Acute hospital admissions from nursing homes: predictors of unwarranted variation?

Areas of consensus on unwarranted and warranted transfers between nursing homes and emergency care facilities in Norway: a Delphi study

BACKGROUND

Transferring residents from nursing homes (NHs) to emergency care facilities (ECFs) is often questioned as many are terminally ill and have access to onsite care. While some NH to ECF transfers have merit, avoiding other transfers may benefit residents and reduce healthcare system costs and provider burden. Despite many years of research in this area, differentiating warranted (i.e., appropriate) from unwarranted NH to ECF transfers remains challenging. In this article, we report consensus on warranted and unwarranted NH to ECF transfers scenarios.

METHODS

A Delphi study was used to identify consensus regarding warranted and unwarranted NH to ECF transfers. Delphi participants included nurses (RNs) and medical doctors (MDs) from NHs, out-of-hours primary care clinics (OOHs), and hospital-based emergency departments. A list of 12 scenarios and 11 medical conditions was generated from the existing literature on causes and medical conditions leading to transfers, and pilot tested and refined prior to conducting the study. Three Delphi rounds were conducted, and data were analyzed using descriptive and comparative statistics.

RESULTS

Seventy-nine experts consented to participate, of whom 56 (71%) completed all three Delphi rounds. Participants reached high or very high consensus on when to not transfer residents, except for scenarios regarding delirium, where only moderate consensus was attained. Conversely, except when pain relieving surgery was required, participants reached low agreement on scenarios depicting warranted NH to ECF transfers. Consensus opinions differ significantly between health professionals, participant gender, and rurality, for seven of the 23 transfer scenarios and medical conditions.

CONCLUSIONS

Transfers from nursing homes to emergency care facilities can be defined as warranted, discretionary, and unwarranted. These categories are based on the areas of consensus found in this Delphi study and are intended to operationalize the terms warranted and unwarranted transfers between nursing homes and emergency care facilities.

How to set up a mobile X-ray unit in the community - Implementation initiatives for patient-centred care

BACKGROUND

Mobile X-ray unit have previously been widely used within hospitals in general, predominately for imaging patients admitted to intensive care units or for patients who cannot tolerate a visit to the radiology department. It is now possible to have an X-ray examination outside the hospital in nursing homes or to bring the service to frail, vulnerable or disabled patients. A visit to the hospital can be a frightening experience for vulnerable patients living with dementia or other neurological disorder. It can potentially have a long-term impact on the patient's recovery or behaviour. This technical note aimed to provide insight into the planning and running of a mobile X-ray unit in a Danish setting.

METHODS

This technical note draws on the lived experiences of radiographers operating and managing a mobile X-ray service, sharing experiences with the implementation process and the challenges and successes of a mobile X-ray unit.

RESULTS AND KEY FINDINGS

Successes include that frail patient, especially those with dementia, benefit from mobile X-ray examinations, as they can remain in familiar surroundings during an X-ray procedure. In general, patients experienced an increased quality of life and less need for sedation medication due to anxiety. Also, working within a mobile X-ray unit is meaningful work for radiographers. Challenges included increased physicality of work, the funding required for the mobile unit, planning a communication strategy to the referring general practitioners, and permission from authorities to perform mobile examinations.

CONCLUSION

We have successfully implemented a mobile radiography unit that provides a better service for vulnerable patients through learning from successes and challenges.

IMPLICATIONS FOR PRACTICE

The mobile radiography setup can benefit vulnerable patients and provide meaningful work for the radiographers. However, transportation of mobile radiography equipment outside the hospital includes many considerations and challenges.

'Weighing up risks': a model of care home staff decision-making about potential resident hospital transfers

Background

care home staff play a crucial role in managing residents’ health and responding to deteriorations. When deciding whether to transfer a resident to hospital, a careful consideration of the potential benefits and risks is required. Previous studies have identified factors that influence staff decision-making, yet few have moved beyond description to produce a conceptual model of the decision-making process.

Objectives

to develop a conceptual model to describe care home staff’s decision-making when faced with a resident who potentially requires a transfer to the hospital.

