The G-COACH programme was developed as a new geriatric co-management programme (See Table in Additional file 1 describing the development process) and operationalised for two cardiac care units with 16 and 26 beds, respectively. The programme theory (See Fig. 1) was developed to be applicable for all units, but we chose the cardiac care units as test-units because of the high prevalence of geriatric needs in this population.
Design
The G-COACH programme was implemented over a 6 month period preceding the feasibility study. The feasibility study was then performed using a one-group experimental design between November 2017 and May 2018. Multiple evaluation methods were used. First, we monitored feasibility indicators to quantify the reach, fidelity and dose. Second, we administered a survey to healthcare professionals to determine if our implementation strategies reached their intended change targets. Third, we conducted a survey to determine how patients experienced and perceived the programme. Fourth, we performed interviews and focus group discussions with healthcare professionals to determine how they experienced the implementation, and how this related to performing the programme. The study was approved by the Medical Ethics Committee of the University Hospitals Leuven (s59543). The study protocol was registered in the ISRCT Registry (ISRCTN22096382–21/05/2020).
Setting
The study was performed in the University Hospitals Leuven, a 1995 bed teaching hospital, in Belgium. Each cardiac care unit has a multidisciplinary team with a medical supervisor, two medical residents, registered nurses, healthcare assistants, a logistic assistant, a physical therapist, a social worker and a dietician. The inpatient geriatric consultation team has two geriatricians, seven nurses and four occupational therapists that provide geriatric consultations on requests. The geriatrics department aimed to redesign their geriatric consultation service into a geriatric co-management service by changing their team structures and processes.
G-COACH intervention
When an older patient was admitted to the cardiac care unit, the patient was screened for eligibility in the programme. The following criteria were used: 75 years or older admitted for acute cardiovascular disease or Transcatheter Aortic Valve Implantation and an expected length of stay of at least 3 days. If eligible, the cardiac care nurse submitted an electronic request for the co-management programme. The geriatrics nurse performed a geriatric assessment at the cardiac care unit, ideally within 24 h of admission. The assessment was used to stratify patients in one of three groups (see additional file 3): 1 = patients at low risk for functional decline, 2 = patients at high risk for functional decline, and 3 = patients with acute complications, and to determine the care needs for each patient.
The risk for functional decline was determined using a prognostic model [15], based on the absence/presence of five characteristics, i.e. mobility impairment, cognitive impairment, loss of appetite, depressive symptoms, and use of physical restraints; information that was obtained by the geriatric nurse during the assessment. Mobility impairment was defined as the use of a walking aid before hospital admission as reported by the patient (and equalled 9 points). Cognitive impairment was defined as a Mini-Cog score of less than 3 out of 5 points (and equalled 7 points) [16]. The presence of depressive symptoms was defined as a score > 3 on the 10-item version of the geriatric Depression Scale (and equalled 5 points) [17]. Loss of appetite was defined as self-reported loss of appetite in the past 3 months and was used as a proxy for risk for malnutrition (and equalled 6 points). Use of restraints was defined as the use of physical restraints (e.g., vests, limb ties or chairs with restraints) or an indwelling urinary catheter between admission to the unit and assessment of the predictors (and equalled 5 points). If patients scored in total more than 10 points, which was equivalent to having two or more risk factors present, they were considered at high risk for functional decline.
The presence of acute complications was determined based on a diagnostic assessment of delirium, behaviour problems, urinary retention, urinary incontinence, and malnutrition. These problems were selected in discussion with the geriatrics team and chosen because the team felt that they could impact these outcomes. If a complication was present, the patient was recruited in this group regardless of risk for functional decline.
