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Original Investigation
January 10, 2022

Effect of a Ward-Based Program on Hospital-Associated Complications and Length of Stay for Older Inpatients: The Cluster Randomized CHERISH Trial

Author Affiliations
  • 1Internal Medicine and Aged Care Department, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
  • 2School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
  • 3School of Clinical Medicine, University of Queensland, Brisbane, Queensland, Australia
  • 4Eat Walk Engage Program, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
  • 5Nutrition and Dietetics Department, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
  • 6John Richards Centre for Rural Ageing Research, La Trobe Rural Health School, La Trobe University, Melbourne, Victoria, Australia
  • 7Department of Nutrition and Dietetics, The Prince Charles Hospital, Brisbane, Queensland, Australia
  • 8Geriatrics Department, Nambour Hospital, Nambour, Queensland, Australia
  • 9Health Services and Systems Research, Duke-NUS Medical School, Singapore
  • 10School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, Queensland, Australia
  • 11STARS Research and Education Alliance, Metro North Health Surgical Treatment and Rehabilitation Service, Brisbane, Queensland, Australia
  • 12College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
  • 13Centre for Research in Geriatric Medicine, University of Queensland, Brisbane, Queensland, Australia
  • 14Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
  • 15Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
  • 16Aged Care Services, Royal Melbourne Hospital, Melbourne, Victoria, Australia
  • 17Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
  • 18Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Queensland, Australia
  • 19Department of Internal Medicine, The Prince Charles Hospital, Brisbane, Queensland, Australia
  • 20Marcus Institute for Ageing Research, Hebrew SeniorLife, Boston, Massachusetts
  • 21Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
JAMA Intern Med. Published online January 10, 2022. doi:10.1001/jamainternmed.2021.7556
Key Points

Question  Can a ward-based, age-friendly improvement program (“Eat Walk Engage”) reduce hospital-associated complications (delirium, functional decline, pressure injuries, falls, and incontinence) and length of stay for older adults admitted to acute medical and surgical wards?

Findings  In this pragmatic cluster randomized trial, which implemented and evaluated Eat Walk Engage in 4 hospitals, comprising 539 patients, there was no reduction in the composite primary outcome of any hospital-associated complication of older people (HAC-OP) (46% intervention vs 52% control) or median length of stay (6 days intervention vs 7 days control). Incident delirium was significantly lower in intervention wards (16% vs 31%), but other individual HAC-OPs were not reduced.

Meaning  Eat Walk Engage did not reduce the composite primary outcome of any HAC-OP, which affected almost half of older inpatients, although there was a significant reduction in delirium.


Importance  Hospital-associated complications of older people (HAC-OPs) include delirium, hospital-associated disability, incontinence, pressure injuries, and falls. These complications may be preventable by age-friendly principles of care, including early mobility, good nutrition and hydration, and meaningful cognitive engagement; however, implementation is challenging.

Objectives  To implement and evaluate a ward-based improvement program (“Eat Walk Engage”) to more consistently deliver age-friendly principles of care to older individuals in acute inpatient wards.

Design, Setting, and Participants  This cluster randomized CHERISH (Collaboration for Hospitalised Elders Reducing the Impact of Stays in Hospital) trial enrolled 539 consecutive inpatients aged 65 years or older, admitted for 3 days or more to study wards, from October 2, 2016, to April 3, 2017, with a 6-month follow-up. The study wards comprised 8 acute medical and surgical wards in 4 Australian public hospitals. Randomization was stratified by hospital, providing 4 clusters in intervention and in control groups. Statistical analysis was performed from August 28, 2018, to October 17, 2021, on an intention-to-treat basis.

Intervention  A trained facilitator supported a multidisciplinary work group on each intervention ward to improve the care practices, environment, and culture to support key age-friendly principles.

Main Outcomes and Measures  Primary outcomes were incidence of any HAC-OP and length of stay. Secondary outcomes were incidence of individual HAC-OPs, facility discharge, 6-month mortality, and all-cause readmission. Outcomes were analyzed at the individual level, adjusted for confounders and clustering.

Results  A total of 265 participants on 4 intervention wards (124 women [46.8%]; mean [SD] age, 75.9 [7.3] years) and 274 participants on 4 control wards (145 women [52.9%]; mean [SD] age, 78.0 [8.2] years) were enrolled. The composite primary outcome of any HAC-OP occurred for 115 of 248 intervention participants (46.4%) and 129 of 249 control participants (51.8%) (intervention group: adjusted odds ratio, 1.07; 95% CI, 0.71-1.61). The median length of stay was 6 days (IQR, 4-9 days) for the intervention group and 7 days (IQR, 5-10 days) for the control group (adjusted hazard ratio, 0.96; 95% credible interval, 0.80-1.15). The incidence of delirium was significantly lower for intervention participants (adjusted odds ratio, 0.53; 95% CI, 0.31-0.90). There were no significant differences in other individual HAC-OPs, facility discharge, mortality, or readmissions.

Conclusions and Relevance  The Eat Walk Engage program did not reduce the composite primary outcome of any HAC-OP or length of stay, but there was a significant reduction in the incidence of delirium.

Trial Registration  anzctr.org.au Identifier: ACTRN12615000879561

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