Methods

data collection occurred in England between May 2018 and November 2019, consisting of 28 semi-structured interviews with 30 members of care home staff across six care home sites and 113 hours of ethnographic observations, documentary analysis and informal conversations (with staff, residents, visiting families, friends and healthcare professionals) at three of these sites.

Results

a conceptual model of care home staff’s decision-making is presented. Except in situations that staff perceived to be urgent enough to require an immediate transfer, resident transfers tended to occur following a series of escalations. Care home staff made complex decisions in which they sought to balance a number of potential benefits and risks to: residents; staff (as decision-makers); social relationships; care home organisations and wider health and social care services.

Conclusions

during transfer decisions, care home staff make complex decisions in which they weigh up several forms of risk. The model presented offers a theoretical basis for interventions to support deteriorating care home residents and the staff responsible for their care.

Factors associated with increased Emergency Department transfer in older long-term care residents: a systematic review

The proportion of adults older than 65 years is rapidly increasing. Care home residents in this age group have disproportionate rates of transfer to the Emergency Department (ED) and around 40% of attendances might be avoidable. We did a systematic review to identify factors that predict ED transfer from care homes. Six electronic databases were searched. Observational studies that provided estimates of association between ED attendance and variables at a resident or care home level were included. 26 primary studies met the inclusion criteria. Seven common domains of factors assessed for association with ED transfer were identified and within these domains, male sex, age, presence of specific comorbidities, polypharmacy, rural location, and care home quality rating were associated with likelihood of ED transfer. The identification of these factors provides useful information for policy makers and researchers intending to either develop interventions to reduce hospitalisations or use adjusted rates of hospitalisation as a care home quality indicator.

Using advance and emergency care plans during transfer decisions: A grounded theory interview study with care home staff

BACKGROUND

Advance care planning has been identified as one of few modifiable factors that could reduce hospital transfers from care homes. Several types of documents may be used by patients and clinicians to record these plans. However, little is known about how plans are perceived and used by care home staff at the time of deterioration.

AIM

To describe care home staff experiences and perceptions of using written plans during in-the-moment decision-making about potential resident hospital transfers.

DESIGN

Qualitative semi-structured interviews analysed using the Straussian approach to grounded theory.

SETTING/PARTICIPANTS

Thirty staff across six care homes (with and without nursing) in the East and West Midlands of England.

RESULTS

Staff preferred (in principle) to keep deteriorating residents in the care home but feared that doing so could lead to negative repercussions for them as individuals, especially when there was perceived discordance with family carers' wishes. They felt that clinicians should be responsible for these plans but were happy to take a supporting role. At the time of deterioration, written plans legitimised the decision to care for the resident within the home; however, staff were wary of interpreting broad statements and wanted plans to be detailed, specific, unambiguous, technically 'correct', understood by families and regularly updated.

CONCLUSIONS

Written plans provide reassurance for care home staff, reducing concerns about personal and professional risk. However, care home staff have limited discretion to interpret plans and transfers may occur if plans are not specific enough for care home staff to use confidently.

Mobile X-ray outside the hospital: a scoping review

BACKGROUND

For several years mobile X-ray equipment has been routinely used for imaging in patients too unwell within the hospital, when transportation to the radiology department was inadvisable. Now, mobile X-ray examinations are also used outside the hospital. The literature describes that fragile patients may benefit from mobile X-ray, but we need to provide insights into the breadth, depth and gaps in a body of literature.

METHODS

The scoping review was performed by searching PubMed, Cinahl, Embase, EconLit and Health Technology Assessment. English-, Danish-, Norwegian-, German-, Italian-, French- and Swedish-language studies, published 1.1.2009-1.5.2020 about mobile X-ray outside the hospital were included. Participants were patients examined using mobile X-ray as the intervention. PRISMA was used when eligible to build up the review. To extract data from the selected articles, we used a structured summary table.

RESULTS

We included 12 studies in this scoping review. The results were divided into four topics:1. Target population 2. Population health 3. Experience of care and 4. Cost effectiveness. The main findings are that target population could be larger for instance including hospice patients for palliative care, group dwelling for people with intellectual disabilities, or psychiatric patients, population health may be improved, image quality seems to be good and mobile X-ray may be cost effective. Limitations of language, databases and grey literature may have resulted in studies being missed.

