Discharge planning from hospital to home

A systematic literature review of predicting patient discharges using statistical methods and machine learning

Discharge planning is integral to patient flow as delays can lead to hospital-wide congestion. Because a structured discharge plan can reduce hospital length of stay while enhancing patient satisfaction, this topic has caught the interest of many healthcare professionals and researchers. Predicting discharge outcomes, such as destination and time, is crucial in discharge planning by helping healthcare providers anticipate patient needs and resource requirements. This article examines the literature on the prediction of various discharge outcomes. Our review discovered papers that explore the use of prediction models to forecast the time, volume, and destination of discharged patients. Of the 101 reviewed papers, 49.5% looked at the prediction with machine learning tools, and 50.5% focused on prediction with statistical methods. The fact that knowing discharge outcomes in advance affects operational, tactical, medical, and administrative aspects is a frequent theme in the papers studied. Furthermore, conducting system-wide optimization, predicting the time and destination of patients after discharge, and addressing the primary causes of discharge delay in the process are among the recommendations for further research in this field.

Unmasking the hidden aftermath: postintensive care unit sequelae, discharge preparedness, and long-term follow-up

A significant portion of individuals who have experienced critical illness encounter new or exacerbated impairments in their physical, cognitive, or mental health, commonly referred to as postintensive care syndrome. Moreover, those who survive critical illness often face an increased risk of adverse consequences, including infections, major cardiovascular events, readmissions, and elevated mortality rates, during the months following hospitalization. These findings emphasize the critical necessity for effective prevention and management of long-term health deterioration in the critical care environment. Although conclusive evidence from well-designed randomized clinical trials is somewhat limited, potential interventions include strategies such as limiting sedation, early mobilization, maintaining family presence during the intensive care unit stay, implementing multicomponent transition programs (from intensive care unit to ward and from hospital to home), and offering specialized posthospital discharge follow-up. This review seeks to provide a concise summary of recent medical literature concerning long-term outcomes following critical illness and highlight potential approaches for preventing and addressing health decline in critical care survivors.

Effects of transitional care interventions on quality of life in people with lung cancer: A systematic review and meta-analysis

AIM

To identify and appraise the quality of evidence of transitional care interventions on quality of life in lung cancer patients.

BACKGROUND

Quality of life is a strong predictor of survival. The transition from hospital to home is a high-risk period for patients' readmission and death, which seriously affect their quality of life.

DESIGN

Systematic review and meta-analysis.

METHODS

The PubMed, Embase, Cochrane Library, Web of Science and CINAHL databases were searched from inception to 22 October 2022. The primary outcome was quality of life. Statistical analysis was conducted using Review Manager 5.4, results were expressed as standard mean difference (SMD) with a 95% confidence interval (CI). The risk of bias of the included studies was assessed using the Cochrane risk of bias assessment tool. This study was complied with PRISMA guidelines and previously registered in PROSPERO (CRD42023429464).

RESULTS

Fourteen randomized controlled trials were included consisting of a total of 1700 participants, and 12 studies were included in the meta-analysis. It was found that transitional care interventions significantly improved quality of life (SMD = 0.21, 95% CI: 0.02 to 0.40, p = .03) and helped reduce symptoms (SMD = -0.65, 95% CI: -1.13 to -0.18, p = .007) in lung cancer patients, but did not significantly reduce anxiety and depression, and the effect on self-efficacy was unclear.

CONCLUSIONS

This study shows that transitional care interventions can improve quality of life and reduce symptoms in patients, and that primarily educational interventions based on symptom management theory appeared to be more effective. But, there was no statistically significant effect on anxiety and depression.

RELEVANCE TO CLINICAL PRACTICE

This study provides references for the application of transitional care interventions in the field of lung cancer care, and encourages nurses and physicians to apply transitional care plans to facilitate patients' safe transition from hospital to home.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Advancements in autologous peripheral nerve transplantation care: a review of strategies and practices to facilitate recovery

Autologous peripheral nerve transplantation, a pioneering technique in nerve injury treatment, has demonstrated remarkable progress. We examine recent nursing strategies and methodologies tailored to various anatomical sites, highlighting their role in postoperative recovery enhancement. Encompassing brachial plexus, upper limb, and lower limb nerve transplantation care, this discussion underscores the importance of personalized rehabilitation plans, interdisciplinary collaboration, and innovative approaches like nerve electrical stimulation and nerve growth factor therapy. Moreover, the exploration extends to effective complication management and prevention strategies, encompassing infection control and pain management. Ultimately, the review concludes by emphasizing the advances achieved in autologous peripheral nerve transplantation care, showcasing the potential to optimize postoperative recovery through tailored and advanced practices.

The beneficial effects of transitional care for patients with stroke: A meta-analysis

INTRODUCTION

Transitional care interventions have emerged as a promising method of ensuring treatment continuity and health care coordination when patients are discharged from hospital to home. However, few studies have investigated the frequency and duration of interventions and the effects of interventions on physical function. Therefore, this study aimed to determine the efficacy of transitional care for patients with stroke.

METHODS

Six databases and the grey literature were searched to obtain relevant articles from October 1, 2022 to March 10, 2023. The primary outcomes studied were motor performance, walking speed, activities of daily living (ADLs) and caregiver burden following hospital-to-home transitional care. The quality of the studies was assessed with Cochrane risk of bias version 2. The quality and sensitivity of the evidence were assessed to ensure rigour of the findings. Meta-analyses were performed using stata 17.0.

RESULTS

A total of 2966 patients were identified from 23 studies. Transitional care improved post-stroke motor performance, walking speed and ADLs, and reduced caregiver burden.

CONCLUSION

The findings suggest that provision of transitional care model implementation in patients with stroke is important because it reduces disability in stroke patients and helps to decrease caregivers' burden.

IMPACT

The findings of the study emphasize the importance of transitional care programmes for stroke patients after they are discharged from the hospital and returned to their homes. To meet the needs of patients, all levels of health professionals including nurses should be aware of the discharge process and care plan.

Disentangling organizational levers and economic benefits in transitional care programs: a systematic review and configurational analysis

BACKGROUND

Promoting safe and efficient transitions of care is critical to reducing readmission rates and associated costs and improving the quality of patient care. A growing body of literature suggests that transitional care (TC) programs are effective in improving quality of life and reducing unplanned readmissions for several patient groups. TC programs are highly complex and multidimensional, requiring evidence on how specific practices and system characteristics influence their effectiveness in patient care, readmission reduction and costs.

METHODS

Using a systematic review and a configurational approach, the study examines the role played by system characteristics (size, ownership, professional skills, technology used), the organizational components implemented, analyzing their combinations, and the potential economic impact of TC programs.

RESULTS

The more organizational components are implemented, the greater the likelihood that a TC program will be successful in reducing readmission rates. Not all components have the same effect. The results show that certain components, 'post-discharge symptom monitoring and management' and 'discharge planning', are necessary but not sufficient to achieve the outcome. The results indicate the existence of two different combinations of components that can be considered sufficient for the reduction of readmissions. Furthermore, while system characteristics are underexplored, the study shows different ways of incorporating the skill mix of professionals and their mode of coordination in TC programs. Four organizational models emerge: the health-based monocentric, the social-based monocentric, the multidisciplinary team and the mono-specialist team. The economic impact of the programs is generally positive. Despite an increase in patient management costs, there is an overall reduction in all post-intervention costs, particularly those related to readmissions.

CONCLUSIONS

The results underline the importance of examining in depth the role of system characteristics and organizational factors in facilitating the creation of a successful TC program. The work gives preliminary insights into how to systematize organizational practices and different coordination modes for facilitating decision-makers' choices in TC implementation. While there is evidence that TC programs also have economic benefits, the quality of economic evaluations is relatively low and needs further study.

The economic impact of a local, collaborative, stepped, and personalized care management for older people with chronic diseases: results from the randomized comparative effectiveness LoChro-trial

BACKGROUND

Within the ageing population of Western societies, an increasing number of older people have multiple chronic conditions. Because multiple health problems require the involvement of several health professionals, multimorbid older people often face a fragmented health care system. To address these challenges, in a two-group parallel randomized controlled trial, a newly developed care management approach (LoChro-Care) was compared with usual care.

