Objective: Testing clinical interventions integrated within health care delivery systems provides advantages, but it is important to make the distinction between the design of the intervention and the operational elements required for effective implementation. Thus, the objective of this study was to describe contextual factors for an outpatient follow-up clinic for older adults with hip fracture. Design: Implementation evaluation of a parallel-group 1:1 single-blinded two-arm pragmatic randomized controlled trial. Setting: Hospital-based multi-disciplinary outpatient clinic in Vancouver, Canada. Participants: Community-dwelling older adults (≥ 65 years) with hip fracture in the previous year. Interventions: Usual care vs. usual care and a comprehensive geriatric clinic for older adults after hip fracture. The primary outcome for the main study was mobility as measured by the Short Physical Performance Battery. Outcome measures: A description of central tenets of implementation that include recruitment, participant characteristics (reach) and aspects of the innovation (e.g., delivery system, fidelity to the intervention, and exercise dose delivered and enacted. Results: We identified the reach for the intervention and delivered the intervention as intended. There were 53 older adults who enrolled in the study; more than 90% of participants returned for the final assessment. We provide a comprehensive description of the intervention and report on dose delivered to participants, and participants’ 12-month maintenance for balance and strength exercises. Conclusions: It is important to move beyond solely assessing outcomes of an intervention and describe factors that influence effective implementation. This is essential if we are to replicate interventions across setting or populations or deliver interventions at broad scale to affect the health of patients, in future. Trial registration: This trial was registered on ClinicalTrials.gov (NCT01254942).
Many interventions designed to meet physical activity guideline recommendations focus on a single component (e.g., walking), to the detriment of other elements of a healthy lifestyle, such as reducing prolonged sitting and doing balance and strength exercises (i.e., bundled multiple behaviors). Adopting these multiple health behaviors within daily life routines may facilitate uptake and support longer-term behavior change. We tested feasibility for a three-part lifestyle intervention to support older women to sit less, move more, and complete balance and strength exercises.We used a convergent parallel mixed-methods, single-arm study design to test feasibility for a 6-week lifestyle intervention: Return to Everyday Activities in the Community and Home (REACH). We collected information at baseline, 3 and 6 weeks (final), and 6 months (follow-up) using questionnaires, semi-structured interviews, and performance-based measures. We describe three key elements: (1) implementation factors such as recruitment, retention, program delivery, and adherence; (2) participants' acceptability and experience with the program; and (3) health outcomes, including participants' global mobility, activity, and perceptions of their physical activity identity, and habit strength for (i) physical activity, (ii) breaking up sitting time, and (iii) balance and strength exercises.We were able to recruit enough participants in the allotted time to conduct one cycle of the REACH group-based program. There were 10 community-dwelling women, median (p25, p75) age 61 (57.5, 71) years, who completed the study. The program was feasible to deliver, with high attendance (mean 5/6 sessions) and positive overall ratings (8/10). Participants rated session content and length high, and educational materials as highly acceptable and understandable. Although participants were active walkers at baseline, few were breaking up prolonged sitting or participating in any balance and strength exercises. At final and follow-up assessments, participants reported developing habits for all three health behaviors, without diminishing physical activity.These results show acceptability of the program and its materials, and feasibility for bundling multiple health behaviors within the REACH program. It also provides confirmation to advance to testing feasibility of this three-part lifestyle intervention with older, less active, adults.ClinicalTrials.gov Identifier, NCT02786394; May 18, 2016.
Older adults face many challenges in the first few months after hip fracture. Rehabilitation holds promise to assist the recovery process. Therefore, we used semistructured interviews to explore older adults’ and allied health professionals’ acceptance of a rehabilitation intervention for hip fracture, and we described perceptions of the early recovery period (<4 months). Interviews were recorded and transcribed verbatim; three authors independently read the transcripts multiple times and together developed themes guided by Interpretive Description. Older adults described the intervention as acceptable and provided valuable feedback for its future implementation. Older adults also provided reflections on their experience of fracture recovery. Themes that emerged included physical limitations and loss of independence, the long recovery time, and coping with additional complications of living with multimorbidity. To overcome challenges, older adults identified the need for social support and physical activity, balanced by their own personal outlook.
