Substitution of a nursing-led inpatient unit for acute services: randomized controlled trial of outcomes and cost of nursing-led intermediate care

Transitional care programs for older adults moving from hospital to home in Canada: A systematic review of text and opinion

BACKGROUND

Investing in transitional care programs is critical for ensuring continuity of health and coordinated care for older adults transitioning across health settings. However, literature delineating the scope of transitional care programs across Canada is limited. The aim of this systematic review of text and opinion is to characterize Canadian transitional care programs for older adults transitioning from hospital to home.

METHODS

Following JBI guidelines for systematic review of text and opinion, we conducted a search of Canadian grey literature sources published online between 2016 to 2023. A 3-phase search was undertaken for: 1) Canadian databases and organizational websites; 2) advanced Google search of national sources and news media reports; and 3) advanced Google search of provincial/territorial sources. Two reviewers independently screened sources for eligibility against inclusion criteria. Data were extracted by one reviewer and verified by a second. Textual data were extracted from multiple sources to characterize each transitional care program.

RESULTS

Grey literature search produced a total of 17,092 text and opinion sources, identifying 119 transitional care programs in Canada. Model of care was a key characteristic defining the design and delivery of transitional care programs within community (n = 42), hospital (n = 45), and facility-based (n = 32) settings. Programs were characterized by goal, population and eligibility, setting and length of program, intervention and services, and healthcare team members. Patient, caregiver, and health system outcomes were reported for 18 programs. The province of Ontario has the most transitional care programs (n = 84) and reported outcomes, followed by British Columbia (n = 10).

CONCLUSIONS

Characterizing transitional care programs is important for informing health services planning and scaling up of transitional care program models across Canada. Recognizing transitional care programs as a core health service is critical to meet the health care needs of older adults at the right time and place.

TRIAL REGISTRATION

PROSPERO ID 298821.

Transitional care programs in Canada for older adults transitioning from hospital to home: protocol for a systematic review of text and opinion

OBJECTIVE

The objective of this systematic review is to identify what transitional care programs exist across Canada, including the characteristics and outcomes of these programs.

INTRODUCTION

There is growing evidence of the benefits of transitional care programs to support older adults moving from hospital to home. However, there is limited literature identifying the types of transitional care programs that exist internationally and little evidence available within Canada.

INCLUSION CRITERIA

Sources of gray literature published from 2016 that focus on older adults receiving services from transitional care programs to move from hospital to home in Canada will be considered for inclusion. Sources of gray literature will be excluded if interventions are targeted at adults younger than 65 years, Indigenous adults younger than 55 years, or if the primary discharge destination is not an independent community dwelling. Interventions designed for older adults waiting in hospital for long-term care placement will also be excluded from this review.

METHODS

An initial limited search of Canadian national gray literature resources will be undertaken, followed by an advanced Google search of Canadian resources and news media reports. Lastly, an advanced search of Google for all 10 provinces and 3 territories will be undertaken to target examples of local transitional care programs that may not be found through a national search, such as local pilot projects, health region-specific programs, and provincial organizations. All identified sources will be retrieved and full text review of selected citations assessed in detail by 2 independent reviewers. Data about the characteristics and outcomes of transitional care programs and results will be extracted and synthesized, with a meta-aggregation approach for grading according to JBI ConQual method.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022298821.

Understanding transitional care programs for older adults who experience delayed discharge: a scoping review

Background

Many hospitalized older adults cannot be discharged because they lack the health and social support to meet their post-acute care needs. Transitional care programs (TCPs) are designed to provide short-term and low-intensity restorative care to these older adults experiencing or at risk for delayed discharge. However, little is known about the contextual factors (i.e., patient, staff and environmental characteristics) that may influence the implementation and outcomes of TCPs. This scoping review aims to answer: 1) What are socio-demographic and/or clinical characteristics of older patients served by TCPs?; 2) What are the core components provided by TCPs?; and 3) What patient, caregiver, and health system outcomes have been investigated and what changes in these outcomes have been reported for TCPs?

Methods

The six-step scoping review framework and PRISMA-ScR checklist were followed. Studies were included if they presented models of TCPs and evaluated them in community-dwelling older adults (65+) experiencing or at-risk for delayed discharge. The data synthesis was informed by a framework, consistent with Donabedian’s structure-process-outcome model.

Results

TCP patients were typically older women with multiple chronic conditions and some cognitive impairment, functionally dependent and living alone. The review identified five core components of TCPs: assessment; care planning and monitoring; treatment; discharge planning; and patient, family and staff education. The main outcomes examined were functional status and discharge destination. The results were discussed with a view to inform policy makers, clinicians and administrators designing and evaluating TCPs as a strategy for addressing delayed hospital discharges.

Conclusion

TCPs can influence outcomes for older adults, including returning home. TCPs should be designed to incorporate interdisciplinary care teams, proactively admit those at risk of delayed discharge, accommodate persons with cognitive impairment and involve care partners. Additional studies are required to investigate the contributions of TCPs within integrated health care systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02099-9.

Effectiveness of nurse-led peri-discharge interventions for reducing 30-day hospital readmissions: Network meta-analysis

BACKGROUND

Existing systematic reviews have compared the effectiveness of nurse-led peri-discharge interventions comprising different components with usual care on reducing all-cause 30-day hospital readmissions. However, conflicting results were reported.

