Faculty Bibliography

CONTEXT/BACKGROUND:Chronic kidney disease (CKD) disproportionately impacts lower socioeconomic groups and is associated with many symptoms and complex decisions. Integration of Kidney Supportive Care (KSC) with CKD care can address these needs. To our knowledge, this approach has not been described in an underserved population. OBJECTIVES/OBJECTIVE:We describe our adaptation of an ambulatory integrated KSC and CKD clinic for implementation in a safety net hospital. We report our utilization metrics; characteristics of the population served; and visit activities. METHODS:We considered modifications from the perspectives of people with CKD, their providers, and the health system. Modifications were informed by meeting notes with key participants (hospital administrators [n = 5], funders [n = 1], and content experts [n = 2]), as well as literature on palliative care program building, safety net hospitals, and KSC. We extracted utilization data for the first 15 months of the clinic's operations, demographics, clinical characteristics, unmet health related social needs, and symptom burden, measured by the Integrated Palliative Outcome Scale-Renal (total Score, and sub-scores of physical, psychological, and practical impact of CKD) from the electronic health record. Results are reported using descriptive statistics. RESULTS:Adaptions were proactive and done by clinical and administrative leaders. Meetings identified challenges of the safety net setting including people presenting with advanced disease and having several social needs. Modifications to our base model were made in staffing, data collection, and work flow. Show rate was approximately 68%, with a majority of people identifying as Black or Hispanic, and uninsured or on Medicaid. Symptom burden was lower than previous reports, driven by a better psychological sub-score. CONCLUSIONS:We describe a feasible ambulatory care model of KSC in a safety net setting that can serve as a framework for the development of other noncancer palliative care ambulatory clinics. Future work will optimize our model.

BACKGROUND/UNASSIGNED:Chronic kidney disease (CKD) impacts more than 800 million people. It causes significant suffering and disproportionately impacts marginalized populations in the United States. Kidney palliative care has the potential to alleviate this distress, but has not been tested. This pilot study evaluates the feasibility of a randomized clinical trial (RCT) testing the efficacy of integrated kidney palliative and CKD care in an urban safety-net hospital. METHODS/UNASSIGNED:, and are receiving care at our safety net hospital. Participants will be randomized in permuted blocks of two or four to either the intervention group, who will receive monthly ambulatory care visits for six months with a palliative care provider trained in kidney palliative care, or to usual nephrology care. Primary outcomes are feasibility of recruitment, retention, fidelity to the study visit protocol, and the ability to collect outcome data. These outcomes include symptom burden, quality of life, and engagement in advance care planning. DISCUSSION/UNASSIGNED:This pilot RCT will provide essential data on the feasibility of testing integrated palliative care in CKD care in an underserved setting. These outcomes will inform a larger, fully powered trial that tests the efficacy of our kidney palliative care approach. CLINICAL TRIAL REGISTRATION/UNASSIGNED:NCT04998110.

IMPORTANCE/UNASSIGNED:The emergency department (ED) offers an opportunity to initiate palliative care for older adults with serious, life-limiting illness. OBJECTIVE/UNASSIGNED:To assess the effect of a multicomponent intervention to initiate palliative care in the ED on hospital admission, subsequent health care use, and survival in older adults with serious, life-limiting illness. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Cluster randomized, stepped-wedge, clinical trial including patients aged 66 years or older who visited 1 of 29 EDs across the US between May 1, 2018, and December 31, 2022, had 12 months of prior Medicare enrollment, and a Gagne comorbidity score greater than 6, representing a risk of short-term mortality greater than 30%. Nursing home patients were excluded. INTERVENTION/UNASSIGNED:A multicomponent intervention (the Primary Palliative Care for Emergency Medicine intervention) included (1) evidence-based multidisciplinary education; (2) simulation-based workshops on serious illness communication; (3) clinical decision support; and (4) audit and feedback for ED clinical staff. MAIN OUTCOME AND MEASURES/UNASSIGNED:The primary outcome was hospital admission. The secondary outcomes included subsequent health care use and survival at 6 months. RESULTS/UNASSIGNED:There were 98 922 initial ED visits during the study period (median age, 77 years [IQR, 71-84 years]; 50% were female; 13% were Black and 78% were White; and the median Gagne comorbidity score was 8 [IQR, 7-10]). The rate of hospital admission was 64.4% during the preintervention period vs 61.3% during the postintervention period (absolute difference, -3.1% [95% CI, -3.7% to -2.5%]; adjusted odds ratio [OR], 1.03 [95% CI, 0.93 to 1.14]). There was no difference in the secondary outcomes before vs after the intervention. The rate of admission to an intensive care unit was 7.8% during the preintervention period vs 6.7% during the postintervention period (adjusted OR, 0.98 [95% CI, 0.83 to 1.15]). The rate of at least 1 revisit to the ED was 34.2% during the preintervention period vs 32.2% during the postintervention period (adjusted OR, 1.00 [95% CI, 0.91 to 1.09]). The rate of hospice use was 17.7% during the preintervention period vs 17.2% during the postintervention period (adjusted OR, 1.04 [95% CI, 0.93 to 1.16]). The rate of home health use was 42.0% during the preintervention period vs 38.1% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of at least 1 hospital readmission was 41.0% during the preintervention period vs 36.6% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of death was 28.1% during the preintervention period vs 28.7% during the postintervention period (adjusted OR, 1.07 [95% CI, 0.98 to 1.18]). CONCLUSIONS AND RELEVANCE/UNASSIGNED:This multicomponent intervention to initiate palliative care in the ED did not have an effect on hospital admission, subsequent health care use, or short-term mortality in older adults with serious, life-limiting illness. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT03424109.

