title: Effects of hospital-wide interventions to improve care for frail older inpatients: a systematic review.
abstract: BACKGROUND
  Although it is widely recognised that frail older persons need adaptation of healthcare services, it is unclear how hospital care in general can best be tailored to their frailty.
  
  
  OBJECTIVE
  To systematically review the evidence for hospital-wide interventions for older patients.
  
  
  METHODS
  PubMed, Cochrane CENTRAL, Cinahl and reference lists of included articles (1980-2009) were searched. Papers describing (1) randomised controlled trials, controlled clinical trials, controlled before-after studies or interrupted time series, (2) patients ≥ 65 years admitted to hospital, (3) hospital-wide organisational interventions, and (4) patient-related outcomes, quality of care, patient safety, resource use or costs were included. Two reviewers extracted data and assessed risk of bias independently, according to Cochrane Effective Practice and Organization of Care Review Group guidelines.
  
  
  RESULTS
  The authors included 20 articles out of 1175. The mean age of the study populations ranged from 74.2 to 85.8 years. Interventions included multidisciplinary (consultative) teams, nursing care models, structural changes in physical environment and/or changes in site of service delivery. Small or no effects were found on patient-related outcomes such as functional performance, length of stay, discharge destination, resource use and costs compared with usual care. Methodological quality evaluation showed data incompleteness and contamination as main sources of bias.
  
  
  CONCLUSIONS
  No single best hospital-wide intervention could be identified using strict methodological criteria. However, several interventions had positive results, and may be used in hospital practice. Since strict methodological designs are not optimal for evaluating highly complex interventions and settings, the authors recommend studying hospital-wide interventions for older persons using adapted quality and research criteria.
authors.affiliation: Department of Geriatric Medicine 925, Radboud University Nijmegen Medical Centre, PO Box 9101, Nijmegen 6500 HB, The Netherlands. f.bakker@ger.umcn.nl
authors.forename: Franka C
authors.initials: FC
authors.lastname: Bakker
authors.forename: Sarah H M
authors.initials: SH
authors.lastname: Robben
authors.forename: Marcel G M
authors.initials: MG
authors.lastname: Olde Rikkert
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D006739:Hospital Administration / Q000379:methods*; D006801:Humans; D010348:Patient Care Team / Q000458:organization & administration; D058996:Quality Improvement / Q000458:organization & administration*; D019984:Quality Indicators, Health Care; D017751:Safety Management / Q000458:organization & administration; D016896:Treatment Outcome