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Mitra B, Law A, Mathew J, Crabtree A, Mertin H, Underhill A, Noonan M, Hunter P, Smit DV. Telehealth consultation before inter-hospital transfer after falls in a subacute hospital (the PREVENT-2 study). Emerg Med Australas 2023; 35:306-311. [PMID: 36358005 DOI: 10.1111/1742-6723.14130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/09/2022] [Accepted: 10/11/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Inter-hospital transfers are increasingly common due to the regionalisation of healthcare, but are associated with patient discomfort, high costs and adverse events. The aim of the present study was to evaluate the effectiveness of a trauma outreach service for preventing inter-hospital transfers to a major trauma centre. METHODS This was an observational pre- and post-intervention study over a 12-month period from 1 October 2020 to 30 September 2021. Eligible patients sustained a fall at Caulfield Hospital, a subacute care hospital specialising in community services, rehabilitation, geriatric medicine and aged mental health. The intervention was delivery of site-specific education at Caulfield Hospital and a trauma outreach service by specialist trauma clinicians at The Alfred Hospital who provided remote assessment, assisted with clinical management decisions and advised on appropriateness of transfer. RESULTS The present study included 160 patients in the pre-intervention phase and 203 after the intervention. The primary outcome of transfer occurred in 19 (11.9%) patients in the pre-intervention phase and 4 (2.0%) in the post-intervention phase (P < 0.001). In the subgroup of patients without pelvis or long bone fractures, pre-intervention transfer occurred for 17 (10.9%) patients and post-intervention transfer occurred for 4 (2.0%) patients (P < 0.001). CT imaging was performed for 54 (33.8%) patients in the pre-intervention and 45 (22.2%) patients in the post-intervention group (P = 0.014). CONCLUSIONS Telehealth consultation with a trauma specialist was associated with significant reduction of inter-hospital transfers, and significant reduction of CT imaging. This supports continuation of the service with scope for expansion and evaluation of patient-centred outcomes.
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Affiliation(s)
- Biswadev Mitra
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Amelia Law
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Joseph Mathew
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Amelia Crabtree
- Health of Older People Unit, Caulfield Hospital, Melbourne, Victoria, Australia
| | - Helen Mertin
- Health of Older People Unit, Caulfield Hospital, Melbourne, Victoria, Australia
| | - Andrew Underhill
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Michael Noonan
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Peter Hunter
- Health of Older People Unit, Caulfield Hospital, Melbourne, Victoria, Australia
| | - De Villiers Smit
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
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McKechnie D, Fisher MJ, Pryor J, Mckechnie R. An examination of the nature and characteristics of patients readmitted to acute care from inpatient brain injury rehabilitation. J Adv Nurs 2020; 76:2586-2596. [PMID: 32748979 DOI: 10.1111/jan.14475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 05/21/2020] [Accepted: 06/26/2020] [Indexed: 11/30/2022]
Abstract
AIM To describe the nature of readmission to acute care and identify patient characteristics associated with avoidable readmission to acute care from inpatient brain injury rehabilitation. DESIGN A retrospective cohort design. METHODS Data prospectively documented between 1 January 2012 -31 December 2018 in local clinical and administrative database were used. Patient medical records were accessed when missing data were identified. Descriptive statistics were used to describe the nature of readmission episodes and univariate and multivariable logistic regression were used to identify patient characteristics associated with readmission to acute care. RESULTS Of the 383 patients admitted for rehabilitation, 83 (22%) experienced readmission to acute care for a total of 171 episodes. Thirty-seven percent of readmission episodes were due to hospital acquired complications and therefore potentially avoidable. Infection accounted for 63% of hospital acquired complications. Patients with an avoidable readmission episode (N = 38) were more likely to have a significantly lower Functional Independence Measure score, be incontinent, have a tracheostomy, require a mobility aid, and be prescribed a dysphagia diet on rehabilitation admission. Patients with a tracheostomy on rehabilitation admission had a 56% probability for an avoidable readmission to acute care. CONCLUSION Brain injury rehabilitation patients with an avoidable readmission to acute care were more likely to have a higher burden of care on rehabilitation admission and infection was the leading cause of avoidable readmission episodes. IMPACT Research into readmission to acute care in the mixed brain injury inpatient rehabilitation population is limited. In this patient population, readmission to acute care is a contemporary issue that can occur at any time during a patient's rehabilitation admission. This study provides valuable information informing practice change for preventing avoidable readmission episodes. Locally developed policy aimed at preventing readmission episodes should include proactive prevention, early recognition of complications and discrete escalation care pathways.
