Implementing ACOVE quality indicators as an intervention checklist to improve care for hospitalized older adults
BACKGROUND
Medicare patients account for approximately 50% of hospital days. Hospitalization in older adults often results in poor outcomes.
OBJECTIVE
To test the feasibility and impact of using Assessing Care of Vulnerable Elders (ACOVE) quality indicators (QIs) as a therapeutic intervention to improve care of hospitalized older adults.
DESIGN
Post-test only prospective intervention with a nonequivalent retrospective control group.
SETTING
Large tertiary hospital in the greater New York Metropolitan area.
PATIENTS
Hospitalized patients, 75 years and over, admitted to medical units.
INTERVENTION
A checklist, comprised of four ACOVE QIs, administered during daily interdisciplinary rounds: venous thrombosis prophylaxis (VTE) (QI 1), indwelling bladder catheters (QI 2), mobilization (QI 3), and delirium evaluation (QI 4).
MEASUREMENTS
Variables were extracted from electronic medical records with QI compliance as primary outcome, and length of stay (LOS), discharge disposition, and readmissions as secondary outcomes. Generalized linear mixed models for binary clustered data were used to estimate compliance rates for each group (intervention group or control group) in the postintervention period, along with their corresponding 95% confidence intervals.
RESULTS
Of the 2,396 patients, 530 were on an intervention unit. In those patients not already compliant with VTE, compliance rate was 57% in intervention vs 39% in control (P < .0056). For indwelling catheters, mobilization, and delirium evaluation, overall compliance was significantly higher in the intervention group 72.2% vs 54.4% (P = .1061), 62.9% vs 48.2% (P < .0001), and 27.9% vs 21.7% (P = .0027), respectively.
CONCLUSION
The study demonstrates the feasibility and effectiveness of integrating ACOVE QIs to improve the quality of care in hospitalized older adults. Journal of Hospital Medicine 2017;12:517-522. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
RESULTS
Of the 2,396 patient admissions, 530 were in the intervention unit and 1,866 were in the control unit. In the intervention group, the average age was 84.65 years, 75.58% were white and 47.21% were married. There was no difference in patient demographics between groups (Table 2).
QI 1: VTE Prophylaxis
Compliance with VTE prophylaxis was met in 78.3% of the intervention subjects and 76.5% of the controls (P < .4371) (Table 3). Of note, the rate of VTE prophylaxis was 57% in the intervention vs 39% in the control group (P < .0056), in the 554 patients for whom compliance was not met. Mechanical prophylaxis was used in 35.6% of intervention subjects vs 30.6 in the control (P = .048). Patients who received no form of prophylaxis were 0.5% in the intervention and 3% in the control (P = .027).
QI 2: Indwelling Bladder Catheters
Out of 2,396 subjects, 406 had an indwelling bladder catheter (16.9%). Compliance with the catheter was met in 72.2% of the intervention group vs 54.4% in the control group (P = .1061). An indication for indwelling bladder catheters was documented in 100% of the subjects. The average number of catheter days was 5.16 in the intervention vs 5.88 in the control (P < .2284). There was statistical significance in catheter compliance in the longer stay (>15 days) subjects, decreasing to 23.32% in the control group while staying constant in the intervention group 71.5% (P = .0006).
QI 3: Mobilization
Of the 2,396 patients, 1,991 (83.1%) were reported as ambulatory prior to admission. In the intervention vs control group, 74 (14%) vs 297 (15.7%), respectively, were nonambulatory. Overall compliance with Q3 was 62.9% in the intervention vs 48.2% in the control (P < .0001). More specifically, the average time to PT order in the intervention group was 1.83 days vs 2.22 days in the control group (P <
QI 4: Delirium Evaluation
In terms of nursing documentation indicating the presence of an acute confusional state, the intervention group had 148 out of 530 nursing notes (27.9%) vs 405 out of 1,866 in the control group (21.7%; P = .0027). However, utilization of the “acute confusion” parameter with documentation of a risk factor did not differ between the groups (5.8% in the intervention group vs 5.6% in the control group, P < .94).
LOS, Discharge Disposition, and 30-Day Readmissions
LOS did not differ between intervention and control groups (6.37 days vs 6.27 days, respectively), with a median of 5 days (P = .877). Discharge disposition in the 2 groups included the following: home/home with services (71.32% vs 68.7%), skilled nursing facility/assisted living/long-term care (24.34 versus 25.83), inpatient hospice/home hospice (2.64 vs 2.25), and expired (1.13 vs 1.77; P < .3282). In addition, 30-day readmissions did not differ (21% vs 20%, respectively, P = .41).
DISCUSSION
Our goal was to explore an evidence-based, standardized approach to improve the care of hospitalized older adults. This approach leverages existing automated EMR alert functions with an additional level of decision support for VEs, integrated into daily multidisciplinary rounds. The use of a daily checklist-based tool offers a cost-effective and practical pathway to distribute the burden of compliance responsibility amongst team members.
As we anticipated and similar to study findings in hospitalized medicine, geriatric trauma, and primary care, compliance with general care QIs was better than geriatric-focused QIs.27,32 Wenger et al33 demonstrated significant improvements with screening for falls and incontinence; however, screening for cognitive impairment did not improve in the outpatient setting by imbedding ACOVE QIs into routine physician practice.
Increased compliance with VTE prophylaxis and indwelling bladder catheters may be explained by national financial incentives for widespread implementation of EMR alert systems. Conversely, mobilization, delirium assessment, and management in hospitalized older adults don’t benefit from similar incentives.
VTE Prophylaxis
The American College of Chest Physicians (ACCP) supports the use of VTE prophylaxis, especially in hospitalized older adults with decreased mobility.34 While greater adoption of EMR has already increased adherence, our intervention resulted in an even higher rate of compliance with the use of pharmacologic VTE prophylaxis.35 In the future, validated scores for risk of thrombosis and bleeding may be integrated into our QI-based checklist.