CONCLUSIONS

Mobile X-ray may be used outside hospital. There seems to be potential benefits to both patients and health care staff. Based on the published studies it is not possible to draw a final conclusion if mobile X-ray examination is a relevant diagnostic offer and for whom. Further studies are needed to assess the feasibility of use in fragile patients, also regarding staff, relatives and societal consequences and therefore the topic mobile X-ray needs more research.

Long-Term Care Facility Ownership and Acute Hospital Service Use in British Columbia, Canada: A Retrospective Cohort Study

OBJECTIVE

Previous studies report higher hospitalization rates in for-profit compared with nonprofit long-term care facilities (LTCFs), but have not included staffing data, a major potential confounder. Our objective was to examine the effect of ownership on hospital admission rates, after adjusting for facility staffing levels and other facility and resident characteristics, in a large Canadian province (British Columbia).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Our cohort included individuals resident in a publicly funded LTCF in British Columbia at any time between April 1, 2012 and March 31, 2016.

MEASURES

Health administrative data were extracted from multiple databases, including continuing care, hospital discharge, and Minimum Data Set (MDS 2.0) assessment records. Cox extended hazards regression was used to estimate hospitalization risk associated with facility- and resident-level factors.

RESULTS

The cohort included 49,799 residents in 304 LTCF facilities (116 publicly owned and operated, 99 for-profit, and 89 nonprofit) over the study period. Hospitalization risk was higher for residents in for-profit (adjusted hazard ratio [adjHR] 1.34; 95% confidence interval [CI] 1.29-1.38) and nonprofit (adjHR 1.37; 95% CI 1.32-1.41) facilities compared with publicly owned and operated facilities, after adjustment for staffing, facility size, urban location, resident demographics, and case mix. Within subtypes, risk was highest in single-site facilities: for-profit (adjHR 1.42; 95% CI 1.36-1.48) and nonprofit (adjHR 1.38, 95% CI 1.33-1.44).

CONCLUSIONS AND IMPLICATIONS

This is the first Canadian study using linked health data from hospital discharge records, MDS 2.0, facility staffing, and ownership records to examine the adjusted effect of facility ownership characteristics on hospital use of LTCF residents. We found significantly lower adjHRs for hospital admission in publicly owned facilities compared with both for-profit and nonprofit facilities. Our finding that publicly owned facilities have lower hospital admission rates compared with for-profit and nonprofit facilities can help inform decision-makers faced with the challenge of optimizing care models in both nursing homes and hospitals as they build capacity to care for aging populations.

Predictors of transport to hospital after emergency ambulance call-out for older people living in residential aged care

OBJECTIVES

People living in residential aged care (RAC) frequently experience ambulance call-out. These episodes may have unintended consequences, yet remain under-investigated. Our aim was to examine clinical and sociodemographic features associated with transfer to hospital for this population.

METHODS

Retrospective cohort study using 6 years of clinical data from Ambulance Victoria (AV). Data analysis included multilevel multivariable logistic regression analysis of factors associated with transport to hospital.

RESULTS

Odds of transfer were greater for people in rural areas, those with a history of depression, cardiovascular disease and osteoporosis, and residents prescribed antipsychotic and antidepressant medication. Ambulance call-out for trauma (commonly low-level fall) was less frequently transferred to hospital than that for a medical complaint.

CONCLUSION

These results will improve prediction of call-outs likely to require transfer. Findings include identification of clinical features to be targeted by community and preventative health programs to reduce risk of acute health deterioration and requirement for emergency hospital transfer.

Mobile X-ray Outside the Hospital vs. X-ray at the Hospital Challenges Exposed in an Explorative RCT Study

BACKGROUND

For frail patients, it may sometimes be preferable to carry out X-ray examinations at the patients' own home. The general state of such patients may worsen due to transport and change of environment when transported for examination at the hospital.

