Objectives: To ascertain the most common causes of delirium, to establish the initiation and timing of delirium, and to determine the duration of delirium in patients with hip fracture.Methods: Five hundred seventy-one (88%) of 650 patients with hip fracture admitted to 4 New York City hospitals were prospectively interviewed on a daily basis, 5 days a week, with the Confusion Assessment Method for the presence of delirium. The patients were enrolled within 48 hours of admission. Their medical charts and the data collected by the study staff were reviewed and summarized. Two of us (R.S.M. and A.L.S.) reviewed the case summaries independently and assigned a cause based on a previously developed classification system, estimated the onset of the delirious episode, and determined whether the delirium had cleared, improved, or persisted at discharge. Subsequently, discrepancies in cause, timing of initiation, and mental status on discharge between the 2 physicians reviewers were discussed until consensus was reached.Results: The prevalence of delirium was 9.5% (54/ 571; 95% confidence interval, 7.0-11.9). Seven percent of episodes were assigned a definite cause, 20% a probable cause, 11% a possible cause, and 61% were attributable to 1 or more comorbid conditions. Twenty-eight (53%) of 54 subjects developed delirium after surgery. The delirium had cleared or improved in 40 (74%) of 54 subjects at the time of discharge.Conclusions: Delirium in patients with hip fracture appears to be a different syndrome from that observed in patients who are otherwise medically ill; it also appears to follow a different clinical course. These results have important implications for the management of delirium in patients with hip fracture.

The U.S. Preventive Services Task Force (USPSTF) bases its recommendations on an evidence-based model of clinical prevention that focuses on specific diseases, well-defined preventive interventions, and evidence of improved health outcomes. Applying this model to prevention for very old patients has been problematic for several reasons: Many geriatric disorders have multiple risk factors, interventions, and expected outcomes; older adults are not often represented in clinical trials; and important outcomes may not be measured and reported in ways that are conducive to evidence synthesis and interpretation. In 2005, the USPSTF convened a geriatrics workgroup to refine USPSTF methodology and processes to better address the preventive needs of older adults. The USPSTF has begun to apply these new approaches to the review and recommendation on interventions to prevent falls in older adults.

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Background Advances have been made in recent years to characterize facilitators and barriers to implementation of complex health care intervention and to classify the implementation strategies available to address these determinants. We study the implementation of a Hospital at Home (HaH) intervention in a multi-hospital health system to understand the selection and use of implementation strategies in its launch, sustainment, and scaling. Methods We report on the implementation portion of an effectiveness-implementation study of the hybrid type 1 design. First, we retrospectively identified determinants of practice most relevant to the HaH intervention using of the Integrated Checklist of Determinants (TICD) assisted by review of archived documents. We also identified implementation strategies using the listing created by the Expert Recommendations for Implementing Change (ERIC) that could potentially address each determinant. Second, we then identified which of the ERIC strategies were actually employed using a modified Delphi process to obtain consensus among HaH program leaders involved in the program implementation. Program leaders also rated the importance and effort expended on each strategy on 1-9 Likert scales. The most relevant implementation strategies identified through these steps were detailed with respect to actors, targets, dosing and justification, and associated with prospectively collected implementation outcomes. Results The majority of ERIC implementation strategies (57 of 73, 78%) were utilized; 7 strategies (10%) were not used. On the remaining 9 strategies (12%), program leaders did not reach consensus regarding utilization. For used strategies, mean importance was 6.87 and mean effort expended was 6.22. Implementation strategies rated most important by program leaders had a broad target of actions that included clinical staff, patients, leadership, external vendors, health plans, and government officials. The strategies varied in temporality and dosing. Over the course of the implementation, adoption, acceptance, and penetration increased over time, while measures of fidelity remained stable. Conclusions Considerable effort and multiple strategies were required to implement Hospital at Home. While potentially daunting, use of existing implementation frameworks can help focus limited efforts and resources by targeting strategies that address the key barriers and enablers to implementation of complex healthcare interventions.

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