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Thompkins S, Schaefer S, Toh D, Horwood C, Thompson CH. Outlier or handover: outcomes for General Medicine inpatients. AUST HEALTH REV 2023; 47:602-606. [PMID: 37640381 DOI: 10.1071/ah22242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 08/15/2023] [Indexed: 08/31/2023]
Abstract
Objective Patients admitted from the emergency department may be co-located on the treating team's 'home ward'. If no bed is available, patients may be sent to another ward, where they may remain under the admitting team as an 'outlier'. Conversely, care may be handed over to the team on whose home ward they are located. We conducted a retrospective analysis to understand the impact of outlier status and handovers of care on outcomes for General Medicine inpatients. Methods General Medicine admissions at the Royal Adelaide Hospital between September 2020 and November 2021 were analysed. We examined the rate of hospital-acquired complications, inpatient mortality rate, mortality within 48 h of admission, Relative Stay Index, time of discharge from hospital and rate of adverse events within 28 days of discharge. Results A total of 3109 admissions were analysed. Handovers within 24 h of admission were associated with a longer length of stay. There was a trend towards higher rates of adverse events within 28 days of discharge with handovers of care. Outlier status did not affect any outcome measures. Conclusions Handovers within the first 24 h of admission are associated with longer than expected length of stay.
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Affiliation(s)
- S Thompkins
- Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - S Schaefer
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - D Toh
- Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - C Horwood
- Southern Adelaide Local Health Network, Bedford Park, SA, Australia
| | - C H Thompson
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
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Mendelsohn E, Honeyford K, Brittin A, Mercuri L, Klaber RE, Expert P, Costelloe C. The impact of atypical intrahospital transfers on patient outcomes: a mixed methods study. Sci Rep 2023; 13:15417. [PMID: 37723183 PMCID: PMC10507077 DOI: 10.1038/s41598-023-41966-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 09/04/2023] [Indexed: 09/20/2023] Open
Abstract
The architectural design of hospitals worldwide is centred around individual departments, which require the movement of patients between wards. However, patients do not always take the simplest route from admission to discharge, but can experience convoluted movement patterns, particularly when bed availability is low. Few studies have explored the impact of these rarer, atypical trajectories. Using a mixed-method explanatory sequential study design, we firstly used three continuous years of electronic health record data prior to the Covid-19 pandemic, from 55,152 patients admitted to a London hospital network to define the ward specialities by patient type using the Herfindahl-Hirschman index. We explored the impact of 'regular transfers' between pairs of wards with shared specialities, 'atypical transfers' between pairs of wards with no shared specialities and 'site transfers' between pairs of wards in different hospital site locations, on length of stay, 30-day readmission and mortality. Secondly, to understand the possible reasons behind atypical transfers we conducted three focus groups and three in-depth interviews with site nurse practitioners and bed managers within the same hospital network. We found that at least one atypical transfer was experienced by 12.9% of patients. Each atypical transfer is associated with a larger increase in length of stay, 2.84 days (95% CI 2.56-3.12), compared to regular transfers, 1.92 days (95% CI 1.82-2.03). No association was found between odds of mortality, or 30-day readmission and atypical transfers after adjusting for confounders. Atypical transfers appear to be driven by complex patient conditions, a lack of hospital capacity, the need to reach specific services and facilities, and more exceptionally, rare events such as major incidents. Our work provides an important first step in identifying unusual patient movement and its impacts on key patient outcomes using a system-wide, data-driven approach. The broader impact of moving patients between hospital wards, and possible downstream effects should be considered in hospital policy and service planning.