METHODS

LoChro-Care consists of individualized care provided by chronic care managers with 7 to 16 contacts over 12 months. Patients aged 65 + with chronic conditions were recruited from inpatient and outpatient departments. Healthcare utilization costs are calculated by using an adapted version of the generic, self-reporting FIMA©-questionnaire with the application of standardized unit costs. Questionnaires were given at 3 time points (T0 baseline, T1 after 12 months, T2 after 18 months). The primary outcome was overall 3-month costs of healthcare utilization at T1 and T2. The data were analyzed using generalized linear models with log-link and gamma distribution and adjustment for age, sex, level of care as well as the 3-month costs of care at T0.

RESULTS

Three hundred thirty patients were analyzed. The results showed no significant difference in the costs of healthcare utilization between participants who received LoChro-Care and those who received usual care, regardless of whether the costs were evaluated 12 (adjusted mean difference € 130.99, 95%CI €-1477.73 to €1739.71, p = 0.873) or 18 (adjusted mean difference €192.99, 95%CI €-1894.66 to €2280.65, p = 0.856) months after the start of the intervention.

CONCLUSION

This study revealed no differences in costs between older people receiving LoChro-Care or usual care. Before implementing the intervention, further studies with larger sample sizes are needed to provide robust evidence on the cost effects of LoChro-Care.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS): DRKS00013904, https://drks.de/search/de/trial/DRKS00013904 ; date of first registration 02/02/2018.

Impact of interventions to improve recovery of older adults following planned hospital admission on quality-of-life following discharge: linked-evidence synthesis

Objectives

To understand the impact of multicomponent interventions to improve recovery of older adults following planned hospital treatment, we conducted two systematic reviews, one of quantitative and one of qualitative evidence, and an overarching synthesis. These aimed to: • understand the effect of multicomponent interventions which aim to enhance recovery and/or reduce length of stay on patient-reported outcomes and health and social care utilisation • understand the experiences of patients, carers and staff involved in the delivery of interventions • understand how different aspects of the content and delivery of interventions may influence patient outcomes.

Review methods

We searched bibliographic databases including MEDLINE ALL, Embase and the Health Management Information Consortium, CENTRAL, and Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database, conducted forward and backward citation searching and examined reference lists of topically similar qualitative reviews. Bibliographic database searches were completed in May/June 2021 and updated in April 2022. We sought primary research from high-income countries regarding hospital inpatients with a mean/median age of minimum 60 years, undergoing planned surgery. Patients experienced any multicomponent hospital-based intervention to reduce length of stay or improve recovery. Quantitative outcomes included length of stay and any patient-reported outcome or experience or service utilisation measure. Qualitative research focused on the experiences of patients, carers/family and staff of interventions received. Quality appraisal was undertaken using the Effective Public Health Practice Project Quality Assessment Tool or an adapted version of the Wallace checklist. We used random-effects meta-analysis to synthesise quantitative data where appropriate, meta-ethnography for qualitative studies and qualitative comparative analysis for the overarching synthesis.

Results

Quantitative review: Included 125 papers. Forty-nine studies met criteria for further synthesis. Enhanced recovery protocols resulted in improvements to length of stay, without detriment to other outcomes, with minimal improvement in patient-reported outcome measures for patients admitted for lower-limb or colorectal surgery. Qualitative review: Included 43 papers, 35 of which were prioritised for synthesis. We identified six themes: 'Home as preferred environment for recovery', 'Feeling safe', 'Individualisation of structured programme', 'Taking responsibility', 'Essential care at home' and 'Outcomes'. Overarching synthesis: Intervention components which trigger successful interventions represent individualised approaches that allow patients to understand their treatment, ask questions and build supportive relationships and strategies to help patients monitor their progress and challenge themselves through early mobilisation.

Discussion

Interventions to reduce hospital length of stay for older adults following planned surgery are effective, without detriment to other patient outcomes. Findings highlight the need to reconsider how to evaluate patient recovery from the perspective of the patient. Trials did not routinely evaluate patient mid- to long-term outcomes. Furthermore, when they did evaluate patient outcomes, reporting is often incomplete or conducted using a narrow range of patient-reported outcome measures or limited through asking the wrong people the wrong questions, with lack of longer-term evaluation. Findings from the qualitative and overarching synthesis will inform policy-making regarding commissioning and delivering services to support patients, carers and families before, during and after planned admission to hospital.

Study registration

This trial is registered as PROSPERO registration number CRD42021230620.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 130576) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 23. See the NIHR Funding and Awards website for further award information.

Management of Residual Risk in Chronic Coronary Syndromes. Clinical Pathways for a Quality-Based Secondary Prevention

Chronic coronary syndrome (CCS), which encompasses a broad spectrum of clinical presentations of coronary artery disease (CAD), is the leading cause of morbidity and mortality worldwide. Recent guidelines for the management of CCS emphasize the dynamic nature of the CAD process, replacing the term "stable" with "chronic", as this disease is never truly "stable". Despite significant advances in the treatment of CAD, patients with CCS remain at an elevated risk of major cardiovascular events (MACE) due to the so-called residual cardiovascular risk. Several pathogenetic pathways (thrombotic, inflammatory, metabolic, and procedural) may distinctly contribute to the residual risk in individual patients and represent a potential target for newer preventive treatments. Identifying the level and type of residual cardiovascular risk is essential for selecting the most appropriate diagnostic tests and follow-up procedures. In addition, new management strategies and healthcare models could further support available treatments and lead to important prognostic benefits. This review aims to provide an overview of the diagnostic and therapeutic challenges in the management of patients with CCS and to promote more effective multidisciplinary care.

Defining ready for discharge from sub-acute care: a qualitative exploration from multiple stakeholder perspectives

BACKGROUND

Planning discharges from subacute care facilities is becoming increasingly complex due to an ageing population and a high demand on services. The use of non-standardised assessments to determine a patient's readiness for discharge places a heavy reliance on a clinician's judgement which can be influenced by system pressures, past experiences and team dynamics. The current literature focusses heavily on discharge-readiness from clinicians' perspectives and in the acute care setting. This paper aimed to explore the perceptions of discharge-readiness from the perspectives of key stakeholders in subacute care: inpatients, family members, clinicians and managers.

METHODS

A qualitative descriptive study was conducted, exploring the views of inpatients (n = 16), family members (n = 16), clinicians (n = 17) and managers (n = 12). Participants with cognitive deficits and those who did not speak English were excluded from this study. Semi-structured interviews and focus groups were conducted and audio-recorded. Following transcription, inductive thematic analysis was completed.

RESULTS

Participants identified that there are both patient-related and environmental factors that influence discharge-readiness. Patient-related factors discussed included continence, functional mobility, cognition, pain and medication management skills. Environmental factors centred around the discharge (home) environment, and were suggested to include a safe physical environment alongside a robust social environment which was suggested to assist to fill any gaps in functional capabilities (i.e. patient-related factors).

CONCLUSIONS

These findings make a unique contribution to the literature by providing a thorough exploration of determining discharge-readiness as a combined narrative from the perspectives from key stakeholders. Findings from this qualitative study identified key personal and environmental factors influencing patients' discharge-readiness, which may allow health services to streamline the determination of discharge-readiness from subacute care. Understanding how these factors might be assessed within a discharge pathway warrants further attention.

Race and Insurance Status Disparities in Post-discharge Disposition After Hospitalization for Major Trauma

BACKGROUND

Investigations detailing predictive measures of hospital disposition after traumatic injury are scarce. We aim to examine the discharge practices among trauma centers in the US and to identify factors that may influence post-hospital disposition.

METHODS

A retrospective analysis of trauma patients using the American College of Surgeons-Trauma Quality Improvement Program dataset from 2007-2017. Primary study outcome was hospital disposition (including long term care facility [LTC], others). Secondary outcomes included: Intensive Care Unit (ICU)-length of stay (LOS), complications, others).

RESULTS

6 899 538 patients were analyzed. Odds of LTC discharge was significantly higher for Black patients (aOR = 1.30, 95% CI:1.24-1.37), abbreviated injury score (AIS) ≥3 (aOR = 4.22, 95% CI: 4.05-4.39), and higher injury severity score (ISS) (aOR = 9.41, 95% CI:9.03-9.80). Significantly more self-pay patients were discharged home compared to other insurance types (P < .0001). Significantly longer hospital- and ICU-LOS were experienced by those who had an AIS ≥3 (hospital: 4.8 days (±7.1) vs. 7.9 (±10.1); ICU: 4.6 (±6.9) vs. 5.9 (±7.9), P < .0001) and had a high ISS (hospital: 4.5 days (±5.9) vs. 16.8 (±17.9); ICU: 3.6 (±5.0) vs. 10.2 (±11.5), P < .0001).

