Effectiveness of a multidisciplinary educational intervention in patients with hip fracture: SWEET HOME study

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Original article

Effectiveness of a multidisciplinary educational intervention in patients with hip fracture: SWEET HOME study夽 Teresa Sanclemente-Boli a,∗ , Sandra Ponce-Ruiz a , Consuelo Álvarez-Lorenzo a , Esperanza Zuriguel-Pérez b , Raquel Tapia-Melenchon a , Marc Ramentol-Sintas c , Maria del Mar Villar-Casares c , Jordi Teixidor-Serra a , Vicente Molero-García a , Judith Sánchez-Raya d , Pilar Lalueza-Broto e , Àlex Ginés-Puertas d , Miriam Garrido-Clua b , Jaume Mestre-Torres c a

Servicio de Cirugía Ortopédica y Traumatológica, Hospital Universitari Vall d’Hebron, Barcelona, Spain Institut de Recerca Vall d’Hebron (VHIR), Barcelona, Spain Servicio de Medicina Interna, Hospital Universitari Vall d’Hebron, Barcelona, Spain d Servicio de Medicina Física I Rehabilitación, Hospital Universitari Vall d’Hebron, Barcelona, Spain e Servicio de Farmacia, Hospital Universitari Vall d’Hebron, Barcelona, Spain b c

a r t i c l e

i n f o

Article history: Received 10 December 2018 Accepted 14 February 2019 Available online xxx Keywords: Elderly Caregiver Patient education Femur fracture

a b s t r a c t Background and Objective: Hip fracture is a common injury among elderly patients. The main goal of our study was to assess the effectiveness of a multidisciplinary educational intervention aimed at hip fracture patients to promote home discharges and reduce in-hospital complications. Materials and Methods: A quasi-experimental study was performed by taking repeated measurements at hospital admission, at hospital discharge, and at both 30 days and one year of discharge. Patients aged ≥65 years with hip fracture who were admitted to the Orthogeriatric Service between February 2016 and January 2017 were included in the study. The educational intervention consisted in two coordinated actions: patient education administered during their hospitalization and multimodal support provided during their discharge home. Results: A total of 67 patients were included in the study (77.6% of whom were women aged 84.19 ± 7,78). Of these, 70.1% were discharged home, which doubles the figures recorded in the 2014–2015 period. The rate of readmission at 30 days and one year of the discharge was 8.5%. At the one-year followup, the patient’s dependence to perform basic activities of daily living was nearer to the pre-fracture level (Barthel: 86.67 ± 19.31; 94.33 ± 14.66), their mobility had improved in comparison with the time of discharge (Parker: 4.73 ± 1.84; 6.73 ± 2.76; Timed Up and Go Test: 38.29 ± 21.27; 21.91 ± 10.97), and their cognitive function had not worsened significantly. The patient education measures improved the patients’ autonomy as perceived by the patients, the caregivers, and the healthcare providers. Satisfaction with the healthcare received was high. Conclusions: As a novelty to the already described benefits in orthogeriatric care models, this study would contribute by proving an increase of the number of patients discharged home in a safe condition. ˜ S.L.U. All rights reserved. © 2019 The Author(s). Published by Elsevier Espana,

Efectividad de una intervención educativa multidisciplinar en pacientes con fractura de fémur: estudio SWEET HOME r e s u m e n Palabras clave: Anciano Cuidadores

Antecedentes y objetivo: La fractura de fémur (FF) es una lesión frecuente en personas de edad avanzada. El objetivo fue evaluar la efectividad de una intervención educativa multidisciplinar en pacientes con FF para favorecer el regreso al domicilio y disminuir las complicaciones hospitalarias.

夽 Please cite this article as: Sanclemente-Boli T, Ponce-Ruiz S, Álvarez-Lorenzo C, Zuriguel-Pérez E, Tapia-Melenchon R, Ramentol-Sintas M, et al. Efectividad de una intervención educativa multidisciplinar en pacientes con fractura de fémur: estudio SWEET HOME. Med Clin (Barc). 2019. https://doi.org/10.1016/j.medcli.2019.02.026 ∗ Corresponding author. E-mail address: [email protected] (T. Sanclemente-Boli). ˜ S.L.U. All rights reserved. 2387-0206/© 2019 The Author(s). Published by Elsevier Espana,

MEDCLE-4823; No. of Pages 8

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Educación en salud Fractura del fémur