OBJECTIVE

We conducted a network meta-analysis to evaluate the comparative effectiveness of different nurse-led peri-discharge interventions, compared with usual care, for reducing all-cause 30-day hospital readmissions.

DESIGN

Network meta-analysis.

METHODS

A total of five international databases were searched for systematic reviews of randomized controlled trials. Additional searches for most updated randomized controlled trials published between 2014 to 2019 were conducted. Data from included randomized controlled trials were extracted for random-effect pairwise meta-analyses. Pooled risk ratios with 95% confidence interval were used to quantify impact of nurse-led peri-discharge interventions on all-cause 30-day hospital readmissions. Network meta-analysis was used to evaluate the comparative effectiveness of different interventions.

RESULTS

From two systematic reviews and additional randomized controlled trial searches, 12 eligible randomized controlled trials (n=150,840) assessing 15 different nurse-led peri-discharge interventions were included. For reducing all-cause 30-day hospital readmissions, pairwise meta-analysis showed that there was no significant difference between nurse-led peri-discharge interventions and usual care (pooled risk ratios = 0.86, 95% confidence interval: 0.71-1.04, moderate quality of evidence). Network meta-analysis indicated no significant difference across different interventions despite variation in complexity.

CONCLUSIONS

Our results indicated that nurse-led peri-discharge interventions were not significantly different from usual care for reducing all-cause 30-day hospital readmissions. Simpler nurse-led peri-discharge interventions are on par with more complex interventions in terms of effectiveness. Benefits of nurse-led peri-discharge interventions may vary across health system context. Therefore, careful consideration is required prior to implementation.

REGISTRATION DETAILS

The protocol for this study has been registered in PROSPERO (Registration No. CRD42020186938). Tweetable abstract: This study suggested that nurse-led peri-discharge interventions do not differ from usual care for reducing all-cause 30-day hospital readmissions.

A Stab in the Dark? Point-of-Care Testing in the Population With Hip Fracture

Hip fracture incidence rises globally in an aging population who live in an era of financial austerity. Health service providers are under pressure both to optimize care and to increase efficiencies in the management of this vulnerable patient group. One area of inefficiency in perioperative processes is the assessment of deranged clotting profiles secondary to warfarinization and in the monitoring of hemoglobin. Delays are inherent in these processes, threatening patient care and impacting on financial incentivisation of performance. Point-of-care testing, while widespread in other areas of health care, is underutilized in hip fracture management. This work explores the application to hip fracture care of this technology and suggests future direction to investigate its potential benefits.

Secondary analysis and literature review of community rehabilitation and intermediate care: an information resource

Background and design

This research was based on a reanalysis of a merged data set from two intermediate care (IC) projects in order to identify patient characteristics associated with outcomes [Nancarrow SA, Enderby PM, Moran AM, Dixon S, Parker SG, Bradburn MJ,et al.The Relationship Between Workforce Flexibility and the Costs and Outcomes of Older Peoples’ Services (COOP). Southampton: National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO); 2010 and Nancarrow SA, Enderby PM, Ariss SM, Smith T, Booth A, Campbell MJ,et al.The Impact of Enhancing the Effectiveness of Interdisciplinary Working (EEICC). Southampton: NIHR SDO; 2012]. Additionally, the impact of different team and staffing structures on patient outcomes and service costs was examined, when possible given the data sets, to enable identification of the most cost-effective service configurations and change over time with service provision. This secondary analysis was placed within updated literature reviews focused on the separate questions.

Research objectives

(1) To identify those patients most likely to benefit from IC and those who would be best placed to receive care elsewhere; (2) to examine the effectiveness of different models of IC; (3) to explore the differences between IC service configurations and how they have changed over time; and (4) to use the findings above to develop accessible evidence to guide service commissioning and monitoring.

Setting

Community-based services for older people are described in many different ways, among which are IC services and community rehabilitation. For the purposes of this report we call the services IC services and include all community-based provision for supporting older people who would otherwise be admitted to hospital or who would require increased length of stay in hospital (e.g. hospital at home schemes, post-acute care, step-up and step-down services).

Participants

The combined data set contained data on 8070 patient admissions from 32 IC teams across England and included details of the service context, costs, staffing/skill mix (800 staff), patient health status and outcomes.

Interventions

The interventions associated with the study cover the range of services and therapies available in IC settings. These are provided by a wide range of professionals and care staff, including nursing, allied health and social care.

Outcome measures

(1) Service data – each team provided information relating to the size, nature, staffing and resourcing of the services. Data were collected on a service pro forma. (2) Team data – all staff members of the teams participating in both studies provided individual information using the Workforce Dynamics Questionnaire. (3) Patient data – patient data were collected on admission and discharge using a client record pack. The client record pack recorded a range of data utilising a number of validated tools, such as demographic data, level of care (LoC) data, therapy outcome measure (TOM) scale, European Quality of Life-5 Dimensions (EQ-5D) questionnaire and patient satisfaction survey.