Inner strength, one's internal process of moving through challenging circumstances, has not been described in persons living with mild cognitive impairment (MCI). This qualitative study used the Listening Guide methodology to explore experiences of inner strength in persons newly diagnosed with MCI. We analyzed 36 joint and individual semi-structured interviews with nine participants with MCI and nine care partners. Analytic poems represented three themes explaining inner strength experiences. In the foundational theme, Me with MCI, participants reconfigured their sense of self. The theme Vacillating between Seeking Relief and Dwelling in Challenge illustrated adjusting to life with MCI. The theme You Get through It characterized inner strengths including perseverance, optimism, accepting MCI, and seeking help. Each participant's inner strength profile was unique and impacted by cognitive impairment, and therefore benefitted from support. Though limited by homogeneity, this study highlights Listening Guide utility and has implications for strengths-based interventions and nursing practice.

BACKGROUND:Pre-injury frailty among older adults with trauma injuries is a predictor of increased morbidity and mortality. OBJECTIVES/OBJECTIVE:We sought to determine the relationship between frailty status and the care trajectories of older adult patients who underwent frailty screening in the emergency department (ED). METHODS:Using a retrospective cohort design, we pooled trauma data from a single institutional trauma database from August 2020 to June 2023. We limited the data to adults 65 years and older, who had trauma injuries and frailty screening at ED presentation (N = 2,862). The predictor variable was frailty status, measured as either robust (score 0), pre-frail (score 1-2), or frail (score 3-5) using the FRAIL index. The outcome variables were measures of clinical care trajectory: trauma team activation, inpatient admission, ED discharge, length of hospital stay, in-hospital death, home discharge, and discharge to rehabilitation. We controlled for age, sex, race/ethnicity, health insurance type, body mass index, Charlson Comorbidity Index, injury type and severity, and Glasgow Coma Scale score. We performed multivariable logistic and quantile regressions to measure the influence of frailty on post-trauma care trajectories. RESULTS:The mean (SD) age of the study population was 80 (8.9) years, and the population was predominantly female (64%) and non-Hispanic White (60%). Compared to those classified as robust, those categorized as frail had 2.5 (95% CI: 1.86-3.23), 3.1 (95% CI: 2.28-4.12), and 0.3 (95% CI: 0.23-0.42) times the adjusted odds of trauma team activation, inpatient admission, and ED discharge, respectively. Also, those classified as frail had significantly longer lengths of hospital stay as well as 3.7 (1.07-12.62), 0.4 (0.28-0.47), and 2.2 (95% CI: 1.71-2.91) times the odds of in-hospital death, home discharge, and discharge to rehabilitation, respectively. CONCLUSION/CONCLUSIONS:Pre-injury frailty is a predictor of clinical care trajectories for older adults with trauma injuries.