CONCLUSIONS

Patient race, insurance status, and injury severity were predictive of post-hospitalization care discharge. Self-pay and Black patients were less likely to be discharged to secondary care facilities. These findings have the potential to improve in-hospital patient management and predict discharge secondary care needs, and necessitate the need for future research to investigate the extent of inequalities in access to trauma care.

Implementing a discharge process for patients undergoing elective surgery: Rapid review

BACKGROUND

Hospital discharge is a 'vulnerable stage' in care. A delayed, inappropriate or poorly planned discharge increases hazards and costs, inhibiting recovery, and often leading to unplanned readmission. New discharge processes could boost practice, reduce the length of stay, and, consequently, reduce costs and improve patients' quality of life.

AIM

To identify technology based interventions that have been implemented to facilitate a safe and timely discharge procedure after elective surgery, and to describe implementation barriers and facilitators and patient satisfaction.

METHOD

This rapid review followed a restricted systematic review framework, searching Medline, EMBASE, CINAHL, PsychINFO, and ClinicalTrials.gov. for relevant studies published from 2015 to 2021 in English.

RESULTS

Eleven studies were included. Most interventions were machine-learning-based, and only one study reported patient involvement. Effective leadership, team work and communication were stated as implementation facilitators. The main barriers to implementation were: lack of support from leaders, poor clinical documentation, resistance to change, and financial and logistical concerns. None of the studies evaluated patient satisfaction.

CONCLUSIONS

Findings highlight factors that support the implementation of technology based interventions aimed at a safe and timely discharge process following elective surgery. Nurses play an important role in the provision of information, and in the development and implementation of discharge processes.

Effectiveness of multicomponent home-based rehabilitation in older patients after hip fracture surgery: A systematic review and meta-analysis

BACKGROUND

Hip fracture is a major burden on health care systems worldwide and requires hospitalisation for a long period.

OBJECTIVE

The aim was to evaluate the effectiveness of multicomponent home-based rehabilitation compared with different control interventions (in-hospital rehabilitation, active control or usual care) in older patients after hip fracture surgery.

DESIGN

Systematic review and meta-analysis of randomised controlled studies.

DATA SOURCES

We searched three electronic databases, including Ovid-MEDLINE, Ovid-Embase, CINAHL and the Cochrane Library for relevant articles up to March 2020.

REVIEW METHODS

Two investigators independently extracted data and assessed study quality using the risk of bias. Data were analysed using Review Manager 5.3. The current review employs the PRISMA procedure.

RESULTS

Out of 2996 studies, 22 articles were relevant for this review and meta-analysis. Among them, five compared the multicomponent home-based rehabilitation with in-hospital rehabilitation, one compared it with active control, six with usual care and ten compared the home exercise only with usual care. There was no significant difference in activities of daily living (ADL) between multicomponent home-based rehabilitation and in-hospital rehabilitation, while multicomponent home-based rehabilitation significantly increased in ADL when compared to usual care. Home exercises also had significant effects on ADL, quality of life(QoL), balance, gait and muscle strength of the knee extensor compared with usual care (p < .05).

CONCLUSIONS

Multicomponent home-based rehabilitation is comparable to in-hospital rehabilitation regarding improvements in muscle strength, gait speed, balance, ADL and QoL.

RELEVANT TO CLINICAL PRACTICE

Multicomponent home-based rehabilitation is comparable to in-hospital rehabilitation regarding improvements in muscle strength, gait speed, balance, ADL and QoL. Also, high adherence to home exercise may be associated with better clinical outcomes. Therefore, more compliance-oriented multicomponent home-based rehabilitation programmes for older patients after hip fracture must be developed by health care professionals, including physical therapist, to ensure optimum home-based rehabilitation.

Effect of mother's knowledge on posteducation toward rehospitalization of young children with pneumonia†

Objective

The rehospitalization rate of children <5 years old with pneumonia is still high. The risk of hospitalization becomes higher in mothers with low knowledge of their child's disease. The purpose of this study was to determine the effect of post–health-education maternal knowledge in cases of rehospitalization and to determine the differences in rehospitalization rate based on the type of health education media.

Methods

This study is a quasi-experiment. Health education was given to both groups: one group received education through audiovisual media and the other group through leaflet media. The level of post–health-education knowledge was measured on the third day, then followed up until the 30th day after the patient was discharged from the hospital.

Results

Post–health-education knowledge significantly reduced the cases of rehospitalization in both groups. However, the rehospitalization rate in the audiovisual group was lower than in the leaflet group (P = 0.047, odds ratio = 5.870).

Conclusions

Post–health-education knowledge is effective in reducing the risk of rehospitalization, and health education using audiovisual media is more effective, compared to health education using leaflets, in reducing the cases of rehospitalization in children <5 years of age with pneumonia.

Blood glucose monitoring during hospitalisation: Advanced practice nurse and semi-automated insulin prescription tools

INTRODUCTION

Hyperglycemia is very common in hospitalized patients and is associated with worse clinical outcomes.

AIMS

We implemented a clinical and educational program to improve the overall glycemic control during hospital admission, and, in patients with HbA_1c > 8%, to improve their metabolic control after hospital admission.

METHODS

Non-critical patients admitted to cardiovascular areas between October-2017 and February-2019. The program was led by an advanced nurse practitioner (ANP) and included a semiautomated insulin prescription tool. Program in 3 phases: 1) observation of routine practice, 2) implementation, and 3) follow-up after discharge.

RESULTS

During the implementation phase the availability of HbA1c increased from 42 to 81%, and the ANP directly intervened in 73/685 patients (11%), facilitating treatment progression at discharge in 48% (de novo insulin in 36%). One-year after discharge, HbA1c in patients who were admitted during the observation phase with HbA1c > 8% (n = 101) was higher than similar patients admitted during implementation phase (8,6 ± 1,5 vs. 7,3 ± 1,2%, respectively, p < 0,001). We evaluated 47710 point of care capillary blood glucose (POC-glucose) in two 9 months periods (one before, one during the program) in cardiology and cardiovascular surgery wards. POC-glucose ≥250 mg/dl (pre vs. during: cardiology 10,7 vs. 8,4%, and surgery 7,4 vs. 4,5%, both p < 0,05) and <70 mg/dl (2,3 vs. 0,8% y 1,5 vs 1%, p < 0,05), respectively, improved during the program.

CONCLUSIONS

The program allowed improving inpatient glycemic control, detect patients with poor glycemic control, and optimize metabolic control 1-year after discharge.

Effectiveness of nurse-led discharge service on adult surgical inpatients: A meta-analysis of randomized controlled trials

Aim

To determine the effectiveness of nurse‐led discharge service for adult surgical inpatients.

Design

The report of this review was conducted by the preferred reporting items for systematic reviews and meta‐analyses (PRISMA) statement checklist.

Methods

The PubMed, Web of Science, ScienceDirect, Cochrane Library (CENTRAL), MEDLINE and Embase as well as four Chinese databases including CNKI, Wanfang database, VIP database and CBM were searched for randomized controlled trials. Two reviewers independently extracted data and assessed risk of bias. And meta‐analyses were conducted for the eligible studies by Review manager 5.4.1.

Results

A total of 1,649 participants were enrolled in 12 randomized controlled trials. The result of readmission rate and emergency visit of intervention group were lower than those of the control group; activities of daily living and quality of life in the intervention group were higher than that of the control group. There was no statistical difference in the length of stay between the two groups.

Strategies for utilisation management of hospital services: a systematic review of interventions

Background

To achieve efficiency and high quality in health systems, the appropriate use of hospital services is essential. We identified the initiatives intended to manage adult hospital services and reduce unnecessary hospital use among the general adult population.

Methods

We systematically reviewed studies published in English using five databases (PubMed, ProQuest, Scopus, Web of Science, and MEDLINE via Ovid). We only included studies that evaluated interventions aiming to reduce the use of hospital services or emergency department, frequency of hospital admissions, length of hospital stay, or the use of diagnostic tests in a general adult population. Studies reporting no relevant outcomes or focusing on a specific patient population or children were excluded.

Results

In total, 64 articles were included in the systematic review. Nine utilisation management methods were identified: care plan, case management, care coordination, utilisation review, clinical information system, physician profiling, consultation, education, and discharge planning. Primary case management was shown to effectively reduce emergency department use. Care coordination reduced 30-day post-discharge hospital readmission or emergency department visit rates. The pre-admission review program decreased elective admissions. The physician profiling, concurrent review, and discharge planning effectively reduced the length of hospital stay. Twenty three studies that evaluated costs, reported cost savings in the hospitals.