Patients at low risk for functional decline and without complications received care by the cardiac care team with no further follow-up by the geriatric co-management team, i.e. co-management was not deemed necessary. If indicated, the geriatric team could provide a proactive consult to the cardiac team based on the care needs identified in the geriatric assessment. Patients at high risk for functional decline received daily follow-up by the geriatrics nurse, who developed an individual care plan for the patient with the cardiac care team. Individual care goals were determined with a particular focus on early rehabilitation and discharge planning. The geriatrics nurse was responsible for the coordination of the care plan and supported the cardiac care team with the implementation of protocols for the management of geriatric syndromes. All patients received physical therapy and were motivated to perform an individual exercise programme three times daily without supervision. Patients with cognitive or functional impairments were further assessed by the occupational therapist. If necessary, consultation by a dietician or speech therapist was requested. The patients were discussed with all care professionals in a weekly team meeting at the cardiac care unit. Patients with acute complication received similar follow-up as patients in the group ‘high risk for functional decline’, with additional follow-up by a geriatrician. The geriatrician reviewed the patient file, performed a medication review and prescribed diagnostic investigations when appropriate. A follow-up plan for the complication was discussed first with the nurse from the geriatrics team, who then discussed the plan with the cardiac care team (mostly the nurses and medical residents). The progression of the complication was reviewed on a daily basis. The geriatrician visited the patient bedside when needed, but the nurse was mainly responsible for the bedside follow-up and discussing the plan with the cardiac care team. (See Additional file 3 for a description of the intervention using the TIDieR guidelines).
Implementation strategies
The implementation of the G-COACH intervention followed the ‘process of change model’ by Grol and Wensing [18], which defines five phases of change: orientation, insight, acceptance, change and maintenance [18]. The maintenance phase was not investigated because of the short study period.
For orientation, the goal was to create awareness and cultivate interest and involvement in the G-COACH programme. A stakeholder analysis identified all individuals who were interested in participating in the project. The results of the context analysis were shared with the stakeholders to create a sense of urgency for change. This was supported by promoting the new programme through an email by the head of the department and head nurses, and the publication of an information sheet on the participating units. The G-COACH programme was then formally introduced by the researchers on the participating units with support of the head nurses, explaining the goals and the expected timeline of the project.
For insight, the goal was that stakeholders understood what their current performance was, what the G-COACH programme was trying to achieve, and what was expected from them. Educational sessions were organised to inform stakeholders on the prevalence and incidence of geriatric syndromes on their unit, the intended change targets, and how the programme would achieve these by explaining the programme components and protocols.
For acceptance, the goal was that stakeholders perceived the programme as valuable and believed it was feasible to perform. Local leaders and champions on the units were asked to promote the programme on the unit and arrangements were made for staffing the geriatric co-management team. The developed protocols were made available and training sessions were organised using case discussions.
For change, the goal was to introduce the programme on a small scale so that stakeholders could experience the change and perceive it as a benefit and added value. An official launch of the program was communicated by the head of the department. To facilitate the change, electronic reminders and protocols were programmed in the electronic patient record. The implementation focused on learning the programme. We started with only one patient, discussed with the healthcare professionals how they perceived their competence, and gradually increased the caseload. At the start, researchers monitored the performance bedside allowing for direct feedback and discussion. In a later phase, cases were reviewed using the electronic patient file and individual feedback was given. In the final phase, indicators were monitored using the electronic patient record and feedback was given at the group level to the team of healthcare professionals. Throughout this process, feedback was gathered by the research team and the protocols were further optimised in order to increase acceptability and feasibility. A working group of participating healthcare professionals was allowed to make adjustments to the protocol.
Sample
In this section, we describe the criteria that were used to recruit patients in the feasibility evaluation. Note that these criteria are slightly different than the criteria used for eligibility in the clinical programme. We believe that all patients who could benefit from co-management should receive it, even if they were not appropriate participants for a feasibility study, e.g. if a research assessment was not possible or if the patient was unable to complete an informed consent. All patients aged 75 years or older were screened within the first 3 days of admission to the participating units. Patients were eligible to participate in the feasibility study if they were admitted for acute cardiovascular disease or Transcatheter Aortic Valve Implantation, had an expected length of stay of 3 days or longer and were not admitted from another hospital or unit (because we did not have baseline data for these patients). Written informed consent was obtained by the researchers. Healthcare professionals were recruited for the evaluation if they had four or more weeks of ‘full time’ experience with the programme. Oral informed consent from the healthcare professionals was obtained by the researchers.