BACKGROUND/UNASSIGNED:In patients with inflammatory bowel disease (IBD) who need intestinal resection, prior data suggest that earlier surgical intervention may be associated with improved outcomes. However, surgery is often deferred for additional trials of advanced therapies, which potentially shifts patients from a fit to a frail preoperative state. OBJECTIVES/UNASSIGNED:This study aimed to evaluate clinical changes that occur in the year prior to intestinal resection in patients with IBD. DESIGN/UNASSIGNED:Retrospective cohort study. METHODS/UNASSIGNED:This was a multi-hospital retrospective study of patients ⩾18 years old who underwent initial IBD-related intestinal resection between January 1, 2018 and May 31, 2023. Clinical characteristics and radiographical skeletal muscle mass were compared using the Wilcoxon Signed-Rank test for continuous variables and McNemar's test for categorical variables. RESULTS/UNASSIGNED: = 0.06). CONCLUSION/UNASSIGNED:In the 6-12 months prior to an IBD-related intestinal resection, as compared to the month prior, individuals were less likely to be malnourished, have an infection, or need hospitalization for IBD. This suggests that minimizing delays to surgery may lead to improved outcomes.

INTRODUCTION/BACKGROUND:Dietary restrictions for patients with end-stage kidney disease (ESKD) are burdensome. Kidney transplantation (KT) candidates who lack neighborhood resources and are burdened by dietary restrictions may have decreased access to KT. METHODS:In our two-center prospective cohort study (2014-2023), 2471 ESKD patients who were evaluated for KT (candidates) reported their perceived burden of dietary restrictions (not at all, somewhat/moderately, or extremely bothered). Neighborhood-level socioeconomic factors were derived from residential ZIP codes. We quantified the association of perceived burden of the dietary restrictions with a chance of listing using Cox models and risk of waitlist mortality using competing risks models. Then we tested whether these associations differed by neighborhood-level socioeconomic factors. RESULTS: = 0.02). The association between dietary burden and waitlist mortality did not differ by neighborhood-level healthy food access. CONCLUSION/CONCLUSIONS:The perceived burden of dietary restrictions is associated with a lower chance of listing for KT, and higher waitlist mortality only among candidates residing in neighborhoods with high food insecurity. Transplant centers should identify vulnerable patients and support them with nutrition education and access to food assistance programs.

OBJECTIVES/OBJECTIVE:To describe the implementation of a mentored staff-delivered sleep program in nursing facilities. DESIGN/METHODS:Modified stepped-wedge unit-level intervention. SETTING AND PARTICIPANTS/METHODS:This program was implemented in 2 New York City nursing facilities, with partial implementation (due to COVID-19) in a third facility. METHODS:Expert mentors provided staff webinars, in-person workshops, and weekly sleep pearls via text messaging. We used the integrated Promoting Action on Research Implementation in Health Services (i-PARiHS) framework as a post hoc approach to describe key elements of the SLUMBER implementation. We measured staff participation in unit-level procedures and noted their commentary during unit workshops. RESULTS:We completed SLUMBER within 5 units across 2 facilities and held 15 leadership meetings before and during program implementation. Sessions on each unit included 3 virtual webinar presentations and 4 in-person workshops for each nursing shift, held over a period of 3 to 4 months. Staff attendance averaged >3 sessions per individual staff member. Approximately 65% of staff present on each unit participated in any given session. Text messaging was useful for engagement, educational reinforcement, and encouraging attendance. We elevated staff as experts in the care of their residents as a strategy for staff engagement and behavior change and solicited challenging cases from staff during workshops to provide strategies to address resident behavior and encourage adoption when successful. CONCLUSIONS AND IMPLICATIONS/CONCLUSIONS:Engaging staff, leadership, residents, and family of nursing facilities in implementing a multicomponent sleep quality improvement program is feasible for improving nursing facilities' sleep environment. The program required gaining trust at multiple levels through presence and empathy, and reinforcement mechanisms (primarily text messages). To improve scalability, SLUMBER could evolve from an interdisciplinary investigator-based approach to internal coaches in a train-the-trainer model to effectively and sustainably implement this program to improve sleep quality for facility residents.

OBJECTIVES/OBJECTIVE:To evaluate the impact of a mentoring program to encourage staff-delivered sleep-promoting strategies on sleep, function, depression, and anxiety among skilled nursing facility (SNF) residents. DESIGN/METHODS:Modified stepped-wedge unit-level intervention. SETTING AND PARTICIPANTS/METHODS:Seventy-two residents (mean age 75 ± 15 years; 55.9% female, 41% non-Hispanic White, 35% Black, 20% Hispanic, 3% Asian) of 2 New York City urban SNFs. METHODS:. RESULTS:. CONCLUSIONS AND IMPLICATIONS/CONCLUSIONS:SNF residents had improvements in sleep quality and depression with intervention, but improvements were not sustained at 3-month follow-up. The COVID-19 pandemic led to premature study termination, so full impacts remain unknown.