Conclusions

Utilisation management interventions can decrease hospital use by improving the use of community-based health services and improving the quality of care by providing appropriate care at the right time and at the right level of care.

Reducing Medication Problems among Minority Individuals with Low Socioeconomic Status through Pharmacist Home Visits

Introduction: In this study, pharmacists conducted home visits for individuals of medically underserved populations in Taiwan (i.e., socioeconomically disadvantaged individuals, middle-aged or older adults, and individuals living alone, with dementia, or with disabilities) to understand their medication habits. We quantified medication problems among various groups and investigated whether the pharmacist home visits helped to reduce the medication problems. Materials and Methods: From April 2016 to March 2019, pharmacists visited the homes of the aforementioned medically underserved individuals in Taipei to evaluate their drug-related problems and medication problems. Age, living alone, diagnoses of dementia or disabilities, and socioeconomic disadvantages contributed significantly to inadequate disease and medical treatment knowledge and self-care skills as well as lifestyle inappropriateness among patients. The patients who were living alone and socioeconomically disadvantaged stored their drugs in inappropriate environments. Results: After the pharmacists visited the patients’ homes twice, the patients improved considerably in their disease and medical treatment knowledge, self-care skills, and lifestyles (p < 0.001). Problems related to the uninstructed reduction or discontinuation of drug use (p < 0.05) and use of expired drugs (p < 0.001) were also mitigated substantially. Discussion and conclusion: Through the home visits, the pharmacists came to fully understand the medicine (including Chinese medicine) and health food usage behaviors of the patients and their lifestyles, enabling them to provide thorough health education. After the pharmacists’ home visits, the patients’ drug-related problems were mitigated, and their knowledge of diseases, drug compliance, and drug storage methods and environments improved, reducing drug waste. Our findings can help policymakers address the medication problems of various medically underserved groups, thereby improving the utilization of limited medical resources.

Discharge planning from hospital

BACKGROUND

Discharge planning is a routine feature of health systems in many countries that aims to reduce delayed discharge from hospital, and improve the co-ordination of services following discharge from hospital and reduce the risk of hospital readmission. This is the fifth update of the original review.

OBJECTIVES

To assess the effectiveness of planning the discharge of individual patients moving from hospital.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two trials registers on 20 April 2021. We searched two other databases up to 31 March 2020. We also conducted reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

Randomised trials that compared an individualised discharge plan with routine discharge that was not tailored to individual participants. Participants were hospital inpatients.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies by older people with a medical condition, people recovering from surgery, and studies that recruited participants with a mix of conditions. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data it was not possible because of differences in the reporting of outcomes, we summarised the reported results for each trial in the text.

MAIN RESULTS

We included 33 trials (12,242 participants), four new trials included in this update. The majority of trials (N = 30) recruited participants with a medical diagnosis, average age range 60 to 84 years; four of these trials also recruited participants who were in hospital for a surgical procedure. Participants allocated to discharge planning and who were in hospital for a medical condition had a small reduction in the initial hospital length of stay (MD - 0.73, 95% confidence interval (CI) - 1.33 to - 0.12; 11 trials, 2113 participants; moderate-certainty evidence), and a relative reduction in readmission to hospital over an average of three months follow-up (RR 0.89, 95% CI 0.81 to 0.97; 17 trials, 5126 participants; moderate-certainty evidence). There was little or no difference in participant's health status (mortality at three- to nine-month follow-up: RR 1.05, 95% CI 0.85 to 1.29; 8 trials, 2721 participants; moderate certainty) functional status and psychological health measured by a range of measures, 12 studies, 2927 participants;  low certainty evidence). There was some evidence that satisfaction might be increased for patients (7 trials), caregivers (1 trial) or healthcare professionals (2 trials) (very low certainty evidence). The cost of a structured discharge plan compared with routine discharge is uncertain (7 trials recruiting 7873 participants with a medical condition; very low certainty evidence).

AUTHORS' CONCLUSIONS

A structured discharge plan that is tailored to the individual patient probably brings about a small reduction in the initial hospital length of stay and readmissions to hospital for older people with a medical condition, may slightly increase patient satisfaction with healthcare received. The impact on patient health status and healthcare resource use or cost to the health service is uncertain.

The effect of video-assisted discharge education after total hip replacement surgery: a randomized controlled study

This study aimed to investigate the effect of a video-assisted discharge education program on activities of daily living, functionality, and patient satisfaction following total hip replacement (THR) surgery. This study included 31 patients who were randomly divided into the physiotherapy group (n = 18), and the video-assisted discharge education (VADE) group (n = 13). Both groups received a physiotherapy program. The VADE group was also received the VADE program. Face-to-face instruction was used in all of the educational programs. There was a significant difference in favor of the VADE group in Harris Hip Score, Nottingham Extended Activities of Daily Living Scale's movement score, Tampa Scale of Kinesiophobia, Patient Satisfaction Questionnaire (p < 0.05). There was a significant difference between groups on resting pain levels in the first week and on resting and activity pain levels in the third month in favor of the VADE group (p < 0.05). The results of this study demonstrated that VADE can be effective in improving patient satisfaction and functionality, reducing pain and kinesiophobia following THR.

Stopping the Revolving Door: Reducing 30-Day Psychiatric Readmissions With Post-discharge Telephone Calls

This prospective study sought to determine the effect of a post-discharge telephone call on 30-day readmission rates at a short-term inpatient psychiatric facility. The patient population consisted of English-speaking adults in the age group of 18-65 years with a high school education or higher and met involuntary commitment criteria. Participants received a telephone call 72 hours after discharge using a standard script. Three hundred and forty-two patients completed the study. A Pearson Chi-Square test was used to analyze the data. We used an alpha level of 0.05 for all statistical tests. Total readmissions were reduced by 3.4% (p = 0.004) during the time of the intervention when compared to patients receiving standard care the year prior. During the intervention period, the average readmission rate was 9.9% (95%CI 5.9-12.1%). We conclude that systematic telephone follow-up has the potential to reduce 30-day readmission rates for inpatient psychiatric facilities. 

Discharge to inpatient care facilities following hip fracture surgery: incidence, risk factors, and 30-day post-discharge outcomes

BACKGROUND

Discharge to an inpatient care facility (skilled-care or rehabilitation) has been shown to be associated with adverse outcomes following elective total joint arthroplasties. Current evidence with regard to hip fracture surgeries remains limited.

METHODS

The 2015-2016 ACS-NSQIP database was used to query for patients undergoing total hip arthroplasty, hemiarthroplasty and open reduction internal fixation for hip fractures. A total of 15,655 patients undergoing hip fracture surgery were retrieved from the database. Inpatient facility discharge included discharges to skilled-care facilities and inpatient rehabilitation units. Multi-variate regression analysis was used to assess for differences in 30-day post-discharge outcomes between home-discharge versus inpatient care facility discharge, while adjusting for baseline differences between the 2 study populations.

RESULTS

A total of 12,568 (80.3%) patients were discharged to an inpatient care facility. Discharge to an inpatient care facility was associated with higher odds of any complication (OR 2.03 [95% CI, 1.61-2.55]; p < 0.001), wound complications (OR 1.79 [95% CI, 1.10-2.91]; p = 0.019), cardiac complications (OR 4.49 [95% CI, 1.40-14.40]; p = 0.012), respiratory complication (OR 2.29 [95% CI, 1.39-3.77]; p = 0.001), stroke (OR 7.67 [95% CI, 1.05-56.29]; p = 0.045, urinary tract infections (OR 2.30 [95% CI, 1.52-3.48]; p < 0.001), unplanned re-operations (OR 1.37 [95% CI, 1.03-1.82]; p = 0.029) and readmissions (OR 1.38 [95% CI, 1.16-1.63]; p < 0.001) following discharge.

CONCLUSION

Discharge to inpatient care facilities versus home following hip fracture surgery is associated with higher odds of post-discharge complications, re-operations and readmissions. These results stress the importance of careful patient selection prior to discharge to inpatient care facilities to minimise the risk of complications.