Results

(1) The provision of IC across England is highly variable with different referral routes, team structures, skill mix and cost-effectiveness; (2) in more recent years, patients referred to IC have more complex needs associated with more severe impairments; (3) patients most likely to improve were those requiring rehabilitation as determined by levels 3, 4 and 5 on the LoC (> 40% for impairment, activity and participation, and > 30% for well-being as determined on the TOM scale); (4) half of all patients with outcome data improved on at least one of the domains of the TOM scale; (5) for every 10-year increase in age there was a 6% decrease in the odds of returning home. The chance of remaining or returning home was greater for females than males; (6) a high percentage of patients referred to IC do not require the service; and (7) teams including clinical support staff and domiciliary staff were associated with a small relative improvement in TOM impairment scores when compared with other teams.

Conclusions

This study provides additional evidence that interdisciplinary teamworking in IC may be associated with better outcomes for patients, but care should be taken with overinterpretation. The measures that were used within the studies were found to be reliable, valid and practical and could be used for benchmarking. This study highlights the need for funding high-quality studies that attempt to examine what specific team-level factors are associated with better outcomes for patients. It is therefore important that studies in the future attempt empirically to examine what process-level team variables are associated with these outcomes.

Funding

The NIHR Health Services and Delivery Research programme.

National trends and local delivery in old age mental health services: towards an evidence base. A mixed-methodology study of the balance of care approach, community mental health teams and specialist mental health outreach to care homes

Background

The rising number of older people with mental health problems makes the effective use of mental health resources imperative. Little is known about the clinical effectiveness and/or cost-effectiveness of different service models.

Aims

The programme aimed to (1) refine and apply an existing planning tool [‘balance of care’ (BoC)] to this client group; (2) identify whether, how and at what cost the mix of institutional and community services could be improved; (3) enable decision-makers to apply the BoC framework independently; (4) identify variation in the structure, organisation and processes of community mental health teams for older people (CMHTsOP); (5) examine whether or not different community mental health teams (CMHTs) models are associated with different costs/outcomes; (6) identify variation in mental health outreach services for older care home residents; (7) scope the evidence on the association between different outreach models and resident outcomes; and (8) disseminate the research findings to multiple stakeholder groups.

Methods

The programme employed a mixed-methods approach including three systematic literature reviews; a BoC study, which used a systematic framework for choosing between alternative patterns of support by identifying people whose needs could be met in more than one setting and comparing their costs/outcomes; a national survey of CMHTs’ organisation, structure and processes; a multiple case study of CMHTs exhibiting different levels of integration encompassing staff interviews, an observational study of user outcomes and a staff survey; national surveys of CMHTs’ outreach activities and care homes. A planned randomised trial of depression management in care homes was removed at the review stage by the National Institute for Health Research (NIHR) prior to funding award.

Results

BoC: Past studies exhibited several methodological limitations, and just two related to older people with mental health problems. The current study suggested that if enhanced community services were available, a substantial proportion of care home and inpatient admissions could be diverted, although only the latter would release significant monies. CMHTsOP: 60% of teams were considered multidisciplinary. Most were colocated, had a single point of access (SPA) and standardised assessment documentation. Evidence of the impact of particular CMHT features was limited. Although staff spoke positively about integration, no evidence was found that more integrated teams produced better user outcomes. Working in high-integration teams was associated with poor job outcomes, but other factors negated the statistical significance of this. Care home outreach: Typical services in the literature undertook some combination of screening (less common), assessment, medication review, behaviour management and training, and evidence suggested intervention can benefit depressed residents. Care home staff were perceived to lack necessary skills, but relatively few CMHTs provided formal training.

Limitations

Limitations include a necessary reliance on observational rather than experimental methods, which were not feasible given the nature of the services explored.

Conclusions

BoC: Shifting care towards the community would require the growth of support services; clarification of extra care housing’s (ECH) role; timely responses to people at risk of psychiatric admission; and improved hospital discharge planning. However, the promotion of care at home will not necessarily reduce public expenditure. CMHTsOP: Although practitioners favoured integration, its goals need clarification. Occupational therapists (OTs) and social workers faced difficulties identifying optimal roles, and support workers’ career structures needed delineating. Care home outreach: Further CMHT input to build care home staff skills and screen for depression may be beneficial. Priority areas for further study include the costs and benefits for older people of age inclusive mental health services and the relative cost-effectiveness of different models of mental health outreach for older care home residents.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

The impact of nursing innovations in the context of governance and incentives

This discursive paper is a structured analysis of four completed national and regional studies carried out in the UK. It sets out retrospectively to explore the impact of key contextual, professional and personal features and mechanisms on innovation and outcomes in nursing and the extent to which these are common or diverge across the studies (cases).

As successive governments across the world turn their attention to developing nursing as a means of increasing productivity and effectiveness in health care, there is a need for evidence to inform workforce policy and planning about the circumstances that enable positive levers and mechanisms, which influence outcomes to operate. This analysis takes advantage of recent conceptual work on organisational governance and incentives by asking new questions of established data to illuminate our understanding of the pathway to innovation in nursing.

Data from the four evaluations (cases) were aggregated and explored thematically within Davies et al.’s framework (Studying health care organisations — links between governance, incentives and outcomes: a review of the literature. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO). http://www.sdo.nihr.ac.uk/files/project/66-final-report.pdf, 2005) of governance, incentives and outcomes. The themes were grouped into three categories: contextual, professional and personal, and interrogated by inter-researcher scrutiny.

