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Balloon Animals, Guitars, and Fewer Blood Draws: Applying Strategies From Pediatrics to the Treatment of Hospitalized AdultsBalloon Animals, Guitars, and Fewer Blood Draws

Michael R. O'Brien, MD; Marjorie S. Rosenthal, MD, MPH; Kumar Dharmarajan, MD, MBA; and Harlan M. Krumholz, MD, SM
[+] Article, Author, and Disclosure Information

From Yale University, New Haven, Connecticut.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2219.

Requests for Single Reprints: Michael R. O'Brien, MD, Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, 333 Cedar Street, SHM IE-61, PO Box 208088, New Haven, CT 06520; e-mail, michael.robert.obrien@yale.edu.

Current Author Addresses: Drs. O'Brien and Rosenthal: Yale School of Medicine, Robert Wood Johnson Foundation Clinical Scholars Program, 333 Cedar Street, SHM IE-61, New Haven, CT 06520.

Drs. Dharmarajan and Krumholz: Yale School of Medicine, Center for Outcomes Research and Evaluation, 1 Church Street, Suite 200, New Haven, CT 06510.

Author Contributions: Conception and design: M.R. O'Brien, M.S. Rosenthal, K. Dharmarajan, H. Krumholz.

Drafting of the article: M.R. O'Brien, M.S. Rosenthal.

Critical revision of the article for important intellectual content: M.S. Rosenthal, K. Dharmarajan, H. Krumholz.

Final approval of the article: M.R. O'Brien, M.S. Rosenthal, K. Dharmarajan, H. Krumholz.

Obtaining of funding: H. Krumholz.

Administrative, technical, or logistic support: M.S. Rosenthal, H. Krumholz.

Collection and assembly of data: M.R. O'Brien.


Ann Intern Med. 2015;162(10):726-727. doi:10.7326/M14-2219
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This commentary discusses how patients in adult hospitals could benefit from the health care approach found in pediatric wards, which includes being sensitive to stressinducing procedures and offering novel programs involving music, unique life specialists, and nonpharmacologic techniques that seek to calm and uplift the spirit.

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Lessons from old and young
Posted on May 25, 2015
Philip St John
University of Manitoba
Conflict of Interest: Dr St John is a geriatrician
Children are not little adults, yet there are lessons to be learned from their care, as O’Brien et al rightly claim(1). Of course, there are also lessons learned from adult medicine that need to be implemented. O’Brien et al curiously omit a large body of literature accrued over decades from the specialty of geriatrics.

In the 1930s and 1940s, the general principles of inpatient geriatric care were clearly articulated – most of which are very similar to those currently adopted in pediatrics - a physical environment appropriate for convalescence; recreational space and activities; an organized health care team that interacts with families; and a hopeful attitude(2-5). These principles were put into practice in hospitals being bombed during the Second World War. In the intervening decades, considerable research has been published demonstrating that inpatient geriatric assessment reduces the risk of disability and institutionalization(6). There is no paucity of evidence, as claimed by O’Brien et al(1).

We need to understand why children’s hospitals have implemented these straightforward, inexpensive and evidence-based approaches, while adult hospitals have ignored them for decades. With an aging population requiring hospital care, we must start treating adults as well as we treat children.

1. O'Brien MR, Rosenthal MS, Dharmarajan K, Krumholz HM. Balloon Animals, Guitars, and Fewer Blood Draws: Applying Strategies From Pediatrics to the Treatment of Hospitalized AdultsBalloon Animals, Guitars, and Fewer Blood Draws. Annals of Internal Medicine. 2015;162(10):726-7.
2. Anonymous. A new outlook in the ward: The West Middlesex Hospital. The Lancet. 1947;249(6457):760-1.
3. St John PD, Hogan DB. The relevance of Marjory Warren's writings today. Gerontologist. 2014;54(1):21-9.
4. Warren M. Care of the chronic aged sick. The Lancet. 1946;247(6406):841-3.
5. Warren MW. Care of Chronic Sick. BMJ. 1943;2(4329):822-3.
6. Ellis G, Whitehead MA, Robinson D, O'Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ. 2011;343:d6553.
Yes, learning from young and old indeed
Posted on May 27, 2015
Michael R. O'Brien, MD
Robert Wood Johnson Clinical Scholars, Yale University
Conflict of Interest: None Declared
Thank you Dr. St John, for your comments, the additional references, and helping to frame our perspective piece within a historical context. We agree, geriatrics is a field that, like pediatrics, has developed a comprehensive ecosystem of evidence-based strategies to reduce the stress and harm of hospitalization, and foster respect and dignity for the hospitalized person. We did reference the Hospital Elder Life Program (1), developed and still practiced here at Yale and our affiliated hospitals, but you are right to point out that much of this important has work has already been done within geriatrics and published in the geriatrics literature.

Our goal was to encourage creatively increasing the uptake of these strategies across all hospitalized adults, not just older adults. The paucity of evidence is referring to our lack of knowledge about the application of these methods across the full spectrum of hospitalized adults, not just particular subpopulations. That being said, we agree it is significantly important that much of this work is already being done in older adults and the field of geriatrics, and you are right to draw our attention to this important body of literature.