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Affiliation(s)
| | - Murray J Fisher
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, Sydney, NSW, Australia.,Nursing Research & Development, Royal Rehab, Ryde, NSW, Australia
| | - Julie Pryor
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, Sydney, NSW, Australia.,Nursing Research & Development, Royal Rehab, Ryde, NSW, Australia
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Digby R, Bolster D, Hughes L, Perta A, Bucknall TK. Examining subacute nurses' roles in a changing healthcare context. J Clin Nurs 2020; 29:2260-2274. [PMID: 32145040 DOI: 10.1111/jocn.15235] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 01/23/2020] [Accepted: 02/07/2020] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To explore and describe nurses' role in the rehabilitation and care of patients in one subacute care facility in Melbourne, Australia. BACKGROUND The role of nurses in subacute care and within the rehabilitation team is evolving and remains unclear. DESIGN Mixed methods. METHODS Fourteen nurses from seven rehabilitation and geriatric evaluation and management wards in one subacute facility in Melbourne, Australia, were observed in practice for two hours and then interviewed. Activities were recorded electronically. Interviews were audio-recorded and transcribed. Data were analysed using content analysis. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ). RESULTS Three main themes are as follows: (a) Nurses as rehabilitators; (b) Teamwork in rehabilitation; and (c) The changing context of subacute care. Nurses prioritised patient personal and clinical care above other responsibilities. They were largely excluded from team decision-making because clinical responsibilities precluded them from attending team meetings. Unsuitable buildings, increased patient acuity and time constraints were further challenges. CONCLUSIONS Nurses have a multifaceted role in patient rehabilitation that is poorly understood. An evaluation of the nursing role within the interdisciplinary team, skills and processes of care may increase understanding, and improve communication and relationships between disciplines potentially benefiting patients. Role clarity and differentiation in nursing skills are required within the nursing workforce. RELEVANCE TO CLINICAL PRACTICE Nurses have a unique role in both clinical care and rehabilitation of patients, and as part of the interdisciplinary team. Respectful professional relationships need fostering within the interdisciplinary team to achieve optimal patient outcomes. The way that team meetings and decision-making occur in the subacute wards requires adjustment to ensure that the valuable contribution of nurses, both to the interdisciplinary team and to the rehabilitation of patients, is used and acknowledged to improve patient care.
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Affiliation(s)
- Robin Digby
- School of Nursing and Midwifery, Faculty of Health, Deakin University Locked Bag, Geelong, Victoria, Australia.,Centre for Quality and Patient Safety Alfred Health Partnership, Alfred Health, Melbourne, Victoria, Australia
| | | | | | - Andrew Perta
- Caulfield Hospital, Caulfield, Victoria, Australia
| | - Tracey K Bucknall
- School of Nursing and Midwifery, Faculty of Health, Deakin University Locked Bag, Geelong, Victoria, Australia.,Centre for Quality and Patient Safety Alfred Health Partnership, Alfred Health, Melbourne, Victoria, Australia
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McKechnie D, Pryor J, Fisher MJ, Alexander T. Examination of the dependency and complexity of patients admitted to in-patient rehabilitation in Australia. AUST HEALTH REV 2020; 44:143-152. [DOI: 10.1071/ah18073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 10/15/2018] [Indexed: 11/23/2022]
Abstract
Objective
The aim of this study was to determine whether there has been a measurable change in the dependency and complexity of patients admitted to in-patient rehabilitation in Australia between 2007 and 2016.
Methods
A retrospective cohort study design was used to examine in-patient rehabilitation data held in the Australasian Rehabilitation Outcomes Centre Registry Database for the period 2007–16. Epidemiological descriptive analysis was used to examine datasets for difference between four discrete years (2007, 2010, 2013 and 2016). Datasets included patient demographics, length of stay (LOS), comorbidities, complications and the Functional Independence Measure (FIM™).
