e-CHAMP: Enhancing Care for Hospitalized Older Adults With Memory Problems

A growing body of evidence demonstrates that older patients with cognitive impairment (CI)
who are hospitalized for the management of their medical illnesses are especially vulnerable
to hospital acquired complications such as falls, injuries, pressure ulcers, restraints, and
delirium. These complications contribute to mortality, poorer functional status, limited
rehabilitation, prolonged length of stay, increased institutionalization, and higher health
care costs. Evidence suggests that interdisciplinary geriatric inpatient services improve
care for hospitalized older adults without CI; however, their effectiveness among older
adults with CI is less clear. One reason may be the ever-quickening pace of care in the
hospital setting. Thus, matching geriatric evaluation and recommendations to the true pace
of hospital care may be one mechanism to improve the care of older adults with CI.

A recent report from the Institute of Medicine suggested that integrating information
technology (IT) into health care is the best route to improve the overall safety and quality
of the health care system. The hypothesis of this study is that missed, delayed, post-hoc,
and incomplete implementation of the geriatric service-based recommendations are significant
factors explaining the poor outcomes among hospitalized older adults with cognitive
impairment (CI). Wishard Memorial Hospital's physicians are already using a Computerized
Decision Support System (CDSS), developed by the Regenstrief Institute, to guide their
medical services. For this study, the content of this CDSS will be modified to the special
needs of older adults with CI. A major advantage of such a system is reducing the time to
implementation of geriatric recommendations with a specific focus on preventing the
initiation of potentially harmful medications and procedures during the critical first 48
hours of hospitalization.

A total of 400 patients with cognitive impairment who have been hospitalized in a medical
ward will be recruited for this study. Patients will be randomized to receive either
standard care or the proactive screening program for CI combined with the modified CDSS. The
electronic medical record for all patients will be reviewed for prescriptions for
potentially inappropriate medications, urinary catheters, or physical restraints during the
first 24 hours and the entire hospital stay. Medical records will be used to determine the
total number of hospital acquired complications that may be related to CI; these include
falls, injuries such as pulling out IV lines or urinary catheters, pressure ulcers, and
new-onset delirium episodes that developed during hospitalization. Also, the time elapsed
between screening for CI and the physician ordering a geriatric consultation will be
calculated using the electronic medical record.

Inclusion Criteria:

- 65 years of age or older

- Hospitalized in a medical ward

- Able to speak English

- Cognitive impairment based on screening at time of hospital admission

Exclusion Criteria:

- Previously enrolled in the study during prior hospitalization (for multiple
admissions; only data from the first admission will be used)

- Enrolled in another clinical trial

- Does not have cognitive impairment based on screening at time of hospital admission