Taking account of the limitations of comparing studies carried out for different purposes and in different policy circumstances, there are compelling messages emerging about the organisational support, professional leadership and factors that motivate change and innovation in nursing. The analysis suggests that separating governance from incentives oversimplifies what is a complex interplay between organisational governance and the professional and personal enabling factors supporting innovation. The nature of these relationships deserves further study.

Intermediate care for older people in the U.K

Intermediate care (IC) has been government policy for implementation in the U.K. for almost 10 years. It was hoped that it would help free up acute hospital resources. However, admission rates continue to rise and are rising fastest in those over the age of 75. Many different models of IC have been tried. Typically, outcomes are very similar to traditional hospital care and they tend to be met with high patient satisfaction. Yet there is no evidence that they reduce acute hospital use or that they are cost efficient. Maybe it is time to rethink our national strategy on this issue?

Dynamic role boundaries in intermediate care services

This paper examines the impact of intermediate care service delivery on the role boundaries of service providers. Two intermediate care teams were selected as case studies to explore the roles of workers in the context of an admission avoidance and assisted discharge service. Data were collected through semi-structured interviews with 26 intermediate care staff, including physiotherapists, occupational therapists, nurses, a social worker and support workers. The study found that therapists' roles were most closely aligned with each other, whilst nurses perceived their roles as being distinct from therapists, with a more medical emphasis. Therapists and nurses delegate a range of tasks to support workers, although the nature of task delegation differed across the two teams. A number of factors were associated with the role flexibility of staff including the setting, duration and nature of care, access to alternative care providers and the ability of staff to undertake joint visits. Contrary to previous research, the practitioners were not threatened by overlapping roles, and recognised that confidence in their own roles and an understanding of the roles of other workers was necessary to avoid feeling threatened. The study concludes that intermediate care can promote role overlap across a range of workers. Role overlap can enhance clinician confidence in their own area of expertise whilst optimising patient care. Role overlap has the potential to optimise limited staff resources in an interprofessional working environment. Interprofessional working can be enhanced in the workplace through joint visits and shared working practices.

Costs and health outcomes of intermediate care: results from five UK case study sites

The objectives of this study were to explore the costs and outcomes associated with different types of intermediate care (IC) services, and also to examine the characteristics of patients receiving such services. Five UK case studies of 'whole systems' of IC were used, with data collected on a sample of consecutive IC episodes between January 2003 and January 2004. Statistical differences in costs and outcomes associated with different IC services and patient groups were explored. Factors associated with variation in IC episode outcomes (EuroQol EQ-5D and Barthel Index) were explored using an econometric framework. Data were available for 2253 episodes of IC. In terms of Department of Health criteria, a large proportion of patients (up to 47% of those for whom data were available) in this study were inappropriately admitted to IC services. As regards service function, compared to supported discharge, admission avoidance services were associated with both lower costs and greater health and functional gains. These gains appear to be driven, in part, by illness severity (more dependent patients tended to gain most benefit). In addition, these gains appear to be larger where the admission was appropriate. Our work suggests a need for the development and application of robust and reliable clinical criteria for admission to IC, and close co-operation between hospital and community service providers over selection of patients and targeting of IC and acute care services to meet defined clinical need.

Care home versus hospital and own home environments for rehabilitation of older people

BACKGROUND

Rehabilitation for older people has acquired an increasingly important profile for both policy-makers and service providers within health and social care agencies. This has generated an increased interest in the use of alternative care environments including care home environments. Yet, there appears to be limited evidence on which to base decisions.This review is the first update of the Cochrane review which was published in 2003.

OBJECTIVES

To compare the effects of care home environments (e.g. nursing home, residential care home and nursing facilities) versus hospital environments and own home environments in the rehabilitation of older people.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Specialised Register and Pending Folder, MEDLINE (1950 to March Week 3 2007), EMBASE (1980 to 2007 Week 13), CINAHL (1982 to March, Week 4, 2007), other databases and reference lists of relevant review articles were additionally reviewed. Date of most recent search: March 2007.

SELECTION CRITERIA

Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) that compared rehabilitation outcomes for persons 60 years or older who received rehabilitation whilst residing in a care home with those who received rehabilitation in hospital or own home environments.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

In this update, 8365 references were retrieved. Of these, 339 abstracts were independently assessed by 2 review authors, and 56 studies and 5 review articles were subsequently obtained. Full text papers were independently assessed by two or three review authors and none of these met inclusion criteria.

AUTHORS' CONCLUSIONS

There is insufficient evidence to compare the effects of care home environments versus hospital environments or own home environments on older persons rehabilitation outcomes. Although the authors acknowledge that absence of effect is not no effect. There are three main reasons; the first is that the description and specification of the environment is often not clear; secondly, the components of the rehabilitation system within the given environments are not adequately specified and; thirdly, when the components are clearly specified they demonstrate that the control and intervention sites are not comparable with respect to the methodological criteria specified by Cochrane EPOC group. The combined effect of these factors resulted in the comparability between intervention and control groups being very weak.