˜ Material y método: Estudio cuasiexperimental con medidas repetidas al ingreso, alta, 30 días y al ano ˜ de seguimiento. Se incluyeron pacientes ≥ 65 anos con FF ingresados en la Unidad de Ortogeriatria entre febrero 2016 y enero 2017. La intervención educativa constó de dos actuaciones coordinadas: una educación sanitaria durante la hospitalización y un soporte multimodal durante la transición al domicilio. Resultados: Se incluyeron 67 pacientes (77,6% mujeres, edad 84,19 ± 7,78). Regresaron al domicilio el ˜ ˜ Al 70,1%, doblando la cifra de los anos 2014 -2015. Hubo un 8,5% de reingresos a los 30 días y al ano. ˜ el nivel de dependencia fue cercano al nivel prefractura (Barthel: 86,67 ± 19,31; 94,33 ± 14,66), la ano, movilidad mejoró respecto al alta (Parker: 4,73 ± 1,84; 6,73 ± 2,76; Timed Up and Go test: 38,29 ± 21,27; 21,91 ± 10,97) y el rendimiento cognitivo no empeoró de forma significativa. La percepción de pacientes, cuidadores y profesionales fue que la Educación Sanitaria mejoró la autonomía del paciente. La satisfacción con el proceso asistencial fue alta. Conclusiones: Este estudio aporta como novedad a los beneficios ya descritos en los modelos asistenciales ortogeriátricos, el incremento del número de pacientes que regresan al domicilio en condiciones de seguridad. ˜ S.L.U. Todos los derechos reservados. © 2019 El Autor(s). Publicado por Elsevier Espana,

Introduction Fractures of the proximal third of the femur in the elderly have experienced an exponential increase in recent years and represent a major health and social problem. They involve an increase in morbidity, mortality, functional impairment and health expenditure, and increase the degree of dependence and institutionalization of these patients the year after the fracture.1 In Catalonia, the annual rate is 5.93/1,000 people over 65 years of age and is more common in women aged 85–89, one of the autonomous communities with the highest incidence of this pathology in Spain.1 Considering the increased life expectancy and aging of the population, these figures will probably continue growing.2 Femoral fracture (FF) is the leading cause of subacute disability in women over 65 years of age,1 determining a great socioeconomic burden. In Catalonia, the mean expenditure per patient the year after a fracture is 2.5 times higher than the previous year,2 with one third corresponding to social-health resources.1 It is well documented that this post-surgery functional decline is influenced by a great complexity of factors, and that the care directed to preserve the maximum possible autonomy of the patient, improve the perception of his health status, maintain his social support network and ensure healthy living conditions is essential.3 The implementation of orthogeriatric units has allowed to reduce the mean stay and mortality, improving diagnostic accuracy and reducing the costs of care for these patients.4,5 Despite the improvements that have led to the creation of these units in the approach of these patients, a significant number of them do not return home after the hospitalization period. At Vall d’Hebron Hospital, during 2014 and 2015 only around 35% were able to return home after discharge. Most of the other patients were referred to a social-health centre (SHC). Referral to a SHC was motivated, in a high proportion of patients, by factors related to the caregiver, social context or home conditions. These services also present a wide variety of organizational resources to respond to the rehabilitation of these patients.2 The institutionalization of patients in some cases does not mean an improvement in their recovery process. The World Health Organization (WHO) recognizes that the patient’s home is where the person can naturally develop their maximum functional and health potential.3 Promoting home discharge after hospitalization due to FF should be a goal associated to improving the quality of care.6 It is important that the patient and his environment perceive that the post-discharge transition to home takes place in an orderly and progressive way, supervised by expert care units. In this sense, we have home hospitalization (HH) services that constitute a care alternative of the health sector capable of providing a set of medical and nursing care to patients at home, when they no longer need the entire hospital infrastruc-

ture but still need active surveillance and complex assistance, in a temporary and limited way.7 We also have evidence that educational interventions can contribute effectively to functional recovery and the improvement of patient adherence8,9 and have been identified as a key element in the efficacy of fracture coordination units.10 A healthcare education aimed at training the patient and their caregiver for a safe home transition, together with the support of these HH units that could provide help during the first days of home discharge, could contribute to a reduction in referrals to SHC and to an improvement in the functional recovery and quality of life of these patients. In this context the SWEET HOME study is being carried out [Healthcare (S) education and folloW-up for Elderly patients with hip fracturE Targeting hospital-to-HOME discharge] in the Orthogeriatric Unit of the Vall d’Hebron Hospital. The main objective of this study is to evaluate the effectiveness of a multidisciplinary educational intervention (EI) in patients with femoral fracture to facilitate the return home. The secondary objectives of the study are to describe the proportion of complications, readmissions and the mediumterm functional autonomy of the patient (one year). Patients and methods Design Quasi-experimental study with repeated measures at admission, at discharge, at 30 days and a year of follow-up, after participating in a multidisciplinary EI. The SWEET HOME study was carried out in the Orthogeriatric Unit of the Vall d’Hebron Hospital from February 2016 to August 2018. It was calculated that the sample should include a minimum of 66 patients for a 95% confidence level, an accuracy of 5% and an expected loss ratio of 10%. A total of 67 patients who received EI were selected between February 2016 and January 2017. All patients who, at the time of FF were ≥65 years of age, their regular residence was their own, family, shared or supervised home and had a caretaker available 24 h during the HH period were included. The exclusion criteria established were: not belonging to the geographic reference area of the hospital, not having a companion with the capacity to act as a caregiver, having a caregiver with a very high risk of abandonment and that the destination home did not meet habitable conditions. Sample selection was performed prospectively and consecutively. Variables and tools Sociodemographic and clinical variables: age, sex, main caregiver, type of fracture and polypharmacy (≥5 drugs).