Results
Between 2007 and 2016, rehabilitation in-patients as a whole: (1) had a mean decrease in total admission FIM score; (2) became more complex, as evidenced by the increased proportion of particular comorbidities impacting on rehabilitation, namely cardiac and respiratory disease, dementia, diabetes and morbid obesity; and (3) had a mean decrease in total discharge FIM score. However, there was an increase in the proportion of patients discharged home from rehabilitation (from 86.5% to 92%) and decreases in onset and rehabilitation LOS of 2.2 and 2.5 days respectively.
Conclusion
The dependency and complexity of patients admitted to in-patient rehabilitation in Australia has increased between 2007 and 2016.
What is known about the topic?
Anecdotal reports suggest that rehabilitation patients in Australia have become more complex, necessitating increased active management of their presenting health condition and comorbid health conditions. However, to date, no systematic investigation has been undertaken to examine trends in rehabilitation in-patient dependency and complexity over time.
What does this paper add?
This study provides measurable evidence of increased dependency and complexity in patients admitted to rehabilitation in Australia. Further, compared with 2007, rehabilitation in-patients as a whole had an increased burden of care on discharge from rehabilitation in 2016.
What are the implications for practitioners?
The changes in patient dependency and complexity reported in this study have implications for rehabilitation service delivery. This is because the increased need for illness or injury and comorbidity management may result in increased potential for acute complications and health deterioration, and compensatory care for patients during rehabilitation. Clinicians may need to widen their skill set to include more acute and chronic illness management.
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McKechnie D, Fisher MJ, Pryor J, McKechnie R. Predictors of unplanned readmission to acute care from inpatient brain injury rehabilitation. J Clin Nurs 2019; 29:593-601. [PMID: 31769573 DOI: 10.1111/jocn.15118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/29/2019] [Accepted: 11/19/2019] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To identify the predictors of unplanned readmission to acute care (RTAC) from inpatient brain injury rehabilitation and to develop a risk prediction model. BACKGROUND RTAC from inpatient rehabilitation is not uncommon. Individual rehabilitation patient populations require their own body of evidence regarding predictors of RTAC. DESIGN Retrospective cohort study. METHODS Adult patients with new onset acquired brain injury admitted to a stand-alone rehabilitation facility between 1 January 2012-31 December 2018 were included in the study. The main measures were RTAC, sensitivity, specificity, the C-statistic and Youden's index. This paper is reported using the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. RESULTS Of 383 patients admitted for rehabilitation, 83 (22%) experienced a RTAC; 69 (18%) patients had at least one unplanned RTAC episode. Patients requiring unplanned RTAC were more likely to have lower Glasgow Coma Scale (GCS) and Functional Independence Measure (FIM) scores on rehabilitation admission, a higher burden of care on rehabilitation discharge and be discharged to a nonhome residence. Rehabilitation admission GCS and motor FIM were identified as the independent RTAC predictors in multivariate regression modelling. The combined C-statistic was 0.86. A GCS cut-off score of ≤14 and motor FIM cut-off score of ≤40 were identified as optimal, yielding a combined Youden's index of 0.56 (sensitivity = 0.72; specificity = 0.83). CONCLUSION Patients requiring an unplanned RTAC had a lower functional status on rehabilitation admission. A prediction model for unplanned RTAC has been developed using validated and readily available clinical measures. RELEVANCE TO CLINICAL PRACTICE The developed RTAC risk prediction model is the first step in preventing unplanned RTAC from inpatient brain injury rehabilitation. Future research should focus on discrete interventions for preventing unplanned RTAC from inpatient brain injury rehabilitation.