OBJECTIVE

The aim of the randomized controlled trial (RCT) was to investigate if mobile X-ray improves healthcare for fragile patients. The primary outcome was the number of hospitalizations.

DATA SOURCES

We collected all data using questionnaires and data from the Electronic Patient Record (ER).

PARTICIPANTS

Patients referred to a mobile X-ray examination living in nursing homes and homes for the elderly in the Aarhus Municipality (Denmark).

INTERVENTION

mobile X-ray examinations compared to those at the hospital. Study appraisal: Data were collected and stored using the computer programme Redcap. Stata was used for statistical calculations. One hundred and thirty-six patients were included in the RCT. We did not find significant differences between mobile X-ray (intervention) and X-ray at the hospital (control) concerning hospitalizations and number of hospital days. Challenges: We met several challenges when carrying out RCT in the planned study population. Doctors often withdraw the referral when they found out that their patient should go to the hospital instead of mobile X-ray. The nursing home staff often considered the patient too frail to allow the test person to ask questions post X-ray. We also met challenges in the randomization method resulting in bias in the first data collection, so we had to adjust the randomization method.

CONCLUSIONS

For the fragile patients in the present explorative study, mobile X-ray did not significantly reduce the number of hospitalizations compared to X-ray at the hospital. Yet, mobile X-ray may be a new important diagnostic tool for more precise treatment to the frailest patients for whom transportation to the hospital is too exhausting. We need studies with focus on this aspect. We also recommend future RCT studies in a population for which mobile X-ray has not yet been a possibility.

Physician Availability in Long-Term Care and Resident Hospital Transfer: A Retrospective Cohort Study

OBJECTIVES

To investigate whether same-day physician access in long-term care homes reduces resident emergency department (ED) visits and hospitalizations.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

161 long-term care homes in Ontario, Canada, and 20,624 residents living in those homes.

METHODS

We administered a survey to Ontario long-term care homes from March to May 2017 to collect their typical wait time for a physician visit. We linked the survey to administrative databases to capture other long-term care home characteristics, resident characteristics, hospitalizations, and ED visits. We defined a cohort of residents living in survey-respondent homes between January and May 2017 and followed each resident for 6 months or until discharge or death. We estimated negative binomial regression models on counts of hospitalizations and ED visits with random intercepts for long-term care homes. We controlled for residents' sociodemographic and illness characteristics, long-term care home size, chain status, rurality, and nurse practitioner access.

RESULTS

Fifty-two homes (32%) reported same-day physician access. Among residents of homes with same-day physician access, 9% had a hospitalization and 20% had an ED visit during follow-up. In contrast, among residents in homes without same-day access, 12% were hospitalized and 22% visited an ED. The adjusted hospitalization and ED rates among residents of homes with same-day physician access were 21% lower (rate ratio = 0.79, P = .02) and 14% lower (rate ratio = 0.86, P = .07), respectively, than residents of other homes. We estimate that nearly 1 in 6 resident hospitalizations could be prevented if all long-term care homes had same-day physician access.

CONCLUSIONS AND IMPLICATIONS

Residents of long-term care homes with same-day physician access experience lower hospitalization and ED visit rates than residents in homes that wait longer for physicians, even after adjusting for important resident and home characteristics. Improved on-demand access to physicians has the potential to reduce hospital transfer rates.

Impact of mobile radiography services in nursing homes on the utilisation of diagnostic imaging procedures

Background

In the last decade, mobile radiography services have been introduced in nursing homes in several countries. Earlier research found an underutilisation of diagnostic imaging among nursing home residents. However, the effects of introducing mobile radiography services on the use of diagnostic imaging are unknown. The purpose of this study was to determine the utilisation of diagnostic imaging among nursing home residents and if there are any differences between hospitals with and without a mobile radiography service.

Methods

Data for 2015 were collected from the radiological information systems of 11 hospitals. The data included information on the anatomical region/organ/organ system, modality, and information on where the examination took place. Using nursing home beds as a proxy for nursing home residents’ differences in the use of diagnostic imaging in areas with hospitals with and without mobile radiography services were analysed. The chi-squared test was used to compare the areas.