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Outcome variables: activity tolerance (post-surgery sitting <24 h); functional capacity (using the Barthel index11 ); mobility (assessed by the Parker index12 and the Timed Up and Go test [TUG]13 ); risk of falls (using STRATIFY scale14 ) and number of falls; cognitive state (using the Pfeiffer questionnaire15 ) and presence of delirium; presence or absence of signs assessed by specialist according to the CAM16 ; nutritional status (through the Mini Nutritional Assessment [MNA]17 ); risk of pressure ulcers (through EMINA18 ) and caregiver burden (using the Zarit scale19 ); destination upon discharge; number of readmissions. Healthcare education was assessed through: (1) the modification of habits perceived by the patient, the caregiver and the professional to improve the autonomy of the patient with a 10point Likert; (2) the consolidation of healthcare education, which was assessed through 4 items: sitting, walking with walker, knowledge of the warning signs and compliance with fall prevention recommendations, with a binary answer Yes/No, and (3) the level of satisfaction with the care received during the care process, which was assessed through a questionnaire created ad hoc according to 10-point Likert scale. Educational intervention procedure During the first 24 h of the patient’s admission to the orthogeriatric unit and through a personal interview the inclusion criteria were confirmed, the patient and the caregiver were informed of the study, requesting their participation after the signing of the informed consent. An educational intervention (EI) was carried out, which consisted of three differentiated time phases: prior to surgery, post-surgery during hospital admission and postdischarge transition from hospital to home. EI had a triple purpose: to improve the patient’s self-care capacity, provided that his baseline situation made it possible; increase real and perceived competence in the patient and the caregiver, and make it possible for them to recognize and manage, one or the other, the warning signs. The EI was led by the nursing care team, with the collaboration of the professionals who usually take part in the care process, through training sessions and the administration of guidelines and outlines on the different aspects addressed by EI. It consisted of two coordinated actions: (1) an educational intervention carried out during hospitalization (pre-surgical and post-surgical phase), reinforced with some recommendations on paper regarding how to prevent delirium, falls and malnutrition and how to recognize and manage alarm signs, and (2) a multidisciplinary support during the transition after discharge (home phase) during the following 15 days, carried out by the professionals of the previously trained HH unit. This multidisciplinary support consisted of: (a) an assessment of the home and its surroundings from the point of view of the patient’s functional capacity; (b) check the consolidation of and/or reinforce the training received during the hospital phase, and (c) act as support in the transition process until the return of the patient to primary care. This intervention phase coincided and overlapped with that of the regular home rehabilitation service. In addition, a nurse from the SWEET HOME research team made a home support visit 30 days post-discharge. The transition to home was carried out in all patients who continued to meet the medical and social criteria. Patients who failed to comply were referred to a SHC. A detailed description of EI is shown in Table 1. Data collection A questionnaire was designed ad hoc for the collection of the variables of interest. Upon admission, through a personal interview, the inclusion criteria were confirmed, the study was reported, and informed consent was obtained. Baseline sociodemographic and clinical variables of the patients were recorded and EI was initi-

