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Testa L, Ryder T, Braithwaite J, Mitchell RJ. Factors impacting hospital avoidance program utilisation in the care of acutely unwell residential aged care facility residents. BMC Health Serv Res 2021; 21:599. [PMID: 34162385 PMCID: PMC8221986 DOI: 10.1186/s12913-021-06575-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 05/25/2021] [Indexed: 12/23/2022] Open
Abstract
Background An existing hospital avoidance program, the Aged Care Rapid Response Team (ARRT), rapidly delivers geriatric outreach services to acutely unwell or older people with declining health at risk of hospitalisation. The aim of the current study was to explore health professionals’ perspectives on the factors impacting ARRT utilisation in the care of acutely unwell residential aged care facility residents. Methods Semi-structured interviews were conducted with two Geriatricians, two ARRT Clinical Nurse Consultants, an ED-based Clinical Nurse Specialist, and an Extended Care Paramedic. Interview questions elicited views on key factors regarding care decisions and care transitions for acutely unwell residential aged care facility residents. Thematic analysis was undertaken to identify themes and sub-themes from interviews. Results Analysis of interviews identified five overarching themes affecting ARRT utilisation in the care of acutely unwell residents: (1) resident care needs; (2) family factors; (3) enabling factors; (4) barriers; and (5) adaptability and responsiveness to the COVID-19 pandemic. Conclusion Various factors impact on hospital avoidance program utilisation in the care of acutely unwell older aged care facility residents. This information provides additional context to existing quantitative evaluations of hospital avoidance programs, as well as informing the design of future hospital avoidance programs. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06575-1.
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Affiliation(s)
- Luke Testa
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia.
| | - Tayhla Ryder
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
| | - Rebecca J Mitchell
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
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102
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Lamppu PJ, Finne-Soveri H, Kautiainen H, Laakkonen ML, Laurila JV, Pitkälä KH. Effects of Staff Training on Nursing Home Residents' End-Of-Life Care: A Randomized Controlled Trial. J Am Med Dir Assoc 2021; 22:1699-1705.e1. [PMID: 34133971 DOI: 10.1016/j.jamda.2021.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This trial examines the effects of end-of-life training on long-term care facility (LTCF) residents' health-related quality of life (HRQoL) and use and costs of hospital services. DESIGN A single-blind, cluster randomized (at facility level) controlled trial (RCT). Our training intervention included 4 small-group 4-hour educational sessions on the principles of palliative and end-of-life care (advance care planning, adverse effects of hospitalizations, symptom management, communication, supporting proxies, challenging situations). Training was provided to all members of staff. Education was based on constructive learning methods and included resident cases, role-plays, and small-group discussions. SETTING AND PARTICIPANTS We recruited 324 residents with possible need for end-of-life care due to advanced illness from 20 LTCF wards in Helsinki. METHODS Primary outcome measures were HRQoL and hospital inpatient days per person-year during a 2-year follow-up. Secondary outcomes were number of emergency department visits and cost of all hospital services. RESULTS HRQoL according to the 15-Dimensional Health-Related Quality-of-Life Instrument declined in both groups, and no difference was present in the changes between the groups (P for group .75, adjusted for age, sex, do-not-resuscitate orders, need for help, and clustering). Neither the number of hospital inpatient days (1.87 vs 0.81 per person-year) nor the number of emergency department visits differed significantly between intervention and control groups (P for group .41). The total hospital costs were similar in the intervention and control groups. CONCLUSIONS AND IMPLICATIONS Our rigorous RCT on end-of-life care training intervention demonstrated no effects on residents' HRQoL or their use of hospitals. Unsupported training interventions alone might be insufficient to produce meaningful care quality improvements.
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Affiliation(s)
- Pauli J Lamppu
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland; Department of Social Services and Health Care, Helsinki Hospital, Geriatric Clinic, Helsinki, Finland
| | | | - Hannu Kautiainen
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - Marja-Liisa Laakkonen
- Department of Social Services and Health Care, Helsinki Hospital, Geriatric Clinic, Helsinki, Finland
| | - Jouko V Laurila
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Kaisu H Pitkälä
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland; Helsinki University Hospital, Unit of Primary Health Care, Helsinki, Finland.
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103
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Carter HE, Lee XJ, Farrington A, Shield C, Graves N, Cyarto EV, Parkinson L, Oprescu FI, Meyer C, Rowland J, Dwyer T, Harvey G. A stepped-wedge randomised controlled trial assessing the implementation, effectiveness and cost-consequences of the EDDIE+ hospital avoidance program in 12 residential aged care homes: study protocol. BMC Geriatr 2021; 21:347. [PMID: 34090368 PMCID: PMC8179705 DOI: 10.1186/s12877-021-02294-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/20/2021] [Indexed: 12/05/2022] Open
Abstract
Background Older people living in residential aged care homes experience frequent emergency transfers to hospital. These events are associated with risks of hospital acquired complications and invasive treatments or interventions. Evidence suggests that some hospital transfers may be unnecessary or avoidable. The Early Detection of Deterioration in Elderly residents (EDDIE) program is a multi-component intervention aimed at reducing unnecessary hospital admissions from residential aged care homes by empowering nursing and care staff to detect and manage early signs of resident deterioration. This study aims to implement and evaluate the program in a multi-site randomised study in Queensland, Australia. Methods A stepped-wedge randomised controlled trial will be conducted at 12 residential aged care homes over 58 weeks. The program has four components: education and training, decision support tools, diagnostic equipment, and implementation facilitation with clinical systems support. The integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework will be used to guide the program implementation and process evaluation. The primary outcome measure will be the number of hospital bed days used by residents, with secondary outcomes assessing emergency department transfer rates, admission rates, length of stay, family awareness and experience, staff self-efficacy and costs of both implementation and health service use. A process evaluation will assess the extent and fidelity of program implementation, mechanisms of impact and the contextual barriers and enablers. Discussion The intervention is expected to improve outcomes by reducing unnecessary hospital transfers. Fewer hospital transfers and admissions will release resources for other patients with potentially greater needs. Residential aged care home staff might benefit from feelings of empowerment in their ability to proactively manage early signs of resident deterioration. The process evaluation will be useful for supporting wider implementation of this intervention and other similar initiatives. Trial registration The trial is prospectively registered with the Australia New Zealand Clinical Trial Registry (ACTRN12620000507987, registered 23/04/2020). Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02294-8.
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Affiliation(s)
- Hannah E Carter
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, 4059, Queensland, Australia.
| | - Xing J Lee
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, 4059, Queensland, Australia
| | - Alison Farrington
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, 4059, Queensland, Australia
| | - Carla Shield
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, 4059, Queensland, Australia
| | - Nicholas Graves
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, 4059, Queensland, Australia.,Duke-NUS Postgraduate Medical School, National University of Singapore, 8 College Rd, Singapore, 169857, Singapore
| | - Elizabeth V Cyarto
- Bolton Clarke Research Institute, 347 Burwood Hwy, Forest Hill, Victoria, 3131, Australia.,Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, 4072, Australia.,Department of Psychiatry, University of Melbourne, Parkville, VIC, 3010, Australia
| | - Lynne Parkinson
- School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW, 2308, Australia
| | - Florin I Oprescu
- School of Health and Behavioural Sciences, University of the Sunshine Coast, Sippy Downs, QLD, 4556, Australia
| | - Claudia Meyer
- Bolton Clarke Research Institute, 347 Burwood Hwy, Forest Hill, Victoria, 3131, Australia.,Rehabilitation, Ageing and Independent Living Research Centre, Monash University, Frankston, Victoria, 3199, Australia.,Centre for Health Communication and Participation, La Trobe University, Bundoora, Victoria, 3083, Australia
| | - Jeffrey Rowland
- Faculty of Medicine, University of Queensland, 20 Weightman St, Herston, QLD, 4006, Australia.,Faculty of Health, School of Nursing, Kelvin Grove Campus, Queensland University of Technology, Brisbane, Australia.,Metro North Health, Royal Brisbane and Women's Hospital, 7 Butterfield St, Herston, QLD, 4029, Australia
| | - Trudy Dwyer
- School of Nursing, Midwifery and Social Sciences, Central Queensland University, Rockhampton, QLD, 4702, Australia
| | - Gillian Harvey
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, 4059, Queensland, Australia.,College of Nursing and Health Sciences, Flinders University, Bedford Park, Australia, 5042
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104
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Dwyer RA, Gabbe BJ, Tran T, Smith K, Lowthian JA. Residential aged care homes: Why do they call '000'? A study of the emergency prehospital care of older people living in residential aged care homes. Emerg Med Australas 2021; 33:447-456. [PMID: 33040460 DOI: 10.1111/1742-6723.13650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/04/2020] [Accepted: 09/08/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the clinical characteristics, medical interventions and patterns of ambulance service use related to the emergency, prehospital care of older people living in residential aged care (RAC) homes. METHODS Retrospective cohort study using secondary analyses of routinely collected clinical and administrative data from Ambulance Victoria and population data from the Australian Bureau of Statistics for the state of Victoria, Australia. Participants included people aged 65 years and over, attended by emergency ambulances from 2008 to 2013, with data captured in the Ambulance Victoria electronic record. RESULTS The mean (standard deviation) age of RAC residents attended by emergency ambulance was 85 (7.3) years and 63% were women. Common comorbidities included dementia (32.7%), ischaemic heart disease (27.7%) and osteoarthritis (24.6%). Polypharmacy was prevalent with 70% currently prescribed antibiotics, over 20% prescribed sedatives and a further 14.9% antipsychotics. Fifteen percent of attendances were for falls, which were more frequent among women than men. Other common reasons for ambulance call-out included uncontrolled pain, respiratory tract infection, non-specific febrile illness and altered conscious state. Almost 90% of people were transported to hospital from the RAC, with just over half of call-outs occurring out-of-hours. CONCLUSION This is the first study to describe emergency prehospital care, case-mix and intervention of frail, older people living in RAC. These results demonstrate a clinically complex group of people with high rates of comorbidity, cognitive impairment and polypharmacy. These valuable data will inform education and training of prehospital clinicians, assist in targeting preventative medicine and primary care programmes and further development of alternate, acute and emergency care pathways for this unique patient group.
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Affiliation(s)
- Rosamond A Dwyer
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Emergency Department, Peninsula Health, Melbourne, Victoria, Australia
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Thach Tran
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Karen Smith
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
| | - Judy A Lowthian
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Bolton Clarke Research Institute, Bolton Clarke, Melbourne, Victoria, Australia
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105
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Thomas RE. Reducing Morbidity and Mortality Rates from COVID-19, Influenza and Pneumococcal Illness in Nursing Homes and Long-Term Care Facilities by Vaccination and Comprehensive Infection Control Interventions. Geriatrics (Basel) 2021; 6:48. [PMID: 34066781 PMCID: PMC8162358 DOI: 10.3390/geriatrics6020048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 12/24/2022] Open
Abstract
The COVID-19 pandemic identifies the problems of preventing respiratory illnesses in seniors, especially frail multimorbidity seniors in nursing homes and Long-Term Care Facilities (LCTFs). Medline and Embase were searched for nursing homes, long-term care facilities, respiratory tract infections, disease transmission, infection control, mortality, systematic reviews and meta-analyses. For seniors, there is strong evidence to vaccinate against influenza, SARS-CoV-2 and pneumococcal disease, and evidence is awaited for effectiveness against COVID-19 variants and when to revaccinate. There is strong evidence to promptly introduce comprehensive infection control interventions in LCFTs: no admissions from inpatient wards with COVID-19 patients; quarantine and monitor new admissions in single-patient rooms; screen residents, staff and visitors daily for temperature and symptoms; and staff work in only one home. Depending on the vaccination situation and the current risk situation, visiting restrictions and meals in the residents' own rooms may be necessary, and reduce crowding with individual patient rooms. Regional LTCF administrators should closely monitor and provide staff and PPE resources. The CDC COVID-19 tool measures 33 infection control indicators. Hand washing, social distancing, PPE (gowns, gloves, masks, eye protection), enhanced cleaning of rooms and high-touch surfaces need comprehensive implementation while awaiting more studies at low risk of bias. Individual ventilation with HEPA filters for all patient and common rooms and hallways is needed.
