539 名连续入院的 65 岁及以上患者，他们在澳大利亚 4 家公立医院的 8 个急性内科和外科病房住院 3 天或以上，随访时间为 6 个月。研究病房包括 8 个急性内科和外科病房。按医院分层随机分组，干预组和对照组各有 4 个组。统计分析于 2018 年 8 月 28 日至 2021 年 10 月 17 日进行，采用意向治疗分析。
干预措施：一名受过培训的协调员支持每个干预病房的多学科工作组，以改善护理实践、环境和文化，以支持关键的以老年人为中心的原则。
主要结果和测量：主要结果是任何 HAC-OP 的发生率和住院时间。次要结果是个别 HAC-OP 的发生率、出院地点、6 个月死亡率和全因再入院率。根据混杂因素和聚类进行调整后，在个体水平上分析了结果。
结果：共有 265 名参与者在 4 个干预病房（124 名女性[46.8%]；平均[SD]年龄 75.9 [7.3]岁）和 274 名参与者在 4 个对照组病房（145 名女性[52.9%]；平均[SD]年龄 78.0 [8.2]岁）入组。248 名干预组参与者中有 115 名（46.4%）和 249 名对照组参与者中有 129 名（51.8%）发生了任何 HAC-OP 的复合主要结局（干预组：调整后的优势比，1.07；95%置信区间，0.71-1.61）。干预组的中位住院时间为 6 天（IQR，4-9 天），对照组为 7 天（IQR，5-10 天）（调整后的危险比，0.96；95%可信区间，0.80-1.15）。干预组的谵妄发生率显著降低（调整后的优势比，0.53；95%置信区间，0.31-0.90）。其他个别 HAC-OP、出院地点、死亡率或再入院率无显著差异。
结论和相关性：Eat Walk Engage 计划并没有降低任何 HAC-OP 或住院时间的复合主要结局，但谵妄的发生率显著降低。
试验注册：anzctr.org.au 标识符：ACTRN12615000879561。