Results

From 11,066 examinations of nursing home residents, 87% were plain radiographs, 8% were CT scans, and 4% were ultrasound examinations. In areas with mobile radiography services, there was a significantly higher proportion of diagnostic imaging used per nursing home bed, 50% per bed compared to 36% per bed in areas without; p = < 0.001. Furthermore, in areas with mobile radiography services, there was a significantly lower proportion of CT and ultrasound used per nursing home bed, 2.5 and 1.4% respectively per bed compared to 4.7 and 2.2% respectively per bed in areas without; p = < 0.001.

Conclusions

This study demonstrate a lower use of radiology by nursing home residents compared to the general population, and indicates that mobile radiography services increase the level closer to the user rate in the general population. The proportions of plain radiographs are significantly higher in areas with a mobile radiography service, while the proportion of more advanced imaging techniques such as CT and ultrasound are lower. The higher use of diagnostic imaging is most likely appropriate because of higher morbidity and lower use of diagnostic imaging among nursing home residents, compared to the general population. Further research is necessary on how to improve diagnostic imaging services for nursing home residents.

Resident-Level Factors Associated with Hospitalization Rates for Newly Admitted Long-Term Care Residents in Canada: A Retrospective Cohort Study

Chez les résidents en soins de longue durée (SLD), l’hospitalisation peut amener des complications telles que le déclin fonctionnel. L’objectif de notre étude était d’examiner l’association entre les données démographiques et de santé et le taux d’hospitalisation des résidents nouvellement admis en SLD. Nous avons mené une étude de cohorte rétrospective incluant tous les centres de SLD de six provinces et d’un territoire du Canada, à l’aide des données de la RAI-MDS 2.0 et de la Discharge Abstract Database. Nous avons inclus les résidents nouvellement admis ayant eu une évaluation entre le 1er janvier et le 31 décembre 2013 (n = 37 998). Les résidents de sexe masculin avec une santé plus instable et une déficience fonctionnelle de modérée à grave présentaient des taux d’hospitalisation plus élevés, tandis que les résidents avec une déficience cognitive de modérée à grave avaient des taux moindres. Les résultats de notre étude pourraient contribuer à l’identification des résidents nouvellement admis qui seraient plus à risque d’hospitalisation et à l’élaboration de stratégies préventives plus ciblées, incluant la réadaptation, la planification préalable de soins, les soins palliatifs et les services gériatriques spécialisés.

Addressing unwarranted clinical variation: A rapid review of current evidence

INTRODUCTION

Unwarranted clinical variation (UCV) can be described as variation that can only be explained by differences in health system performance. There is a lack of clarity regarding how to define and identify UCV and, once identified, to determine whether it is sufficiently problematic to warrant action. As such, the implementation of systemic approaches to reducing UCV is challenging. A review of approaches to understand, identify, and address UCV was undertaken to determine how conceptual and theoretical frameworks currently attempt to define UCV, the approaches used to identify UCV, and the evidence of their effectiveness.

DESIGN

Rapid evidence assessment (REA) methodology was used.

DATA SOURCES

A range of text words, synonyms, and subject headings were developed for the major concepts of unwarranted clinical variation, standards (and deviation from these standards), and health care environment. Two electronic databases (Medline and Pubmed) were searched from January 2006 to April 2017, in addition to hand searching of relevant journals, reference lists, and grey literature.

DATA SYNTHESIS

Results were merged using reference-management software (Endnote) and duplicates removed. Inclusion criteria were independently applied to potentially relevant articles by 3 reviewers. Findings were presented in a narrative synthesis to highlight key concepts addressed in the published literature.

RESULTS

A total of 48 relevant publications were included in the review; 21 articles were identified as eligible from the database search, 4 from hand searching published work and 23 from the grey literature. The search process highlighted the voluminous literature reporting clinical variation internationally; yet, there is a dearth of evidence regarding systematic approaches to identifying or addressing UCV.

CONCLUSION

Wennberg's classification framework is commonly cited in relation to classifying variation, but no single approach is agreed upon to systematically explore and address UCV. The instances of UCV that warrant investigation and action are largely determined at a systems level currently, and stakeholder engagement in this process is limited. Lack of consensus on an evidence-based definition for UCV remains a substantial barrier to progress in this field.

