Design and methods of the Hospital Elder Life Program (HELP), a multicomponent targeted intervention to prevent delirium in hospitalized older patients: efficacy and cost-effectiveness in Dutch health care

BACKGROUND: The Hospital Elder Life Program (HELP) has been shown to be highly efficient and (cost-)effective in reducing delirium incidence in the USA. HELP provides multicomponent protocols targeted at specific risk factors for delirium and introduces a different view on care organization, with trained volunteers playing a pivotal role. The primary aim of this study is the quantification of the (cost-)effectiveness of HELP in the Dutch health care system. The second aim is to investigate the experiences of patients, families, professionals and trained volunteers participating in HELP. METHODS/DESIGN: A multiple baseline approach (also known as a stepped-wedge design) will be used to evaluate the (cost-) effectiveness of HELP in a cluster randomized controlled study. All patients aged 70 years and older who are at risk for delirium and are admitted to cardiology, internal medicine, geriatrics, orthopedics and surgery at two participating community hospitals will be included. These eight units are implementing the intervention in a successive order that will be determined at random. The incidence of delirium, the primary outcome, will be measured with the Confusion Assessment Method (CAM). Secondary outcomes include the duration and severity of delirium, quality of life, length of stay and the use of care services up to three months after hospital discharge. The experiences of patients, families, professionals and volunteers will be investigated using a qualitative design based on the grounded theory approach. Professionals and volunteers will be invited to participate in focus group interviews. Additionally, a random sample of ten patients and their families from each hospital unit will be interviewed at home after discharge. DISCUSSION: We hypothesize that HELP will reduce delirium incidence during hospital admission and decrease the duration and severity of delirium and length of hospital stays among these older patients, which will lead to reduced health care costs. The results of this study may fundamentally change our views on care organization for older patients at risk for delirium. The stepped-wedge design was chosen for ethical, practical and statistical reasons. The study results will be generalizable to the Dutch hospital care system, and the proven cost-effectiveness of HELP will encourage the spread and implementation of this program. TRIAL REGISTRATION: Netherlands Trial register: NTR384

Design and methods of the Hospital Elder Life Program (HELP), a multicomponent targeted intervention to prevent delirium in hospitalized older patients: efficacy and cost-effectiveness in Dutch health care

Background The Hospital Elder Life Program (HELP) has been shown to be highly efficient and (cost-)effective in reducing delirium incidence in the USA. HELP provides multicomponent protocols targeted at specific risk factors for delirium and introduces a different view on care organization, with trained volunteers playing a pivotal role. The primary aim of this study is the quantification of the (cost-)effectiveness of HELP in the Dutch health care system. The second aim is to investigate the experiences of patients, families, professionals and trained volunteers participating in HELP. Methods/Design A multiple baseline approach (also known as a stepped-wedge design) will be used to evaluate the (cost-) effectiveness of HELP in a cluster randomized controlled study. All patients aged 70 years and older who are at risk for delirium and are admitted to cardiology, internal medicine, geriatrics, orthopedics and surgery at two participating community hospitals will be included. These eight units are implementing the intervention in a successive order that will be determined at random. The incidence of delirium, the primary outcome, will be measured with the Confusion Assessment Method (CAM). Secondary outcomes include the duration and severity of delirium, quality of life, length of stay and the use of care services up to three months after hospital discharge. The experiences of patients, families, professionals and volunteers will be investigated using a qualitative design based on the grounded theory approach. Professionals and volunteers will be invited to participate in focus group interviews. Additionally, a random sample of ten patients and their families from each hospital unit will be interviewed at home after discharge. Discussion We hypothesize that HELP will reduce delirium incidence during hospital admission and decrease the duration and severity of delirium and length of hospital stays among these older patients, which will lead to reduced health care costs. The results of this study may fundamentally change our views on care organization for older patients at risk for delirium. The stepped-wedge design was chosen for ethical, practical and statistical reasons. The study results will be generalizable to the Dutch hospital care system, and the proven cost-effectiveness of HELP will encourage the spread and implementation of this program