Cost and Effectiveness of Long-Term Care Following Integrated Discharge Planning: A Prospective Cohort Study

Little is known about the effects of seamless hospital discharge planning on long-term care (LTC) costs and effectiveness. This study evaluates the cost and effectiveness of the recently implemented policy from hospital to LTC between patients discharged under seamless transition and standard transition. A total of 49 elderly patients in the standard transition cohort and 119 in the seamless transition cohort were recruited from November 2016 to February 2018. Data collected from medical records included the Multimorbidity Frailty Index, Activities of Daily Living Scale, and Malnutrition Universal Screening Tool during hospitalization. Multiple linear regression and Cox regression models were used to explore risk factors for medical resource utilization and medical outcomes. After adjustment for effective predictors, the seamless cohort had lower direct medical costs, a shorter length of stay, a higher survival rate, and a lower unplanned readmission rate compared to the standard cohort. However, only mean total direct medical costs during hospitalization and 6 months after discharge were significantly (p < 0.001) lower in the seamless cohort (USD 6192) compared to the standard cohort (USD 8361). Additionally, the annual per-patient economic burden in the seamless cohort approximated USD 2.9–3.3 billion. Analysis of the economic burden of disability in the elderly population in Taiwan indicates that seamless transition planning can save approximately USD 3 billion in annual healthcare costs. Implementing this policy would achieve continuous improvement in LTC quality and reduce the financial burden of healthcare on the Taiwanese government.

Systematic review on the use of patient-held health records in low-income and middle-income countries

OBJECTIVE

To review the available evidence on the benefit of patient-held health records (PHRs), other than maternal and child health records, for improving the availability of medical information for handover communication between healthcare providers (HCPs) and/or between HCPs and patients in low-income and middle-income countries (LMICs).

METHODS

The literature searches were conducted in PubMed, EMBASE, CINAHL databases for manuscripts without any restrictions on dates/language. Additionally, articles were located through citation checking using previous systematic reviews and a grey literature search by contacting experts, searching of the WHO website and Google Scholar.

RESULTS

Six observational studies in four LMICs met the inclusion criteria. However, no studies reported on health outcomes after using PHRs. Studies in the review reported patients' experience of carrying the records to HCPs (n=3), quality of information available to HCPs (n=1) and the utility of these records to patients (n=6) and HCPs (n=4). Most patients carry PHRs to healthcare visits. One study assessed the completeness of clinical handover information and found that only 41% (161/395) of PHRs were complete with respect to key information on diagnosis, treatment and follow-up. No protocols or guidelines for HCPs were reported for use of PHRs. The HCPs perceived the use of PHRs improved medical information availability from other HCPs. From the patient perspective, PHRs functioned as documented source of information about their own condition.

CONCLUSION

Limited data on existing PHRs make their benefits for improving health outcomes in LMICs uncertain. This knowledge gap calls for research on understanding the dynamics and outcomes of PHR use by patients and HCPs and in health systems interventions.

PROSPERO REGISTRATION NUMBER

CRD42019139365.

Economic evidence with respect to cost-effectiveness of the transitional care model among geriatric patients discharged from hospital to home: a systematic review

BACKGROUND

The German hospital-to-home discharge management of geriatric patients has long been criticized. The implementation of the American Transitional Care Model (TCM) could help to reduce readmissions and costs. The objective of this review was to check the scientific evidence of the cost-effectiveness of the TCM.

METHODS

A systematic literature search in six databases for the time period of 26 years was conducted. The studies had to meet all pre-defined inclusion criteria. The data extraction is based on a criteria chart from literature. The methodological quality was assessed using the tools of the National Heart, Lung, and Blood Institute as well as the Consensus Health Economic Criteria list. The results transferability to German health care system was explained based on the criteria from the literature.

RESULTS

Three American studies met all criteria. They showed partial cost analyses but no full economic analyses. It could be assumed that the economic effect of the TCM changes over time. The costs of a care coordinator could not be determined because few detailed information was reported. The TCM may have negative consequences for hospitals. The results are not transferable to Germany.

CONCLUSION

There is no scientific evidence for the cost-effectiveness of the defined TCM. The optimal TCM duration still needs to be clarified. A detailed overview with units and prices and an additional consideration of the hospital perspective could help to make the information more transparent when deciding about the TCM implementation. A full economic analysis under German conditions or for similar European countries is necessary.

What works? Interventions to reduce readmission after hip fracture: A rapid review of systematic reviews

BACKGROUND

Hip fracture is a common serious injury in older people and reducing readmission after hip fracture is a priority in many healthcare systems. Interventions which significantly reduce readmission after hip fracture have been identified and the aim of this review is to collate and summarise the efficacy of these interventions in one place.

METHODS

In a rapid review of systematic reviews one reviewer (ELS) searched the Ovid SP version of Medline and the Cochrane Database of Systematic Reviews. Titles and abstracts of 915 articles were reviewed. Nineteen systematic reviews were included. (ELS) used a data extraction sheet to capture data on interventions and their effect on readmission. A second reviewer (RK) verified data extraction in a random sample of four systematic reviews. Results were not meta-analysed. Odds and risk ratios are presented where available.

RESULTS

Three interventions significantly reduce readmission in elderly populations after hip fracture: personalised discharge planning, self-care and regional anaesthesia. Three interventions are not conclusively supported by evidence: Oral Nutritional Supplementation, integration of care, and case management. Two interventions do not affect readmission after hip fracture: Enhanced Recovery pathways and comprehensive geriatric assessment.

CONCLUSIONS

Three interventions are most effective at reducing readmissions in older people: discharge planning, self-care, and regional anaesthesia. Further work is needed to optimise interventions and ensure the most at-risk populations benefit from them, and complete development work on interventions (e.g. interventions to reduce loneliness) and intervention components (e.g. adapting self-care interventions for dementia patients) which have not been fully tested yet.

Optimization of Heart Failure Patients Discharge Plan in Rajaie Cardiovascular Medical and Research Center: An Action Research

BACKGROUND

Chronic heart failure can lead to frequent hospitalizations. Improving the discharge planning is an approach to reduce hospitalization. Since there has not been enough structured and effective discharge plan in Iranian hospitals, the present study was designed to optimize this program.

METHOD

This is a participatory action research based on Hart and Bond's framework, conducted in a cardiovascular center in Iran from June 2016 to April 2018 during two cycles. Based on the optimization strategies obtained through semi-structured interviews with 15 participants, three focus group discussions and six expert panels, the operational discharge plan, including three areas of patient empowerment, telephone follow-up and home visit, was designed, implemented for three months and evaluated for 23 patients. European Heart Failure Self-Care Behavior Scale and information registration form to record the number of hospitalization and length of hospital stay were used to collect the quantitative data. The non-parametric Wilcoxon test was used to analyze the data by SPSS 16. Qualitative participatory evaluation was performed during a group discussion and analyzed based on qualitative content analysis method with conventional approach P<0.05 was statistically significant.

RESULTS

Considering the solutions provided by the participants, the operational discharge plan was designed and implemented with the cooperation of relevant stakeholders. Evaluation showed significant effects of designed discharge plan on self-care behavior (P<0.001), number of hospitalizations (P<0.001), and length of hospital stay (P<0.001).

CONCLUSION

Changes were made to improve the heart failure patients' discharge plan using action research, which resulted in reduced re-hospitalization and improved self-care behavior.

Factors Associated With Discharge Planning Practices for Patients Receiving Inpatient Psychiatric Care

OBJECTIVE

This study examined associations of patient, hospital, and service system factors with provision of discharge planning to individuals treated in hospital psychiatric units.

METHODS

This retrospective cohort analysis used 2012-2013 New York State Medicaid claims data of 18,185 patients ages <65 years who were treated in hospital psychiatric units and discharged to the community. The claims data were linked to data from managed behavioral health care organizations indicating whether inpatient staff scheduled a follow-up outpatient appointment with a mental health provider. Additional data regarding hospital and service system characteristics were obtained from the American Hospital Association Annual Survey, the Area Health Resource File, and other state administrative databases. Rates and adjusted odds ratios were assessed for the likelihood of inpatient staff scheduling a follow-up appointment.

RESULTS

Inpatient staff scheduled outpatient appointments for 79.8% of discharges. The adjusted odds of not having an outpatient appointment scheduled as part of the patient's discharge plan were significantly associated with several factors, including being homeless on admission, having a diagnosis of a co-occurring substance use disorder, having high levels of medical comorbid conditions, and not being engaged in psychiatric outpatient services in the month prior to admission.

CONCLUSIONS

Patient characteristics were more strongly associated with failure to receive discharge planning than were hospital and service system characteristics.

Measuring Processes of Integrated Care for Hospital to Home Transitions

Background:

Integrated care is a promising approach to improve transitions from hospital for older adults. Measures of integrated care tend to be survey-based or outcomes focused. This study determined the feasibility of using hospital chart data to measure integrated processes of care.

Methods:

This paper reports on two objectives: 1) the development of an integrated care transition framework and associated features of care; 2) a pilot study to test if the features could be applied to 214 hospital patient charts.