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ated. The variables were collected by the researchers both in the hospital and at home, according to the phase of the care process, at hospital discharge, in the follow-up stage (24 h, 7 days and 14 days), at 30 days and a year. Data analysis Means and standard deviation or percentages were used to perform the descriptive analysis of the baseline sociodemographic and clinical characteristics, as appropriate. The changes in the quantitative outcome variables were analysed using the repeated measures Student’s t-test and a repeated measure one-factor analysis of variance (ANOVA) when there were more than two different measures. In the case of categorical outcome variables, the changes were analysed with comparisons of proportions in binary contrasts by means of the ␹2 test. The evaluation of an improved autonomy perception after healthcare education is shown in the form of means and standard deviations. Finally, means and standard deviations of the responses to each of the 10 items are shown in the case of the ad hoc-designed scale to assess satisfaction with the care process. The Cronbach’s alpha index was calculated to assess the internal consistency of the first 9 items. In the case of item 10, on overall satisfaction, Pearson’s correlation with the rest of the scale was calculated as an additional indicator of the quality of the scale. The results of this scale have been obtained in a segregated manner, both for the patient and for the caregiver. A p value < 0.05 was considered significant. All statistical analyses have been carried out with SPSS-22. Ethical considerations This study was developed according to the principles established in the Declaration of Helsinki. It was approved by the Clinical Research Ethics Committee of the Vall d’Hebron Hospital [PR (KG) 339/2015]. All participants signed the informed consent. Results Sixty seven out of the 368 patients who were candidates for receiving EI were selected for the SWEET HOME study. Fig. 1 shows details of the sample flow diagram throughout the different phases of the study. Regarding the sociodemographic characteristics of the sample selected at admission (n = 67), highlights that 77.6% were women, with an mean age of 84.19 ± 7.78 years; in 53% the reason for admission was subcapital fracture; in 79.1% the caregiver was a relative; polypharmacy was recorded in 56.7% of patients. Upon admission, 100% had high risk of falls and 85.1% a moderate risk of pressure ulcers. More than half of the patients had a normal nutritional status (57.1%), 31.7% risk of malnutrition, and 11.1% malnutrition. Barthel prefracture index scored 84.55 ± 20.51, with 15.2% considered as dependent (≤60) and the score on the Pfeiffer questionnaire was 1.77 ± 2.40, with 24.2% having cognitive impairment (≥3) with or without delirium prior to admission. Of the 67 patients, 58.2% started sitting in the first 24 h post-intervention. 70.1% returned home after discharge. Of these, 91.5% were still at home 30 days later and 66% a year later. After discharge, 10.6% of deaths occurred annually. There were no significant differences in the variables collected between patients who returned home after discharge and those who had other destinations when compared to admission. When making the same comparison at one year, patients who went home had a significantly lower level of dependence than those who went to other destinations at the time of admission (Barthel: 94.52 ± 14.45; 79.38 ± 20.25; p = 0.002) and greater mobility with respect to discharge (Parker: 4.73 ± 1.84; 2.29 ± 0.76; p = 0.002).

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Table 1 Description of the educational intervention. Sessions

Healthcare Education (HE) contents

Presurgical phase

Post-surgical phase

Home phase

Individual and specific patient and caregiver session

Information on the main complications arising from hospitalization of the elderly

First 24 h after admission

−

−

Prevention of delirium

First day until discharge

Hospital discharge day up to 15 days post-discharge

Malnutrition/undernutrition prevention Fall prevention Surgical and accompanying process

First day until discharge

Performed by a nurse from the SWEET HOME research team Duration 1 h approx. Information was provided on paper Informative session to the patient and caregiver Performed by a nurse and/or doctor of the SWEET HOME research team Daily sessions (1 or 2) to the patient and caregiver if the caregiver’s clinical and training situation allowed it Performed by the nursing team responsible for the patient Support on paper

Daily sessions (1 or 2) to the patient and caregiver Performed by nursing team and rehabilitation team (doctor, occupational therapist, and physiotherapist)

Session before hospital discharge and 3 home visits Performed by the home hospitalization (HH) doctor and nurse

Home visit by a nurse from the SWEET HOME research team

Hours before surgery

First day until discharge −

−

−

First day

−

− −

Second day Third day

−

Fourth day

First 24 h after admission

First day until discharge

Hospital discharge day up to 15 days post-discharge

Assessment of adaptations for home return Gait re-education

−

First day until discharge

Home adaptation assessment

−

24/48 h before discharge

Hospital discharge day up to 15 days post-discharge 24 h post-discharge and 7 and 14 days post-discharge

−

−

Support of previous HE stages

Transfers (bed-chair) with caregiver presence Transfers with caregiver collaboration Transfers made by caregiver with nursing team supervision and hygiene (shower) with caregiver Medication administration and alarm signs awareness by patient and/or caregiver Fall prevention Dislocation prevention if necessary

Check consolidation and support healthcare education Help during the transition after discharge Support the educational intervention and monitor the patient

The main results are shown below for the group of patients who returned home and remained in the same during each evaluation interval. Between discharge and 30 post-discharge days, 4 patients (8.5%) re-entered an acute care hospital once. In no case was the reason for readmission related to FF. Between 30 post-discharge days and the year there were 4 readmissions in acute care. The results of the Barthel, Pfeiffer, Parker and TUG index at the different evaluation intervals are shown in Table 2. Of the 31 patients who stayed at home after a year, 12.8% had a delirium episode 48 h after admission, 23.9% at discharge and 2.4% at 30 days. There were no significant differences between delirium episodes after 48 h and at discharge (␹2 = 1.97; p = 0.166) or between 48 h and 30 days post-discharge (␹2 = 3.3; p = 0.069). There was a significant reduction between discharge and 30 days (␹2 = 8.61; p = 0.003), as was predictable in patients who had overcome an episode of femoral fracture and had returned home. A high risk of falls remained at 30 days and at one year in 100% of patients. Only one fall occurred during hospitalization and none between discharge and 30 days post-discharge. Two patients