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Affiliation(s)
- Roger E Thomas
- Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, AB T2M 1M1, Canada
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106
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Rolland Y, Mathieu C, Tavassoli N, Berard E, Laffon de Mazières C, Hermabessière S, Houles M, Perrin A, Krams T, Qassemi S, Cambon A, Magre E, Cantet C, Charpentier S, Lauque D, Azema O, Chicoulaa B, Oustric S, McCambridge C, Gombault-Datzenko E, Molinier L, Costa N, De Souto Barreto P. Factors Associated with Potentially Inappropriate Transfer to the Emergency Department among Nursing Home Residents. J Am Med Dir Assoc 2021; 22:2579-2586.e7. [PMID: 33964225 DOI: 10.1016/j.jamda.2021.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 04/01/2021] [Accepted: 04/01/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To determine the factors associated with the potentially inappropriate transfer of nursing home (NH) residents to emergency departments (EDs) and to compare hospitalization costs before and after transfer of individuals addressed inappropriately vs those addressed appropriately. DESIGN Multicenter, observational, case-control study. SETTING AND PARTICIPANTS 17 hospitals in France, 1037 NH residents. MEASURES All NH residents transferred to the 17 public hospitals' EDs in southern France were systematically included for 1 week per season. An expert panel composed of family physicians, emergency physicians, geriatricians, and pharmacists defined whether the transfer was potentially inappropriate or appropriate. Residents' and NHs' characteristics and contextual factors were entered into a mixed logistic regression to determine factors associated independently with potentially inappropriate transfers. Hospital costs were collected in the national health insurance claims database for the 6 months before and after the transfer. RESULTS A total of 1037 NH residents (mean age 87.2 ± 7.1, 68% female) were transferred to the ED; 220 (21%) transfers were considered potentially inappropriate. After adjustment, anorexia [odds ratio (OR) 2.41, 95% confidence interval (CI) 1.57-3.71], high level of disability (OR 0.90, 95% CI 0.81-0.99), and inability to receive prompt medical advice (OR 1.67, 95% CI 1.20-2.32) were significantly associated with increased likelihood of potentially inappropriate transfers. The existence of an Alzheimer's disease special care unit in the NH (OR 0.66, 95% CI 0.48-0.92), NH staff trained on advance directives (OR 0.61, 95% CI 0.41-0.89), and calling the SAMU (mobile emergency medical unit) (OR 0.47, 95% CI 0.34-0.66) were significantly associated with a lower probability of potentially inappropriate transfer. Although the 6-month hospitalization costs prior to transfer were higher among potentially inappropriate transfers compared with appropriate transfers (€6694 and €4894, respectively), transfer appropriateness was not significantly associated with hospital costs. CONCLUSIONS AND IMPLICATIONS Transfers from NHs to hospital EDs were frequently appropriate. Transfer appropriateness was conditioned by NH staff training, access to specialists' medical advice, and calling the SAMU before making transfer decisions. TRIAL REGISTRATION clinicaltrials.gov, NCT02677272.
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Affiliation(s)
- Yves Rolland
- Gérontopôle, Toulouse University Hospital, Toulouse, France; INSERM, UMR 1027, Toulouse, France
| | - Celine Mathieu
- Gérontopôle, Toulouse University Hospital, Toulouse, France; CREAI-ORS Occitanie, Toulouse, France
| | - Neda Tavassoli
- Gérontopôle, Toulouse University Hospital, Toulouse, France.
| | - Emilie Berard
- Service d'Epidémiologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France, UMR 1027, INSERM-Université de Toulouse III, Toulouse, France
| | | | | | - Mathieu Houles
- Gérontopôle, Toulouse University Hospital, Toulouse, France
| | - Amélie Perrin
- Gérontopôle, Toulouse University Hospital, Toulouse, France
| | - Thomas Krams
- Gérontopôle, Toulouse University Hospital, Toulouse, France
| | - Soraya Qassemi
- Gérontopôle, Toulouse University Hospital, Toulouse, France
| | | | - Elodie Magre
- Gérontopôle, Toulouse University Hospital, Toulouse, France
| | | | - Sandrine Charpentier
- Emergency Department, University Paul Sabatier Toulouse III, Toulouse University Hospital, INSERM, UMR 1027, Toulouse, France
| | - Dominique Lauque
- Emergency Department, University Paul Sabatier Toulouse III, Toulouse University Hospital, INSERM, UMR 1027, Toulouse, France
| | - Olivier Azema
- Observatoire Régional des Urgences d'Occitanie (ORU Occitanie), Toulouse University Hospital, Toulouse, France
| | - Bruno Chicoulaa
- Département Universitaire de Médecine Générale (DUMG), Université Toulouse III, Toulouse University Hospital, Toulouse, France
| | - Stéphane Oustric
- Département Universitaire de Médecine Générale (DUMG), Université Toulouse III, Toulouse University Hospital, Toulouse, France
| | | | | | - Laurent Molinier
- INSERM, UMR 1027, Toulouse, France; Department of Medical Information (DIM), Toulouse University Hospital, Toulouse, France
| | - Nadège Costa
- INSERM, UMR 1027, Toulouse, France; Department of Medical Information (DIM), Toulouse University Hospital, Toulouse, France
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107
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McManamny TE, Dwyer R, Cantwell K, Boyd L, Sheen J, Smith K, Lowthian JA. Emergency ambulance demand by older adults from rural and regional Victoria, Australia. Australas J Ageing 2021; 41:e74-e81. [PMID: 33955132 DOI: 10.1111/ajag.12960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 04/02/2021] [Accepted: 04/05/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe the demographic profile and clinical case mix of older adults following calls for an emergency ambulance in rural Victoria, Australia. METHODS Retrospective cohort study using ambulance electronic patient care records from rural-dwelling older adults (≥65 years old) who requested emergency ambulance attendance during 2017. RESULTS A total of 84 785 older adults requested emergency ambulance attendance, representing a rate of 278 per 1000 population aged ≥65 years. More than 10% of calls were to residential aged care homes. Medical complaints and trauma accounted for 69% and 18% of attendances, respectively. The predominant cause of trauma was ground-level falls. Common reasons for call-outs were for pain (17.5%), respiratory problems (9.7%) and cardiovascular problems (8.5%). Increased demand was associated with increasing age and winter months. CONCLUSION Older adults from rural Victoria have high rates of emergency ambulance attendance and transportation to an emergency department, particularly with increasing age.
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Affiliation(s)
- Tegwyn E McManamny
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Ambulance Victoria, Doncaster, VIC, Australia
| | - Rosamond Dwyer
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Peninsula Health, Frankston, VIC, Australia
| | - Kate Cantwell
- Ambulance Victoria, Doncaster, VIC, Australia.,Department of Community Emergency Health and Paramedicine, Monash University, Frankston, VIC, Australia
| | | | - Jade Sheen
- School of Psychology, Deakin University, Burwood, VIC, Australia
| | - Karen Smith
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Ambulance Victoria, Doncaster, VIC, Australia.,School of Primary and Allied Health Care, Monash University, Frankston, VIC, Australia
| | - Judy A Lowthian
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Bolton Clarke Research Institute, Bentleigh, VIC, Australia.,Faculty of Health and Behavioural Sciences, University of Queensland, St Lucia, QLD, Australia.,Institute of Future Environments, Queensland University of Technology, Brisbane, QLD, Australia
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108
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Validation of the Delirium Diagnostic Tool-Provisional (DDT-Pro) in a skilled nursing facility and comparison to the 4 'A's test (4AT). Gen Hosp Psychiatry 2021; 70:116-123. [PMID: 33813146 DOI: 10.1016/j.genhosppsych.2021.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/24/2021] [Accepted: 03/26/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To validate the Delirium Diagnostic Tool (DDT-Pro) in a SNF and compare its performance to the 4 A's Test (4AT) in real life conditions. METHODS Prospective cross-sectional study of 262 consecutively admitted adults to a SNF, independently assessed by psychiatrists using DSM-5 delirium criteria and by geriatricians using the DDT-Pro (0-9 points) and 4AT (0-12 points). RESULTS 141 (53.8%) participants had dementia and 79 (30.1%) had delirium. DDT-Pro and 4AT were moderately correlated (-0.59). Accuracies against DSM-5 diagnosis ranged from 80 to 85% and were comparable between tools regardless of dementia. Recommended delirium cutoff for the DDT-Pro (≤6) had 77.2% sensitivity, 84% specificity, and NPV = 89.5% and 4AT (≥4) had 54.4% sensitivity and 92.9% specificity, with lower specificity in the dementia subsample. DDT-Pro sensitivity increased (84.8%) at ≤7cutoff. Sensitivity and specificity of all DDT-Pro and 2/4 4AT items displayed gradients along severity levels, but two dichotomously rated 4AT items had low positivity. The tools had low concordance (p < 0.05) for delirium positivity. CONCLUSIONS DDT-Pro is valid to detect delirium in SNF population where simple, structured tools with high sensitivity are needed. DDT-Pro items assess the three core domains of delirium as a continuous measure and may have advantages over the 4AT.
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109
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Poeck J, Bretschneider C, Freihoff S, Günther A, Hasseler M, Schneider N, Bleidorn J, Schwabe S. "… darum rufe ich jetzt den Rettungsdienst!". Pflege 2021; 34:141-150. [PMID: 33913337 DOI: 10.1024/1012-5302/a000804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
"… that's why I call the ambulance!" - A qualitative study of emergency scenarios in nursing homes Abstract. Background: In nursing homes, emergencies lead to frequent utilisation of emergency medical services (EMS) and emergency department visits. A broad interprofessional perspective of involved practitioners on emergencies in nursing homes has been little studied so far. Aim: Characterization, identification and prioritization of emergency scenarios by relevance and frequency in nursing homes. Methods: We conducted two multi-method, interprofessional group discussions with a total of 18 participants from nursing, medicine and science in January and February 2020. Group discussions were recorded, transcribed and analyzed using qualitative content analysis according to Mayring. Results: Emergency scenarios in nursing homes arise from interactions between person-related aspects and contextual conditions. The following person-related aspects were named as relevant: Falls, unstable vital signs, abnormal behavior, neurological symptoms and lifelessness. Contextual conditions are classified into organizational-structural, political-legal and ethical aspects. The following were considered to be most relevant: lack of communication between the actors, uncertainties among staff, absent living wills and increasing workload in nursing. Conclusions: Emergencies in nursing homes turn out to be complex emergency scenarios. Contextual conditions are important for dealing with emergency scenarios in nursing homes. Recommended actions should be based on the perspective of involved practitioners on emergencies and take greater account of the contextual conditions.
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Affiliation(s)
- Juliane Poeck
- Institut für Allgemeinmedizin, Universitätsklinikum Jena
| | | | - Silke Freihoff
- Institut für Allgemeinmedizin, Medizinische Hochschule Hannover.,Klinik für Rehabilitationsmedizin, Medizinische Hochschule Hannover
| | | | - Martina Hasseler
- Fakultät Gesundheitswesen, Ostfalia Hochschule für angewandte Wissenschaften - Hochschule Braunschweig / Wolfenbüttel
| | - Nils Schneider
- Institut für Allgemeinmedizin, Medizinische Hochschule Hannover
| | - Jutta Bleidorn
- Institut für Allgemeinmedizin, Universitätsklinikum Jena
| | - Sven Schwabe
- Institut für Allgemeinmedizin, Medizinische Hochschule Hannover
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Gasperini B, Pelusi G, Frascati A, Sarti D, Dolcini F, Espinosa E, Prospero E. Predictors of adverse outcomes using a multidimensional nursing assessment in an Italian community hospital. PLoS One 2021; 16:e0249630. [PMID: 33857183 PMCID: PMC8049226 DOI: 10.1371/journal.pone.0249630] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 03/22/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND There is growing evidence about the role of nurses in patient outcomes in several healthcare settings. However, there is still a lack of evidence about the transitional care setting. We aimed to assess the association between patient characteristics identified in a multidimensional nursing assessment and outcomes of mortality and acute hospitalization during community hospital stay. METHODS A retrospective observational study was performed on patients consecutively admitted to a community hospital (CH) in Loreto (Ancona, Italy) between January 1st, 2018 and May 31st, 2019. The nursing assessment included sociodemographic characteristics, functional status, risk of falls (Conley Score) and pressure damage (Norton scale), nursing diagnoses, presence of pressure sores, feeding tubes, urinary catheters or vascular access devices and comorbidities. Two logistic regression models were developed to assess the association between patient characteristics identified in a multidimensional nursing assessment and outcomes of mortality and acute hospitalization during CH stay. RESULTS We analyzed data from 298 patients. The mean age was 83 ± 9.9 years; 60.4% (n = 180) were female. The overall mean length of stay was 42.8 ± 36 days (32 ± 32 days for patients who died and 33.9 ± 35 days for patients who had an acute hospitalization, respectively). An acute hospitalization was reported for 13.4% (n = 40) of patients and 21.8% (n = 65) died. An increased risk of death was related to female sex (OR 2.25, 95% CI 1.10-4.62), higher Conley Score (OR 1.19; 95% CI 1.03-1.37) and having a vascular access device (OR 3.64, 95% CI 1.82-7.27). A higher Norton score was associated with a decreased risk of death (OR 0.71, 95% CI 0.62-0.81). The risk for acute hospitalization was correlated with younger age (OR 0.94, 95% CI 0.91-0.97), having a vascular access device (OR 2.33, 95% CI 1.02-5.36), impaired walking (OR 2.50, 95% CI 1.03-6.06) and it is inversely correlated with a higher Conley score (OR 0.84, 95% CI 0.77-0.98). CONCLUSION Using a multidimensional nursing assessment enables identification of risk of nearness of end of life and acute hospitalization to target care and treatment. The present study adds further knowledge on this topic and confirms the importance of nursing assessment to evaluate the risk of patients' adverse outcome development.