Identification of hospital cost drivers using sparse group lasso

Public hospital spending consumes a large share of government expenditure in many countries. The large cost variability observed between hospitals and also between patients in the same hospital has fueled the belief that consumption of a significant portion of this funding may result in no clinical benefit to patients, thus representing waste. Accurate identification of the main hospital cost drivers and relating them quantitatively to the observed cost variability is a necessary step towards identifying and reducing waste. This study identifies prime cost drivers in a typical, mid-sized Australian hospital and classifies them as sources of cost variability that are either warranted or not warranted-and therefore contributing to waste. An essential step is dimension reduction using Principal Component Analysis to pre-process the data by separating out the low value 'noise' from otherwise valuable information. Crucially, the study then adjusts for possible co-linearity of different cost drivers by the use of the sparse group lasso technique. This ensures reliability of the findings and represents a novel and powerful approach to analysing hospital costs. Our statistical model included 32 potential cost predictors with a sample size of over 50,000 hospital admissions. The proportion of cost variability potentially not clinically warranted was estimated at 33.7%. Given the financial footprint involved, once the findings are extrapolated nationwide, this estimation has far-reaching significance for health funding policy.

Managers' experience of success criteria and barriers to implementing mobile radiography services in nursing homes in Norway: a qualitative study

Background

In order to meet the future challenges posed by ageing populations, new technology, telemedicine and a more personalized healthcare system are needed. Earlier research has shown mobile radiography services to be highly beneficial for nursing home residents in addition to being cost-effective. Despite the benefits, mobile radiography services are uncommon in Europe and Norway. The purpose of this study was to explore success criteria and barriers in the process of implementing mobile radiography services, from the point of view of the hospital and municipal managers.

Methods

Eleven semi-structured interviews were conducted with managers from five hospitals and six municipalities in Norway where mobile radiography services had been implemented. Core issues in the interview guide were barriers and facilitators in the different phases of implementation. The framework method for thematic analysis was used for analysing the data inductively in a research team.

Results

Five main categories were developed through the success criteria and barriers experienced by the participants: national health policy, regional and municipal policy and conditions, inter-organizational implementation projects, experienced outcome, and professional skills and personal characteristics. The categories were allocated into three higher-order classifications: macro, meso and micro levels. The main barriers experienced by the managers were financial, procedural and structural. In particular, the reimbursement system, lack of management across healthcare levels and the lack of compatible information systems acted as barriers. The main facilitators were external funding, enthusiastic individuals in the organizations and good collaboration between hospitals and municipalities.

Conclusions

The managers experienced financial, structural and procedural barriers. The main success criteria in the process were external funding, and the support and engagement from the individuals in the organizations. This commitment was mainly facilitated by the intuitive appeal of mobile radiography. Changes in healthcare management and in the financial system might facilitate services across healthcare levels. In addition, compatible information systems across healthcare levels are needed in order to facilitate the use of new technology and mobile services.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3115-9) contains supplementary material, which is available to authorized users.

Mobile radiography services in nursing homes: a systematic review of residents' and societal outcomes

Background

Demographic changes are leading to an ageing population in Europe, and predict an increase in the number of nursing home residents over the next 30 years. Nursing home residents need specialised healthcare services such as radiology due to both chronic and acute illnesses. Mobile radiography, x-ray examinations performed in the nursing homes, may be a good way of providing services to this population. The aim of this systematic review was to identify the outcomes of mobile radiography services for nursing home residents and society.

Methods

A systematic review based on searches in the Medline, Cochrane, PubMed, Embase and Svemed + databases was performed. Titles and abstracts were screened according to a predefined set of inclusion criteria: empirical studies in the geriatric population, and reports of mobile radiography services in a clinical setting. All publications were quality appraised using MMAT or CASP appraisal tools. Data were extracted using a summary table and results were narratively synthesised.