1. Inouye SK, Bogardus ST Jr, Baker DI, Leo-Summers L, Cooney LM Jr. The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Hospital Elder Life Program. J Am Geriatr Soc. 2000; 48:1697-706.
Balloon Animals, Guitars & a Crochet Needle
Posted on May 27, 2015
Dr. Adam Krajewski, Bob Parke & Lwam Mehari
Humber River Hospital and University of Toronto
Conflict of Interest: None Declared
We are pleased that this short insightful article was published. There is much to say about the benefits of balloon animals, guitars and fewer blood draws in the literature supporting the active engagement of child life therapy in pediatrics. Similarly, there is strong evidence and the accumulation of anecdotal experience to support the engagement of recreational therapy for adult patients.
Several years ago we had an experience of an older woman, whom we will call Mila, who suffered a stroke. After a few weeks from the onset of the stroke, Mila’s affect was noticeably flat. She was withdrawn, sad and unengaged in recommended physiotherapy and occupational therapies. At that time we had access to a recreational therapist to whom a referral was made. From her assessment she found out that Mila had derived much pleasure and satisfaction from crocheting scarfs and blankets for her nieces, nephews and grandchildren. Shortly after her stroke and with physical function not imminently returning, Mila felt diminished as a person and was giving up on life.
Following her assessment, the recreational therapist found a device that secured the crochet needle in place and could be clamped to the hospitals over-bed table. With a slight adaptation of technique, Mila began to crochet again. Incredibly, we found that stitch by stitch Mila’s affect began to improve. Each small success in crocheting played both an integral and meaningful role in Mila’s progressive re-engagement into the full range of therapies offered to stroke survivors. Due to her renewed willingness to participate in these therapies, she became a candidate for inpatient rehab at a specialized stroke facility where she was transferred from an acute care setting.
We tell this story that happened several years ago to reinforce the authors’ statements about the benefit of an Elder Life Program in reducing “functional decline.” The presence of a recreational therapist, her assessment, and the addition of a crochet needle proved more successful than pharmaceuticals and psycho-social therapies in improving affect and maximizing the return of physical function.
We support the belief that Elder Care programs in hospitals, including recreational therapy, will go a long way in making hospitals senior friendly. These programs can help to better manage delirium, functional decline and the negative impacts of boredom thereby contributing to improved behaviors. All of this can be done in a cost effective way while improving patient experiences for everyone involved.
Ultimately, from an ethics perspective the addition of “balloon animals, guitars (crochet needle) and fewer blood draws adds to the dignity, value and level of worth with which we view our adult and elderly patients.
Thank you for a welcomed article.
Contrasting old and young
Posted on May 28, 2015
Phil St John
University of Manitoba
Conflict of Interest: Dr St John is a geriatrician.
Thank you for your prompt reply. Juxtaposing the contrast between the approach in paediatrics and in adult medicine is very useful. It then begs the question – “Why do we treat children differently than adults, particularly frail older adults?”

The glacial pace of dissemination of research findings should be a source of study (as well as consternation). O’Brien references the very important work of Inouye et al(1). However, it is worth noting that this research was conducted some time ago. Yet there have been consistent problems sustaining this model of care, which is not particularly difficult, or expensive(2,3). Several years before that, there were trials of acute care of the elderly units (ACE), which used a similar approach on a distinct unit(4). ACE units are not universal in modern hospitals.

Inpatient geriatric assessment has now been studied in 22 RCTs(5). We should all be grateful to the over 10 000 people who were willing to be enrolled in the control arms of these studies, as well as to the research ethics committees which allowed them to proceed. Thanks to them, we now know that a patient centered approach which humanizes care, and attends to functional, cognitive and psychosocial factors results in less disability than standard care. Since a substantial proportion of disability is associated with hospitalization(6), better hospital care may reduce the population burden of disability substantially.

Contrasting the care of adults and children may finally change care for the better. Certainly, the inability to deliver evidence based, common-sense care is a spectacular failure of modern medicine.



1. Inouye SK, Bogardus ST Jr, Baker DI, Leo-Summers L, Cooney LM Jr. The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Hospital Elder Life Program. J Am Geriatr Soc. 2000; 48:1697-706.

2. SteelFisher GK, Martin LA, Dowal SL, Inouye SK. Learning from the closure of clinical programs: a case series from the Hospital Elder Life Program. J Am Geriatr Soc. 2013 Jun;61(6):999-1004.

3. SteelFisher GK, Martin LA, Dowal SL, Inouye SK. Sustaining clinical programs during difficult economic times: a case series from the Hospital Elder Life Program. J Am Geriatr Soc. 2011 Oct;59(10):1873-82.

4. Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995 May 18;332(20):1338-44.

5. Ellis G, Whitehead MA, Robinson D, O'Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ. 2011 Oct 27;343

6. Gill TM, Allore HG, Gahbauer EA, Murphy TE. Change in disability after hospitalization or restricted activity in older persons. JAMA. 2010 Nov 3;304(17):1919-28
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