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Affiliation(s)
- Beatrice Gasperini
- Section of Hygiene and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Geriatrics, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Fano (PU), Italy
| | - Gilda Pelusi
- School of Nursing, Università Politecnica delle Marche, Ancona, Italy
| | | | - Donatella Sarti
- Section of Hygiene and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | | | - Emma Espinosa
- Geriatrics, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Fano (PU), Italy
| | - Emilia Prospero
- Section of Hygiene and Public Health, Università Politecnica delle Marche, Ancona, Italy
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111
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Bryant J, Hobden B, Waller A, Clapham M, Sanson-Fisher R. Participation in future planning by community-dwelling older Australians receiving aged care services: Findings from a cross-sectional survey. Australas J Ageing 2021; 40:373-380. [PMID: 33719124 DOI: 10.1111/ajag.12927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 01/17/2021] [Accepted: 01/18/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine in a sample of older community-dwelling adults: (1) the proportion who have engaged in medical and financial planning; (2) the factors associated with advance care directive (ACD) completion and substitute decision maker (SDM) appointment; and (3) for those without an ACD, what might prompt completion. METHODS A cross-sectional survey was undertaken with individuals receiving community aged care services in metropolitan and regional communities. Data collection was conducted by case managers during a home visit. RESULTS Overall, 158 individuals (M = 78 years, SD = 8.7) participated (53.5% consent rate). Financial planning participation (will = 85%; enduring power of attorney = 66%) was higher than medical planning participation (SDM: 54%; ACD: 30%). No health status factors were significantly associated with ACD completion or SDM appointment. Diagnosis of a life-limiting illness was most likely to prompt ACD completion (77.6%). CONCLUSIONS One third of older people residing in the community have completed an ACD. Strategies to improve uptake in this vulnerable population require further exploration.
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Affiliation(s)
- Jamie Bryant
- Health Behaviour Research Collaborative, Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Breanne Hobden
- Health Behaviour Research Collaborative, Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Amy Waller
- Health Behaviour Research Collaborative, Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Matthew Clapham
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Robert Sanson-Fisher
- Health Behaviour Research Collaborative, Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
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112
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Chen BA, Lai FC, Tsao LI, Chien HH, Chen CF, Jeng C. Decision difficulties of long-term-care facility nurses in transferring residents to the emergency department: A cross-sectional nationwide study. J Adv Nurs 2021; 77:2728-2738. [PMID: 33624335 DOI: 10.1111/jan.14802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/22/2021] [Accepted: 01/27/2021] [Indexed: 11/28/2022]
Abstract
AIMS To examine the level of decision difficulties of long-term-care facility (LTCF) nurses when transferring residents to the emergency department (ED) and associated influencing factors. DESIGN A cross-sectional nationwide study. METHODS The LTCFs were selected through random stratified sampling across the whole Taiwan during February 2018 to January 2019. LTCF nurses who met the selection criteria were invited to participate with two or three nurses selected from each LTCF. The Patient Transfer Decision Difficulty Scale (PTDDS) was used to measure the level of difficulty in making decisions related to the transfer of residents to the ED. Data were collected by mailing the questionnaires and asking the nurses to return the completed form in 2 weeks. Data were analysed using simple linear regression and multiple regression with stepwise methods. RESULTS In total, 618 valid questionnaires with an 85.32% response rate from 319 LTCFs were used for the data analysis. Decision difficulties that LTCF nurses experienced were moderate, the nursing personnel-bed ratio, LTCF professional training and basic life support training were predictive factors of the level of difficulty experience (scores of PTDDS) for the LTCF nurse (F = 6.81, p < .001). CONCLUSIONS Enhancing emergency training in LTCF can improve nurses' decision-making ability to refer LTCF residents to emergency treatment. IMPACT What problem did the study address? The study addressed the difficult decision LTCF nurses may experience when transferring a resident to the emergency department. What were the main findings? All LTCF nurses faced a moderate level of difficulty in decision-making. 'Transfer timing' was most often considered in the decision-making process when a resident was transferred to the ED. Where and on whom will the research have impact? Results of this study have considerable reference value for LTCF managers and nurses in the decision-making ability and suitability of transferring residents for emergency treatment.
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Affiliation(s)
- Bor-An Chen
- Emergency Department, Keelung Hospital, Ministry of Health and Welfare, Keelung, Taiwan.,Department of Nursing, Ching Kuo Institute of Management and Health, Keelung, Taiwan
| | - Fu-Chih Lai
- Post-Baccalaureate Nursing Program in Nursing and College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Lee-Ing Tsao
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Hui-Hui Chien
- Nursing Department, Yuanshan Branch, Taipei Veterans General Hospital, Ilan, Taiwan
| | - Chun-Fu Chen
- Taipei Medical University-Shuang HO Hospital, Ministry of Health and Welfare
| | - Chii Jeng
- School of Nursing, Taipei Medical University, Taipei, Taiwan
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113
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Viray P, Low Z, Sinnappu R, Harvey PA, Brown S. Residential aged care facility COVID-19 outbreaks and magnitude of spread among residents: observations from a Victorian residential in-reach service. Intern Med J 2021; 51:99-101. [PMID: 33572024 PMCID: PMC8014598 DOI: 10.1111/imj.15143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 11/28/2022]
Abstract
There is a paucity of Australian literature exploring the spread of COVID-19 among residents living in residential aged care facilities (RACF). In this case series of COVID-19 outbreaks in six RACF, we collected data on the cumulative proportion of residents who tested positive for COVID-19 within 21 days of the index case being identified. We describe the observations of a Residential In-Reach service within these six RACF and found that rapid cohorting strategies, personal protective equipment availability and adequacy of use, embedded infection control staff, and adequate outbreak preparedness plans may have influenced the differences observed between RACF in the containment and minimisation of the spread of COVID-19 amongst residents.
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Affiliation(s)
- Paul Viray
- Northern Health Epping, Austin Health, Melbourne, Victoria, Australia
| | - Zi Low
- Northern Health Epping, Melbourne, Victoria, Australia
| | | | | | - Sandra Brown
- Northern Health Epping, Melbourne, Victoria, Australia
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114
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Testa L, Hardy JE, Jepson T, Braithwaite J, Mitchell RJ. Health service utilisation and health outcomes of residential aged care residents referred to a hospital avoidance program: A multi-site retrospective quasi-experimental study. Australas J Ageing 2021; 40:e244-e253. [PMID: 33547756 DOI: 10.1111/ajag.12906] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 12/03/2020] [Accepted: 12/09/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare the health system utilisation patterns and health outcomes of residential aged care facility (RACF) residents reviewed by a hospital avoidance program to those of RACF residents who received usual care. METHODS A retrospective evaluation of a hospital avoidance program provided by a hospital-based medical and nursing outreach team. Residents reviewed by the program were randomly matched 1:1 to comparison group residents based on age group, sex and number of co-morbidities. Number of hospital admissions, excess hospital length of stay and excess hospital treatment costs were compared. RESULTS Residents reviewed by the program spent an average 9-10 days fewer in hospital with AUD$2,091 to $8,014 lower hospital treatment costs compared to comparison group residents. CONCLUSION Rapid provision of outreach services for the management of acute care of RACF residents may reduce the number of days residents spend in hospital, as well as reducing the associated hospital treatment costs.
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Affiliation(s)
- Luke Testa
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - James E Hardy
- Royal North Shore Hospital, Sydney, New South Wales, Australia.,The University of Sydney, Sydney, New South Wales, Australia
| | - Therese Jepson
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Rebecca J Mitchell
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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115
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Carey N, Boersema GC, du Toit HS. Improving early detection of infection in nursing home residents in South Africa. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2021; 14:100288. [PMID: 33520656 PMCID: PMC7830222 DOI: 10.1016/j.ijans.2021.100288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 08/21/2020] [Accepted: 01/17/2021] [Indexed: 11/17/2022] Open
Abstract
This paper sets out key challenges related to detection and management of infection in nursing home residents, and then explores the situation in South Africa, and use of decision support tools as a mechanism to improve this area of practice. In line with global trends, concerns have been raised about the rapidly increasing aging population in South Africa and the ability of the current healthcare system to keep pace with patient demand, particularly nursing home residents. Nursing home residents, who often exhibit atypical signs and symptoms, are at increased risk of infection and unplanned admissions, which account for 65% of all bed days, and cost the US healthcare economy more than a trillion dollars a year. Evidence suggests that the current workforce in South Africa receive limited training in this area and are largely unprepared to meet the demands of the aging population. Building the capacity and skills of the workforce in South Africa is one approach that could help to improve the early detection of infection and assist the nursing home workforce to provide more effective and timely care, particularly during the current COVID-19 pandemic. Decision support tools, such as the Early Detection of Infection Scale, can help ensure consistency and ensure more timely treatment, minimising unplanned admissions and healthcare expenditure. However, the potential benefits or indeed how easily this could be integrated in to nursing homes in South Africa is unknown. An important first step, as in other parts of the world, is therefore to explore views and opinions of how infections are detected and managed in practice by nurses, care workers and managers in nursing homes.
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Affiliation(s)
- Nicola Carey
- School of Health Sciences, Faculty of Health & Medical Sciences, University of Surrey, Kate Granger Building, Priestly Road, Surrey Research Park, Guildford, Surrey GU2 7YH, United Kingdom
| | | | - Helena S du Toit
- Department of Health Studies, University of South Africa, PO Box 392, Unisa, Pretoria, 0003, South Africa
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116
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Salles N, Saillour-Glénisson F, Sibe M, Langlois E, Kret M, Durrieu J, Arditi N, Abraham M, Perry F. Effectiveness and organizational conditions of effectiveness of telemedicine in nursing homes. A study protocol of a comparative prospective cohort (EFFORT study). Digit Health 2021; 7:2055207620982422. [PMID: 33598307 PMCID: PMC7841670 DOI: 10.1177/2055207620982422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 12/01/2020] [Indexed: 11/17/2022] Open
Abstract
The profile of nursing home (NH) residents has changed over the past decade with more dependency, more severe chronic diseases and more treatments prescribed. For residents, the major consequence is the higher risk of unplanned hospitalization. French guidelines recommend the development of interactive telemedicine (InT) in NHs in order to improve access to care, and to decrease the rate of avoidable unplanned hospitalizations. Methods and analysis: The aim of this study is to analyze the impact of an InT protocol delivered in NHs on the rate of unplanned hospitalizations, and on the quality of life at work and the organizational conditions of effectiveness of telemedicine in NHs. We will perform a mixed methods study combining a cluster non-randomized controlled trial in two matched parallel arms (telemedicine group and control group) and qualitative analysis of the evolution of organizational and professional contexts in NHs. Ethics and dissemination: The study protocol was approved and sponsored by the French Ministry of Health. The study received ethical approval from the Bordeaux University Hospital Institutional Review Board. We will communicate the final results to the public via conferences and results will also be submitted for publication in international peer-reviewed scientific journals. Trial registration number NCT03486977
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Affiliation(s)
- Nathalie Salles
- Pole de Gérontologie Clinique, CHU Bordeaux, Bordeaux, France
| | - Florence Saillour-Glénisson
- Unité de Soutien Méthodologique à la Recherche Clinique et Épidémiologique du CHU de Bordeaux, Bordeaux, France
| | - Matthieu Sibe
- Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université de Bordeaux, Bordeaux, France
| | - Emmanuel Langlois
- Centre Emile Durkheim, Science Politique et Sociologie Comparatives (UMR 5116), Université de Bordeaux, Bordeaux, France
| | - Marion Kret
- Unité de Soutien Méthodologique à la Recherche Clinique et Épidémiologique du CHU de Bordeaux, Bordeaux, France
| | - Jessica Durrieu
- Pole de Gérontologie Clinique, CHU Bordeaux, Bordeaux, France
| | - Nora Arditi
- Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université de Bordeaux, Bordeaux, France
| | - Maelys Abraham
- Centre Emile Durkheim, Science Politique et Sociologie Comparatives (UMR 5116), Université de Bordeaux, Bordeaux, France
| | - Frederic Perry
- Recherche Clinique et de l'Innovation, CHU Bordeaux, Bordeaux, France
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117
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Guion V, de Souto Barreto P, Rolland Y. Trajectories of Symptoms in Nursing Home Residents after a Transfer to the Emergency Department. J Nutr Health Aging 2021; 25:318-324. [PMID: 33575722 DOI: 10.1007/s12603-020-1476-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To describe the trajectories of pain, dyspnea, fever, confusion, agitation and fatigue of nursing home residents' (NHRs) after a transfer to the emergency department (ED). DESIGN Observational multicenter study. SETTING 17 EDs in France. PARTICIPANTS 751 NHRs presenting to EDs over four non-consecutive weeks (one week per season) in 2016. MEASUREMENTS Trajectories of symptoms (binary variables) including pain, dyspnea, fever, agitation, confusion and fatigue at four times: before ED transfer, during the transfer, in the ED and after discharge. RESULTS Group-based multi-trajectory modelling was performed to identify groups of NHRs following similar trajectories of symptoms evolution after a transfer to ED. Five groups were identified. In group 1 (n=190), NHRs presented with confusion and a rising prevalence of fatigue. In group 2 (n=212), NHRs presented with a highly prevalent but declining pain. In group 3 (n=158), NHRs presented with similar peaking pain prevalence, rising confusion and fatigue, and a high but stable agitation prevalence. In group 4 (n=144), NHRs presented with a highly prevalent but declining dyspnea, rising then declining fever, rising confusion, and a high and fluctuating fatigue prevalence. In group 5 (n=47), NHRs presented with a highly prevalent but declining fever, rising then declining dyspnea, stable and high both fatigue and pain prevalence, stable and low prevalence of confusion. CONCLUSION Symptom alleviation in NHRs transferred to ED was better achieved in those with pain, fever or dyspnea rather than in those with confusion, agitation and fatigue. NHRs' resilience through the stress of an ED transfer could be predicted by comorbidity and functional abilities, challenged by acute conditions representing various levels of stress intensity, and evaluated on the course of non-specific symptoms. NHRs' resilience is key to estimate the appropriateness of an ED transfer and should facilitate advance care planning regarding NHRs' hospitalizations.