Results:

Twenty-four features were tested, and fifteen features could be reliably measured using chart review. Of these, the percent of patients classified as receiving integrated care varied widely across the items, from 0.05% to 84.1%.

Discussion:

The framework presented in this paper can guide measurement of system and clinical delivery of integrated care transitions. In combination with other tools, chart review can provide perspective on day-to-day care delivery not otherwise accessible, and highlight areas requiring practice change.

Conclusion:

Multiple measurement perspectives are needed to improve our understanding of how integrated care is being implemented. While chart review cannot address the full breadth of integrated care, it can help understand how processes of care are being implemented in routine daily care.

Adult patient and/or carer experiences of planning for hospital discharge after major trauma: a qualitative systematic review protocol

OBJECTIVE

To investigate patient and/or carer experiences of planning for discharge from an acute setting after a major trauma event.

INTRODUCTION

The experience of injury through major trauma is a worldwide issue that affects people of any age. These patients often experience long-lasting disability. During discharge from the acute setting, patients are at a high risk of experiencing an adverse event due to the complex nature of the process. This review aims to explore patient/carer opinion of their encounter with the discharge planning process following major trauma.

INCLUSION CRITERIA

This review will consider studies that include patients aged between 18 and 65 who had major traumatic central nervous system injury or were allocated an Injury Severity Score >12, with demonstrated possibility of having an ongoing disability at least one year post-injury. Qualitative studies exploring patient and/or carer experiences of their participation in discharge planning from a trauma unit, acute ward or inpatient rehabilitation to a community setting will be included.

METHODS

A three-stage search will be conducted and will include unpublished and gray literature. Databases to be searched include PubMed, Embase, PyscInfo, Scopus and CINAHL. Only studies published in English will be considered. Identified studies will be screened for inclusion in the review by two independent reviewers. Data will be extracted using a standardized tool and reviewers will discuss any disagreement. Data synthesis will adhere to the meta-aggregative approach to categorize findings. The categories will be synthesized into a set of findings that can be applied as evidence-based practice.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019138431.

Pharmacologically treated diabetes and hospitalization among older Norwegians receiving homecare services from 2009 to 2014: a nationwide register study

INTRODUCTION

The aim was to assess whether annual hospitalization (admissions, length of stay and total days hospitalized) among persons >65 years receiving home care services in Norway were higher for persons with diabetes than those without diabetes. Given the growing prevalence of diabetes, this issue has great importance for policy makers who must plan for meeting these needs.

RESEARCH DESIGN AND METHODS

Data were obtained from national Norwegian registries, and the study population varied from 112 487 to 125 593 per calendar year during 2009-2014. Diabetes was defined as having been registered with at least one prescription for blood glucose lowering medication. Overall and cause-specific hospitalization were compared, as well as temporal trends in hospitalization. Hospitalization outcomes for persons with and without diabetes were compared using log-binomial regression or quantile regression, adjusting for age and gender. Results are reported as incidence rate ratios (IRRs).

RESULTS

Higher total hospitalization rates (IRR 1.17; 95% CI 1.12 to 1.22) were found among persons with, versus without, diabetes, and this difference remained stable throughout the study period. Similar reductions over time in hospital length of stay were observed among persons with and without diabetes, but total annual days hospitalized decreased significantly (p=0.001) more among those with diabetes than among those without diabetes.

CONCLUSIONS

Among older recipients of home care services in Norway, diabetes was associated with a higher overall risk of hospitalization and increased days in the hospital. Given the growing prevalence of diabetes, it is important for policy makers to plan for meeting these needs.

Does the Clinical Frailty Scale at Triage Predict Outcomes From Emergency Care for Older People?

STUDY OBJECTIVE

We determine whether the Clinical Frailty Scale applied at emergency department (ED) triage is associated with important service- and patient-related outcomes.

METHODS

We undertook a single-center, retrospective cohort study examining hospital-related outcomes and their associations with frailty scores assessed at ED triage. Participants were aged 65 years or older, registered on their first ED presentation during the study period at a single, centralized ED in the United Kingdom. Baseline data included age, sex, Clinical Frailty Scale score, National Early Warning Score-2 and the Charlson Comorbidity Index score; outcomes included length of stay, readmissions (any future admissions), and mortality (inhospital or out of hospital) up to 2 years after ED presentation. Survival analysis methods (standard and competing risks) were applied to assess associations between ED triage frailty scores and outcomes. Unadjusted incidence curves and adjusted hazard ratios are presented.

RESULTS

A total of 52,562 individuals representing 138,328 ED attendances were included; participants' mean age was 78.0 years, and 55% were women. Initial admission rates generally increased with frailty. Mean length of stay after 30- or 180-day follow-up was relatively low; all Clinical Frailty Scale categories included patients who experienced zero days' length of stay (ie, ambulatory care) and patients with relatively high numbers of inhospital days. Overall, 46% of study participants were readmitted by the 2-year follow-up. Readmissions increased with Clinical Frailty Scale score up until a score of 6 and then attenuated. Mortality rates increased with increasing frailty; the adjusted hazard ratio was 3.6 for Clinical Frailty Scale score 7 to 8 compared with score 1 to 3.

CONCLUSION

Frailty assessed at ED triage (with the Clinical Frailty Scale) is associated with adverse outcomes in older people. Its use in ED triage might aid immediate clinical decisionmaking and service configuration.

"What should I do when I get home?" treatment plan discussion at discharge between specialist physicians and older in-patients: mixed method study

Background

During discharge from hospital, older patients and physicians discuss the plan for managing patients’ health at home. If not followed at home, it can result in poor medication management, readmissions, or other adverse events. Comorbidities, polypharmacy and cognitive impairment may create challenges for older patients. We assessed discharge conversations between older in-patients and physicians for treatment plan activities and medication information, with emphasis on the role of cognitive function in the ongoing conversation.

Methods

We collected 11 videos of discharge consultations, medication lists, and self-reported demographic information from hospitalised patients ≥65 years at the Geriatric department in a general hospital. Mini Mental State Examination score < 25 was classified as low cognitive function. We used microanalysis of face-to-face dialogue to identify and characterise sequences of interaction focused on and distinguishing the treatment plan activities discussed. In addition to descriptive statistics, we used a paired-sample t-test and Mann-Whitney U test for non-parametric data.

Results

Patients’ median age was 85 (range: 71–90);7 were females and 4 males. Median of 17 (range: 7 to 23) treatment plan activities were discussed. The proportions of the activities, grouped from a patient perspective, were: 0.40 my medications, 0.21 something the hospital will do for me, 0.18 someone I visit away from home, 0.12 daily routine and 0.09 someone coming to my home. Patients spoke less (mean 190.9 words, SD 133.9) during treatment plan activities compared to other topics (mean 759 words, SD 480.4), (p = .001). Patients used on average 9.2 (SD 3.1) medications; during the conversations, an average of 4.5 (SD 3.3) were discussed, and side effects discussed on average 1.2 (SD 2.1) times. During treatment plan discussions, patients with lower cognitive function were less responsive and spoke less (mean 116.5 words, SD 40.9), compared to patients with normal cognition (mean 233.4 words, SD 152.4), (p = .089).

Conclusion

Physicians and geriatric patients discuss many activities during discharge conversations, mostly focusing on medication use without stating side effects. Cognitive function might play a role in how older patients respond. These results may be useful for an intervention to improve communication between physicians and older hospitalised patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05860-9.

Mothers' experiences of exclusive breastfeeding in a postdischarge home setting

Re‐establishment and maintenance of exclusive breastfeeding (EBF) is recommended by the World Health Organization for the nutritional rehabilitation of malnourished infants under 6 months; however, there is no explicit guidance on how this should be achieved. The IBAMI study—a pilot study conducted in Kilifi, Kenya—implemented these recommendations using an intervention for hospitalized infants and their mothers that included ward‐based breastfeeding peer supporters. This paper explores how the challenges of maintaining EBF are recontextualized after infant hospitalization for malnutrition. Four weeks after discharge, semistructured interviews on experiences of trying to maintain EBF in a postdischarge home setting were conducted with a total of 20 mothers. Although most stated the aspiration of maintaining EBF for 6 months, a range of challenges were reported and not all had successfully maintained EBF post discharge. Reported challenges include the stress of household chores, food insecurity, technical difficulties and social stigma of expressing breast milk, pressure from neighbours and family members to introduce mixed feeding, and needing more community‐based awareness and support. Most of these challenges were specific to the home setting and were not easily surmountable, despite the breastfeeding practices mothers had learned in the ward. Indeed, in some cases, challenges were exacerbated by the overmedicalized nature of the breastfeeding practices taught in the ward. In order to aid the transition from ward to home, there may be a need to further translate ward‐based education and promotional messaging for EBF into a community setting, targeting other caregivers as well.