Frailty screening in older hospitalized patients

Hospitals become more and more ‘geriatric institutions’ and in daily practice, nurses have to deal with an increasing number of older patients. When older people with acute health problems are hospitalized, they are at high risk of rapid functional decline both during their hospital stay as well as after discharge. Frailty and functional decline contribute to negative health outcomes. Therefore, an active approach in detecting frailty in hospitalized older patients is considered to be necessary, as a starting point for proactive interventions. This thesis focuses on the screening for frailty in daily nursing care for hospitalized older patients. This thesis contains several studies with three aims: (1) generating an overview of available hospital screening tools for frailty and their psychometric properties, (2) obtaining information regarding the quality and usefulness of the Maastricht Frailty Screening Tool for Hospitalized Patients (MFST-HP screening tool), and (3) exploring opinions of hospital nurses on conducting frailty screening

Bringing the pieces together:Integrating cardiac and geriatric care in older patients with heart disease

Due to the increasing aging population, the number of older cardiac patients is also expected to rise in the next decades. The treatment of older cardiac patients is complex due to the simultaneously presence of comorbidities and polypharmacy, and geriatric conditions such as functional impairment, fall risk and malnutrition. However, the assessment of geriatric conditions is not part of the medical routine in cardiology and therefore these conditions are frequently unrecognized although they have a significant impact on treatment and on outcomes. In addition, treatments are mostly based on single-disease oriented guidelines and inadequately take other conditions into account. This may lead to conflicting recommendations and treatments that do not address important outcomes for older patients such as daily functioning, symptom relief and quality of life. Thus, the care of older cardiac patients is currently suboptimal which increases the risk of functional loss, readmission and mortality. The overall aim of the work described in this thesis is to explore the integration of cardiac and geriatric care for older patients with heart disease. First, by examining how hospitalized older cardiac patients at high risk for adverse events could be identified. Second, by investigating lifestyle-related secondary prevention of cardiovascular complications in older cardiac patients. And third, by developing a transitional care intervention for older cardiac patients and evaluating the effect on unplanned hospital readmission and mortality

Bridging the gap:Adapting transitional care to older cardiac patients' needs

Hospital readmission and mortality rates of older cardiac patients are high. Multimorbidity and geriatric conditions are common in this population and increase this risk. In frail patients with cardiovascular disease, the risk of readmission and mortality is even 2-3 times higher. The identification of patients at risk is important to enable adequate treatment, based on patients’ individual risk factors and needs. Especially patients who are transferred between care settings or discharged from hospital to home, are at high risk of adverse events. The aims of this thesis are 1) to evaluate strategies to identify patients at high risk of readmission and mortality, 2) to evaluate a transitional care intervention in frail older cardiac patients and 3) to evaluate new approaches in cardiac rehabilitation. Bridging the gap between hospital and home by combining disease management, case management and home-based cardiac rehabilitation did not lead to reduction of readmission and mortality in frail cardiac patients. The Cardiac Care Bridge (CCB) intervention is in its current form not recommended for implementation in clinical practice. If, with adequate risk assessment high-risk patients eligible for high-intensity preventive interventions can be identified, the CCB intervention may be reconsidered. For future purpose, interventions should as much as possible be integrated within existing care systems and should focus on patients’ own needs and preferences to achieve goals. Educational strategies focusing on interdisciplinary collaboration, system empowerment and identifying patients’ own drivers could improve the intervention quality to bridge the gap between current practice and older cardiac patients’ needs

Measuring the quality of care for patients with acute coronary syndrome: a process approach

Wagner, C. [Promotor]Wulp, I. van der [Copromotor]Bruijne, M.C. de [Copromotor

Clinical impression for identification of vulnerable older patients in the Emergency Department