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Affiliation(s)
- V Guion
- Vincent Guion, Gerontopole, 20 rue du Pont Saint-Pierre, Cité de la Santé, CHU de Toulouse, 31059 Toulouse, France,
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118
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Carter HE, Lee XJ, Dwyer T, O'Neill B, Jeffrey D, Doran CM, Parkinson L, Osborne SR, Reid-Searl K, Graves N. The effectiveness and cost effectiveness of a hospital avoidance program in a residential aged care facility: a prospective cohort study and modelled decision analysis. BMC Geriatr 2020; 20:527. [PMID: 33287716 PMCID: PMC7720399 DOI: 10.1186/s12877-020-01904-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 11/17/2020] [Indexed: 11/29/2022] Open
Abstract
Background Residential aged care facility residents experience high rates of hospital admissions which are stressful, costly and often preventable. The EDDIE program is a hospital avoidance initiative designed to enable nursing and care staff to detect, refer and quickly respond to early signals of a deteriorating resident. The program was implemented in a 96-bed residential aged care facility in regional Australia. Methods A prospective pre-post cohort study design was used to collect data on costs of program delivery, hospital admission rates and length of stay for the 12 months prior to, and following, the intervention. A Markov decision model was developed to synthesize study data with published literature in order to estimate the cost-effectiveness of the program. Quality adjusted life years (QALYs) were adopted as the measure of effectiveness. Results The EDDIE program was associated with a 19% reduction in annual hospital admissions and a 31% reduction in the average length of stay. The cost-effectiveness analysis found the program to be both more effective and less costly than usual care, with 0.06 QALYs gained and $249,000 health system costs saved in a modelled cohort of 96 residents. A probabilistic sensitivity analysis estimated that there was an 86% probability that the program was cost-effective after taking the uncertainty of the model inputs into account. Conclusions This study provides promising evidence for the effectiveness and cost-effectiveness of a nurse led, early intervention program in preventing unnecessary hospital admissions within a residential aged care facility. Further research in multi-site randomised studies is needed to confirm the generalisability of these results. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-020-01904-1.
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Affiliation(s)
- Hannah E Carter
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Australia.
| | - Xing J Lee
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Australia
| | - Trudy Dwyer
- Central Queensland University, Rockhampton, Australia
| | - Barbara O'Neill
- Central Queensland University, Rockhampton, Australia.,University of Connecticut, Storrs, USA
| | | | - Christopher M Doran
- Cluster for Resilience and Wellbeing, Central Queensland University, Brisbane, Australia
| | - Lynne Parkinson
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Sonya R Osborne
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Australia.,School of Nursing and Midwifery, Centre for Health Research, Institute for Resilient Regions, University of Southern Queensland, Ipswich, Australia
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119
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Hodge SY, Ali MR, Gordon AL. Recognizing and responding to deterioration in care homes: a scoping review protocol. JBI Evid Synth 2020; 19:447-453. [PMID: 33230017 DOI: 10.11124/jbisrir-d-19-00413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To identify the available published primary research and any relevant policies, guidelines, or protocols regarding how care home staff recognize and respond to an acutely deteriorating resident. INTRODUCTION Older people living in care homes have complex health care needs. Chronic illnesses, comorbidities, frailty, cognitive impairment, and physical dependency can contribute to unpredictable changes in their health status that can lead to residents becoming unwell and acutely deteriorating. Exploring how care home staff recognize and respond to acutely deteriorating health among residents is important to understand whether opportunities exist to minimize these unpredictable changes in health. INCLUSION CRITERIA This scoping review will consider studies that feature the recognition and response to acute deterioration in care home residents. This review will consider qualitative and quantitative primary research. Non-indexed and gray literature such as policies, deterioration tools, and reports from health policy organizations will also be included. METHODS The searches will be conducted using bibliographic databases, university repositories, and non-indexed and gray literature, such as reports by health care and health policy organizations. The studies will be independently selected from the inclusion criteria by two researchers based on their title and abstract. In case of disagreement, a third researcher will be consulted. An adapted version of the JBI data extraction form will be used to extrapolate data from included studies. The results will be presented in tabular form, accompanied by a narrative summary related to the objectives of the scoping review.
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Affiliation(s)
- Sevim Y Hodge
- Division of Rehabilitation, Ageing and Well Being, University of Nottingham, Nottingham, UK.,Institute of Nursing and Midwifery Care Excellence, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Mohammad R Ali
- Nottingham Respiratory Research Unit, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Adam L Gordon
- Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
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120
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Afonso-Argilés FJ, Meyer G, Stephan A, Comas M, Wübker A, Leino-Kilpi H, Lethin C, Saks K, Soto-Martin M, Sutcliffe C, Verbeek H, Zabalegui A, Renom-Guiteras A. Emergency department and hospital admissions among people with dementia living at home or in nursing homes: results of the European RightTimePlaceCare project on their frequency, associated factors and costs. BMC Geriatr 2020; 20:453. [PMID: 33153444 PMCID: PMC7643440 DOI: 10.1186/s12877-020-01835-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 10/14/2020] [Indexed: 11/21/2022] Open
Abstract
Background Evidence is lacking on the differences between hospitalisation of people with dementia living in nursing homes and those living in the community. The objectives of this study were: 1) to describe the frequency of hospital admission among people with dementia in eight European countries living in nursing homes or in the community, 2) to examine the factors associated with hospitalisation in each setting, and 3) to evaluate the costs associated with it. Methods The present study is a secondary data analysis of the RightTimePlaceCare European project. A cross-sectional survey was conducted with data collected from people with dementia living at home or who had been admitted to a nursing home in the last 3 months, as well as from their caregivers. Data on hospital admissions at 3 months, cognitive and functional status, neuropsychiatric symptoms, comorbidity, polypharmacy, caregiver burden, nutritional status, and falls were assessed using validated instruments. Multivariate regression models were used to investigate the factors associated with hospital admission for each setting. Costs were estimated by multiplying quantities of resources used with the unit cost of each resource and inflated to the year 2019. Results The study sample comprised 1700 people with dementia living in the community and nursing homes. Within 3 months, 13.8 and 18.5% of people living in nursing homes and home care, respectively, experienced ≥1 hospital admission. In the nursing home setting, only polypharmacy was associated with a higher chance of hospital admission, while in the home care setting, unintentional weight loss, polypharmacy, falls, and more severe caregiver burden were associated with hospital admission. Overall, the estimated average costs per person with dementia/year among participants living in a nursing home were lower than those receiving home care. Conclusion Admission to hospital is frequent among people with dementia, especially among those living in the community, and seems to impose a remarkable economic burden. The identification and establishment of an individualised care plan for those people with dementia with polypharmacy in nursing homes, and those with involuntary weight loss, accidental falls, polypharmacy and higher caregiver burden in the home care setting, might help preventing unnecessary hospital admissions.
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Affiliation(s)
- F Javier Afonso-Argilés
- Department of Geriatric Medicine and Palliative Care. Badalona Serveis Assistencials, Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gabriele Meyer
- Department of Nursing Science, Witten/Herdecke University, Witten, Germany. .,Institute of Health and Nursing Sciences, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.
| | - Astrid Stephan
- Department of Nursing Science, Witten/Herdecke University, Witten, Germany.,Institute of Health and Nursing Sciences, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Mercè Comas
- Department of Epidemiology and Evaluation. Hospital del Mar, Parc de Salut Mar, Barcelona, Spain.,Member of the Health Services Research on Chronic Patients Network (REDISSEC), Madrid, Spain
| | - Ansgar Wübker
- RWI - Leibniz-Institute for Economic Research, Leibniz Science Campus Ruhr and RUB, Essen, Germany
| | - Helena Leino-Kilpi
- Department of Nursing Science and Nurse Director, Turku University Hospital, University of Turku, Turku, Finland
| | - Connie Lethin
- Department of Health Sciences. Faculty of Medicine, Lund University, SE-221 00, Lund, Sweden.,Clinical Memory Research Unit. Department of Clinical Sciences, Lund University, SE-221 00, Lund, Sweden
| | - Kai Saks
- Department of Internal Medicine, University of Tartu, Tartu, Estonia
| | - Maria Soto-Martin
- Department of Geriatric Medicine, Gerontopole, Alzheimer Disease Research Center, Inserm UMR 1027, University Hospital of Toulouse, Toulouse, France
| | | | - Hilde Verbeek
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands.,Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands
| | - Adelaida Zabalegui
- Hospital Clinic de Barcelona, Barcelona, Spain.,School of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Anna Renom-Guiteras
- Universitat Autònoma de Barcelona, Barcelona, Spain.,Member of the Health Services Research on Chronic Patients Network (REDISSEC), Madrid, Spain.,Department of Geriatric Medicine, Parc de Salut Mar, Barcelona, Spain
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121
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Müller C, Hesjedal-Streller B, Fleischmann N, Tetzlaff B, Mallon T, Scherer M, Köpke S, Balzer K, Gärtner L, Maurer I, Friede T, König HH, Hummers E. Effects of strategies to improve general practitioner-nurse collaboration and communication in regard to hospital admissions of nursing home residents (interprof ACT): study protocol for a cluster randomised controlled trial. Trials 2020; 21:913. [PMID: 33153484 PMCID: PMC7643262 DOI: 10.1186/s13063-020-04736-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Germany, up to 50% of nursing home residents are admitted to a hospital at least once a year. It is often unclear whether this is beneficial or even harmful. Successful interprofessional collaboration and communication involving general practitioners (GPs) and nurses may improve medical care of nursing home residents. In the previous interprof study, the six-component intervention package interprof ACT was developed to facilitate collaboration of GPs and nurses in nursing homes. The aim of this study is to evaluate the effectiveness of the interprof ACT intervention. METHODS This multicentre, cluster randomised controlled trial compares nursing homes receiving the interprof ACT intervention package for a duration of 12 months (e.g. comprising appointment of mutual contact persons, shared goal setting, standardised GPs' home visits) with a control group (care as usual). A total of 34 nursing homes are randomised, and overall 680 residents recruited. The intervention package is presented in a kick-off meeting to GPs, nurses, residents/relatives or their representatives. Nursing home nurses act as change agents to support local adaption and implementation of the intervention measures. Primary outcome is the cumulative incidence of hospitalisation within 12 months. Secondary outcomes include admissions to hospital, days admitted to hospital, use of other medical services, prevalence of potentially inappropriate medication and quality of life. Additionally, health economic and a mixed methods process evaluation will be performed. DISCUSSION This study investigates a complex intervention tailored to local needs of nursing homes. Outcomes reflect the healthcare and health of nursing home residents, as well as the feasibility of the intervention package and its impact on interprofessional communication and collaboration. Because of its systematic development and its flexible nature, interprof ACT is expected to be viable for large-scale implementation in routine care services regardless of local organisational conditions and resources available for medical care for nursing home residents on a regular basis. Recommendations will be made for an improved organisation of primary care for nursing home residents. In addition, the results may provide important knowledge and data for the development and evaluation of further strategies to improve outpatient care for elderly care-receivers. TRIAL REGISTRATION ClinicalTrials.gov NCT03426475 . Initially registered on 7 February 2018.
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Affiliation(s)
- Christiane Müller
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, D-37073, Göttingen, Germany.
| | - Berit Hesjedal-Streller
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, D-37073, Göttingen, Germany
| | - Nina Fleischmann
- Nursing Science, Fulda University of Applied Sciences, Building 31, Room 122, Leipziger Straße 123, D-36037, Fulda, Germany
| | - Britta Tetzlaff
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistraße 52, D-20246, Hamburg, Germany
| | - Tina Mallon
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistraße 52, D-20246, Hamburg, Germany
| | - Martin Scherer
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistraße 52, D-20246, Hamburg, Germany
| | - Sascha Köpke
- Institute of Nursing Science, University Clinic Cologne, Gleueler Straße 176-178, D-50935, Köln, Germany
| | - Katrin Balzer
- Institute for Social Medicine and Epidemiology, Nursing Research Group, University of Lübeck, Ratzeburger Allee 160, Haus 50, D-23538, Lübeck, Germany
| | - Linda Gärtner
- Institute for Social Medicine and Epidemiology, Nursing Research Group, University of Lübeck, Ratzeburger Allee 160, Haus 50, D-23538, Lübeck, Germany
| | - Indre Maurer
- Chair of Organization and Corporate Development, Georg-August-University Göttingen, Platz der Göttinger Sieben 3, D-37073, Göttingen, Germany
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Humboldtallee 32, D-37073, Göttingen, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistraße 52, D-20246, Hamburg, Germany
| | - Eva Hummers
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, D-37073, Göttingen, Germany
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122
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Hullick CJ, Hall AE, Conway JF, Hewitt JM, Darcy LF, Barker RT, Oldmeadow C, Attia JR. Reducing Hospital Transfers from Aged Care Facilities: A Large-Scale Stepped Wedge Evaluation. J Am Geriatr Soc 2020; 69:201-209. [PMID: 33124692 DOI: 10.1111/jgs.16890] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/18/2020] [Accepted: 09/28/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Older people living in residential aged care facilities (RACFs) experience acute deterioration requiring assessment and decision making. We evaluated the impact of a large-scale regional Aged Care Emergency (ACE) program in reducing hospital admissions and emergency department (ED) transfers. DESIGN A stepped wedge nonrandomized cluster trial with 11 steps, implemented from May 2013 to August 2016. SETTING A large regional and rural area of northern and western New South Wales, Australia. PARTICIPANTS Nine hospital EDs and 81 RACFs participated in the evaluation. INTERVENTION The ACE program is an integrated nurse-led intervention underpinned by a community of practice designed to improve the capability of RACFs managing acutely unwell residents. It includes telephone support, evidence-based algorithms, defining goals of care for ED transfer, case management in the ED, and an education program. MEASUREMENTS ED transfers and subsequent hospital admissions were collected from administrative data including 13 months baseline and 9 months follow-up. RESULTS A total of 18,837 eligible ED visits were analyzed. After accounting for clustering by RACFs and adjusting for time of the year as well as RACF characteristics, a statistically significant reduction in hospital admissions (adjusted incident rate ratio = .79; 95% confidence interval [CI] = .68-.92); P = .0025) was seen (i.e., residents were 21% less likely to be admitted to the hospital). This was also observed in ED visit rates (adjusted incidence rate ratio = .80; 95% CI = .69-.92; P = .0023) (i.e., residents were 20% less likely to be transferred to the ED). Seven-day ED re-presentation fell from 5.7% to 4.9%, and 30-day hospital readmissions fell from 12% to 10%. CONCLUSION The stepped wedge design allowed rigorous evaluation of a real-world large-scale intervention. These results confirm that the ACE program can be scaled up to a large geographic area and can reduce ED visits and hospitalization of older people with complex healthcare needs living in RACFs.