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Affiliation(s)
| | | | | | - Luca Mercuri
- Information Communications and Technology Department, Imperial College Healthcare NHS Trust, London, UK
| | - Robert Edward Klaber
- Department of Paediatrics, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
- Academic Centre for Paediatrics and Child Health, Imperial College London, London, UK
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Ling L, Xia X, Yuan H, Liu S, Guo Z, Zhang C, Ma J. Effectiveness of the graded transport mode for the intrahospital transport of critically ill patients: A retrospective study. Front Public Health 2023; 10:979238. [PMID: 36711413 PMCID: PMC9880033 DOI: 10.3389/fpubh.2022.979238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 12/26/2022] [Indexed: 01/15/2023] Open
Abstract
Aim The purpose of this study was to evaluate the effectiveness of the graded transport mode in the intrahospital transport (IHT) of critically ill patients. Methods This is a retrospective study, including 800 patients and categorized them into control and observation groups. The control group included 420 critically ill patients who were transported via conventional methods from our emergency resuscitation unit from June 2017 to December 2017. The observation group included 380 critically ill patients who were transported through a graded transport mode from January 2018 to June 2018. We performed intergroup comparisons of the incidence rates and causes of adverse events (AEs), transport time, length of stay, and mortality rate. Results The observation group had significantly lower transport time and AE incidence rates than the control group. However, no significant differences were observed in terms of the length of stay and mortality rate between the two groups. Conclusion The most notable merits of the graded transport mode in the IHT of critical care patients include the fact that it significantly reduces the incidence of AEs during IHT, shortens the transport time, and improves transport efficiency, thereby ensuring the safety of critically ill patients.
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Affiliation(s)
| | | | | | | | | | | | - Jin Ma
- *Correspondence: Jin Ma ✉
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4
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Morales-Puerto M, Ruiz-Díaz M, Aranda-Gallardo M, Morales-Asencio JM, Alcalá-Gutiérrez P, Rodríguez-Montalvo JA, León-Campos Á, García-Mayor S, Canca-Sánchez JC. Development of a Clinical Prediction Rule for Adverse Events in Multimorbid Patients in Emergency and Hospitalisation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148581. [PMID: 35886434 PMCID: PMC9324433 DOI: 10.3390/ijerph19148581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/05/2022] [Accepted: 07/12/2022] [Indexed: 11/16/2022]
Abstract
(1) Background: There is currently a global consensus that the quality of comprehensive care for acutely hospitalised elderly people should include addressing functionality and mobility, cognitive status, prevention of pressure ulcers, urinary incontinence, falls and delirium, as well as pain control and medication-related problems. The aim of this study is to develop and validate a clinical prediction rule for multimorbid patients admitted to an acute care hospital unit for any of the five adverse events included in our vulnerability pentad: falls, pressure ulcers, urinary incontinence, pain and delirium. (2) Methods: Longitudinal analytical clinimetric study, with two cohorts. The study population will consist of multimorbid patients hospitalised for acute care, referred from the Emergency Room. A clinical prediction rule will be proposed, incorporating predictive factors of these five adverse outcomes described. This study has received funding, awarded in November 2020 (PI-0107-2020), and was approved in October 2019 by the Research Ethics Committee ″Costa del Sol″. (3) Conclusions: Preventing adverse events in hospitalised patients is particularly important for those with multimorbidity. By applying a clinical prediction rule to detect specific risks, an estimate can be obtained of their probability of occurrence.
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Affiliation(s)
- Marta Morales-Puerto
- Hospital Costa del Sol, Servicio Andaluz de Salud, Autovía A7, Km, 187 Marbella, 29603 Málaga, Spain; (M.M.-P.); (M.R.-D.); (P.A.-G.); (J.A.R.-M.); (J.C.C.-S.)
| | - María Ruiz-Díaz
- Hospital Costa del Sol, Servicio Andaluz de Salud, Autovía A7, Km, 187 Marbella, 29603 Málaga, Spain; (M.M.-P.); (M.R.-D.); (P.A.-G.); (J.A.R.-M.); (J.C.C.-S.)
| | - Marta Aranda-Gallardo
- Hospital Costa del Sol, Servicio Andaluz de Salud, Autovía A7, Km, 187 Marbella, 29603 Málaga, Spain; (M.M.-P.); (M.R.-D.); (P.A.-G.); (J.A.R.-M.); (J.C.C.-S.)
- Department of Nursing, Faculty of Health Sciences, Universidad de Málaga, C/Arquitecto Francisco Peñalosa 3, 29017 Málaga, Spain; (J.M.M.-A.); (Á.L.-C.); (S.G.-M.)
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29590 Málaga, Spain
- Correspondence: ; Tel.: +34-6-97957591
| | - José Miguel Morales-Asencio
- Department of Nursing, Faculty of Health Sciences, Universidad de Málaga, C/Arquitecto Francisco Peñalosa 3, 29017 Málaga, Spain; (J.M.M.-A.); (Á.L.-C.); (S.G.-M.)