Background: Systematic reviews highlight a preponderance of prolonged sedentary behavior in the hospital setting, with possible consequences for patients’ health and mobility. To date, most of the published literature in this field focus on the hospital experience for older adults with dementia or stroke. Few data describe hospital activity patterns in specialized geriatric units for frail older adults, who are already at risk of spending prolonged periods of time sitting. Yet, promoting older adults’ activity throughout hospitalization, when possible, is an avenue for exploration to identify opportunities to encourage more daily functional activities, and minimize the risk of post-hospital syndrome. Methods: This was a two-part observational study to describe (1) the hospital indoor environment and (2) patients’ activity patterns (using behavioral mapping) within public areas of two hospital units. One combined-trained physiotherapist and occupational therapist recorded information on indoor environmental features for two acute geriatric hospital units, such as potential opportunities for sitting and walking (i.e., handrails, chairs, benches, etc.), and identified obstacles which may impede activity (i.e., food or laundry carts in hallways, etc.). The observer also systematically scanned these units every 15 minutes (8 am to 4 pm) over two days/unit (one weekday and one weekend day) using standard behavioral mapping methods. There were three to four observation stations identified on each unit to count the number of people who were present, distinguish their role (patient, visitor), approximate age, gender, and body position or activity (sitting, standing, walking). We did not enter patients’ rooms. We described units’ indoor environment, and observed activity for each unit. We used Chi square tests to compare differences in observations between units, day of the week, and gender. Results: For both units there were similar indoor environmental features, with the exception of the floorplans, number of beds, minor differences in flooring materials, and an additional destination room (two lounges attached to one unit). Both units had items such as laundry carts against walls in hallways, blocking handrails, when present. We observed between 46–86% (average 60%) of admitted patients in the public areas of hospital units, with variability depending on unit and day: More than half of the observations were of patients sitting. Approximately 20% of patients were observed more than once: This included five women and seven men. There were significant associations for gender and observations on weekdays (men > women; Chi square = 17.01, p < 0.0001), and weekend days (women > men; Chi square = 6.11, p = 0.013). There were more visitor observations on Unit 2. Conclusions: These exploratory findings are an opportunity to, generate hypotheses for future testing, and act as a starting point to collaborate with front line clinicians to highlight the indoor environment’s role in promoting activity, and develop future strategies to safely introduce more activity into the acute care setting for older adults.
Objective: To synthesize evidence on older adults’ sedentary behavior and physical activity during rehabilitation and recovery for hip fracture (1) across the care continuum and (2) from clinical interventions. Design: We conducted a systematic review of peer-reviewed publications using CINAHL, Embase, Ovid MEDLINE, PsycINFO, and SportDiscus (last search: 17 October 2017). Study selection: We included studies that measured sedentary behavior and physical activity of older adults with hip fracture using activity monitors (e.g. accelerometers). We identified literature at Level 1 (title and abstract) and Level 2 (full text), and conducted forward and backward searches. We assessed observational studies’ adherence to reporting guidelines and intervention studies’ risk of bias. Results: We included 14 studies (882 participants). Four studies reported sedentary behavior data, while all studies reported information on physical activity. Settings included hospital, rehabilitation centers, and the community. Nine studies were observational; five were experimental design. Older adults had excessive sedentary time (>10 hours/day) and low physical activity. Participants’ average upright time differed across settings. During hospital stay, it ranged 16–52 minutes/day, while in the community, it ranged 51–261 minutes/day. Data from five interventions reported on physical activity change: two studies increased between 14 and 27 minutes/day. Another study reported participants accumulated 6994 steps/day at the end of the intervention, but for two other interventions, activity was below 5000 steps/day. Conclusion: Based on available evidence, older adults with hip fracture engage in prolonged sedentary behavior and have low levels of physical activity during rehabilitation and recovery.