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Affiliation(s)
- Carolyn J Hullick
- Belmont District Hospital, Belmont, New South Wales, Australia.,Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, New South Wales, Australia
| | - Alix E Hall
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, New South Wales, Australia
| | - Jane F Conway
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, Australia.,Faculty of Medicine and Health, University of New England, Armidale, New South Wales, Australia
| | - Jacqueline M Hewitt
- Hunter New England Central Coast Primary Health Network, Newcastle, New South Wales, Australia
| | - Leigh F Darcy
- Hunter Primary Care, Warabrook, New South Wales, Australia
| | - Roslyn T Barker
- Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia
| | - Christopher Oldmeadow
- Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, New South Wales, Australia
| | - John R Attia
- Belmont District Hospital, Belmont, New South Wales, Australia.,Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, New South Wales, Australia
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123
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Lamppu PJ, Pitkala KH. Staff Training Interventions to Improve End-of-Life Care of Nursing Home Residents: A Systematic Review. J Am Med Dir Assoc 2020; 22:268-278. [PMID: 33121871 DOI: 10.1016/j.jamda.2020.09.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/25/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The aim was to review evidence from all randomized controlled trials (RCTs) using palliative care education or staff training as an intervention to improve nursing home residents' quality of life (QOL) or quality of dying (QOD) or to reduce burdensome hospitalizations. DESIGN A systematic review with a narrative summary. SETTING AND PARTICIPANTS Residents in nursing homes and other long-term care facilities. METHODS We searched MEDLINE, CINAHL, PsycINFO, the Cochrane Library, Scopus, and Google Scholar, references of known articles, previous reviews, and recent volumes of key journals. RCTs were included in the review. Methodologic quality was assessed. RESULTS The search yielded 932 articles after removing the duplicates. Of them, 16 cluster RCTs fulfilled inclusion criteria for analysis. There was a great variety in the interventions with respect to learning methods, intensity, complexity, and length of staff training. Most interventions featured other elements besides staff training. In the 6 high-quality trials, only 1 showed a reduction in hospitalizations, whereas among 6 moderate-quality trials 2 suggested a reduction in hospitalizations. None of the high-quality trials showed effects on residents' QOL or QOD. Staff reported an improved QOD in 1 moderate-quality trial. CONCLUSIONS AND IMPLICATIONS Irrespective of the means of staff training, there were surprisingly few effects of education on residents' QOL, QOD, or burdensome hospitalizations. Further studies are needed to explore the reasons behind these findings.
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Affiliation(s)
- Pauli J Lamppu
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland; Department of Social Services and Health Care, Geriatric Clinic, Helsinki Hospital, Helsinki, Finland.
| | - Kaisu H Pitkala
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland; Unit of Primary Health Care, Helsinki University Hospital, Helsinki, Finland
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124
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Tark A, Agarwal M, Dick AW, Song J, Stone PW. Impact of the Physician Orders for Life-Sustaining Treatment (POLST) Program Maturity Status on the Nursing Home Resident's Place of Death. Am J Hosp Palliat Care 2020; 38:812-822. [PMID: 32878457 DOI: 10.1177/1049909120956650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The Physician Orders for Life-Sustaining Treatment (POLST) program was developed to enhance quality of care delivered at End-of-Life (EoL). Although positive impacts of the POLST program have been identified, the association between a program maturity status and nursing home resident's likelihood of dying in their current care settings remain unanswered. This study aims to evaluate the impact of the POLST program maturity status on nursing home residents' place of death. Using multiple national-level datasets, we examined total 595,152 residents and their place of death. The result showed that the long-stay residents living in states where the program was mature status had 12% increased odds of dying in nursing homes compared that of non-conforming status. Individuals residing in states with developing program status showed 11% increase in odds of dying in nursing homes. The findings demonstrate that a well-structured and well-disseminated POLST program, combined with a continued effort to meet high standards of quality EoL care, can bring out positive health outcomes for elderly patients residing in care settings.
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Affiliation(s)
- Aluem Tark
- Columbia University School of Nursing, New York, NY, USA.,4083University of Iowa College of Nursing, Iowa City, IA, USA
| | - Mansi Agarwal
- Columbia University School of Nursing, New York, NY, USA
| | | | - Jiyoun Song
- Columbia University School of Nursing, New York, NY, USA
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125
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Ooi M, Lewis ET, Brisbane J, Tubb E, McClean T, Assareh H, Hillman K, Achat H, Cardona M. Feasibility of Using a Risk Assessment Tool to Predict Hospital Transfers or Death for Older People in Australian Residential Aged Care. A Retrospective Cohort Study. Healthcare (Basel) 2020; 8:E284. [PMID: 32825603 PMCID: PMC7551645 DOI: 10.3390/healthcare8030284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/18/2020] [Accepted: 08/18/2020] [Indexed: 12/19/2022] Open
Abstract
Residents of Aged Care Facilities (RACF) experience burdensome hospital transfers in the last year of life, which may lead to aggressive and potentially inappropriate hospital treatments. Anticipating these transfers by identifying risk factors could encourage end-of-life discussions that may change decisions to transfer. The aim was to examine the feasibility of identifying an end-of-life risk profile among RACF residents using a predictive tool to better anticipate predictors of hospital transfers, death or poor composite outcome of hospitalisation and/or death after initial assessment. A retrospective cohort study of 373 permanent residents aged 65+ years was conducted using objective clinical factors from records in nine RACFs in metropolitan Sydney, Australia. In total, 26.8% died and 34.3% experienced a composite outcome. Cox proportional hazard regression models confirmed the feasibility of estimating the level of risk for death or a poor composite outcome. Knowing this should provide opportunities to initiate advance care planning in RACFs, facilitating decision making near the end of life. We conclude that the current structure of electronic RACF databases could be enhanced to enable comprehensive assessment of the risk of hospital re-attendance without admission. Automation tools to facilitate the risk score calculation may encourage the adoption of prediction checklists and evaluation of their association with hospital transfers.
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Affiliation(s)
- Meidelynn Ooi
- Medical School, The University of New South Wales, Kensington 2052, Australia;
| | - Ebony T Lewis
- School of Population Health, Faculty of Medicine, University of New South Wales, Kensington 2052, Australia;
- School of Psychology, Faculty of Science, University of New South Wales, Kensington 2052, Australia
| | - Julianne Brisbane
- Uniting (Aged Care Services), Sydney 2067, Australia; (J.B.); (E.T.); (T.M.)
| | - Evalynne Tubb
- Uniting (Aged Care Services), Sydney 2067, Australia; (J.B.); (E.T.); (T.M.)
| | - Tom McClean
- Uniting (Aged Care Services), Sydney 2067, Australia; (J.B.); (E.T.); (T.M.)
| | - Hassan Assareh
- Agency for Clinical Innovation, St Leonards 2065, Australia;
| | - Ken Hillman
- Intensive Care Unit, Liverpool Hospital, Liverpool 2170, Australia;
| | - Helen Achat
- Western Sydney Local Health District, North Parramatta 2151, Australia;
| | - Magnolia Cardona
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast 4226, Australia
- EBP Professorial Unit, Gold Coast University Hospital, Southport 4215, Australia
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126
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Sunner C, Giles MT, Parker V, Dilworth S, Bantawa K, Kable A, Oldmeadow C, Foureur M. PACE-IT study protocol: a stepped wedge cluster randomised controlled trial evaluating the implementation of telehealth visual assessment in emergency care for people living in residential aged-care facilities. BMC Health Serv Res 2020; 20:672. [PMID: 32690008 PMCID: PMC7372753 DOI: 10.1186/s12913-020-05539-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022] Open
Abstract
Background Transfer of residential aged-care facility (RACF) residents to Emergency Departments (ED) is common, risky and expensive. RACF residents who present to ED are more likely to have hospital readmissions, longer stays and face major risks related to hospital acquired complications. Aged Care Emergency services (ACE) is a nurse led, protocol- guided, telephone RACF/ED outreach model that has been shown to be effective in reducing hospitalisation and length of hospital stay for RACF residents in the Hunter New England Local Health District, New South Wales (NSW). The Partnerships in Aged-Care Emergency services using Interactive Telehealth (PACE-IT) project enhances ACE by incorporating interactive video assessment and consultation. The PACE-IT project’s primary aim is to assess whether augmentation of ACE services through the addition of protocol-guided interactive Visual Telehealth Consultation (VTC) for clinical decision-making, plus telephone follow-up, reduces RACF resident transfers to ED. Methods A stepped-wedge cluster randomised controlled trial will be conducted. The intervention will be delivered sequentially to 8 clusters; each cluster comprises one ED and two RACFs in NSW, Australia. The 16 RACFs in the study will be selected for order of implementation using a computer-generated randomisation sequence. A 2-step randomisation process will be undertaken, randomising the hospital EDs first and then randomising the RACFs aligned with each hospital. The PACE-IT intervention comprises: an initial phone call by RACFs to the ACE service in the ED; the ACE service in ED responds with a protocol-guided VTC, a management plan agreed between all participants; an automated consultation summary letter to the General Practitioner and the RACF; a post VTC 24 h follow-up phone call to the RACF. Discussion If shown to be effective, the intervention has the potential to improve the clinical care and quality of life for residents. Findings will provide high level evidence that will inform sustainable change and broad translation into practice across NSW. It will show how the change has been achieved and highlight success factors for scalability and sustainability. It will inform review of processes, the development of policy and guidelines that will integrate PACE-IT into existing service models in NSW. Trial registration The trial is registered with the Australian New Zealand Clinical Trials Registry (Trial ID ACTR N12619001692123) 02/12/2020.)
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Affiliation(s)
- Carla Sunner
- Hunter New England Nursing and Midwifery Research Centre, James Fletcher Campus, 72 Watt Street, Newcastle, NSW, 2300, Australia. .,School of Nursing and Midwifery, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
| | - Michelle Therese Giles
- Hunter New England Nursing and Midwifery Research Centre, James Fletcher Campus, 72 Watt Street, Newcastle, NSW, 2300, Australia.,School of Nursing and Midwifery, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Vicki Parker
- Hunter New England Nursing and Midwifery Research Centre, James Fletcher Campus, 72 Watt Street, Newcastle, NSW, 2300, Australia.,University of New England, Madgwick Drive, Armidale, NSW, 2351, Australia
| | - Sophie Dilworth
- Dementia Advisory Service Community Aged Care Services, Hunter New England Local Health District, Locked Bay 119, Wallsend, NSW, 2287, Australia
| | - Kamana Bantawa
- Hunter New England Nursing and Midwifery Research Centre, James Fletcher Campus, 72 Watt Street, Newcastle, NSW, 2300, Australia
| | - Ashley Kable
- School of Nursing and Midwifery, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Chris Oldmeadow
- Hunter Medical Research Institute, Locked Bag 1000, Kookaburra Circuit, New Lambton, NSW, 2305, Australia
| | - Maralyn Foureur
- Hunter New England Nursing and Midwifery Research Centre, James Fletcher Campus, 72 Watt Street, Newcastle, NSW, 2300, Australia.,School of Nursing and Midwifery, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
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127
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Nursing Home Residents' Functional Trajectories and Mortality After a Transfer to the Emergency Department. J Am Med Dir Assoc 2020; 22:393-398.e3. [PMID: 32660854 DOI: 10.1016/j.jamda.2020.05.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/15/2020] [Accepted: 05/16/2020] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To describe nursing home residents' (NHRs) functional trajectories and mortality after a transfer to the emergency department (ED). DESIGN Case-control observational multicenter study. SETTING AND PARTICIPANTS In total, 1037 NHRs presenting to 17 EDs in France over 4 nonconsecutive weeks in 2016. METHODS Finite mixture models were fitted to longitudinal data on activities of daily living (ADL) scores before transfer (time 1), during hospitalization (time 2), and within 1 week after discharge (time 3) to identify groups of NHRs following similar functional evolution. Factors associated with mortality were investigated by Cox regressions. RESULTS Trajectory modeling identified 4 distinct trajectories of ADL. The first showed a high and stable (across time 1, time 2, and time 3) functional capacity around 5.2/6 ADL points, with breathlessness as the main condition leading to transfer. The second displayed an initial 37.8% decrease in baseline ADL performance (between time 1 and time 2), followed by a 12.5% recovery of baseline ADL performance (time 2‒time 3), with fractures as the main condition. The third displayed a similar initial decrease, followed by a 6.7% recovery. The fourth displayed an initial 70.1% decrease, followed by an 8.5% recover, with more complex geriatric polypathology situations. Functional decline was more likely after being transferred for a cerebrovascular condition or for a fracture, after being discharged from ED to a surgery department, and with a heavier burden of distressing symptoms during transfer. Mortality after ED transfer was more likely in older NHRs, those in a more severe condition, those who were hospitalized more frequently in the past month, and those transferred for cerebrovascular conditions or breathlessness. CONCLUSIONS AND IMPLICATIONS Identified trajectories and factors associated with functional decline and mortality should help clinicians decide whether to transfer NHRs to ED. NHRs with high functional ability seem to benefit from ED transfers whereas on-site alternatives should be sought for those with poor functional ability.