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29590 Málaga, Spain
| | - Purificación Alcalá-Gutiérrez
- Hospital Costa del Sol, Servicio Andaluz de Salud, Autovía A7, Km, 187 Marbella, 29603 Málaga, Spain; (M.M.-P.); (M.R.-D.); (P.A.-G.); (J.A.R.-M.); (J.C.C.-S.)
| | - José Antonio Rodríguez-Montalvo
- Hospital Costa del Sol, Servicio Andaluz de Salud, Autovía A7, Km, 187 Marbella, 29603 Málaga, Spain; (M.M.-P.); (M.R.-D.); (P.A.-G.); (J.A.R.-M.); (J.C.C.-S.)
| | - Álvaro León-Campos
- Department of Nursing, Faculty of Health Sciences, Universidad de Málaga, C/Arquitecto Francisco Peñalosa 3, 29017 Málaga, Spain; (J.M.M.-A.); (Á.L.-C.); (S.G.-M.)
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29590 Málaga, Spain
| | - Silvia García-Mayor
- Department of Nursing, Faculty of Health Sciences, Universidad de Málaga, C/Arquitecto Francisco Peñalosa 3, 29017 Málaga, Spain; (J.M.M.-A.); (Á.L.-C.); (S.G.-M.)
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29590 Málaga, Spain
| | - José Carlos Canca-Sánchez
- Hospital Costa del Sol, Servicio Andaluz de Salud, Autovía A7, Km, 187 Marbella, 29603 Málaga, Spain; (M.M.-P.); (M.R.-D.); (P.A.-G.); (J.A.R.-M.); (J.C.C.-S.)
- Department of Nursing, Faculty of Health Sciences, Universidad de Málaga, C/Arquitecto Francisco Peñalosa 3, 29017 Málaga, Spain; (J.M.M.-A.); (Á.L.-C.); (S.G.-M.)
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29590 Málaga, Spain
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Murata M, Nakagawa N, Kawasaki T, Yasuo S, Yoshida T, Ando K, Okamori S, Okada Y. Adverse events during intrahospital transport of critically ill patients: A systematic review and meta-analysis. Am J Emerg Med 2021; 52:13-19. [PMID: 34861515 DOI: 10.1016/j.ajem.2021.11.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/10/2021] [Accepted: 11/12/2021] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Intrahospital transport of critically ill patients is often necessary for diagnostic procedures, therapeutic procedures, or admission to the intensive care unit. The aim of this study was to investigate and describe safety and adverse events during intrahospital transport of critically ill patients. MATERIAL AND METHODS A systematic search was performed of MEDLINE and the Cochrane Central Register of Controlled Trials for studies published up to June 3, 2020, and of the International Clinical Trials Platform Search Portal and ClinicalTrials.gov for ongoing trials. We selected prospective and retrospective cohort studies published in English on intrahospital transport of critically ill patients, and then performed a meta-analysis. The primary outcome was the incidence of all adverse events that occurred during intrahospital transport. The secondary outcomes were death due to intrahospital transport or life-threatening adverse events, minor events in vital signs, adverse events related to equipment, durations of ICU and hospital stay, and costs. RESULTS A total of 12,313 intrahospital transports and 1898 patients from 24 studies were included in the meta-analysis. Among 24 studies that evaluated the primary outcome, the pooled frequency of all adverse events was 26.2% (95% CI: 15.0-39.2) and the heterogeneity among these studies was high (I2 = 99.5%). The pooled frequency of death due to intrahospital transport and life-threatening adverse events was 0% and 1.47% each, but heterogeneity was also high. CONCLUSIONS Our findings suggest that adverse events can occur during intrahospital transport of critically ill patients, and that the frequency of critical adverse events is relatively low. The results of this meta-analysis could assist in risk-benefit analysis of diagnostic or therapeutic procedures requiring intrahospital transport of critically ill patients. TRIAL REGISTRATION UMIN000040963.