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Affiliation(s)
| | - Murray J Fisher
- Sydney Nursing School, The University of Sydney, Sydney, NSW, Australia.,Nursing Research & Development, Royal Rehab, Sydney, NSW, Australia
| | - Julie Pryor
- Sydney Nursing School, The University of Sydney, Sydney, NSW, Australia.,Nursing Research & Development, Royal Rehab, Sydney, NSW, Australia
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McKechnie D, Pryor J, McKechnie R, Fisher MJ. Predictors of Readmission to Acute Care from Inpatient Rehabilitation: An Integrative Review. PM R 2019; 11:1335-1345. [PMID: 31041836 DOI: 10.1002/pmrj.12179] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 04/23/2019] [Indexed: 11/09/2022]
Abstract
Readmission to acute care (RTAC) from inpatient rehabilitation can have negative consequences for individuals and associated financial costs are increasing. Consequently, preventing avoidable RTAC represents a target for improvement in quality of care. The aim of this integrative review was to identify predictors of RTAC from inpatient rehabilitation. A systematic search of MEDLINE, EMBASE, ProQuest, and CINAHL databases was used. Thematic analysis was used to examine extracted data. Strong evidence indicating that the principal predictors of RTAC are lower functional status on admission to rehabilitation, a more severe injury and a higher number of comorbidities was identified in this review. This is despite the heterogeneous nature of impairment groups and factors/measures examined. However, the relevance of some predictors of RTAC (such as patient demographics, invasive devices and primary diagnoses) may be dependent on rehabilitation setting, impairment group or time between rehabilitation admission and RTAC (eg, below 3 vs 30 days). Consequently, findings of this integrative review highlight that RTAC is a complex, multifactorial patient issue with a complex interplay between the predictors and reasons for RTAC. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
| | - Julie Pryor
- Royal Rehab, Sydney, Australia.,Sydney Nursing School, The University of Sydney, Sydney, Australia
| | | | - Murray J Fisher
- Royal Rehab, Sydney, Australia.,Sydney Nursing School, The University of Sydney, Sydney, Australia
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Considine J, Street M, Bucknall T, Rawson H, Hutchison AF, Dunning T, Botti M, Duke MM, Mohebbi M, Hutchinson AM. Characteristics and outcomes of emergency interhospital transfers from subacute to acute care for clinical deterioration. Int J Qual Health Care 2019; 31:117-124. [PMID: 29931281 DOI: 10.1093/intqhc/mzy135] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 05/03/2018] [Accepted: 05/24/2018] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To describe characteristics and outcomes of emergency interhospital transfers from subacute to acute hospital care and develop an internally validated predictive model to identify features associated with high risk of emergency interhospital transfer. DESIGN Prospective case-time-control study. SETTING Acute and subacute healthcare facilities from five health services in Victoria, Australia. PARTICIPANTS Cases were patients with an emergency interhospital transfer from subacute to acute hospital care. For every case, two inpatients from the same subacute care ward on the same day of emergency transfer were randomly selected as controls. Admission episode was the unit of measurement and data were collected prospectively. MAIN OUTCOME MEASURES Patient and admission characteristics, transfer characteristics and outcomes (cases), serious adverse events and mortality. RESULTS Data were collected for 603 transfers in 557 patients and 1160 control patients. Cases were significantly more likely to be male, born in a non-English speaking country, have lower functional independence, more frequent vital sign assessments and experience a serious adverse event during first acute care or subacute care admissions. When adjusted for health service, cases had significantly higher inpatient mortality, were more likely to have unplanned intensive care unit admissions and rapid response team calls during their entire hospital admission. CONCLUSIONS Patients who require an emergency interhospital transfer from subacute to acute hospital care have hospital admission rates and in-hospital mortality. Clinical instability during the first acute care admission (serious adverse events or increased surveillance) may prompt reassessment of patient suitability for movement to a separate subacute care hospital.