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128
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Savioli G, Ceresa IF, Luzzi S, Gragnaniello C, Giotta Lucifero A, Del Maestro M, Marasco S, Manzoni F, Ciceri L, Gelfi E, Ricevuti G, Bressan MA. Rates of Intracranial Hemorrhage in Mild Head Trauma Patients Presenting to Emergency Department and Their Management: A Comparison of Direct Oral Anticoagulant Drugs with Vitamin K Antagonists. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E308. [PMID: 32585829 PMCID: PMC7353902 DOI: 10.3390/medicina56060308] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 12/18/2022]
Abstract
Background and objectives: Anticoagulants are thought to increase the risks of traumatic intracranial injury and poor clinical outcomes after blunt head trauma. The safety of using direct oral anticoagulants (DOACs) compared to vitamin K antagonists (VKAs) after intracranial hemorrhage (ICH) is unclear. This study aims to compare the incidence of post-traumatic ICH following mild head injury (MHI) and to assess the need for surgery, mortality rates, emergency department (ED) revisit rates, and the volume of ICH. Materials and Methods: This is a retrospective, single-center observational study on all patients admitted to our emergency department for mild head trauma from 1 January 2016, to 31 December 2018. We enrolled 234 anticoagulated patients, of which 156 were on VKAs and 78 on DOACs. Patients underwent computed tomography (CT) scans on arrival (T0) and after 24 h (T24). The control group consisted of patients not taking anticoagulants, had no clotting disorders, and who reported an MHI in the same period. About 54% in the control group had CTs performed. Results: The anticoagulated groups were comparable in baseline parameters. Patients on VKA developed ICH more frequently than patients on DOACs and the control group at 17%, 5.13%, and 7.5%, respectively. No significant difference between the two groups was noted in terms of surgery, intrahospital mortality rates, ED revisit rates, and the volume of ICH. Conclusions: Patients with mild head trauma on DOAC therapy had a similar prevalence of ICH to that of the control group. Meanwhile, patients on VKA therapy had about twice the ICH prevalence than that on the control group or patients on DOAC, which remained after correcting for age. No significant difference in the need for surgery was determined; however, this result must take into account the very small number of patients needing surgery.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
- Department of Clinical-Surgical, PhD School in Experimental Medicine, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
| | - Iride Francesca Ceresa
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
| | - Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (S.L.); (A.G.L.); (S.M.)
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Cristian Gragnaniello
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, IL 60656, USA;
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (S.L.); (A.G.L.); (S.M.)
| | - Mattia Del Maestro
- Department of Clinical-Surgical, PhD School in Experimental Medicine, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Stefano Marasco
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (S.L.); (A.G.L.); (S.M.)
| | - Federica Manzoni
- Clinical Epidemiology and Biometry Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Luca Ciceri
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
| | - Elia Gelfi
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
| | - Giovanni Ricevuti
- Department of Drug Science, University of Pavia, Italy, -Saint Camillus International University of Health Sciences-Rome-Italy, 27100 Pavia, Italy;
| | - Maria Antonietta Bressan
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
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129
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Dwyer RA, Gabbe BJ, Tran T, Smith K, Lowthian JA. Predictors of transport to hospital after emergency ambulance call-out for older people living in residential aged care. Australas J Ageing 2020; 39:350-358. [PMID: 32558049 DOI: 10.1111/ajag.12803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 02/20/2020] [Accepted: 04/10/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES People living in residential aged care (RAC) frequently experience ambulance call-out. These episodes may have unintended consequences, yet remain under-investigated. Our aim was to examine clinical and sociodemographic features associated with transfer to hospital for this population. METHODS Retrospective cohort study using 6 years of clinical data from Ambulance Victoria (AV). Data analysis included multilevel multivariable logistic regression analysis of factors associated with transport to hospital. RESULTS Odds of transfer were greater for people in rural areas, those with a history of depression, cardiovascular disease and osteoporosis, and residents prescribed antipsychotic and antidepressant medication. Ambulance call-out for trauma (commonly low-level fall) was less frequently transferred to hospital than that for a medical complaint. CONCLUSION These results will improve prediction of call-outs likely to require transfer. Findings include identification of clinical features to be targeted by community and preventative health programs to reduce risk of acute health deterioration and requirement for emergency hospital transfer.
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Affiliation(s)
- Rosamond A Dwyer
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia.,Peninsula Health, Frankston, Vic., Australia
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
| | - Thach Tran
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
| | - Karen Smith
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia.,Ambulance Victoria, Blackburn North, Vic., Australia
| | - Judy A Lowthian
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia.,Bolton Clarke Research Institute, Bentleigh, Vic., Australia
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130
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Morcos M, Corns J, Hillen JB. Pharmacist-Initiated Management of a Suspected Case of Risperidone-Induced Neuroleptic Malignant Syndrome in an Aged-Care Resident. The Role of Residential Medication Management Reviews in Medication Safety. J Pharm Pract 2020; 33:382-385. [DOI: 10.1177/0897190018806414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 70-year-old female aged-care resident was referred by her general practitioner for a residential medication management review after nurses reported difficulties with swallowing, episodes of hyperthermia, elevated blood pressure, and tachycardia. These symptoms were accompanied by increasing confusion and drowsiness. Risperidone had recently been prescribed to treat behavioral and psychological symptoms of dementia. This case study describes the pharmacist-initiated management of the symptoms through a national medication review program. It demonstrates the valuable role collaborative medication reviews play in managing adverse drug reactions in aged-care.
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131
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Craswell A, Wallis M, Coates K, Marsden E, Taylor A, Broadbent M, Nguyen KH, Johnston-Devin C, Glenwright A, Crilly J. Enhanced primary care provided by a nurse practitioner candidate to aged care facility residents: A mixed methods study. Collegian 2020. [DOI: 10.1016/j.colegn.2019.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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132
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Nursing home patients and Emergency Department attendance in a single urban Irish catchment area: an observational study surrounding the introduction of a community medicine for older person service. Ir J Med Sci 2020; 190:379-385. [PMID: 32472242 DOI: 10.1007/s11845-020-02267-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Nursing home (NH) patients are at a high risk of Emergency Department (ED) attendance, and adverse events in the ED. With an increasing NH population, monitoring trends in ED utilization is important to aid service planning, and attention to potentially preventable attendances should be paid, to identify areas that may benefit from specialist support. AIMS This 12-year (2008-2019) study aimed to observe trends in ED utilization of NH patients in a single urban Irish catchment area, surrounding the introduction of a Community Medicine for the Older Person (CMOP) outreach program. METHOD A retrospective review of all NH attendances within the catchment area was performed based upon NH address. Attendance, admission, discharge, and died in department (DID) were adjusted per annual NH bed numbers (PBC). Trends were observed and compared pre and post the CMOP activation. Comparisons of continuous variables were performed using an unpaired parametric Student's t test. RESULTS There were 6877 attendances, with 58% (n = 3989) admitted, 40% (n = 2785) discharged, and 2% (n = 123) DID. There was a statistically significant difference in mean discharge rate PBC pre and post the CMOP introduction (0.22 vs 0.16, P = 0.04). There was no statistically significant difference in attendance, admission, or DID. CONCLUSION This is the first Irish study of NH ED utilization over an extended period. ED attendances PBC have not decreased since the introduction of the CMOP. Discharges PBC, however, have decreased and may represent a decrease in potentially preventable attendance/improvement in appropriateness of ED transfers, following the introduction of this intervention.
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133
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Mäkinen M, Haavisto E, Lindström V, Brolin K, Castrén M. Finnish and Swedish prehospital emergency care providers' knowledge and attitudes towards pressure ulcer prevention. Int Emerg Nurs 2020; 55:100873. [PMID: 32448755 DOI: 10.1016/j.ienj.2020.100873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 04/01/2020] [Accepted: 04/16/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Despite the knowledge that transportation by emergency medical services may increase the risk of pressure ulcers (PU), there is still lack of knowledge about the possibility of prehospital emergency care providers to be a part of preventing and reducing the risk of PUs. METHODS A survey was carried out during 2017 in Finland and Sweden. Validated questionnaires were used. RESULTS A total of 179 (72.7%) Finnish and 188 (28.8%) Swedish prehospital emergency care providers participated in the study. The overall rate of correct answers and the mean total knowledge score was 58.8% (SD 21.8), 20/34, in the Finnish group and 70.5% (SD 15.7), 24/34, in the Swedish group (p < 0.000). The percent of the total and the mean attitude score was in the Finnish group 71.3% (SD 0.48), 37.1/52, and in the Swedish group 69.4% (SD 0.77), 36.1/52 (p < 0.813). Half of the Finnish and most of the Swedish participants felt they needed more education about PUs (Fin 50.2% & Swe: 76.0%). CONCLUSIONS Prehospital emergency care providers don't see themselves as responsible for PU prevention. Therefore, there is a need for increasing the level of knowledge on PU prevention and classification among prehospital emergency care providers. They could play a key role in developing methods to improve PU prevention and identifying patients in risk of developing PUs.
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Affiliation(s)
- M Mäkinen
- Department of Emergency Medicine and Services, Helsinki University Hospital and Helsinki University, Helsinki, Finland.
| | - E Haavisto
- University of Turku, Department of Nursing Science, Satakunta Central Hospital, Sweden.
| | - V Lindström
- Department of Neurobiology, Care Sciences, and Society Division of Nursing Karolinska Institutet, Stockholm, Sweden; Academic EMS, Stockholm, Sweden.
| | - K Brolin
- Academic EMS, Stockholm, Sweden; The Ambulance Medical Service in Stockholm (AISA), Sweden.
| | - M Castrén
- Department of Emergency Medicine and Services, Helsinki University Hospital and Helsinki University, Helsinki, Finland.
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134
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135
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Hoffmann F, Allers K. Ten-year trends in end-of-life hospitalizations of nursing home residents in Germany, 2006-2015. Maturitas 2020; 134:47-53. [PMID: 32143776 DOI: 10.1016/j.maturitas.2020.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 02/03/2020] [Accepted: 02/18/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVES We investigated trends in end-of-life hospitalizations among nursing home residents (NHR) over 10 years and looked at differences between age groups and sexes as well as the length of terminal hospital stays. STUDY DESIGN Retrospective cohort study based on health insurance claims data of the AOK Bremen/Bremerhaven. All NHR aged 65 years or more who died between 2006 and 2015 were included. MAIN OUTCOME MEASURES We assessed the proportions of decedents who were in hospital on the day of death and during the last 3, 7, 14 and 30 days of life, stratified by two-year periods. Multiple logistic regressions were conducted to study changes over time, adjusting for covariates. RESULTS A total of 10,781 decedents were included (mean age 86.1 years, 72.1 % females). Overall, 29.2 % died in hospital, with a slight decrease from 30.3 % in 2006-2007 to 28.3 % in 2014-2015 (OR 0.86; 95 % CI 0.75-0.98). Of the 3150 terminal hospitalizations, 35.5 % lasted up to 3 days and the mean length of stay decreased from 9.0 (2006-2007) to 7.5 days (2014-2015). When looking at the last 7, 14 and 30 days of life, no changes over time were found. Male sex and younger age were associated with a higher chance of end-of-life hospitalization in almost all analyses. CONCLUSIONS End-of-life hospitalizations of NHR are common in Germany. There has been a small decrease during recent years in the proportion of in-hospital deaths, but not of hospitalizations during the last 7, 14 and 30 days of life. This might be explained by shorter durations of hospital stays.
