Making Hospitals Safer for Older Adults: Updating Quality Metrics by Understanding Hospital-Acquired Delirium and Its Link to Falls

Background: Despite technological and scientific advances, Hospital Acquired Pressure Ulcers (HAPUs) remain a common, expensive, but preventable adverse event. The global prevalence ranges from 9% to 53% while three million people develop HAPUs in the United States and 60,000 people die from associated complications. HAPU prevalence is reported as high as 42% in ICUs (ICU) costing on average $48,000 to clinically manage. Objective: The purpose of this systematic review was to evaluate the effectiveness of multi-component interventions (care bundles), incorporating the Braden scale for assessment, in reducing the prevalence of HAPUs in older adults hospitalized in ICUs. Methods: This was a systematic review of the literature using the Cochrane method. A systematic search was performed in six databases (CINAHL, Cochrane Library, Google Scholar, JBI Evidence-Based Practice Database, PubMed, and ProQuest) from January 2012 until December 2018. Bias was assessed with the Critical Appraisal Skills Programme Checklist, and the quality of evidence was evaluated with the American Association of Critical-Care Nurses Levels of Evidence. Results: The search identified 453 studies for evaluation; 9 studies were reviewed. From the analysis, pressure ulcer prevention programs incorporated three strategies: 1) Evidence-based care bundles with risk assessments upon admission to the ICU; 2) Unit-based skincare expertise; and 3) Staff education with auditing feedback. Common clinical management processes included in the care bundles were frequent risk reassessments, daily skin inspections, moisture removal treatments, nutritional and hydration support, offloading pressure techniques, and protective surface protocols. The Braden scale was an effective risk assessment for the ICU. Through early risk identification and preventative strategies, HAPU programs resulted in prevalence reduction, less severe ulcers, and reduced care costs. Conclusion: Older adults hospitalized in the ICU are most vulnerable to developing HAPUs. Early and accurate identification of risk factors for pressure is essential for prevention. Care bundles with three to five evidence-based interventions, and risk assessment with the Braden scale, were effective in preventing HAPUs in older adults hospitalized in intensive care settings. Higher quality evidence is essential to better understanding the impact of HAPU prevention programs using care bundles with risk assessments on patient outcomes and financial results.

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Accelerometer‐Measured Hospital Physical Activity and Hospital‐Acquired Disability in Older Adults

Journal of the American Geriatrics Society ◽

10.1111/jgs.16231 ◽

2019 ◽

Vol 68 (2) ◽

pp. 261-265 ◽

Cited By ~ 10

Author(s):

Juliessa M. Pavon ◽

Richard J. Sloane ◽

Carl F. Pieper ◽

Cathleen S. Colón‐Emeric ◽

Harvey J. Cohen ◽

...

Keyword(s):

Physical Activity ◽

Older Adults ◽

Acquired Disability ◽

Hospital Acquired

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Effect of a geriatric management unit on the outcomes of hospitalized older adults with cancer in Mexico.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.12039 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. 12039-12039

Author(s):

Gretell Henriquez Santos ◽

Andrea de la O Murillo ◽

Enrique Soto Perez De Celis

Keyword(s):