30 days post-discharge

fell three times without apparent lesions between 30 days postdischarge and the year of follow-up, of which one remained at home (3.2% of those remained at home) and another was referred to SHC. At admission, 24.1% of the patients showed risk or malnutrition, compared to 37.9% per year, this worsening being statistically significant (␹2 = 4.40; p = 0.036). 34.1% of caregivers experienced severe overload at 30 days post-discharge Table 3 shows the results of the perception of patients, caregivers and professionals regarding the modification of patient and caregiver habits related to the healthcare education received. The consolidation of the different aspects of healthcare education was between 91 and 97% of patients at 24 h discharge and between 95 and 97% at 14 days, coinciding with the end of the intervention period of the HH team (Table 4). There was no statistically significant difference between the different moments evaluated. Table 5 shows the satisfaction data with the care received during the entire care process of both patients and caregivers. The correlation between patient and caregiver responses is moderately high (r = 0.656; p < 0.001).

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Recruitment Candidate patients (n = 368)

Excluded (n = 301) • n=140 social criteria (46.5%) • n=20 medical criteria (6.6%) • n=62 outside recruiting period (20.6%) • n=37 24h caregiver not available (12.3%) • n=42 others (out of area, no consent, other reasons) (14%) Assignment Admission Receive the intervention (n=67)

Deaths n=3 (4.5%)

Discharge to SocialHealth Centre =17 (25, 4%)

Discharge to home + HH n =47 (70, 1%)

Losses: • n=4 acute hospital readmissions (8.5%) Losses • n=8 destination change (SHC, nursing home, etc.) (17%) • n=3 do not provide data (6.4%) • n=5 deaths (10.6%)

30 days n=43 (64.2%)

1 year n =31 (46.3%) Fig. 1. Sample flow diagram in the different phases of the study.

Table 2 Descriptive statistics of the results in quantitative variables at the different times of the study. Variable a

Barthel Pfeiffer/SPMSQb Parker TUG

Admission, M (SD) Discharge, M (SD) Statistical c

94.33 (14.66) 1.18 (2.21) − −

49.17 (11.68) − − −

F1(1.29) = 518.32 − − −

p

30 days, M (SD) Statistical

p

1 year, M (SD) Statistical

p

< 0.001 − − −

65.17 (14.17) 0.93 (2.18) 4.73 (1.84) 38.29 (21.27)

< 0.001 0,33 − −

86.67 (19.31) 1.61 (2.57) 6.73 (2.36) 21.91 (10.27)

< 0.001 0,155 < 0.001 < 0.001

F2(1.29) = 113.79 F2(1.27) = 1.00 − −

F3(1.29) = 15.56 F3(1.27) = 2.14 t(29) =-5.25 t(27) = 4.24

M: mean; SD: standard deviation; SPMSQ: Short Portable Mental Status Questionnaire; F (gl): ANOVA statistic (degree of freedom); t (gl): t test (degree of freedom); F1: Admission-discharge contrast; F2: Contrast 30 days-admission; F3: Contrast 1 year-admission; TUG: Timed Up and Go scale. a Mauchly sphericity test is not assumed, the F correction is applied for the lower limit; F (1.29) = 138.69; p < 0.001; n = 30. b Sphericity assumption; F (2.54) = 3.29; p = 0,045; n = 28; F4(1.27) (30 day-1 year contrast) = 6.95; p = 0.014. c Pre-fracture data.

Discussion Although there are already studies in our country that have shown the benefits of a multidisciplinary geriatric intervention in elderly patients with hip fracture,20 this is the first study conducted in Spain that analyses the possible increase in patients >65 years with FF returning home after the hospitalization period and after receiving an EI based on healthcare education and multidisciplinary support during the transition to home.

The baseline sociodemographic characteristics of our sample, with a high mean age (84.2 ± 7.7 years) and formed by approximately 75% of women, they are very similar to those reported by other authors with patients admitted for similar injuries in Spanish hospitals, but our sample had a better functionality,21 a fact that may be due to the exclusion of institutionalized people in our study, which represent a high-risk group with greater functional limitation and worse prognosis.22

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Table 3 Evaluation of healthcare education (HE) according to the perception of the patient, the caregiver and the professionals. HE perception

M ± SD

n

According to the patient, HE modifies the patient’s habits According to the caregiver, HE modifies the caregiver’s habits According to the nurse, HE modifies the habits of: The patient The caregiver According to the PCNA, HE modifies the habits of: The patient The caregiver

7.92 ± 1.34 8.34 ± 1.14

39 47

6.70 ± 2.17 7.70 ± 1.70

43 47

6.55 ± 2.55 7.53.20 ± 1.71

44 47

M: mean; SD: standard deviation; PCNA: patient care nursing assistant.