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Affiliation(s)
- Falk Hoffmann
- Carl von Ossietzky University Oldenburg, Department of Health Services Research, Oldenburg, Germany.
| | - Katharina Allers
- Carl von Ossietzky University Oldenburg, Department of Health Services Research, Oldenburg, Germany
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136
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Fassmer AM, Pulst A, Spreckelsen O, Hoffmann F. Perspectives of general practitioners and nursing staff on acute hospital transfers of nursing home residents in Germany: results of two cross-sectional studies. BMC FAMILY PRACTICE 2020; 21:29. [PMID: 32046652 PMCID: PMC7014634 DOI: 10.1186/s12875-020-01108-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 02/05/2020] [Indexed: 02/08/2023]
Abstract
Background Visits in emergency departments and hospital admissions are common among nursing home (NH) residents and they are associated with significant complications. Many of these transfers are considered inappropriate. This study aimed to compare the perceptions of general practitioners (GPs) and NH staff on hospital transfers among residents and to illustrate measures for improvement. Methods Two cross-sectional studies were conducted as surveys among 1121 GPs in the German federal states Bremen and Lower Saxony and staff from 1069 NHs (preferably nursing staff managers) from all over Germany, each randomly selected. Questionnaires were sent in August 2018 and January 2019, respectively. The answers were compared between GPs and NH staff using descriptive statistics, Mann-Whitney U tests and χ2-tests. Results We received 375 GP questionnaires (response: 34%) and 486 NH questionnaires (response: 45%). GPs estimated the proportion of inappropriate transfers higher than NH staff (hospital admissions: 35.0% vs. 25.6%, p < 0.0001; emergency department visits: 39.9% vs. 20.9%, p < 0.0001). The majority of NH staff and nearly half of the GPs agreed that NH residents do often not benefit from hospital admissions (NHs: 61.4% vs. GPs: 48.8%; p = 0.0009). Both groups rated almost all potential measures for improvement differently (p < 0.0001), however, GPs and NH staff considered most areas to reduce hospital transfers importantly. The two most important measures for GPs were more nursing staff (91.6%) and better communication between nursing staff and GP (90.9%). NH staff considered better care / availability of GP (82.8%) and medical specialists (81.3%) as most important. Both groups rated similarly the importance of explicit advance directives (GPs: 77.2%, NHs: 72.4%; p = 0.1492). Conclusions A substantial proportion of hospital transfers from NHs were considered inappropriate. Partly, the ratings of possible areas for improvement differed between GPs and NH staff indicating that both groups seem to pass the responsibility to each other. These findings, however, support the need for interprofessional collaboration.
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Affiliation(s)
- Alexander Maximilian Fassmer
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany.
| | - Alexandra Pulst
- Department of Health Services Research, Institute for Public Health and Nursing Research, University of Bremen, Bremen, Germany.,Health Sciences, University of Bremen, Bremen, Germany
| | - Ove Spreckelsen
- Division of General Practice, Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Falk Hoffmann
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
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137
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Jackman C, Laging R, Laging B, Honan B, Arendts G, Walker K. Older person with vague symptoms in the emergency department: Where should I begin? Emerg Med Australas 2019; 32:141-147. [PMID: 31854096 DOI: 10.1111/1742-6723.13433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 11/18/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Christine Jackman
- Emergency Department, Cabrini, Melbourne, Victoria, Australia.,Eastern Health Clinical School, Melbourne, Victoria, Australia.,School of Medicine, Deakin University Medical School, Geelong, Victoria, Australia
| | - Rohan Laging
- Emergency Department, Cabrini, Melbourne, Victoria, Australia.,Emergency Department, Alfred Hospital, Melbourne, Victoria, Australia
| | - Bridget Laging
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Melbourne, Victoria, Australia
| | | | - Glenn Arendts
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia.,Emergency Department, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Katie Walker
- Emergency Department, Cabrini, Melbourne, Victoria, Australia.,Health Services, Monash University, Melbourne, Victoria, Australia
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138
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Abstract
BACKGROUND End-of-life hospitalizations in nursing home residents are common, although they are often burdensome and potentially avoidable. AIM We aimed to summarize the existing evidence on end-of-life hospitalizations in nursing home residents. DESIGN Systematic review (PROSPERO registration number CRD42017072276). DATA SOURCES A systematic literature search was carried out in PubMed, CINAHL, and Scopus (date of search 9 April 2019). Studies were included if they reported proportions of in-hospital deaths or hospitalizations of nursing home residents in the last month of life. Two authors independently selected studies, extracted data, and assessed the quality of studies. Median with interquartile range was used to summarize proportions. RESULTS A total of 35 studies were identified, more than half of which were from the United States (n = 18). While 29 studies reported in-hospital deaths, 12 studies examined hospitalizations during the last month of life. The proportion of in-hospital deaths varied markedly between 5.9% and 77.1%, with an overall median of 22.6% (interquartile range: 16.3%-29.5%). The proportion of residents being hospitalized during the last month of life ranged from 25.5% to 69.7%, and the median was 33.2% (interquartile range: 30.8%-38.4%). Most studies investigating the influence of age found that younger age was associated with a higher likelihood of end-of-life hospitalization. Four studies assessed trends over time, showing heterogeneous findings. CONCLUSION There is a wide variation in end-of-life hospitalizations, even between studies from the same country. Overall, such hospitalizations are common among nursing home residents, which indicates that interventions tailored to each specific health care system are needed to improve end-of-life care.
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Affiliation(s)
- Katharina Allers
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Rieke Schnakenberg
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
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139
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Marsden E, Taylor A, Wallis M, Craswell A, Broadbent M, Barnett A, Crilly J. Effect of the Geriatric Emergency Department Intervention on outcomes of care for residents of aged care facilities: A non‐randomised trial. Emerg Med Australas 2019; 32:422-429. [DOI: 10.1111/1742-6723.13415] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 09/17/2019] [Accepted: 10/23/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Elizabeth Marsden
- Sunshine Coast Hospital and Health ServiceSunshine Coast University Hospital Sunshine Coast Region Queensland Australia
- School of Nursing, Midwifery and ParamedicineUniversity of Sunshine Coast Sunshine Coast Region Queensland Australia
| | - Andrea Taylor
- Sunshine Coast Hospital and Health ServiceSunshine Coast University Hospital Sunshine Coast Region Queensland Australia
| | - Marianne Wallis
- School of Nursing, Midwifery and ParamedicineUniversity of Sunshine Coast Sunshine Coast Region Queensland Australia
| | - Alison Craswell
- School of Nursing, Midwifery and ParamedicineUniversity of Sunshine Coast Sunshine Coast Region Queensland Australia
| | - Marc Broadbent
- School of Nursing, Midwifery and ParamedicineUniversity of Sunshine Coast Sunshine Coast Region Queensland Australia
| | - Adrian Barnett
- AStat, Institute of Health and Biomedical Innovation and School of Public Health and Social WorkQueensland University of Technology Brisbane Queensland Australia
| | - Julia Crilly
- Menzies Health Institute QueenslandGriffith University Griffith Queensland Australia
- Department of Emergency MedicineGold Coast Health Gold Coast Queensland Australia
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140
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Brickman KR, Silvestri JA. The emergency care model: A new paradigm for skilled nursing facilities. Geriatr Nurs 2019; 41:242-247. [PMID: 31669057 DOI: 10.1016/j.gerinurse.2019.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 10/09/2019] [Accepted: 10/11/2019] [Indexed: 10/25/2022]
Abstract
The population of individuals age 65 and older is increasing in the United States. One third of these individuals will utilize nursing home care before death. Nursing home residents ("NHR") average 1.8 emergency department visits annually. Improving the quality of nursing home care is of vital importance. This project describes a new paradigm for the management of acute emergent health issues affecting NHR. The model features a multidisciplinary team coordinated by emergency providers resulting in a 55% reduction in unplanned hospital admissions compared to skilled nursing facility regional data. Additionally, a reduction in ancillary lab costs was observed. Implementation of this paradigm on a national scale could result in a projected cost savings in excess of $10 billion per year for the Center for Medicare and Medicaid Services ("CMS").
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Affiliation(s)
- Kristopher R Brickman
- Department of Emergency Medicine, University of Toledo College of Medicine and Life Sciences, 3000 Arlington Ave, Toledo, OH 43614, United States.
| | - Joseph A Silvestri
- Department of Emergency Medicine, University of Toledo College of Medicine and Life Sciences, 3000 Arlington Ave, Toledo, OH 43614, United States
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141
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Shrapnel S, Dent E, Nicholson C. A nurse-led model of care within an emergency department reduces representation rates for frail aged care residents. Aging Clin Exp Res 2019; 31:1695-1698. [PMID: 30617858 DOI: 10.1007/s40520-018-1101-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 12/13/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hospital Emergency Departments (EDs) experience high presentation rates from older adults residing in Aged Care Facilities (ACFs), yet very few intervention studies have addressed the care needs of this population group. We designed and implemented a nurse-led model of care for older adults from ACFs, and determined its impact on patient outcomes. METHODS This 12-month pre-post intervention study was conducted during 2013-2014, with follow-up during 2015-2016. Participants included all older adults presenting from ACFs to the ED of Mater Hospital Brisbane (MHB), Australia. Frailty status was determined using the Clinical Frailty Scale (CFS). RESULTS All participants were frail (n = 1130), with 19% severely frail, 55% very-severely frail, and 26% terminally ill. The intervention resulted in several improvements in patient outcomes, including significant reductions in ward admissions and 28-day representation rates. CONCLUSION Significant improvements can be achieved by integration of an acute frail older person service into an ED.
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Affiliation(s)
- Sophie Shrapnel
- Mater/UQ Centre for Integrated Care and Innovation, Mater Health Services, Level 2 Aubigny Place, Raymond Tce, South Brisbane, QLD, 4101, Australia.
- Mater Research Institute, University of Queensland, Brisbane, QLD, Australia.
| | - Elsa Dent
- Mater/UQ Centre for Integrated Care and Innovation, Mater Health Services, Level 2 Aubigny Place, Raymond Tce, South Brisbane, QLD, 4101, Australia
- Mater Research Institute, University of Queensland, Brisbane, QLD, Australia
- Torrens University of Australia, Brisbane, QLD, Australia
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Caroline Nicholson
- Mater/UQ Centre for Integrated Care and Innovation, Mater Health Services, Level 2 Aubigny Place, Raymond Tce, South Brisbane, QLD, 4101, Australia
- Mater Research Institute, University of Queensland, Brisbane, QLD, Australia
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142
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Nemiroff L, Marshall EG, Jensen JL, Clarke B, Andrew MK. Adherence to “No Transfer to Hospital” Advance Directives Among Nursing Home Residents. J Am Med Dir Assoc 2019; 20:1373-1381. [DOI: 10.1016/j.jamda.2019.03.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 03/28/2019] [Accepted: 03/29/2019] [Indexed: 10/26/2022]
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143
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144
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Abstract
Aim: To identify discrete approaches to specialist healthcare support for older care home residents in the UK and to estimate their prevalence. Background: Internationally, a range of new initiatives are emerging to meet the multiple and complex healthcare needs of care home residents. However, little is known about their relative effectiveness and, given their heterogeneity, a classification scheme is required to enable research staff to explore this. Method: A UK survey collected information on the funding, age, coverage, aims, staffing and activities of 64 specialist care home support services. Latent class analysis (LCA) was used to allocate the sample into subgroups with similar characteristics. Findings: Three classes were identified. Class 1 (55% of sample) contained services with a high probability of providing scheduled input (regular preplanned visits) and support for all residents and a moderate probability of undertaking medication management, but a low probability of training care home staff (‘predominantly direct care’). Class 2 (23% of sample) had a moderate/high probability of providing scheduled input, support for all residents, medication management and training (‘direct and indirect care’). Class 3 (22% of sample) had a low probability of providing scheduled input, support for all residents and medication management, but a high probability of providing training for care home staff (‘predominantly indirect care’). Consultants were more likely to be members of services in Class 1 than Class 2, and Class 2 than Class 3. Conclusions: LCA offers a promising approach to the creation of a taxonomy of specialist care home support services. The skills and knowledge required by healthcare staff vary between classes, raising important issues for service design. The proposed classification can be used to explore the extent to which different organisational forms are associated with better resident, process and service outcomes.
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145
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Hoffmann F, Strautmann A, Allers K. Hospitalization at the end of life among nursing home residents with dementia: a systematic review. BMC Palliat Care 2019; 18:77. [PMID: 31506100 PMCID: PMC6737675 DOI: 10.1186/s12904-019-0462-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 09/06/2019] [Indexed: 12/24/2022] Open
Abstract
Background Half of nursing home residents (NHR) suffer from dementia. End-of-life hospitalizations are often burdensome in residents with dementia. A systematic review was conducted to study the occurrence of hospitalizations at the end of life in NHR with dementia and to compare these figures to NHR without dementia. Methods A systematic literature search in MEDLINE, CINAHL and Scopus was conducted in May 2018. Studies were included if they reported proportions of in-hospital deaths or hospitalizations of NHR with dementia in the last month of life. Two authors independently selected studies, extracted data, and assessed quality of studies. Results Nine hundred forty-five citations were retrieved; 13 studies were included. Overall, 7 studies reported data on in-hospital death with proportions ranging between 0% in Canada and 53.3% in the UK. Studies reporting on the last 30 days of life (n = 8) varied between 8.0% in the Netherlands and 51.3% in Germany. Two studies each assessed the influence of age and sex. There seem to be fewer end-of-life hospitalizations in older age groups. The influence of sex is inconclusive. All but one study found that at the end of life residents with dementia were hospitalized less often than those without (n = 6). Conclusions We found large variations in end-of-life hospitalizations of NHR with dementia, probably being explained by differences between countries. The influence of sex and age might differ when compared to residents without dementia. More studies should compare NHR with dementia to those without and assess the influence of sex and age. Trial registration PROSPERO registration number CRD42018104263.