Postoperative Anemia Predicts Length of Stay for Geriatric Patients Undergoing Minimally Invasive Lumbar Spine Fusion Surgery

Introduction:

We hypothesize that postoperative anemia will predict length of stay (LOS) for geriatric patients undergoing minimally invasive (MIS) lumbar spine fusions.

Materials and Methods:

Patients who underwent MIS lateral and transforaminal lumbar interbody fusion between January 2017 and March 2018 at an academic tertiary care referral center were selected. Eighty-one patients were included. The primary outcome variable was LOS, measured in days. The predictors studied were preoperative hemoglobin (Hgb), postoperative day 1 Hgb, postoperative nadir Hgb, intraoperative Hgb decrement (preoperative Hgb-postoperative day 1 Hgb), perioperative Hgb decrement (preoperative Hgb-postoperative nadir Hgb), age, American Society of Anesthesiologists–Physical Status (ASA-PS) score, volume of perioperative intravenous (IV) fluids (IVFs), and number of levels fused. Simple linear regression and analysis of variance were used for statistical analysis.

Results:

In the present study, preoperative anemia was not associated with longer LOS (P = .15). Postoperative anemia was associated with longer LOS as both postoperative day 1 Hgb (P = .05*) and postoperative nadir Hgb (P < .0001*) predicted longer LOS. Greater intraoperative Hgb decrement did not predict longer LOS (P = .36); however, greater perioperative Hgb decrement predicted longer LOS (P < .0001*). Older age (P = .01*) and greater number of levels fused (P = .03*) predicted longer LOS; however, a greater ASA-PS classification did not predict longer LOS. Greater IVF administration was associated with longer LOS (P < .0001*).

Discussion:

Postoperative nadir Hgb (P < .0001*) was more predictive of longer LOS than postoperative day 1 Hgb (P = .05*). There is a perioperative Hgb decrement associated with longer LOS (P < .0001*). Geriatric patients may be more susceptible to the potential contributors to Hgb decrement, including occult bleeding post-op and hemodilution from IVF administration.

Conclusion:

Postoperative anemia, perioperative decrement in Hgb, older age, greater number of levels fused, and greater total IVFs administered predict longer LOS. Understanding the impact of these factors on LOS is critical as these procedures increasingly move to the outpatient setting.

Models and methods for determining the optimal number of beds in hospitals and regions: a systematic scoping review

BACKGROUND

Determining the optimal number of hospital beds is a complex and challenging endeavor and requires models and techniques which are sensitive to the multi-level, uncertain, and dynamic variables involved. This study identifies and characterizes extant models and methods that can be used to determine the required number of beds at hospital and regional levels, comparing their advantages and challenges.

METHODS

A systematic search was conducted using Web of Science, Scopus, Embase and PubMed databases, with the search terms hospital bed capacity, hospital bed need, hospital, bed size, model, and method.

RESULTS

Twenty-three studies met the criteria to be included in the review. Of these studies, a total of 11 models and 5 methods were identified, mainly designed to determine hospital bed capacity at the regional level. Common determinants of the required number of hospital beds in these models included demographic changes, average length of stay, admission rates, and bed occupancy rates.

CONCLUSIONS

There are no specific norms for the required number of beds at hospital and regional levels, but some of the identified models and methods may be used to estimate this number in different contexts. Moreover, it is important to consider alternative approaches to planning hospital capacity like care pathways to fix the limitations of "bed numbers".

Minimum Competency Recommendations for Programs That Provide Rehabilitation Services for Persons With Disorders of Consciousness: A Position Statement of the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research Traumatic Brain Injury Model Systems

Persons who have disorders of consciousness (DoC) require care from multidisciplinary teams with specialized training and expertise in management of the complex needs of this clinical population. The recent promulgation of practice guidelines for patients with prolonged DoC by the American Academy of Neurology, American Congress of Rehabilitation Medicine (ACRM), and National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) represents a major advance in the development of care standards in this area of brain injury rehabilitation. Implementation of these practice guidelines requires explication of the minimum competencies of clinical programs providing services to persons who have DoC. The Brain Injury Interdisciplinary Special Interest Group of the ACRM, in collaboration with the Disorders of Consciousness Special Interest Group of the NIDILRR-Traumatic Brain Injury Model Systems convened a multidisciplinary panel of experts to address this need through the present position statement. Content area-specific workgroups reviewed relevant peer-reviewed literature and drafted recommendations which were then evaluated by the expert panel using a modified Delphi voting process. The process yielded 21 recommendations on the structure and process of essential services required for effective DoC-focused rehabilitation, organized into 4 categories: diagnostic and prognostic assessment (4 recommendations), treatment (11 recommendations), transitioning care/long-term care needs (5 recommendations), and management of ethical issues (1 recommendation). With few exceptions, these recommendations focus on infrastructure requirements and operating procedures for the provision of DoC-focused neurorehabilitation services across subacute and postacute settings.

Frailty and functional decline after emergency abdominal surgery in the elderly: a prospective cohort study

Background

Frailty has been associated with an increased risk of adverse postoperative outcomes in elderly patients. We examined the impact of preoperative frailty on loss of functional independence following emergency abdominal surgery in the elderly.

Methods

This prospective cohort study was performed at a tertiary hospital, enrolling patients 65 years of age and above who underwent emergency abdominal surgery from June 2016 to February 2018. Premorbid variables, perioperative characteristics and outcomes were collected. Two frailty measures were compared in this study-the Modified Fried's Frailty Criteria (mFFC) and Modified Frailty Index-11 (mFI-11). Patients were followed-up for 1 year.

Results

A total of 109 patients were prospectively recruited. At baseline, 101 (92.7%) were functionally independent, of whom seven (6.9%) had loss of independence at 1 year; 28 (25.7%) and 81 (74.3%) patients were frail and non-frail (by mFFC) respectively. On univariate analysis, age, Charlson Comorbidity Index and frailty (mFFC) (univariate OR 13.00, 95% CI 2.21-76.63, p < 0.01) were significantly associated with loss of functional independence at 1 year. However, frailty, as assessed by mFI-11, showed a weaker correlation than mFFC (univariate OR 4.42, 95% CI 0.84-23.12, p = 0.06). On multivariable analysis, only premorbid frailty (by mFFC) remained statistically significant (OR 15.63, 95% CI 2.12-111.11, p < 0.01).

Conclusions

The mFFC is useful for frailty screening amongst elderly patients undergoing emergency abdominal surgery and is a predictor for loss of functional independence at 1 year. Including the risk of loss of functional independence in perioperative discussions with patients and caregivers is important for patient-centric emergency surgical care. Early recognition of this at-risk group could help with discharge planning and priority for post-discharge support should be considered.

Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

Background

Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.

Objectives

To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.

Data sources

Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.

Review methods

Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.

Findings

A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.

Limitations

Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.

Conclusions

Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.

Future work

Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.

Study registration

This study is registered as PROSPERO CRD42017080637.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The Discharge Communication Study: research protocol for a mixed methods study to investigate and triangulate discharge communication experiences of patients, GPs, and hospital professionals, alongside a corresponding discharge letter sample

BACKGROUND

Discharge letters are crucial during care transitions from hospital to home. Research indicates a need for improvement to increase quality of care and decrease adverse outcomes. These letters are often sent from the hospital discharging physician to the referring clinician, typically the patient's General Practitioner (GP) in the UK, and patients may or may not be copied into them. Relatively little is known about the barriers and enablers to sending patients discharge letters. Hence, the aim of this study was to investigate from GP, hospital professional (HP) and patient perspectives how to improve processes of patients receiving letters and increase quality of discharge letters. The study has a particular focus on the impacts of receiving or not receiving letters on patient experiences and quality of care.

METHODS

The setting was a region in the West Midlands of England, UK. The research aimed to recruit a minimum of 30 GPs, 30 patients and 30 HPs in order to capture 90 experiences of discharge communication. Participating GPs initially screened and selected a range of recent discharge letters which they assessed to be successful and unsuccessful exemplars. These letters identified potential participants who were invited to take part: the HP letter writer, GP recipient and patient. Participant viewpoints are collected through interviews, focus groups and surveys and will be "matched" to the discharge letter sample, so forming multiple-perspective "quartet" cases. These "quartets" allow direct comparisons between different discharge experiences within the same communicative event. The methods for analysis draw on techniques from the fields of Applied Linguistics and Health Sciences, including: corpus linguistics; inferential statistics; content analysis.