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Affiliation(s)
- Julie Considine
- Deakin University, School of Nursing and Midwifery, Gheringhap St, Geelong, VIC, Australia.,Centre for Quality and Patient Safety Research - Eastern Health Partnership, Arnold St, Box Hill, VIC, Australia
| | - Maryann Street
- Deakin University, School of Nursing and Midwifery, Gheringhap St, Geelong, VIC, Australia.,Centre for Quality and Patient Safety Research - Eastern Health Partnership, Arnold St, Box Hill, VIC, Australia
| | - Tracey Bucknall
- Deakin University, School of Nursing and Midwifery, Gheringhap St, Geelong, VIC, Australia.,Centre for Quality and Patient Safety Research - Alfred Health Partnership, Commercial Rd, Melbourne, VIC, Australia
| | - Helen Rawson
- Deakin University, School of Nursing and Midwifery, Gheringhap St, Geelong, VIC, Australia.,Centre for Quality and Patient Safety Research - Monash Health Partnership, Clayton Rd, Clayton, VIC, Australia
| | - Anastasia F Hutchison
- Deakin University, School of Nursing and Midwifery, Gheringhap St, Geelong, VIC, Australia.,Centre for Quality and Patient Safety Research - Epworth HealthCare Partnership, Bridge Rd, Richmond, VIC, Australia
| | - Trisha Dunning
- Deakin University, School of Nursing and Midwifery, Gheringhap St, Geelong, VIC, Australia.,Centre for Quality and Patient Safety Research - Barwon Health Partnership, Bellerine St, Geelong, VIC, Australia
| | - Mari Botti
- Deakin University, School of Nursing and Midwifery, Gheringhap St, Geelong, VIC, Australia.,Centre for Quality and Patient Safety Research - Epworth HealthCare Partnership, Bridge Rd, Richmond, VIC, Australia
| | - Maxine M Duke
- Deakin University, School of Nursing and Midwifery, Gheringhap St, Geelong, VIC, Australia.,Centre for Quality and Patient Safety Research, Gheringhap St, Geelong, VIC, Australia
| | - Mohammadreza Mohebbi
- Faculty of Health Biostatistics Unit, Deakin University, Pigdons Rd, Geelong, VIC, Australia
| | - Alison M Hutchinson
- Deakin University, School of Nursing and Midwifery, Gheringhap St, Geelong, VIC, Australia.,Centre for Quality and Patient Safety Research - Monash Health Partnership, Clayton Rd, Clayton, VIC, Australia
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Considine J, Street M, Hutchinson AM, Bucknall T, Rawson H, Hutchison AF, Dunning T, Duke MM, Mohebbi M, Botti M. Timing of emergency interhospital transfers from subacute to acute care and patient outcomes: A prospective cohort study. Int J Nurs Stud 2019; 91:77-85. [DOI: 10.1016/j.ijnurstu.2018.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 12/06/2018] [Accepted: 12/06/2018] [Indexed: 11/26/2022]
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Street M, Considine J. Analysis of the impact of limitation of medical treatment orders during unplanned transfers from sub-acute care to Emergency Departments. ACTA ACUST UNITED AC 2015; 19:37-43. [PMID: 26601595 DOI: 10.1016/j.aenj.2015.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 09/24/2015] [Accepted: 10/02/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The impact of limitation of medical treatment orders (LOMT) on patient outcomes following transfer from sub-acute care to the Emergency Department remains unclear. METHODS Retrospective medical record review of 431 adult in-patients who required ambulance transfer following clinical deterioration during a sub-acute care admission during 2010. RESULTS Common reasons for transfer were respiratory (18.9%) or neurological (19.0%) conditions; 35.7% (154/431) were transferred within one week of sub-acute care admission. LOMT orders were in place for 37.8% (n=163) patients who were older (p<0.001), with more comorbidities (p<0.005), specifically cardiac, renal and pulmonary disease than patients without LOMT. Patients with LOMT orders had more physiological abnormalities before transfer; tachypnoea (43.7% vs 28.6%), hypoxaemia (63.5% vs 48.4%) and severe hypoxaemia (27.6% vs 14.5%). There were no differences in rates of admission, cardiac arrest, Medical Emergency Team activation or ICU admission. For admitted patients, those with LOMT orders had significantly (p≤0.005) higher mortality: in-hospital (21.9% vs 11.3%); 30 days (23.9% vs 12.3%) and 60 days (28.2% vs 13.4%). CONCLUSIONS Patients with LOMT had higher levels of comorbidity and were more acutely ill during their sub-acute care admission. Once transferred those with a LOMT had similar rates of cardiac arrest, MET activation and unplanned ICU admission, but higher mortality.
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Affiliation(s)
- Maryann Street
- Deakin University, School of Nursing and Midwifery and Centre for Quality and Patient Safety, Geelong, Victoria, Australia; Eastern Health - Deakin University Nursing & Midwifery Research Centre, Level 2, 5 Arnold Street, Box Hill, Victoria 3128, Australia.
| | - Julie Considine
- Deakin University, School of Nursing and Midwifery and Centre for Quality and Patient Safety, Geelong, Victoria, Australia; Eastern Health - Deakin University Nursing & Midwifery Research Centre, Level 2, 5 Arnold Street, Box Hill, Victoria 3128, Australia
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