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Affiliation(s)
- Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstr. 140, 26129, Oldenburg, Germany.
| | - Anke Strautmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstr. 140, 26129, Oldenburg, Germany
| | - Katharina Allers
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstr. 140, 26129, Oldenburg, Germany
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146
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Muench U, Simon M, Guerbaai RA, De Pietro C, Zeller A, Kressig RW, Zúñiga F. Preventable hospitalizations from ambulatory care sensitive conditions in nursing homes: evidence from Switzerland. Int J Public Health 2019; 64:1273-1281. [PMID: 31482196 PMCID: PMC6867979 DOI: 10.1007/s00038-019-01294-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 08/24/2019] [Accepted: 08/27/2019] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVES Reducing nursing home hospitalizations for ambulatory care sensitive conditions (ACSC) has been identified as an opportunity to improve patient well-being and reduce costs. The aim of this study was to identify number of hospitalizations for ACSCs for nursing home residents in a Swiss national sample, examine demographic characteristics of nursing home hospitalizations due to ACSCs, and calculate hospital expenses from these hospitalizations. METHODS Using merged hospital administrative data with payment data based on diagnosis-related groups (DRGs) for the year 2013, we descriptively examined nursing home residents who were 65 years of age or older and were admitted to an acute care hospital. RESULTS Approximately 42% of all nursing home admissions were due to ACSCs. Payments to Swiss hospitals for ACSCs can be estimated at between 89 and 105 million Swiss francs in 2013. CONCLUSIONS A sizable share of hospitalizations for nursing home residents is for ACSCs, and the associated costs are substantial. Programs and policies designed to reduce these potentially avoidable hospitalizations from the nursing home setting could lead to an increased patient well-being and lower costs.
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Affiliation(s)
- Ulrike Muench
- Department of Social and Behavioural Sciences, University of California San Francisco, School of Nursing, San Francisco, USA
| | - Michael Simon
- Department of Public Health, Institute of Nursing Science, Faculty of Medicine, University of Basel, Bernoullistr. 28, 4056, Basel, Switzerland.,Nursing and Midwifery Research Unit, Inselspital Bern University Hospital, Bern, Switzerland
| | - Raphaëlle-Ashley Guerbaai
- Department of Public Health, Institute of Nursing Science, Faculty of Medicine, University of Basel, Bernoullistr. 28, 4056, Basel, Switzerland
| | - Carlo De Pietro
- Department of Business Economics, Health and Social Care at the University of Applied Sciences and Arts of Southern Switzerland, Lugano, Switzerland
| | - Andreas Zeller
- Faculty of Medicine, University of Basel, Basel, Switzerland.,Center for Primary Health Care, University of Basel, Basel, Switzerland
| | - Reto W Kressig
- Faculty of Medicine, University of Basel, Basel, Switzerland.,FELIX PLATTER, University Medicine of Aging, Basel, Switzerland
| | - Franziska Zúñiga
- Department of Public Health, Institute of Nursing Science, Faculty of Medicine, University of Basel, Bernoullistr. 28, 4056, Basel, Switzerland.
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Theou O, Sluggett JK, Bell JS, Lalic S, Cooper T, Robson L, Morley JE, Rockwood K, Visvanathan R. Frailty, Hospitalization, and Mortality in Residential Aged Care. J Gerontol A Biol Sci Med Sci 2019; 73:1090-1096. [PMID: 29985993 DOI: 10.1093/gerona/glx185] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 09/28/2017] [Indexed: 01/05/2023] Open
Abstract
Background Frailty predicts mortality in residential aged care, but the relationship with hospitalization is inconsistent. The purpose of this study was to investigate and compare whether frailty is associated with hospitalization and mortality among residents of aged care services. Methods A prospective cohort study of 383 residents aged 65 years and older was conducted in six Australian residential aged care services. Frailty was assessed using the FRAIL-NH scale and a 66-item frailty index. Results Overall, 125 residents were hospitalized on 192 occasions and 85 died over the 12-month follow-up. Over this period, less than 3% of the nonfrail/vulnerable residents but more than 20% of the most frail residents died at the facility without hospitalization. Using the FRAIL-NH, residents with mild/moderate frailty had higher numbers of hospitalizations (adjusted incidence rate ratio 1.57, 95% confidence interval [CI] 1.11-2.20) and hospital days (incidence rate ratio 1.48, 95% CI 1.32-1.66) than nonfrail residents. Residents who were most frail had lower numbers of hospitalizations (incidence rate ratio 0.65, 95% CI 0.42-0.99) and hospital days (incidence rate ratio 0.39, 95% CI 0.33-0.46) than nonfrail residents. Similar patterns of associations with number of hospital days were observed for the frailty index. Most frail residents had a higher risk of death than nonfrail residents (for FRAIL-NH, adjusted hazard ratio 2.96, 95% CI 1.50-5.83; for frailty index, hazard ratio 5.28, 95% CI 2.05-13.59). Conclusions Residents with mild/moderate frailty had higher risk of hospitalization and death than nonfrail residents. Residents who were most frail had higher risk of death but lower risk of hospitalization than nonfrail residents.
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Affiliation(s)
- Olga Theou
- National Health and Medical Research Council Centre of Research Excellence in Frailty and Healthy Ageing, University of Adelaide, South Australia, Australia.,Department of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, Canada
| | - Janet K Sluggett
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - J Simon Bell
- National Health and Medical Research Council Centre of Research Excellence in Frailty and Healthy Ageing, University of Adelaide, South Australia, Australia.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Samanta Lalic
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Tina Cooper
- Resthaven Incorporated, Adelaide, South Australia, Australia
| | - Leonie Robson
- Resthaven Incorporated, Adelaide, South Australia, Australia
| | - John E Morley
- National Health and Medical Research Council Centre of Research Excellence in Frailty and Healthy Ageing, University of Adelaide, South Australia, Australia.,Divisions of Geriatric Medicine and Endocrinology, School of Medicine, Saint Louis University, Missouri
| | - Kenneth Rockwood
- National Health and Medical Research Council Centre of Research Excellence in Frailty and Healthy Ageing, University of Adelaide, South Australia, Australia.,Department of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, Canada
| | - Renuka Visvanathan
- National Health and Medical Research Council Centre of Research Excellence in Frailty and Healthy Ageing, University of Adelaide, South Australia, Australia.,Adelaide Geriatrics Training and Research with Aged Care Centre, School of Medicine, University of Adelaide, South Australia, Australia.,Aged and Extended Care Services, The Queen Elizabeth Hospital, South Australia, Australia
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148
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Franco JG, Trzepacz PT, Gaviria AM, Sepúlveda E, Viñuelas E, Palma J, Grau I, Vilella E. Distinguishing characteristics of delirium in a skilled nursing facility in Spain: Influence of baseline cognitive status. Int J Geriatr Psychiatry 2019; 34:1217-1225. [PMID: 30990571 DOI: 10.1002/gps.5120] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 04/08/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Mild cognitive impairment (MCI) and dementia (DEM) are prevalent in skilled nursing facilities (SNFs), confounding delirium detection. We report characteristics of delirium in an SNF to ascertain distinguishing features for delirium diagnosis, despite challenges of comorbidity with MCI and DEM. METHODS Cross-sectional study of 200 consecutive patients from an SNF in Catalunya, Spain, assessed within the first 24 to 48 admission hours by independent experts with Spanish-Informant Questionnaire on Cognitive Decline in the Elderly (for MCI-DEM), Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) delirium criteria, and Delirium Rating Scale Revised-98 (DRS-R98) for delirium phenomenology. Delirium characteristics were modeled in successive steps, according to the presence of delirium and MCI-DEM, with analysis of variance (ANOVA), receiver operator characteristic analyses, and conditional logistic regression. RESULTS The final model produced symptoms that represented each of the three delirium core domains (ie, cognitive, higher order thinking, and circadian). The DRS-R98 items rated these symptoms as moderate-severe attention/vigilance, mild-severe language, and moderate-severe sleep-wake cycle alterations. The delirium discriminant accuracy of the three symptoms together was high: 84.6% in the MCI-DEM group to 92.8% in the No MCI-DEM group. CONCLUSIONS Impairments of attention, language, and sleep-wake cycle indicate delirium in SNF patients regardless of the underlying MCI-DEM status. Because delirium is underdetected in SNFs, where nursing staff/patient ratios are low, brief simple tools that measure these symptoms could potentially enhance delirium detection.
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Affiliation(s)
- José G Franco
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Spain.,Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Paula T Trzepacz
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ana M Gaviria
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Spain.,Grupos de investigación Psicología & Neurociencias y Salud Comportamental & Organizacional, Facultad de Psicología, Universidad de San Buenaventura, Medellín, Colombia
| | - Esteban Sepúlveda
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Spain
| | - Eva Viñuelas
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Spain
| | - José Palma
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Spain
| | - Imma Grau
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Spain
| | - Elisabet Vilella
- Hospital Psiquiatric Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Reus, Spain
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149
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Lehn SF, Zwisler AD, Pedersen SGH, Gjørup T, Thygesen LC. Development of a prediction model for 30-day acute readmissions among older medical patients: the influence of social factors along with other patient-specific and organisational factors. BMJ Open Qual 2019; 8:e000544. [PMID: 31259284 PMCID: PMC6567955 DOI: 10.1136/bmjoq-2018-000544] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 01/21/2019] [Accepted: 05/16/2019] [Indexed: 12/23/2022] Open
Abstract
Background Readmission rate is one way to measure quality of care for older patients. Knowledge is sparse on how different social factors can contribute to predict readmission. We aimed to develop and internally validate a comprehensive model for prediction of acute 30-day readmission among older medical patients using various social factors along with demographic, organisational and health-related factors. Methods We performed an observational prospective study based on a group of 770 medical patients aged 65 years or older, who were consecutively screened for readmission risk factors at an acute care university hospital during the period from February to September 2012. Data on outcome and candidate predictors were obtained from clinical screening and administrative registers. We used multiple logistic regression analyses with backward selection of predictors. Measures of model performance and performed internal validation were calculated. Results Twenty percent of patients were readmitted within 30 days from index discharge. The final model showed that low educational level, along with male gender, contact with emergency doctor, specific diagnosis, higher Charlson Comorbidity Index score, longer hospital stay, cognitive problems, and medical treatment for thyroid disease, acid-related disorders, and glaucoma, predicted acute 30-day readmission. Area under the receiver operating characteristic curve (0.70) indicated acceptable discriminative ability of the model. Calibration slope was 0.98 and calibration intercept was 0.01. In internal validation analysis, both discrimination and calibration measures were stable. Conclusions We developed a model for prediction of readmission among older medical patients. The model showed that social factors in the form of educational level along with demographic, organisational and health-related factors contributed to prediction of acute 30-day readmissions among older medical patients.
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Affiliation(s)
- Sara Fokdal Lehn
- Department of Medicine, Holbæk University Hospital, Holbæk, Denmark
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Ann-Dorthe Zwisler
- Knowledge Center for Rehabilitation and Palliative Care, University of Southern Denmark, Nyborg, Denmark
| | | | - Thomas Gjørup
- Emergency Clinic, Gentofte Hospital, Hellerup, Denmark
| | - Lau Caspar Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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150
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Pulst A, Fassmer AM, Schmiemann G. Experiences and involvement of family members in transfer decisions from nursing home to hospital: a systematic review of qualitative research. BMC Geriatr 2019; 19:155. [PMID: 31164101 PMCID: PMC6549333 DOI: 10.1186/s12877-019-1170-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 05/23/2019] [Indexed: 11/23/2022] Open
Abstract
Background Nursing home residents (NHR) are characterized by increasing frailty, multimorbidity and care dependency. These conditions result in frequent hospital transfers which can lead to negative effects on residents’ health status and are often avoidable. Reasons for emergency department (ED) visits or hospital admissions are complex. Prior research indicated factors influencing transfer decisions in view of nursing staff and general practitioners. The aim of this systematic review is to explore how family members experience and influence transfers from nursing home (NH) to hospital and how they are involved in the transfer decision. Methods A systematic literature search was performed in Medline via PubMed, Ebsco Scopus and CINAHL in May 2018. Studies were eligible if they contained information a) about the decision to transfer NHR to hospital and b) the experiences or influence of family members. The review followed Joanna Briggs Institute's (JBI) approach for qualitative systematic reviews. Screening, selection and quality appraisal of studies were performed independently by two reviewers. Synthesis of qualitative data was conducted through meta-aggregation. Results After screening of n = 2863 articles, in total n = 10 qualitative studies were included in the review. Results indicate that family members of NHR experience decision-making before hospitalization differently. They mainly reported NH-related, hospital-related, and family/resident-related factors influencing the transfer decision. The involvement of family members in the decision-making process varies - from no involvement to insistence on a decision in favor of their personal preferences. However, hospital transfer decisions and other treatment decisions (e.g. advance care planning (ACP) discussions) were commonly discussed with physicians and nurses. Conflicts between family members and healthcare providers mostly arose around the interpretation of resident’s best interest. In general, family members perceive discussions as challenging thus leading to emotional stress and discomfort. Conclusion The influence of NHR family members concerning hospital transfer decisions varies. Family members are an important link for communication between resident and medical staff and for communication between NH and hospital. Interventions aiming to reduce hospitalization rates have to take these findings into account. Electronic supplementary material The online version of this article (10.1186/s12877-019-1170-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexandra Pulst
- Department of Health Services Research, Institute for Public Health and Nursing Research, University of Bremen, Grazer Str. 4, 28359, Bremen, Germany. .,Health Sciences Bremen, University of Bremen, 28359, Bremen, Germany.
| | - Alexander Maximilian Fassmer
- Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Ammerländer Heerstraße 114-118, 26129, Oldenburg, Germany
| | - Guido Schmiemann
- Department of Health Services Research, Institute for Public Health and Nursing Research, University of Bremen, Grazer Str. 4, 28359, Bremen, Germany.,Health Sciences Bremen, University of Bremen, 28359, Bremen, Germany
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