Advanced nursing practice and Newton's three laws of motion

This article considers the reasons for the development of advanced practice roles among nurses and other healthcare professions. It explores the implications of financial constraints, consumer preferences and the development of new healthcare services on the reorganization of professional boundaries. It makes use of Sir Isaac Newton's three laws of motion to demonstrate how professional development in nursing has taken place in response to a number of external influences and demands. It also considers the significance of skill mix for the nursing profession, in particular the development and likely expansion of the physician assistant role. The application of different professionals and grades within a healthcare team or organization is central to the Government's Agenda for Change proposals and nurses have successfully adopted a number of roles traditionally performed by doctors. Nurses have demonstrated that they are capable of providing high quality care and contributing directly to positive patient outcome. Advanced nursing roles should not only reflect the changing nature of healthcare work, they should also be actively engaged in reconstructing healthcare boundaries.

Effectiveness of intermediate care in nursing-led in-patient units

BACKGROUND

The Nursing led inpatient Unit (NLU) is one of a range of services that have been considered in order to manage more successfully the transition between hospital and home for patients with extended recovery times. This is an update of an earlier review published in The Cochrane Library in Issue 3, 2004.

OBJECTIVES

To determine whether nursing-led inpatient units are effective in preparing patients for discharge from hospital compared to usual inpatient care.

SEARCH STRATEGY

We searched The Cochrane Library, the Specialized Register of the Cochrane Effective Practice and Organisation of Care (EPOC) group, MEDLINE, CINAHL, EMBASE, BNI and HMIC databases. Citation searches were undertaken on the science and social science citation indices. Authors were contacted to identify additional data. The initial search was done in January 2001. The register search was updated in October 2006, the other database searches were updated in November 2006 and the citation search was run in January 2007.

SELECTION CRITERIA

Controlled trials and interrupted time series designs that compared the NLU to usual inpatient care managed by doctors. Patients over 18 years of age following an acute hospital admission for a physical health condition.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Ten random or quasi-random controlled trials reported on a total of 1896 patients. There was no statistically significant effect on inpatient mortality (OR 1.10, 95% CI 0.56 to 2.16) or mortality to longest follow up (OR 0.92, 95% CI 0.65 to 1.29) but higher quality studies showed a larger non-significant increase in inpatient mortality (OR 1.52, 95% CI 0.86 to 2.68). Discharge to institutional care was reduced for the NLU (OR 0.44 95% CI 0.22 to 0.89) and functional status at discharge increased (SMD 0.37, 95% CI 0.20 to 0.54) but there was a near significant increase in inpatient stay (WMD 5.13 days 95% CI -0.5 days to 10.76 days). Early readmissions were reduced (OR 0.52 95% CI 0.34 to 0.80). One study compared a NLU for the chronically critically ill with ICU care. Mortality (OR 0.62 95% CI 0.35 to 1.10) and length of inpatient stay differ did not differ (WMD 2 days, 95% CI 10.96 to -6.96 days). Early readmissions were reduced (OR 0.33 95% CI 0.12 to 0.94). Costs of care on the NLU were higher for UK studies but lower for US based studies.

AUTHORS' CONCLUSIONS

There is some evidence that patients discharged from a NLU are better prepared for discharge but it is unclear if this is simply a product of an increased length of inpatient stay. No statistically significant adverse effects were noted but the possibility of increased early mortality cannot be discounted. More research is needed.

Effectiveness of nursing-led inpatient care for patients with post-acute health care needs: secondary data analysis from a programme of randomized controlled trials

OBJECTIVES

To determine whether transfer to a nursing-led inpatient unit (NLIU) prior to discharge from hospital can improve clinical outcome and reduce length of stay and readmission rate for medically stable post-acute patients assessed as requiring inpatient care.

METHOD

Retrospective secondary data analysis of individual patient data (n=471) from a programme of three, purposefully replicated, pragmatic randomized controlled trials. Patients were referred to the NLIU by their consultant (attending doctor/surgeon) for nursing-led subacute/post-acute care and randomly allocated to a treatment group for planned transfer to the NLIU for the remainder of their hospital stay or to a control group for traditional consultant-led care in acute wards. Outcome measures were physical function (Barthel Index), length of stay, discharge destination, mortality, psychological well-being (General Health Questionnaire-12), health-related distress (Nottingham Health Profile Distress Index), incidence of complications and readmission within 7, 28, 90 and 180 days.

RESULTS

Patients allocated to the NLIU showed greater improvement in physical function (P<0.001) and were more likely to be discharged to live independently in the community than controls [odds ratio (OR)=0.42, P=0.001] although they spent longer in hospital (P= 0.003). They showed greater improvement in psychological well-being (P = 0.001) and health-related distress (P =0.025) and a lower incidence of pressure ulcers (OR=0.33, P=0.011).

CONCLUSION

Transfer to a NLIU can have a beneficial effect on outcomes of care for post-acute patients with complex health and social needs although length of stay is longer. This study strengthens the evidence of effectiveness of the NLIU model of care and provides evidence of effectiveness of post-acute and subacute models of care.