Results

Ten publications were included. Three overarching outcomes were identified: 1) reduced number of hospitalisations and outpatient examinations or treatments, 2) reduced number of transfers between nursing homes and hospitals and 3) increased access to x-ray examinations. These outcomes were interlinked with the more specific outcomes for residents and society reported in the literature. For residents there was a reduction in burdensome transfers and waiting time and adequate treatment and care increased. For society, released resources could be used more efficiently, and overall costs were reduced substantially.

Conclusions

This review indicates that mobile radiography services for nursing home residents in the western world are of comparable quality to hospital-based examinations and have clear potential benefits. Mobile radiography reduced transfers to and from hospital, increased the number of examinations carried out and facilitated timely diagnosis and access to treatments. Further research is needed to formally evaluate potential improvements in care quality and cost-effectiveness.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2173-8) contains supplementary material, which is available to authorized users.

Hospitalisation in adults with intellectual disabilities compared with the general population in Norway

BACKGROUND

Previous studies have found that adults with intellectual disabilities (ID) are hospitalised more often than the general population (GP). This study investigates hospital discharge rates and main diagnostic causes for hospitalisation among administratively defined people with ID compared with the GP in Norway.

METHOD

Data from the Norwegian Labour and Welfare Service was combined with data from the Norwegian Patient Register (N_total  = 1 764 072 and N_ID  = 7573) for the period 2008-2011. Data from a Norwegian patient report generator and Statistics Norway are also analysed.

RESULTS

During the study period, 11% of people with ID and 11.5% of the GP were admitted to hospitals. The length of the average hospital stay was just over 4 days for both groups. Among those who were hospitalised, the majority were only admitted to hospital once during the study period: ID 66% and GP 70%. People with ID were admitted somewhat more often than people in the GP. Contrary to the GP, adults with ID were more frequently hospitalised at a younger age and less frequently at old age. The most common International Classification of Diseases diagnostic group for hospitalisation among people with ID is injury, poisoning and certain other consequences of external causes, whereas for the GP, it is diseases of the circulatory system.

CONCLUSION

This study finds that the proportion of people being hospitalised per year is statistically, but only slightly, different among adult people with ID and the GP. The results must be interpreted in light of the organisation of the health care system in Norway.

Impact of a Novel Collaborative Long-Term Care -EMS Model: A Before-and-After Cohort Analysis of an Extended Care Paramedic Program

To compare system and clinical outcomes before and after an extended care paramedic (ECP) program was implemented to better address the emergency needs of long-term care (LTC) residents. Data were collected from emergency medical services (EMS), hospital, and ten LTC facility charts for two five-month time periods, before and after ECP implementation. Outcomes include: number of EMS patients transported to emergency department (ED) and several clinical, safety, and system secondary outcomes. Statistics included descriptive, chi-squared, t-tests, and ANOVA; α = <0.05. 413 cases were included (before: n = 136, 33%; after n = 277, 67%). Median patient age was 85 years (IQR 77-91 years) and 292/413 (70.7%) were female. The number of transports to ED before implementation was 129/136 (94.9%), with 147/224 (65.6%) after, p < 0.001. In the after period, fewer patients seen by ECP were transported: 58/128 (45.3%) vs. 89/96 (92.7%) of those not seen by ECP, p < 0.001. Hospital admissions were similar between phases: 39/120 (32.5%) vs. 56/213 (29.4%), p = NS, but in the after phase, fewer ECP patients were admitted vs. non-ECP: 21/125 (16.8%) vs. 35/88 (39.8%), p < 0.001. Mean EMS call time (dispatch to arrive ED or clear scene) was shorter before than after: 25 minutes vs. 57 minutes, p < 0.001. In the after period, calls with ECP were longer than without ECP: 1 hour, 35 minutes vs. 30 minutes, p < 0.001. The mean patient ED length-of-stay was similar before and after: 7 hours, 29 minutes compared to 8 hours, 11 minutes; p = NS. In the after phase, ED length-of-stay was somewhat shorter with ECPs vs. no ECPs: 7 hours, 5 minutes vs. 9 hours, p = NS. There were zero relapses after no-transport in the before phase and three relapses from 77 calls not transported in the after phase (3/77, 3.9%); two involved ECP (2/70, 2.8%). Reductions were observed in the number of LTC patients transported to the ED when the ECP program was introduced, with fewer patients admitted to the hospital. EMS calls take longer with ECP involved. The addition of ECP to the LTC model of care appears to be beneficial and safe, with few relapse calls identified.