Objectives To investigate whether the clinical impression of vulnerability (CIV) and the Dutch Safety Management Program (VMS), a screening instrument on four geriatric domains (ADL, falls, malnutrition, delirium), are useful predictors of 1-year mortality in older patients in the Emergency Department (ED). Methods This was a prospective observational study in the ED of a tertiary care teaching hospital. Patients aged 65 years and older visiting the ED, and their attending physicians and nurses were included. CIV appraised by physician and nurse and the VMS-screening were recorded. Results We included 196 patients of whom 64.8%, 61.7%, and 52.6% were considered vulnerable based on the CIV of physicians, nurses, and VMS-screening respectively. Agreement between CIV of physicians and nurses, and VMS-screening were both fair (overall agreement 63.3% for both, and respectively kappa 0.32 and kappa 0.31). CIV of physicians, nurses, and VMS-screening had a sensitivity of respectively 94%, 86%, and 73% for predicting 1-year mortality. A positive CIV was associated mostly with factors which can be observed directly during first patient contact after arrival to the ED, such as age, nutritional status and functional impairment. Conclusion The CIV is a simple dichotomous question which can be used as a first step in the identification of vulnerable older ED patients, whereas the more time-consuming VMS-46 screening is more specific for detection of vulnerability. The CIV is therefore useful in a busy ED environment where time and resources are limited

Clinical impression for identification of vulnerable older patients in the Emergency Department

Objectives To investigate whether the clinical impression of vulnerability (CIV) and the Dutch Safety Management Program (VMS), a screening instrument on four geriatric domains (ADL, falls, malnutrition, delirium), are useful predictors of 1-year mortality in older patients in the Emergency Department (ED). Methods This was a prospective observational study in the ED of a tertiary care teaching hospital. Patients aged 65 years and older visiting the ED, and their attending physicians and nurses were included. CIV appraised by physician and nurse and the VMS-screening were recorded. Results We included 196 patients of whom 64.8%, 61.7%, and 52.6% were considered vulnerable based on the CIV of physicians, nurses, and VMS-screening respectively. Agreement between CIV of physicians and nurses, and VMS-screening were both fair (overall agreement 63.3% for both, and respectively kappa 0.32 and kappa 0.31). CIV of physicians, nurses, and VMS-screening had a sensitivity of respectively 94%, 86%, and 73% for predicting 1-year mortality. A positive CIV was associated mostly with factors which can be observed directly during first patient contact after arrival to the ED, such as age, nutritional status and functional impairment. Conclusion The CIV is a simple dichotomous question which can be used as a first step in the identification of vulnerable older ED patients, whereas the more time-consuming VMS-46 screening is more specific for detection of vulnerability. The CIV is therefore useful in a busy ED environment where time and resources are limited

Does the Dutch Safety Management Program predict adverse outcomes for older patients in the emergency department?

Purpose: Frailty screening in the emergency department may identify frail patients at risk for adverse outcomes. This study investigated if the Dutch Safety Management Program (VMS) screener predicts outcomes in older patients in the emergency department. Methods: In this prospective cohort study, patients aged 70 years or older presenting to the emergency department were recruited on workdays between 10:00 AM and 7:00 PM from May 2017 until August 2017. Patients were screened in four domains: activities of daily living, malnutrition, risk of delirium, and risk of falling. After 90 days of follow up, mortality, functional decline, living situation, falls, readmission to the emergency department, and readmission to the hospital were recorded. VMS was studied using the total VMS score as a predictor with ROC curve analysis, and using a cut-off point to divide patients into frail and non-frail groups to calculate positive predictive value (PPV) and negative predictive value (NPV). Results: A total of 249 patients were included. Higher VMS score was associated with 90-day mortality (AUC 0.65, 95% CI 0.54-0.76) and falling (AUC 0.67, 95% CI 0.56-0.78). VMS frailty predicted mortality (PPV 0.15, NPV 0.94, p = 0.05) and falling (PPV 0.22, NPV 0.92, p = 0.02), but none of the other outcomes. Conclusion: In this selected group of patients, higher VMS score was associated with 90-day mortality and falls. The low positive predictive value shows that the VMS screener is unsuitable for identifying high-risk patients in the ED. The high negative predictive value indicates that the screener can identify patients not at risk for adverse medical outcomes. This could be useful to determine which patients should undergo additional screening