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Background Although the importance of clinical ethics in contemporary clinical environments is established, development of formal clinical ethics services in the Australia health system has, to date, been ad hoc. This study was designed to systematically follow and reflect upon the first 18 months of activity by a newly established committee, to examine key barriers and facilitators to establishing a new service in an Australian hospital setting. Methods: how the study was performed and statistical tests used A qualitative case study approach was utilised. The study gathered and analysed data using observations of committee meetings, document analysis of agendas and minutes, and semi-structured interviews with committee members to generate semantic themes. By interpreting the thematic findings in reference to national capacity building resources, this study also aimed to provide practice-based reflections for other health agencies. Results: the main findings An overarching theme was a strong shared commitment to supporting clinicians with difficult decisions about patient care, and with navigating difficult discussions with patients and families. The role of the new committee in providing a pathway to raise with senior managers system-wide issues experienced by clinicians was also a key theme. Consumer and community participation in the new service remained a challenge in spite of strong clinical engagement, as did unresolved governance issues and a need for clearer policy relationship between the committee and the organisation. Conclusions: brief summary and potential implications Considering these themes in relation to the national capacity building resources, three areas are likely to require ongoing negotiation and further development: the clinical ethics committee as link between workforce and Executive; incorporating consumers and patients; and ethical reasoning. There is scope to increase clarity for the committee on its role at a governance and policy level, and on how to engage consumers, patients and families in the practices of the service. The capacity of the committee to reflect on complex cases may be enhanced by explicitly discussing different ethical frameworks and ways of deliberating.

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