The organisation, form and function of intermediate care services and systems in England: results from a national survey

This paper reports the results of a postal survey of intermediate care coordinators (ICCs) on the organisation and delivery of intermediate care services for older people in England, conducted between November 2003 and May 2004. Questionnaires, which covered a range of issues with a variety of quantitative, tick-box and open-ended questions, were returned by 106 respondents, representing just over 35% of primary care trusts (PCTs). The authors discuss the role of ICCs, the integration of local systems of intermediate care provision, and the form, function and model of delivery of services described by respondents. Using descriptive and statistical analysis of the responses, they highlight in particular the relationship between provision of admission avoidance and supported discharge, the availability of 24-hour care, and the locations in which care is provided, and relate their findings to the emerging evidence base for intermediate care, guidance on implementation from central government, and debate in the literature. Whilst the expansion and integration of intermediate care appear to be continuing apace, much provision seems concentrated in supported discharge services rather than acute admission avoidance, and particularly in residential forms of post-acute intermediate care. Supported discharge services tend to be found in residential settings, while admission avoidance provision tends to be non-residential in nature. Twenty-four-hour care in non-residential settings is not available in several responding PCTs. These findings raise questions about the relationship between the implementation of intermediate care, and the evidence for and aims of the policy as part of National Health Service modernisation, and the extent to which intermediate care represents a genuinely novel approach to the care and rehabilitation of older people.

The evolving role of the acute care nurse practitioner in critical care

PURPOSE OF REVIEW

The newest nurse practitioner role is the acute care nurse practitioner. This paper presents the latest data on the role from both a US and international perspective.

RECENT FINDINGS

Now present in the USA for at least 15 years, the acute care nurse practitioner role has become well established in critical care settings and is moving into international healthcare. The few outcome studies conducted to date demonstrate the acute care nurse practitioner provides quality patient and family care, improves patient satisfaction, is cost effective, and is an answer to the hospital's shortage of medical residents with new restrictions on working hours.

SUMMARY

The role of acute care nurse practitioners in critical care is increasing worldwide. Most countries are experimenting with this latest nurse practitioner as an extended-role healthcare provider with many potential benefits to patients and their families, as well as the healthcare system.

A cost effectiveness analysis within a randomised controlled trial of post-acute care of older people in a community hospital

OBJECTIVE

To assess the cost effectiveness of post-acute care for older people in a locality based community hospital compared with a department for care of elderly people in a district general hospital, which admits patients aged over 76 years with acute medical conditions.

DESIGN

Cost effectiveness analysis within a randomised controlled trial.

SETTING

Community hospital and district general hospital in Yorkshire, England.

PARTICIPANTS

220 patients needing rehabilitation after an acute illness for which they required admission to hospital.

INTERVENTIONS

Multidisciplinary care in the district general hospital or prompt transfer to the community hospital.

MAIN OUTCOME MEASURES

EuroQol EQ-5D scores transformed into quality adjusted life years (QALYs), and health and social service costs over six months from randomisation.

RESULTS

The mean QALY score for the community hospital group was marginally non-significantly higher than that for the district general hospital group (0.38 v 0.35) at six months after recruitment. The mean (standard deviation) costs per patient of the health and social services resources used were similar for both groups: community hospital group 7233 pounds sterling (euros 10,567; 13,341 dollars) (5031 pounds sterling), district general hospital group 7351 pounds sterling(6229 pounds sterling), and these findings were robust to several sensitivity analyses. The incremental cost effectiveness ratio for community hospital care dominated. A cost effectiveness acceptability curve, based on bootstrapped simulations, suggests that at a willingness to pay threshold of 10,000 pounds sterling per QALY, 51% of community hospital cases will be cost effective, which rises to 53% of cases when the threshold is 30,000 pounds sterling per QALY.

CONCLUSION

Post-acute care for older people in a locality based community hospital is of similar cost effectiveness to that of an elderly care department in a district general hospital.

Effectiveness of intermediate care delivered in nurse-led units

This mini-review provides an overview of evidence regarding the effectiveness, costs and patient experience relating the intermediate care in nursing-led units. The core of the evidence is derived from a high quality systematic review of 10 controlled trials involving 1669 patients. Other studies on patient experience and costs not included in the review are also considered. There is some evidence of patient benefit in the short term in terms of independence. However this does not seem to be sustained. Total inpatient stay is increased and hence overall costs of the initial episode are increased with no evidence of longer-term savings. The approach seems to be broadly acceptable to patients. Provided it is not simply used to house patients who cannot benefit, nursing-led units may be a viable alternative to acute care for some patients. However, the core features of the units that provided the evidence must be considered in order to maximize the potential for delivering quality care.

End of life care: a discursive analysis of specialist palliative care nursing

AIM

The aim of this paper is to consider alternative approaches to service delivery for patients with chronic life-limiting illnesses other than cancer. It will also discuss the issues that arise when considering specialist palliative care services within a broader public health context in the United Kingdom.

BACKGROUND

Contemporary specialist palliative care in the United Kingdom can be said to have two main client groups: the majority are people with a diagnosis of cancer, and a minority are those with a number of other chronic illnesses. From the evidence to date, patients dying from chronic, non-malignant disease experience a considerable number of unmet needs in terms of symptom control and psychosocial support. Although debates in the literature over the last decade have challenged the focus of specialist palliative care services on patients with a cancer diagnosis, only a minority of those with other chronic illnesses receive specialist palliative care services.