Internal Medicine ◽

Older Adults ◽

Developing Countries ◽

Hospital Mortality ◽

Management Unit ◽

Charlson Index ◽

Tumor Type ◽

Risk Of Death ◽

Hospitalized Older Adults ◽

Hospital Acquired

12039 Background: Geriatric assessments and interventions improve the outcomes of hospitalized older adults with cancer, but their implementation in developing countries is limited. We studied the effect of a specialized geriatrician-led inpatient geriatric management unit compared with a conventional internal medicine ward on the outcomes of hospitalized Mexican older adults with cancer. Methods: This retrospective study included patients aged ≥65 with solid tumors who had a cancer-related hospitalization at a public academic center in Mexico City between March 2015 and October 2018. Patients hospitalized in the geriatric management unit (cases) were paired in a 1:2 fashion with those in internal medicine wards (controls). Pairing was done by age (+/- 5 years), tumor type, and admission date (+/- 3 months). We studied the effect of being hospitalized in the geriatric management unit on length of stay (LOS), incidence of delirium, hospital-acquired complications, and in-hospital mortality. Multivariate logistic regression models for each outcome were created using variables which were significant on univariate analysis. Results: 300 patients (100 cases, 200 controls, median age 75) were included. The most common tumors were gastrointestinal (GI) (53%) and genitourinary (25%). Both groups were comparable regarding baseline comorbidities (Charlson index 8.5 vs. 7.7, p = 0.99) and illness severity at admission (NEWS2 score 2.6 vs. 2.3, p = 0.82). No difference in median LOS was found between cases and controls (9.1 vs. 9.5 days, p = 0.34). Diagnosis of a GI tumor (OR 3.4, 95% CI 1.3-5.5), hospital-acquired complications (OR 4.9, 95% CI 2.5-7.3), and delirium (OR 5.5, 95% CI 2.3-8.7) were associated with longer LOS. 14% of patients in both groups had delirium. Hospitalization in the geriatric management unit reduced the risk of delirium (OR 0.35, 95% CI 0.1-0.9), while a higher Charlson index (OR 1.2, 95% CI 1.0-1.4), NEWS2 score (OR 1.2, 95% CI 1.1-1.4), and hospital-acquired complications (OR 7.3, 95% CI 2.9-18.5) increased it. 34% of patients developed hospital-acquired complications. Diagnosis of a GI tumor (OR 1.9, 95% CI 1.1-3.3) and higher NEWS2 score (OR 1.2, 95% CI 1.1-1.4) increased the risk of hospital-acquired complications. No differences in in-hospital mortality were seen between cases and controls (12% vs. 10%, p = 0.59). A higher NEWS2 score at admission (OR 1.4, 95% CI 1.2-1.7) and delirium (OR 10.7, 95% CI 3.2-36.3) increased the risk of death. Conclusions: Among older Mexican adults hospitalized for a cancer-related diagnosis, receiving care in a geriatric management unit led to a significant decrease in the risk of delirium. No improvements were seen in LOS, complications, or in-hospital mortality, which were associated with tumor and patient-related characteristics. Geriatric co-management can lead to improved geriatric outcomes in developing countries with limited resources.

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Hospital-acquired delirium in older adults

Canadian Medical Association Journal ◽

10.1503/cmaj.130299 ◽

2013 ◽

Vol 186 (1) ◽

pp. E61-E61 ◽

Cited By ~ 2

Author(s):

N. Stall ◽

C. L. Wong

Keyword(s):

Older Adults ◽

Hospital Acquired

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What you need to know about: delirium in older adults in hospital

British Journal of Hospital Medicine ◽

10.12968/hmed.2020.0603 ◽

2021 ◽

pp. 1-10

Author(s):

Howell T Jones ◽

Daniel HJ Davis

Keyword(s):

Older Adults ◽

Cognitive Function ◽

Environmental Factors ◽

Acute Onset ◽

Clinical Syndrome ◽

Acute Illness ◽

Fluctuating Course ◽

Hospital Acquired ◽

Severe Deterioration

Delirium is a clinical syndrome characterised by a disturbance of perception, consciousness and/or cognitive function, with an acute onset, fluctuating course and a severe deterioration arising over hours or days. Delirium is usually triggered by a combination of influences including acute illness, surgery, drugs and environmental factors. It is commonly seen in older people presenting to hospital, but can also develop during hospitalisation. There are three types of delirium: hypoactive, hyperactive and mixed. All patients over 65 years old presenting to hospital should be screened for delirium using the ‘4AT’ tool. An alternate method for diagnosing hospital-acquired delirium is described. This article outlines a 10-stage method for diagnosing, managing and preventing delirium, with emphasis on which areas of the history and examination should be prioritised, what the salient investigations are and both non-pharmacological and pharmacological approaches to preventing and treating delirium. Finally, this article explores which patients require specialist referrals or investigations and how to best follow up patients with delirium.

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