anticipation and swift recognition of complications can improve outcomes and reduce hospital‐acquired complications such as functional decline.
In general acute geriatric medicine, it has been shown that providing specialist care environments with staff who are interested in caring for older people and who have had relevant specialist training can also prevent the development of the geriatric syndromes in the hospital. An example is the Acute Care for Elders (ACE) unit, in which a prepared environment, interdisciplinary collaborative care, multidimensional assessment, non‐pharmacological prescription, medical review, home planning, and transitional care combine to improve a range of outcomes including improved functional status, lower risk of nursing home placement, and higher levels of patient and professional satisfaction with care.62 This system of care, tailored toward the older person, also reduces other errors such as inappropriate prescribing.
The transition of care from hospital to home is a complex process involving a multitude of components. As a result, significant numbers of adverse events related to patient safety take place during this phase. A valid and reliable tool is essential to evaluate interventions aimed at improving transition care. Although many tools are available, a recent systematic review found no validated instrument that assesses all aspects of transitional patient care.63 The Care Transition Measure (CTM) is widely used in the US, while the Partners at Care Transitions Measure (PACT‐M) was recently evaluated in the UK.64
Interventions for the geriatric syndromes
There are many well‐founded interventions for the prevention and management of geriatric syndromes in the hospital65. These generally fall into the following categories: risk identification and assessment tools, single‐ or multicomponent practical interventions, changes to systems of care, and educational programs. Many of these approaches are complemented by or have been incorporated into national or international campaigns and guidelines for widespread use. All are most effective if underpinned by strong leadership and robust measurement and reporting systems.
Some examples of commonly used risk assessment tools in the UK are the multitude of available falls risk assessment tools, the Waterlow score for assessing pressure sore risk, and the Malnutrition Universal Screening Tool (MUST). There are challenges to the effective use of such screening tools: they should be completed by staff who have a sound understanding of the conditions they are assessing, and identification of risk must be followed by justifiable actions to prevent the development of the geriatric syndrome.
The best known and most widely used general assessment tool for older people is the Comprehensive Geriatric Assessment (CGA). It contains six key elements: assessment of functional ability, cognitive function, physical health, socioeconomic status, nutritional status, mobility, and falls risk. Its purpose is to provide a holistic assessment of all issues relevant to a frail patient: it has been shown that if the CGA is combined with strong and sustained interventions, better long‐term outcomes can be achieved.66 However, it is unclear whether it impacts hospital‐acquired complications, although it undoubtedly identifies those who are the frailest and at the highest risk of adverse outcomes.
A good example of a practical intervention designed to prevent the development of a geriatric syndrome in the hospital is the multicomponent intervention for delirium tested as part of the Elder Life Program.67 In this study, six well‐known risk factors for delirium (cognitive impairment, visual and hearing impairment, sleep deprivation, immobility, and dehydration) were addressed comprehensively by a trained interdisciplinary team and tested in a controlled clinical trial: the incidence of delirium was reduced from 15% in the ‘usual care’ group to 9.9% in the intervention group (giving a matched odds ratio of 0.60, with p = 0.02). The practical methods used in each protocol were simple, commonsense management that it could be argued should form part of best practice and good, empathetic care for all elderly patients. Other multifactorial interventions, when supported by strong leadership and robust measurement and reporting, have been shown to be key to reducing other geriatric syndromes, such as falls.68
Hospital‐acquired infections
In recent years, significant progress has been made in reducing hospital‐acquired infections (HAIs) across all age groups, not just in older people. This has partly been driven by regulatory and public pressure in response to a shift in societal attitudes about acceptable levels of risk, which have made HAIs a major organizational priority and a matter for statutory regulation. HAIs are relatively easy to measure and identify, so the impact of interventions for them can be easily assessed, unlike some other hospital‐acquired complications common in older people. There are now standard definitions for HAIs, an increasing trend toward mandatory reporting of infections, and, in most hospitals, infection control departments that independently monitor and act to reduce HAIs.
The underlying causes of HAIs are complex, ranging from individual actions or inactions, such as failures to follow rules and procedures, to systemic failures or problems with design and technology. Consequently, many interventions that have been successful in tackling HAIs are equally as complex and increasingly seen as part of more general quality improvement programs rather than solutions in isolation. For example, HAIs are one of the primary outcome measures of the Safer Patients Initiative,69 a long‐term collaborative programme developed by the Health Foundation in partnership with the US Institute for Healthcare Improvement and 24 participating UK NHS Trust sites. This ongoing initiative focuses on reliability and safety of care through the application of continuous quality improvement techniques adapted from process industries and manufacturing.
Some of the other multifaceted interventions that have been shown to reduce the rates of HAIs include the use of care bundles to tackle central‐line infections and ventilator‐associated pneumonias in intensive care units or using combined approaches to improve hand hygiene in general wards. Other effective infection control measures have included advances in treatment, regularly updated antibiotic prescribing guidelines, and the use of other precautions such as minimizing ward transfers. The design of the hospital environment plays an important part in providing adequate isolation and cleaning facilities and allowing sterile practices to be carried out with minimal contamination. Other innovations include using decision‐support systems in antibiotic prescription and allowing patients to participate in infection control initiatives (although older people may be less willing or able to do this).
Medication safety
Reducing medication errors requires a multifaceted approach involving computerized systems, simplification and standardization of clinical processes, education and training, and wider cultural and organizational change.70
Much work has been carried out to reduce medication errors in general. The underlying principles are common to all successful safety and quality improvement processes: systems must be designed to prevent errors from occurring in the first place, make errors more visible when they occur, and limit the effects of errors so they do not lead to harm. Standardization of processes, paying particular attention to high‐risk medications, and involvement and collaboration with both patients and clinicians have been shown to be successful strategies.
Several categories of interventions have been shown to maximize medication safety for older people in particular. Much as for falls or delirium, the first step is to identify and prevent inappropriate prescribing. Assessment instruments such as the Beers Criteria, Screening Tool of Older Persons' Prescriptions (STOPP), and Screening Tool to Alert to Right Treatment (START)71 give lists of drugs to avoid in older patients. These tools are useful for both the prevention and measurement of inappropriate prescribing. The potential drawbacks of such tools are that they may not be internationally useable, they rely on correct usage by prescribers, and they may not include all classes of relevant drugs.
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