Table 4 Consolidation of the healthcare education received during hospitalization. Variable

24 h (n)

7 days (n)

14 days (n)

␸12 ␹2 (gl)

␸13 ␹2 (gl)

␸23 ␹2 (gl)

Able to seat Walks with the aid of a walker Knows the warning signs Complies with fall prevention recommendations

94.9 (39) − 96.9 (32) 90.9 (33)

− 90.0 (39) 100 (32) 93.8 (32)

− 95.0 (40) 95.0 (40) 97.1 (34)

− − 1,008(1) 0.193(1)

− − 0.161(1) 1.150(1)

− 0.714(1) 1.616(1) 0.418(1)

n: number of cases; ␸12: comparison 24 h-7 days; ␸13: comparison 24 h-14 days; ␸23: comparison 7 days-14 days; ␹2 (gl) = ␹2 (degrees of freedom). The consolidation results are shown as percentages for the 24 h post-discharge, 7 days and 14 days. None of the comparisons is statistically significant.

Table 5 Patient and caregiver satisfaction with the entire care process. Satisfaction

1 2 3 4 5 6 7 8

Dedicated time Care received in the hospital Care received at home Adequate information Satisfaction with care expectations Care received will improve quality of life Extrapolate care to all patients with FF Overall satisfaction with care received

Patient, M (SD)

␣

r (p)

Caregiver, M (SD)

n = 30

n = 28

7.81 (2.07) 8.32 (1.45) 8.45 (1.89) 7.87 (2.25) 8.03 (2.12) 8.29 (1.90) 8.74 (1.98) 8.52 (2.08)

7.27 (2.13) 8.03 (1.77) 7.90 (2.19) 7.67 (2.45) 7.23 (2.40) 8.07 (2.08) 7.83 (2.97) 8.40 (2.17)

0,930

−

−

0.883 (<0.001)

␣

r (p)

0.954

−

−

0.789 (<0.001)

M: mean; SD: standard deviation; ␣: Cronbach’s alpha internal consistency (reliability) index; r (p): Pearson’s correlation (statistical significance between general satisfaction question and rest of the scale).

Of the total of patients included in the study, 70% were able to return home, a figure that doubles the mean 35% observed of the total number of patients who came from home and returned to it in the previous period 2014–2015 (118 of 348 in 2014 and 151 of 436 in 2015), according to data from the rehabilitation service of our hospital. However, it should be borne in mind that the participants of the SWEET HOME study were selected based on certain characteristics, which could help explain this increase. Since the cohort with available data is historical, no comparative studies have been conducted between the two populations. Additionally, the number of readmissions of patients from home at 30 days post-discharge is below 10%, a figure that is maintained annually and is similar or even better than that reported by similar studies.23,24 The level of mean dependence manifested at discharge, corresponding to severe dependence, has improved markedly at one year, with an increase of 37.5 points in the Barthel and being close to the threshold of pre-fracture dependence (low dependence). The mobility achieved after discharge has improved significantly one year, and cognitive performance has not significantly worsened one year after discharge with respect to admission. Regarding hospital complications, episodes of delirium they have remained at discharge with respect to admission, being below 25%, when it was described that it can reach 50% in patients with this pathology.25 The percentage of falls was very low, both during and after hospitalization.

Intense caregiver burden at 30 days post-discharge was below 35%, a figure clearly below 50% found by a study conducted in our country with patients with the same pathology,26 although evaluated with different scales. In general, the idea that person-centred care can have an impact on better functional recovery, reduced complications and fewer hospital readmissions27,28 is supported by our results. In addition to the impact of EI on the number of patients returning home, functionality, hospital complications and readmissions, the process evaluation results show that EI has achieved its objectives and was perceived very satisfactorily. Patients, caregivers and professionals have the perception that care habits to improve patient autonomy have changed substantially after the healthcare education received, with the lowest perception corresponding to professionals and the highest to caregivers. The consolidation of these behaviours ranged between 90 and 100% in the HH period and the satisfaction of patients and caregivers with different aspects of the care received during the care process was generally very high. The ad hoc-designed scale which assessed satisfaction with the care received shows good psychometric characteristics (see Table 5), indicating that it is a valid measure to assess satisfaction in patients and caregivers. Both patients and caregivers show very high satisfaction rates with different aspects, with mean scores between 7.8 and 8.7 for patients and between 7.2 and 8.1 for caregivers. The aspect best valued by the patients was the opinion that the care process received should be extended to all patients with FF,