DISCUSSION

Current models of specialist palliative care may not be the most appropriate for addressing the complex problems experienced by the many patients with a non-cancer diagnosis. We suggest that care should be structured around patient problems, viewing specialist palliative care as a service for those with complex end of life symptoms or problems. A role for innovative nurse-led care is proposed.

CONCLUSION

Reframing the approach to specialist palliative care in the United Kingdom will require great effort on the part of all health and social care professionals, not least nurses. Critical and creative thinking are prerequisites to the development of new models of working. We suggest that a more coherent approach to research and education is required, in particular strategies that explore how patients and nurses can work together in exploring experiences of illness in order to develop more proactive approaches to care.

Economic evaluation of a nursing-led inpatient unit: the impact of findings on management decisions of service utility and sustainability

AIMS

The nursing-led inpatient unit is designed to substitute for a period of care in acute hospital wards and to improve patient outcome prior to discharge to the community. This paper aims to evaluate the cost, from the UK National Health Service perspective, of transfer to a nursing-led inpatient unit for intermediate care and to discuss the impact of these findings to the future development and sustainability of the nursing-led inpatient unit.

BACKGROUND

Recent economic analyses have showed that nursing-led inpatient units are associated with increased costs of care with length of stay as the main driver of inpatient costs.

METHOD

The cost-effectiveness analysis was part of a randomized-controlled trial with a sample size of 175, of which 89 were in the nursing-led inpatient unit arm and 86 in the control arm. Resource use data included length of stay, investigations performed, multiprofessional input and nursing input. Clinical outcome was measured using Barthel Index, a functional status measure.

RESULTS

Cost per day was lower on the nursing-led inpatient unit although cost per hospital stay was higher due to significantly increased length of stay. Postdischarge community care costs were lower. The incremental cost-effectiveness ratio of the treatment was 1044 pounds sterling per point improvement of the Barthel Index.

CONCLUSIONS

The nursing-led inpatient unit was associated with higher costs however, the question of whether the nursing-led inpatient unit is cost-effective has not been clearly answered because of the limited follow-up period of the study. The increased cost of care on the nursing-led inpatient unit was not a major factor in local management decisions about the future of the unit. The changes in the context of service provision within which the nursing-led inpatient unit operated as a result of substantial investment in intermediate care did have a major impact.

Economic evaluation of nurse led intermediate care versus standard care for post-acute medical patients: cost minimisation analysis of data from a randomised controlled trial

OBJECTIVE

To undertake an economic evaluation of nurse led intermediate care compared with standard hospital care for post-acute medical patients.

DESIGN

Cost minimisation analysis from an NHS perspective, comprising secondary care, primary care, and community care, using data from a pragmatic randomised controlled trial.

SETTING

Nurse led unit and acute general medical wards in large, urban, UK teaching hospital.

PARTICIPANTS

238 patients.

OUTCOME MEASURE

Costs to acute hospital trusts and to the NHS over six months.

RESULTS

On an intention to treat basis, nurse led care was associated with higher costs during the initial admission period (nurse led care 7892 pounds sterling (14,970 dollars; 11,503 euros), standard care 4810 pounds sterling, difference 3082 pounds sterling (95% confidence interval 1161 pounds sterling to 5002 pounds sterling)). During the readmission period, costs were similar (nurse led care 1444 pounds sterling, standard care 1879 pounds sterling, difference -435 pounds sterling, -1406 pounds sterling to 536 pounds sterling). Total costs at six months were significantly higher (nurse led care 10,529 pounds sterling , standard care 7819 pounds sterling, difference 2710 pounds sterling, 518 pounds sterling to 4903 pounds sterling). Sensitivity analyses suggested that the trend for nurse led care to be more expensive was maintained even with substantial cost reductions, although differences were no longer significant.

CONCLUSION

Acute hospitals may not be cost effective settings for nurse led intermediate care. Both inpatient and total costs were significantly higher for nurse led care than for standard care of post-acute medical patients, suggesting that this model of care should not be pursued unless clinical or organisational benefits justify the increased investment.

Post-acute intermediate care in nursing-led units: a systematic review of effectiveness

OBJECTIVE

In order to determine whether post-acute intermediate care in nursing-led inpatient units (NLUs) is effective in preparing patients for discharge from hospital we conducted a systematic review of the evidence.

REVIEW METHODS

The Cochrane Library, Effective Practice and Organisation of Care specialist register, Medline, Cinahl, Embase, British Nursing Index and the HMIC databases were searched for all available dates up to mid-2003. The science and social science citation indices were searched for papers that cited key works. Authors of papers were asked to identify additional research. Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time-series designs that compared the NLU to usual post-acute inpatient care for adults were included in the review. Studies were assessed for quality. Statistical meta-analysis on the results of controlled trials was performed. Sensitivity analyses were conducted to determine the impact of methodological quality on conclusions.

OUTCOMES

Outcomes considered were mortality, institutionalisation after discharge, functional status early readmission, length of inpatient stay and cost.