The sample size was informed by the work of Billingham et al. (2013) on the sample sizes of pilot studies [19]. We aimed to recruit 30 patients and 30 healthcare professionals who were exposed to the programme, because we believed this number was sufficient to inform us about the performance of the programme. After the first cohort of 30 patients we performed an interim analysis to identify areas for improvement and gave feedback. This process was repeated two more times. The aggregated data from the three cohorts are reported in this paper.
Variables
Sample characteristics
Demographic data included age, gender and living situation. Baseline clinical characteristics included functional status (Katz Activities of Daily Living Index) [20], cognitive status (Mini Cog) [16], depressive symptoms (Geriatric Depression Scale 10-item version) [17], and nutritional status (Mini Nutritional Assessment short form) [21]. Patient data were collected by researchers on admission to the unit.
Feasibility indicators
Feasibility indicators were the reach, fidelity and dose of the programme. The reach of the programme was measured using the electronic patient records. A patient was considered to be ‘reached’ if a geriatric assessment and an interdisciplinary care plan was documented in the electronic patient record. The fidelity and dose of the programme was observed using registrations in the electronic patient record and by patient interviews (e.g. whether or not the patient performed an exercise programme). The fidelity refers to how well the programme was implemented according to the protocol, while the dose refers to how much of the programme was implemented according to the protocol [22]. Indicators were derived from the programme theory and drafted before the start of the study. A standardised checklist was developed to score the indicators and was piloted with the first patients. The researchers monitored the performance on the indicators on a daily basis.
Implementation targets
We observed the extent to which our overall programme implementation was successful using an eleven-item survey developed by our research team. The questions were based on the implementation targets that were developed for the implementation strategy: awareness, knowledge, motivation to change, perceived acceptability and feasibility, and believe in the benefit, value and success of the programme. Each question had five response options: completely agree, agree, neutral, do not agree and completely do not agree (see additional file 4 for more details). The survey was piloted internally for ‘readability’ by five nurses and clinician researchers (the intended target population).
Patients experiences
Patient experiences were captured using a researcher administered survey. The questions were developed by the research team, internally reviewed, and piloted with the first patients. Nine closed-ended questions informed after the perceived acceptability, usefulness and benefit of the programme. The questions referred to statements about the programme and patients could answer ‘yes’, ‘no’ or ‘neutral’ (see additional file 4) All patients who were recruited in the study were approached by a researcher for the face-to-face survey interview on the day of or the day before discharge from the hospital. The survey was administered in the patients’ room. The response rate was 74% (111/151).
Implementation determinants
To capture how healthcare professionals experienced the implementation and determine important determinants (barriers and facilitators) for the implementation, four focus groups and six individual interviews were organised. The participants included nine cardiac care nurses, six geriatrics nurses, two head nurses, a geriatrician, three physical therapists, and six medical residents. One medical resident and social worker declined to participate. One social worker was on leave of absence and could not participate. An interview guide was drafted and was discussed with an experienced qualitative researcher. The interviews were conducted by one researcher in a meeting room at the hospital. The focus groups were conducted by two researchers in a meeting room at the hospital. One researcher was the moderator and the second researcher observed the discussion and took notes. All interviews were tape recorded and written out verbatim. After each interview, a methodological report was drafted, i.e. evaluating the quality of the interview, describing the conditions of the interview, first impressions of important themes, and reflections about how the researcher interpreted the interviews.
Analysis
The feasibility indicators were reported as frequencies and proportions. Sample characteristics were reported as frequencies and proportions for categorical data and mean and standard deviations for continuous data. The survey data was categorical and reported as frequencies and proportions. A thematic analysis was used to identify the determinants, i.e. reading the transcripts, initial coding, collating codes in themes, reviewing the themes and defining the themes [23]. The process was performed by two researchers and the results were discussed within the research team. Qualitative data were reported using a narrative and thick description.