BACKGROUND: Postoperative nausea and vomiting (PONV) is a common occurrence after cardiac surgery. However, in contrast to other surgical populations, routine PONV prophylaxis is not a standard of care in cardiac surgery. We hypothesized that routine administration of a single prophylactic dose of ondansetron (4 mg) at the time of stopping postoperative propofol sedation before extubation in the cardiac surgery intensive care unit would decrease the incidence of PONV. METHODS: With institutional human ethics board approval and written informed consent, we conducted a randomized controlled trial in patients ≥19 years of age with no history of PONV undergoing elective or urgent cardiac surgery procedures requiring cardiopulmonary bypass. The primary outcome was the incidence of PONV in the first 24 hours postextubation, compared by the χ 2 test. Secondary outcomes included the incidence and times to first dose of rescue antiemetic treatment administration, the incidence of headaches, and the incidence of ventricular arrhythmias. RESULTS: PONV within the first 24 hours postextubation occurred in 33 of 77 patients (43%) in the ondansetron group versus 50 of 82 patients (61%) in the placebo group (relative risk, 0.70 [95% confidence interval {CI}, 0.51–0.95]; absolute risk difference, −18% [95% CI, −33 to −2]; number needed to treat, 5.5 [95% CI, 3.0–58.4]; χ 2 test, P = .022). Kaplan-Meier “survival” analysis of the times to first rescue antiemetic treatment administration over 24 hours indicated that patients in the ondansetron group fared better than those in the placebo group (log-rank [Mantel-Cox] test; P = .028). Overall, 32 of 77 patients (42%) in the ondansetron group received rescue antiemetic treatment over the first 24 hours postextubation versus 47 of 82 patients (57%) in the placebo group (relative risk, 0.73 [95% CI, 0.52–1.00]; absolute risk difference, −16% [95% CI, −31 to 1]); P = .047. There were no significant differences between the groups in the incidence of postoperative headache (ondansetron group, 5 of 77 patients [6%] versus placebo group, 4 of 82 patients [5%]; Fisher exact test; P = .740) or ventricular arrhythmias (ondansetron group, 2 of 77 patients [3%] versus placebo group, 4 of 82 patients [5%]; P = .68). CONCLUSIONS: These findings support the routine administration of ondansetron prophylaxis at the time of discontinuation of postoperative propofol sedation before extubation in patients following cardiac surgery. Further research is warranted to optimize PONV prophylaxis in cardiac surgery patients.
'/%3e%3c/defs%3e%3cpath fill='%23012169' d='M0 0h10080v5040H0z'/%3e%3cpath stroke='%23fff' stroke-width='.6' d='m0 0 6 3m0-3L0 3' clip-path='url(%23b)' transform='scale(840)'/%3e%3cpath stroke='%23e4002b' stroke-width='.4' d='m0 0 6 3m0-3L0 3' clip-path='url(%23c)' transform='scale(840)'/%3e%3cpath stroke='%23fff' stroke-width='840' d='M2520 0v2520M0 1260h5040'/%3e%3cpath stroke='%23e4002b' stroke-width='504' d='M2520 0v2520M0 1260h5040'/%3e%3cg fill='%23fff'%3e%3cuse xlink:href='%23d' x='2520' y='3780'/%3e%3cuse xlink:href='%23a' x='7560' y='4200'/%3e%3cuse xlink:href='%23a' x='6300' y='2205'/%3e%3cuse xlink:href='%23a' x='7560' y='840'/%3e%3cuse xlink:href='%23a' x='8680' y='1869'/%3e%3cuse xlink:href='%23e' x='8064' y='2730'/%3e%3c/g%3e%3c/svg%3e)