RESULTS

Nine random or quasi-random controlled trials involving 1669 patients were reviewed. Quality was variable. The mean age of patients in all studies was over 70 years. There was no statistically significant difference in inpatient mortality between NLU and usual inpatient care (OR 1.10, 95% CI 0.56-2.16). The NLU was associated with reduced odds of discharge to institutional care (OR 0.44 95% CI 0.22-0.89), better functional status at discharge (SMD 0.37, 95% CI 0.20-0.54) and reduced odds of early readmission (OR 0.52 95% CI 0.34-0.80). Length of stay until discharge home was increased by 5.13 days (WMD) (95% CI-0.5-10.76 days). At longest follow up (3-6 months) there was no statistically significant difference in the proportion of patients in institutional care (OR 0.97, 95% CI 0.60-1.58). The results were not generally sensitive to study quality.

CONCLUSIONS

The NLU successfully functions as a form of intermediate care, so far there is no evidence of adverse outcome from the lower level of routine medical care. However, more research is required to confirm safety. Patients discharged from NLUs have higher levels of function although it is unclear if the benefit is simply a product of an increased stay. There is no evidence of benefit over the longer term.

Effectiveness of intermediate care in nursing-led in-patient units

BACKGROUND

The Nursing led inpatient Unit (NLU) is one of a range of services that have been considered in order to manage more successfully the transition between hospital and home for patients with extended recovery times.

OBJECTIVES

To determine whether nursing-led inpatient units are effective in preparing patients for discharge from hospital compared to usual inpatient care.

SEARCH STRATEGY

We searched The Cochrane Library, the Specialized Register of the Cochrane Effective Practice and Organisation of Care (EPOC) group, MEDLINE, CINAHL, EMBASE, BNI and HMIC databases. Citation searches were undertaken on the science and social science citation indices. Authors were contacted to identify additional data.

SELECTION CRITERIA

Controlled trials and interrupted time series designs that compared the NLU to usual inpatient care managed by doctors. Patients over 18 years of age following an acute hospital admission for a physical health condition.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Ten random or quasi-random controlled trials reported on a total of 1896 patients. There was no statistically significant effect on inpatient mortality ( OR 1.10, 95% CI 0.56 to 2.16) or mortality to longest follow up (OR 0.92, 95% CI 0.65 to 1.29) but higher qaulity studies showed a larger non-significant increase in inpatient mortality (OR 1.52, 95% CI 0.86 to 2.68). Discharge to institutional care was reduced for the NLU (OR 0.44 95% CI 0.22 to 0.89) and functional status at discharge increased (SMD 0.37, 95% CI 0.20 to 0.54) but there was a near significant increase in inpatient stay (WMD 5.13 days 95% CI -0.5 days to 10.76 days). Early readmissions were reduced (OR 0.52 95% CI 0.34 to 0.80). One study compared a NLU for the chronically critically ill with ICU care. Mortality (OR 0.62 95% CI 0.35 to 1.10) and length of inpatient stay differ did not differ (WMD 2 days, 95% CI 10.96 to -6.96 days). Early readmissions were reduced (OR 0.33 95% CI 0.12 to 0.94). Costs of care on the NLU were higher for UK studies but lower for US based studies.

REVIEWERS' CONCLUSIONS

There is some evidence that patients discharged from a NLU are better prepared for discharge but it is unclear if this is simply a product of an increased length of inpatient stay. No statistically significant adverse effects were noted but the possibility of increased early mortality cannot be discounted. More research is needed.

Nurse-led inpatient care: opening the 'black box'

With recent evaluations contradicting early reports of improved outcomes from nurse-led inpatient care, the 'black box' of nurse-led care must be opened in order to examine the model of treatment. We present findings on the processes of care in one nurse-led unit (NLU), compared with an acute ward. Patterns and quality of nursing care were quantified using bar-code technology to measure type, frequency and duration of nursing activities and Quality Patient Care Scale to measure the quality of care. NLU quality matched, but did not exceed, quality on the acute ward. Patterns of care differed between wards, but activities associated with therapeutic nursing were no more frequent on the NLU. These findings support the hypothesis that disappointing outcomes in recent evaluations may be linked to failure to implement a therapeutic model of nursing.

Nursing-led in-patient units for intermediate care: a survey of multidisciplinary discharge planning practice

The effectiveness of post-acute intermediate care in nursing-led intermediate care in-patient units (NLIU) has been studied over the past 20 years. Accounts, both positive and negative, have tended to view it as a uni-disciplinary intervention. The previous studies are in effect a series of single case studies and as such need to be accompanied by richer descriptions of care processes in order to be useful. A survey was conducted, in parallel with a randomized-controlled trial (n=177), to compare multidisciplinary care and discharge planning practice on the NLIU with 16 wards that referred patients to it. The findings identify that a wide range of professions participate in care on the NLIU with physiotherapists and occupational therapists most widely involved. In general the team composition and care processes differed little between the NLIU and control wards. There was some evidence that there was lower participation in care on the NLIU from occupational therapy and social work. It is concluded that the NLIU is a complex multidisciplinary intervention. Positive results from some NLIUs may only be generalizable to settings with similar skill mix across the multidisciplinary team as that found in the acute hospital. Reduced skill mix may be a causal factor leading to extended stays and increased total care costs. This caution should be extended to other models of intermediate care, whether or not they are nursing-led.