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while in the case of caregivers it was the treatment received. Patient ratings are slightly higher than those of caregivers. The overall satisfaction was 8.5 and 8.4, respectively, for patients and caregivers. These data show that both patients and caregivers report a very high level of satisfaction with the healthcare education received. In line with the available evidence,3–5 this research has shown that multidisciplinary management in the care of the orthogeriatric patient is considered by patients, caregivers and professionals as a good model of care. The focus of EI was a healthcare education program for the empowerment of the patient and his main caregiver, providing training and specific monitoring protocols to the nursing team to make effective the acquisition of skills by the patient and his caregiver, without neglecting the motivational and positive reinforcement aspect necessary to face the transfer of the patient to his or her home. In addition, our study incorporates more intense recommendations and healthcare education compared to the usual standards of our unit (supplementary material). Our study supports the available evidence regarding the important role that healthcare education can play in improving functional recovery and improving adherence in different pathologies,8–10 extending it to the field of patients with FF. It is noteworthy that, despite not being one of the objectives of the research, this study has favoured the interaction between the different healthcare specialties, enhancing the commitment of professionals and the feeling of belonging. In our opinion, the results could be even better if home services (family workers, etc.) were included as support for post-discharge home care, similar to the home return plan for patients with stroke in Catalonia.29 Limitations of the study include: (1) absence of a control group; (2) Although the sample studied is of an acceptable size for a preliminary study, a multicentre study with a larger number of patients would better support the results; (3) very restrictive inclusion criteria, which have left out potentially candidate patients; (4) given the baseline profile of the patients in this study, the extrapolation of the results to more fragile patients cannot be guaranteed, and (5) some issues of interest would require a qualitative approach, such as exploring the experiences and perceptions of the patient or caregivers in the care process. This is the first study that combines multidisciplinary care in an orthogeriatric unit, with a standardized healthcare education and multidisciplinary support during the transition from hospital to home in elderly patients undergoing FF surgery. The data obtained in this research show optimistic results regarding the proportion of patients discharged to home, functional and clinical improvements, and patient and caregiver satisfaction with the care received during the care process. In general, the data support the fact that a care model based on the nursing team playing a key role and coordinating the clinical processes can improve the quality provided by orthogeriatrics. Financing This study has received a grant from the Health Strategic Research and Innovation Plan 2016–2020 (PERIS) SLT002/16/00292 of l’Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS). Conflict of interests The authors declare no conflict of interest. Acknowledgements We wish to thank all patients, caregivers, family members and professionals involved in the SWEET HOME study: social worker,

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physiotherapist, occupational therapist, rehabilitation specialist, traumatologists, nutritionists, doctors and nurses of the Home Hospitalization Unit, as well as all nurses, auxiliary nurses and caretakers of the Orthogeriatric Unit of the Vall d’Hebron University Hospital (Barcelona).