Assessment tools for determining appropriateness of admission to acute care of persons transferred from long-term care facilities: a systematic review

Background

Residents of long-term care facilities have a high risk of acute care admission. Estimates of the frequency of inappropriate transfers vary substantially throughout the studies and various assessment tools have been used. The purpose of this study is to systematically review and describe the internationally existing assessment tools used for determining appropriateness of hospital admissions among long-term care residents.

Method

Systematic review of the literature of two databases (PubMed and CINAHL®). The search covered seven languages and the period between January 2000 and December 2012. All quantitative studies were included if any assessment tool for appropriateness of hospital and/or emergency department admission of long-term care residents was used. Two pairs of independent researchers extracted the data.

Results

Twenty-nine articles were included, covering study periods between 1991 and 2009. The proportion of admissions considered as inappropriate ranged from 2% to 77%. Throughout the studies, 16 different assessment tools were used; all were based on expert opinion to some extent; six also took into account published literature or interpretation of patient data. Variation between tools depended on the concepts studied, format and application, and aspects evaluated. Overall, the assessment tools covered six aspects: specific medical diagnoses (assessed by n = 8 tools), acuteness/severity of symptoms (n = 7), residents’ characteristics prior to admission (n = 6), residents’ or families’ wishes (n = 3), existence of a care plan (n = 1), and availability or requirement of resources (n = 10). Most tools judged appropriateness based on one fulfilled item; five tools judged appropriateness based on a balance of aspects. Five tools covered only one of these aspects and only six considered four or more aspects. Little information was available on the psychometric properties of the tools.

Conclusions

Most assessment tools are not comprehensive and do not take into account residents’ individual aspects, such as characteristics of residents prior to admission and wishes of residents or families. The generalizability of the existing tools is unknown. Further research is needed to develop a tool that is evidence-based, comprehensive and generalizable to different regions or countries in order to assess the appropriateness of hospital admissions among long-term care residents.

Reducing hospital admissions from nursing homes: a systematic review

Background

The geriatric nursing home population is vulnerable to acute and deteriorating illness due to advanced age, multiple chronic illnesses and high levels of dependency. Although the detriments of hospitalising the frail and old are widely recognised, hospital admissions from nursing homes remain common. Little is known about what alternatives exist to prevent and reduce hospital admissions from this setting. The objective of this study, therefore, is to summarise the effects of interventions to reduce acute hospitalisations from nursing homes.

Methods

A systematic literature search was performed in Cochrane Library, PubMed, MEDLINE, EMBASE and ISI Web of Science in April 2013. Studies were eligible if they had a geriatric nursing home study population and were evaluating any type of intervention aiming at reducing acute hospital admission. Systematic reviews, randomised controlled trials, quasi randomised controlled trials, controlled before-after studies and interrupted time series were eligible study designs. The process of selecting studies, assessing them, extracting data and grading the total evidence was done by two researchers individually, with any disagreement solved by a third. We made use of meta-analyses from included systematic reviews, the remaining synthesis is descriptive. Based on the type of intervention, the included studies were categorised in: 1) Interventions to structure and standardise clinical practice, 2) Geriatric specialist services and 3) Influenza vaccination.

Results

Five systematic reviews and five primary studies were included, evaluating a total of 11 different interventions. Fewer hospital admissions were found in four out of seven evaluations of structuring and standardising clinical practice; in both evaluations of geriatric specialist services, and in influenza vaccination of residents. The quality of the evidence for all comparisons was of low or very low quality, using the GRADE approach.

Conclusions

Overall, eleven interventions to reduce hospital admissions from nursing homes were identified. None of them were tested more than once and the quality of the evidence was low for every comparison. Still, several interventions had effects on reducing hospital admissions and may represent important aspects of nursing home care to reduce hospital admissions.