MÉTHODOLOGIE:
Phase A: planification: An executive committee led by Patrick Archambault and Josée Rivard (Director of Nursing) will meet every two weeks during the 12-month collaborative. The six other members will be a transition coach, telemonitoring nurse, ED Director, ED Head nurse, geriatric specialist and a patient representative. An extended ACE CTI team including members from the ED, geriatric acute care unit, hospital administration and community representatives will meet monthly (see Table 4 in additional file).
Phase B: formation Wiki101: Our executive committee and extended team members will complete the Wiki101 online and classroom training modules (see Figure 5 in additional file) to learn how to navigate and edit knowledge tools in WikiTrauma. We will also train emergency physicians, geriatricians, family physicians, nurses (ward, home care and telemonitoring) and social workers about how to navigate and provide feedback on our wiki-based ACE knowledge tools. We will track the number participants having completed Wiki101 and ask participants to note the time spent completing this training.
Phase C: adaptation des outils de connaissance ACE: We will use WikiTrauma to house the original versions of the knowledge tools provided by the Mount Sinai ACE program and collaborate with knowledge users to create a new set adapted for use in the CISSS CA. We will also create new knowledge tools as needed during implementation of the ACE program. As the project evolves, we will present the program and our context-adapted tools to the various community-based and hospital-based stakeholders and consult them about their needs to maximise their buy-in with this program and its tools. All team members will be asked to make suggestions directly in WikiTrauma. These comments will be reviewed during our bi-monthly team meetings and integrated after peer review by the executive committee to insure reliability. ACE Program leaders at the Mount Sinai/CFHI/TVN will also have access to these online tools to provide expert oversight of our tool adaptation and creation process. For new patient-centered knowledge tools (e.g. self-care management guides), we will solicit feedback from our patient representative, Mme Poiré, who will lead a subcommittee of 6 caregivers and patients from the CISSS CA Users Committee. Focus groups will solicit in-person feedback for more in-depth feedback. Finally, frail elderly patients will give feedback during regular care using paper versions of our tools. We will document feedback in detail including time spent providing it. Throughout the 12 months, continuous improvements and adjustments will be made to our wiki-based KT tools by team members and health professionals using them. Our wiki will track these changes automatically and we will also use a Google Analytics account to track the use of the tools throughout the year.
Phase D: conception de l'étude et mise en place (3 mois): To study the impact of our context-adapted ACE CTI Program, we will conduct a before and after implementation trial with a 3-month baseline control group cohort and a 3-month post-intervention cohort. Eligible patients will: i) be aged ≥65 years; ii) be slated for discharge from an acute care hospital or the ED; iii) be rated ≥ 4 on the Canadian Study of Health and Aging-Clinical Frailty scale (CSHA-CFS); iv) be able to understand and read French or English; and v) be able to give informed consent. For clients who cannot provide informed consent or read, their authorized caregiver will give proxy consent. The research team will recruit in a consecutive manner by conducting daily AM screening of lists of hospitalized patients or ED patients aged 65 and older. A trained research assistant will assess the CSHA-CFS score and eligibility. We will keep detailed information on the flow of clients throughout the trial. All participants (providers, clients and caregivers) will sign consent forms approved by the ethics boards of the CISSS CA. Baseline data will be collected on age, sex, race, language, education level, family income, pre-hospital living situation (e.g. home, apartment, intermediate nursing homes, etc.), geography (rural vs urban: as defined by Statistics Canada for Rural and Small Town (120)), access to Internet, use of technology (mobile phone, tablet, computer), reason for hospital admission/consultation in ED, quality of life at admission (HR-QoL using 2 subscales from the Nottingham Health Profile: Social Isolation and Emotional Reactions (121-124)), CSHA-CFS (43,125-126), functional autonomy measured by the Older Americans Resources and Services (OARS) Activities of Daily Living (ADL) Scale (127-129), and Caregiver Burden Index (130-131).