References 1. Cancio Trujillo JM, Clèries M, Inzitari M, Ruiz Hidalgo D, Santaeugènia Gonzàlez SJ, et al. Impacte en la supervivència i despesa associada a la fractura de fèmur en les persones grans a Catalunya. Monogràfics de la Central de Resultats, número 16. Barcelona: Agència de Qualitat i Avaluació Sanitàries de Catalunya. Departament de Salut. Generalitat de Catalunya; 2015. 2. Observatori del Sistema de Salut de Catalunya. Central de Resultats. Processos. La fractura de coll de fèmur en població de 65 anys o més. Dades 2014. Barcelona: Agència de Qualitat i Avaluació Sanitàries de Catalunya. Departament de Salut. Generalitat de Catalunya; 2015. 3. OMS. Informe mundial sobre el envejecimiento y la salud. Ginebra: Organización Mundial de la Salud; 2015. 4. Grigoryan KV, Javedan H, Rudolph JL. Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis. J Orthop Trauma. 2014;28(3):e49–55, http://dx.doi.org/10.1097/BOT.0b013e3182a5a045. 5. Tarazona-Santabalbina FJ, Belenguer-Varea A, Rovira-Daudi E, Cuesta-Peredó D. Orthogeriatric care: improving patient outcomes. Clin Interv Aging. 2016;11:843–56, http://dx.doi.org/10.2147/CIA.S72436. 6. Plaza Carmona M, Jiménez Mola S, Seco Calvo J. Proceso de recuperación en las personas mayores intervenidas por fractura de cadera. Metas Enfer. 2016;19(7):12–8. 7. Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS). Evalu˜ 2018 [consultada el ación de la hospitalización domiciliaria en Cataluna; 15 de noviembre de 2018] http://aquas.gencat.cat/es/ambits/avaluaciotecnologies-qualitat/qualitat-serveis/avaluacio hospitalitzacio domiciliaria catalunya/ 8. Menéndez-Jándula B, Souto JC, Oliver A, Montserrat I, Quintana M, Gich I, et al. Comparing Self-Management of Oral Anticoagulant Therapy with Clinic Management. Ann Intern Med. 2005;142:1–10. 9. Molina-Robles E, Colomer-Codinachs M, Roquet-Bohils M, Chirveches-Pérez E, Ortiz-Jurado P, Subirana-Casacuberta M. Efectividad de una intervención educativa y de ejercicio físico sobre la capacidad funcional de los pacientes en hemodiálisis. Enferm Clin. 2018;28(3):162–70. 10. Wu CH, Chen CH, Chen PH, Yang JJ, Chang PC, Huang TC, et al. Identifying characteristics of an effective fracture liaison service: systematic literature review. Osteoporos Int. 2018;10. 11. Cid-Ruzafa J, Damián-Moreno J. Valoración de la discapacidad física: el índice de Barthel. Rev Esp Salud Publica. 1997;71(2):127–37. 12. Parker MJ, Maheshwer CB. The use of a hip score in assessing the results of treatment of proximal femoral fractures. Int Orthop. 1997;21(4):262–4, http://dx.doi.org/10.1007/s002640050163. 13. Podsiadlo D, Richardson S. The timed “up & go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142–8, http://dx.doi.org/10.1111/j.1532-5415.1991.tb01616.x. 14. Enríquez M, Aranda-Gallardo M, Canca-Sánchez J, Vazquez-Blanco M, MoyaSuárez A, Morales-Asencio JM. Adaptación transcultural del instrumento «STRATIFY» para la valoración del riesgo de caídas. Enferm Clin. 2017;27:63–140. ˜ 15. Martínez J, Duenas-Herrero R, Onís MC, Aguado C, Albert C, Luque Luquec R. Adaptación y validación al castellano del cuestionario de Pfeiffer (SPMSQ) para ˜ detectar la existencia de deterioro cognitivo en personas mayores de 65 anos. Med Clin (Barc). 2001;117:129–34. 16. Ynouye SK, Van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Inter Med. 1990;113:941–8. 17. Nestlé Nutrition Institute. Mini Nutritional Assessment. MNA® . ©Nestlé, 1994, Revisión 2006. N67200 12/99 10M. 18. Fuentelsaz C. Validación de la escala EMINA©: un instrumento de valoración del riesgo de desarrollar úlceras por presión en pacientes hospitalizados. Enferm Clin. 2001;11:97–103. 19. Martín Carraswco M, Salvadó I, Nadal Álava S, Miji LC, Rico JM, Lanz P, et al. Adaptación para nuestro medio de la escala de carga del cuidador (Caregiver Burden Interview) de Zarit. Gerontology. 1996;6:338–46. 20. Vidán M, Serra JA, Moreno C, Riquelme G, Ortiz J. Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial. J Am Geriatr Soc. 2005;53(9):1476–82, http://dx.doi.org/10.1111/j.1532-5415.2005.53466.x. 21. Molero Bastante M, García López MV, Pedraza Cantero AD, Pomares Martínez MD, Gómez Gómez M. Relación entre fragilidad y fractura cadera en el anciano. Metas Enfer. 2013;16(7):24–9. 22. Gosch M, Hoffman-Weltin Y, Roth T, Blaufh M, Nicholas JA, Kammerlander C. Orthogeriatric co-management improves the outcome of long-term care residents with fragility fractures. Arch Orthop Trauma Surg. 2016;136(10):1403–9, http://dx.doi.org/10.1007/s00402-016-2543-4. 23. Fisher AA, Davis MW, Rubenach SE, Sivakumaran S, Smith PN, Budge MM. Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare. J Orthop Trauma. 2006;20(3):172–8.

G Model

ARTICLE IN PRESS

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T. Sanclemente-Boli et al. / Med Clin (Barc). 2019;xxx(xx):xxx–xxx

24. Folbert ECE, Smit RS, van der Velde D, Regtuijt EMM, Klaren MH, Hegeman JH. Geriatric fracture center: a multidisciplinary treatment approach for older patients with a hip fracture improved quality of clinical care and short-term treatment outcomes. Geriatr Orthop Surg Rehabil. 2012;3(2):59–67, http://dx.doi.org/10.1177/2151458512444288. 25. Marcantonio ER. Delirium in Hospitalized Older Adults. N Engl J Med. 2017;377:1456–66, http://dx.doi.org/10.1056/NEJMcp1605501. ˜ 26. Ariza-Vega P, Ortiz-Pina M, Kristensen MT, Castellote-Caballero Y, Jiménez-Moleón JJ. High perceived caregiver burden for relatives of patients following hip fracture surgery. Disabil Rehabil. 2017;16:1–8, http://dx.doi.org/10.1080/09638288.2017.1390612.

27. Blakey EP, Jackson D, Walthall H, Aveyard H. What is the experience of being readmitted to hospital for people 65 years and over? A review of the literature. Contem Nurse. 2017;53:698–712, http://dx.doi.org/ 10.1080/10376178.2018.1439395. 28. Griffiths B, Davies A. Reducing hospital admissions with person-centred intermediate care. Nurs Times. 2017;113(2):55–7. 29. Consorci Sanitari de Barcelona. Pla de retorn al domicili per a pacients amb ictus. Atenció integrada social i sanitària per a pacients amb malaltia vascular cerebral; 2016,; 2016 [consultada el 1 de diciembre de 2018] http://www.consorci.org/media/upload/arxius/noticies/PlaRetornPacientsIctus AinaPlaza.pdf