DISCUSSION

This mixed-methods study is novel in attempting to triangulate views of patients, GPs and HPs in relation to specific discharge letters. Patient and practitioner involvement will inform design decisions and interpretation of findings. Recommendations for improving discharge letters and the process of patients receiving letters will be made, with the intention of informing guidelines on discharge communication. Ethics approval was granted in July 2017 by the UK Health Research Authority. Findings will be disseminated in peer-reviewed journals, reports and newsletters, and presentations.

Interventions to Promote Early Discharge and Avoid Inappropriate Hospital (Re)Admission: A Systematic Review

Increasing pressure on limited healthcare resources has necessitated the development of measures promoting early discharge and avoiding inappropriate hospital (re)admission. This systematic review examines the evidence for interventions in acute hospitals including (i) hospital-patient discharge to home, community services or other settings, (ii) hospital discharge to another care setting, and (iii) reduction or prevention of inappropriate hospital (re)admissions. Academic electronic databases were searched from 2005 to 2018. In total, ninety-four eligible papers were included. Interventions were categorized into: (1) pre-discharge exclusively delivered in the acute care hospital, (2) pre- and post-discharge delivered by acute care hospital, (3) post-discharge delivered at home and (4) delivered only in a post-acute facility. Mixed results were found regarding the effectiveness of many types of interventions. Interventions exclusively delivered in the acute hospital pre-discharge and those involving education were most common but their effectiveness was limited in avoiding (re)admission. Successful pre- and post-discharge interventions focused on multidisciplinary approaches. Post-discharge interventions exclusively delivered at home reduced hospital stay and contributed to patient satisfaction. Existing systematic reviews on tele-health and long-term care interventions suggest insufficient evidence for admission avoidance. The most effective interventions to avoid inappropriate re-admission to hospital and promote early discharge included integrated systems between hospital and the community care, multidisciplinary service provision, individualization of services, discharge planning initiated in hospital and specialist follow-up.

Safe handovers for every patient: an interrupted time series analysis to test the effect of a structured discharge bundle in Dutch hospitals

OBJECTIVE

Patient handovers are often delayed, patients are hardly involved in their discharge process and hospital-wide standardised discharge procedures are lacking. The aim of this study was to implement a structured discharge bundle and to test the effect on timeliness of medical and nursing handovers, length of hospital stay (LOS) and unplanned readmissions.

DESIGN

Interrupted time series with six preintervention and six postintervention data collection points (September 2015 to June 2017).

SETTING

Internal medicine and surgical wards PARTICIPANTS: Patients (≥18 years) admitted for more than 48 hours to surgical or internal medicine wards.

INTERVENTION

The Transfer Intervention Procedure (TIP), containing four elements: planning the discharge date within 48 hours postadmission; arrangements for postdischarge care; preparing handovers and personalised patient discharge letter; and a discharge conversation 12-24 hours before discharge.

OUTCOME MEASURES

The number of medical and nursing handovers sent within 24 hours. Secondary outcomes were median time between discharge and medical handovers, LOS and unplanned readmissions.

RESULTS

Preintervention 1039 and postintervention 1052 patient records were reviewed. No significant change was observed in the number of medical and nursing handovers sent within 24 hours. The median (IQR) time between discharge and medical handovers decreased from 6.15 (0.96-15.96) to 4.08 (0.33-13.67) days, but no significant difference was found. No intervention effect was observed for LOS and readmission. In subgroup analyses, a reduction of 5.6 days in the median time between discharge and medical handovers was observed in hospitals with high protocol adherence and much attention for implementation.

CONCLUSION

Implementation of a structured discharge bundle did not lead to improved timeliness of patient handovers. However, large interhospital variation was observed and an intervention effect on the median time between discharge and medical handovers was seen in hospitals with high protocol adherence. Future interventions should continue to create awareness of the importance of timely handovers.

TRIAL REGISTRATION NUMBER

NTR5951; Results.

Implementation fidelity of a strategy to integrate service delivery: learnings from a transitional care program for individuals with complex needs in Singapore

BACKGROUND

To cope with rising demand for healthcare services in Singapore, Regional Health Systems (RHS) comprising of health and social care providers across care settings were set up to integrate service delivery. Tasked with providing care for the western region, in 2012, the National University Health System (NUHS) - RHS developed a transitional care program for elderly patients with complex healthcare needs who consumed high levels of hospital resources. Through needs assessment, development of personalized care plans and care coordination, the program aimed to: (i) improve quality of care, (ii) reduce hospital utilization, and (iii) reduce healthcare-related costs. In this study, recognizing the need for process evaluation in conjunction with outcome evaluation, we aim to evaluate the implementation fidelity of the NUHS-RHS transitional care program to explain the outcomes of the program and to inform further development of (similar) programs.

METHODS

Guided by the modified version of the Conceptual Framework for Implementation Fidelity (CFIF), adherence and moderating factors influencing implementation were assessed using non-participatory observations, reviews of medical records and program databases.

RESULTS

Most (10 out of 14) components of the program were found to be implemented with low or moderate level of fidelity. The frequency or duration of the program components were observed to vary based on the needs of users, availability of care coordinators (CC) and their confidence. Variation in fidelity was influenced predominantly by: (1) complexity of the program, (2) extent of facilitation through guiding protocols, (3) facilitation of program implementation through CCs' level of training and confidence, (4) evolving healthcare participant responsiveness, and (5) the context of suboptimal capability among community providers.

CONCLUSION

This is the first study to assess the context-specific implementation process of a transitional care program in the context of Southeast Asia. It provides important insights to facilitate further development and scaling up of transitional care programs within the NUHS-RHS and beyond. Our findings highlight the need for greater focus on engaging both healthcare providers and users, training CCs to equip them with the relevant skills required for their jobs, and building the capability of the community providers to implement such programs.

Local, collaborative, stepped and personalised care management for older people with chronic diseases (LoChro): study protocol of a randomised comparative effectiveness trial

BACKGROUND

Multimorbid older adults suffering from a long-term health condition like depression, diabetes mellitus type 2, dementia or frailty are at high risk of losing their autonomy. Disability and multimorbidity in the older population are associated with social inequality and lead to soaring costs. Our local, collaborative, stepped and personalised care management for older people with chronic diseases (LoChro-Care) aims at improving outcomes for older multimorbid patients with chronic conditions whose social and medical care must be improved.

METHODS

The study will evaluate the effects of LoChro-Care on functional health, depressive symptoms and satisfaction with care, resource utilisation as well as health costs in older persons with long-term conditions. The trial will compare the effectiveness of LoChro-Care and usual care in a cross-sectoral setting from hospital to community care. We will recruit 606 older adults (65+) admitted to local hospital inpatient or outpatient departments who are at risk of loss of independence. Half of them will be randomised to receive the LoChro-Care intervention, comprising seven to 16 contacts with chronic care managers (CCM) within 12 months. The hypothesis that LoChro-Care will result in better patient-centred outcomes will be tested through mixed-method process and outcome evaluation and valid measures completed at baseline and at 12 and 18 months. Cost-effectiveness analyses from the healthcare perspective will include incremental cost-effectiveness ratios.

DISCUSSION

The trial will provide evidence about the effectiveness of local, collaborative, stepped and personalised care management for multimorbid patients with more than one functional impairment or chronic condition. Positive results will be a first step towards the implementation of a systematic cross-sectoral chronic care management to facilitate the appropriate use of available medical and nursing services and to enhance self-management of older people.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS): DRKS00013904 ; Trial registration date: 02. February 2018.

KSHF Guidelines for the Management of Acute Heart Failure: Part II. Treatment of Acute Heart Failure

The prevalence of heart failure (HF) is on the rise due to the aging of society. Furthermore, the continuous progress and widespread adoption of screening and diagnostic strategies have led to an increase in the detection rate of HF, effectively increasing the number of patients requiring monitoring and treatment. Because HF is associated with substantial rates of mortality and morbidity, as well as high socioeconomic burden, there is an increasing need for developing specific guidelines for HF management. The Korean guidelines for the diagnosis and management of chronic HF were introduced in March 2016. However, chronic and acute HF represent distinct disease entities. Here, we introduce the Korean guidelines for the management of acute HF with reduced or preserved ejection fraction. Part II of this guideline covers the treatment of acute HF.