At discharge, we will note: 1) destination, 2) final diagnoses for hospital admission or ED consultation, and 3) length of hospital and ED stay. After discharge, telephone follow-up will be performed at: 1) 48 hours to perform the Care Transition Measure (1) and verify uptake of all ACE CTI interventions; and 2) 30 days to measure the OARS ADL score and functional decline (defined as a drop in 3 points on the 28-point OARS ADL score (132)). At 30-day follow-up, we will also verify the following data: 1) current living situation, 2) ED visits, 3) number of primary care provider visits (e.g. physician or advance practice nurse) and reasons for visit, 2) OARS ADL score, 3) HR-QoL (Social Isolation and Emotional Reactions subscales); and 4) Caregiver Burden Index. Medical records and administrative hospital databases will be verified to calculate hospital-level outcomes for patients aged ≥65 years for periods before and after our intervention: 1) number of ED visits, 2) rate of hospital readmission, 3) overall ED admission rate, 4) alternate level care days, and 5) rate of patients returning home as opposed to other institutional settings. Once our post-intervention observation period will be completed, we will continue to monitoring the following monthly hospital-level ACE performance indicators using the current hospital administrative databases for the complete duration of this program: 1) ED visits, 2) hospital readmission rate, 3) ED admission rate, 4) alternate level care days.
To calculate costs (ACE CTI Program, Wiki-suite intervention, telemonitoring service) and potential cost-savings, we will document resource use (time spent, salary). The telemonitoring administrative database will document the number of telemonitoring interventions (phone calls, emergency response interventions, volunteer visits) occurring during the 3-month study period. Patient expenses (telemonitoring equipment and monthly service fee) and the CISSS CA expenses (salaries for 24/7 telemonitoring nurses) will be documented. We will also ask the ACE CTI implementation team members to keep a logbook to track hours spent on 1) administration and data collection for this study, 2) time spent in Wiki101 training during study setup, 3) time spent to adapt/create knowledge tools, and 3) time spent with patients (transitions coach).
Phase E: implantation (3 mois): After the training in using the context-adapted ACE CTI KT tools, we will set an official start date for patient recruitment and encouraging health professionals to use of our context-adapted tools with patients. Patients in the intervention cohort will be recruited to receive our context-adapted ACE Care Transitions Intervention. This intervention will include 1) sending a discharge summary to their primary care provider, 2) planning a follow-up appointment with their family physician, 3) assigning a transition coach for a 30-day transition period, 4) pre- and post-hospitalization medication list reconciliation, 5) offering access to our context-adapted patient-oriented KT tools, 5) access to the CISSS CA telemonitoring program.
Phase F: analyses (3 mois): Our primary outcome of interest will be the quality of care transition from hospital to the community using the Care Transition Measure, a 12 item self-report questionnaire administered by phone 48h after hospital/ED discharge (133). Secondary outcomes will be: 1) living situation, 2) length of hospital/ED stay, 3) functional decline, 4) quality of life, 5) burden of care, 5) number of ED visits, 6) the rate of hospital readmission, 7) overall ED admission rate, 8) alternate level care days, 9) rate of patients returning home as opposed to other institutional settings; 10) uptake of the ACE CTI, and 11) cost of the various elements of our intervention. We will compare the change in hospital-level averages for each of these variables before and after intervention. Initial 2-sample comparisons of the intervention and control groups will be conducted using appropriate statistical tests (e.g. Wilcoxon rank sum test for non-normally distributed continuous variables and Fisher exact test for dichotomous variables). The χ2 test will be used for dichotomous outcomes testing statistical significance between the intervention and control groups. Logistic regression analysis will be used to adjust for possible imbalances in baseline characteristics. Considering the premises (alpha=0.05, beta=0.8, standard deviation=16 (133)), we will need a sample of 64 patients in each cohort to detect a minimally clinical important difference of 8 for the CTM measure (ranging from 0 to 100).
INDICATEURS MESURÉS:
Indicateurs de performance déjà mesurés par notre établissement (12 mois pré-intervention et 12 mois post-intervention):
Taux de consultation élevé pour les PA à l'urgence (27%);
Durée moyenne de séjour à l'urgence élevée (11.35 heures);
Taux d'occupation élevé par les patients NSA (moyenne de 8 lits/jour);
Durée moyenne de séjour élevée (16.6 jours à l'UCDG);
Taux de réadmission dans les 30 jours suivant une hospitalisation élevée (11%);
Pourcentage élevé de visites à l'urgence pour des problématiques non-urgentes (54%, 4335/8036) des consultations de PA de 75 ans et plus se font pour des problèmes mineurs (triés P4 et P5 selon l'Échelle canadienne de triage).
Taux d'assiduité de 85% (pour les patients inscrits à un GMF, nous voulons que seulement 15% des patients inscrits dans un GMF consultent à l'urgence pour des raisons classées P4 et P5 selon l'échelle de triage).
Indicateurs de performance de la FCASS: