[Inappropriateness of hospital use in two acute geriatrics department: description of the phenomenon and analysis of risk factors]

Factors predisposing nursing home resident to inappropriate transfer to emergency department. The FINE study protocol

Background

Each year, around one out of two nursing home (NH) residents are hospitalized in France, and about half to the emergency department (ED). These transfers are frequently inappropriate. This paper describes the protocol of the FINE study. The first aim of this study is to identify the factors associated with inappropriate transfers to ED.

Methods/design

FINE is a case-control observational study. Sixteen hospitals participate. Inclusion period lasts 7 days per season in each center for a total period of inclusion of one year. All the NH residents admitted in ED during these periods are included. Data are collected in 4 times: before transfer in the NH, at the ED, in hospital wards in case of patient's hospitalization and at the patient's return to NH. The appropriateness of ED transfers (i.e. case versus control NH residents) is determined by a multidisciplinary team of experts.

Results

Our primary objective is to determine the factors predisposing NH residents to inappropriate transfer to ED. Our secondary objectives are to assess the cost of the transfers to ED; study the evolution of NH residents' functional status and the psychotropic and inappropriate drugs prescription between before and after the transfer; calculate the prevalence of potentially avoidable transfers to ED; and identify the factors predisposing NH residents to potentially avoidable transfer to ED.

Discussion

A better understanding of the determinant factors of inappropriate transfers to ED of NH residents may lead to proposals of recommendations of better practice in NH and would allow implementing quality improvement programs in the health organization.

French Multicenter Evaluation of the Appropriateness of Admission to the Emergency Department of the Over-80s

BACKGROUND

Persons over 80 represents 40% of patients in French emergency services. We assessed the appropriateness of these admissions and sought to identify risk factors for inappropriate hospital stays.

METHODS

The appropriateness of admission was assessed in a prospective, cross-sectional, multicenter study in eight hospitals in France by means of the Appropriateness Evaluation Protocol (French version, AEPf) during two non-consecutive periods of four weeks in 2010. We analyzed admission of patients aged 80 and over who were admitted to the hospital after a stay in the emergency department of the same hospital. Demographics and morbidity factors were recorded as were administrative hospitalization data to identify risk factors associated with inappropriate admissions. We also evaluated the economic impact of inappropriate admissions. For cost analysis, all variables were obtained from anonymized hospital reports of a diagnosis-related group system used for funding of the hospitals by health insurance.

RESULTS

During two different periods, 1577 patients were included. 139 (8.8%) hospital admissions were inappropriate according to explicit criteria of the AEPf, but 18 of these (1.1%) were in fact considered appropriate by the physician responsible for the admission, leading to 121 (7.7%) inappropriate admissions. Multivariate logistic regression showed that patients with heart disease were less often subject to inappropriate admission (odds ratio OR= 0.36 [0.23; 0.56], p < 0.001), as also were patients who usually lived in a nursing home (OR = 0.53 [0.30; 0.87], p = 0.018) and patients with higher Acute Physiology Scores (OR = 0.97 [0.95; 0.99], p < 0.001). Inappropriate admission increased when patients had a syndrome as the main diagnosis (OR = 1.81 [1.81; 2.83], p = 0.010). By contrast, cognitive functions, gait and balance disturbance or falls, behavioral disorders and method of transport to the emergency department did not change the probability of inappropriateness. The median cost of the hospital stay of an older patient was 3 606.5 [2 498.1; 4 994.2] euros for inappropriate admissions.

CONCLUSION

Inappropriate emergency admissions of older patients were infrequent. None of the geriatric syndromes were linked with the phenomenon and principle causes were severity of illness, mention of a cardiac disease, unclear pattern of consultation and institutionalized way of life.

Causes of inappropriate hospital days: development and validation of a French assessment tool for rehabilitation centres

OBJECTIVE

To develop and validate a list of criteria to assess the causes of inappropriate hospital days for patients admitted to rehabilitation centres and sub-acute care units.

DESIGN

The tool was developed by a multidisciplinary panel of 33 experts, using a formalized consensus method. It collects both the needs of patients (distinguishing healthcare needs (9 criteria) and accommodation needs (9 criteria)) and the reasons for inappropriateness (19 criteria). Inappropriate days were identified using the tool to assess appropriateness of hospital days validated previously. Reliability was studied by measuring agreement between two independent simultaneous ratings.

SETTING

The validation study was performed on a randomized sample of 576 hospital days from 22 wards in France.

MAIN OUTCOME MEASURES

Inter-rater reliability was evaluated using the κ-statistic and prevalence-adjusted and bias-adjusted kappa (PABAK).

RESULTS

For patient accommodation needs, the inter-rater reliability was estimated by a κ-value of 0.80 (95% confidence interval (95% CI) 0.66-0.92) and a PABAK of 0.80 (95% CI 0.63-0.91). There was good agreement on the reasons for inappropriateness, with κ-values from 0.30 to 0.60 and PABAK from 0.46 to 0.69. The κ-coefficient varied from 0.33 to 0.49 for the assessment of patient healthcare needs, with PABAK ranging from 0.49 to 0.72.

CONCLUSIONS

The instrument is suitable and valid to assess the causes of inappropriate hospital days in rehabilitation centres and sub-acute care units. The study showed that the tool can be easily used by healthcare workers, which makes it useful for quality improvement.