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Affiliation(s)
- Maki Murata
- Department of Emergency Medicine and Critical Care, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Natsuki Nakagawa
- Department of Respiratory Medicine, The University of Tokyo Hospital, Japan.
| | - Takeshi Kawasaki
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shunsuke Yasuo
- Department of Emergency and Critical Care Medicine, Kyoto-Katsura Hospital, Kyoto, Japan
| | - Takuo Yoshida
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Koichi Ando
- Division of Respiratory Medicine and Allergology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Satoshi Okamori
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Okada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Preventive Services, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Patry C, Perozziello A, Pardineille C, Aubert C, de Malglaive P, Choquet C, Raynaud-Simon A, Sanchez M. Older medical outliers on surgical wards: impact on 6-month outcomes. Emerg Med J 2021; 39:181-185. [PMID: 34140319 DOI: 10.1136/emermed-2020-210192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 05/17/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Medical patients are on occasion admitted transiently to surgical wards when more appropriate wards are at capacity, potentially leading to suboptimal care. The aim of this study was to compare 6-month outcomes in older adults diagnosed with medical conditions in the ED then admitted inappropriately to surgical wards (defined as outliers), with outcomes in comparable patients admitted to medical wards (controls). METHODS In a matched cohort study, 100 consecutive medical outliers from the ED aged 75 years and over were matched according to age, sex and diagnosis to 200 controls. Collected data included number of diagnoses reported in acute care, level of patient illness severity, length of stay, mortality and destination of patients discharged from acute care units (home, rehabilitation facility, nursing home or palliative care facility). An assessment was made of patient vital status and living environment (home, nursing home or hospital) at 6 months post-ED admission. RESULTS Mean age was 85.6 years. The most common ED diagnoses were gait disorders/falls (18%), neurological disorders (17%) and exhaustion (16%). Outliers displayed lower illness severity levels (0.001) and shorter lengths of stay from ED admission to acute care discharge (p=0.040). Subsequent to acute care, outliers were less commonly discharged home (45% vs 59%) and more commonly discharged to rehabilitation facilities (42% vs 28%). At 6 months post-ED admission, multivariable regression analysis showed that outlier status (OR=0.44 (0.25-0.83); p=0.011) and numbers of diagnoses reported in acute care (OR=0.87 (0.76-0.98); p=0.028) were independently associated with lower probability of living at home. CONCLUSION Outlying of older patients to surgical wards negatively affects their prospects of living at home at 6 months after hospital admission. Older patients hospitalised via the ED are entitled to appropriate medical care.
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Affiliation(s)
- Claire Patry
- Geriatric Department, Bichat University Hospital, Assistance Publique - Hopitaux de Paris (APHP), Paris, France
| | - Anne Perozziello
- Health Information Management Department, Bichat University Hospital, Assistance Publique - Hopitaux de Paris (APHP), Paris, France
| | - Clio Pardineille
- Geriatric Department, Sainte-Périne University Hospital, Assistance Publqiue - Hopitaux de Paris (APHP), Paris, France
| | - Christiane Aubert
- Geriatric Department, Bichat University Hospital, Assistance Publique - Hopitaux de Paris (APHP), Paris, France
| | - Pauline de Malglaive
- Geriatric Department, Bichat University Hospital, Assistance Publique - Hopitaux de Paris (APHP), Paris, France
| | - Christophe Choquet
- Emergency Department - Bichat University Hospital, Assistance Publique - Hopitaux de Paris (APHP), Paris, France
| | - Agathe Raynaud-Simon
- Geriatric Department, Bichat University Hospital, Assistance Publique - Hopitaux de Paris (APHP), Paris, France.,University of Paris, Paris, France
| | - Manuel Sanchez
- Geriatric Department, Bichat University Hospital, Assistance Publique - Hopitaux de Paris (APHP), Paris, France .,University of Paris, Paris, France
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La Regina M, Vertulli C, Gussoni G, Fontanella A, Ballardini G, Brucato A, Orlandini F, Murialdo G, Campanini M, Manfellotto D. Not-for-profit observational study to evaluate the quality and safety of care in <em>outliers</em> hospitalized with medical diseases - Study Protocol of Safety Issues and SurvIval For Medical Outliers (SISIFO study). ITALIAN JOURNAL OF MEDICINE 2021. [DOI: 10.4081/itjm.2021.1447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The progressive cutting of hospital beds in some health systems, together with the increased needs related to the aging population, has led to the phenomenon of patients hospitalized outside the appropriate ward (outliers). This is particularly relevant in the context of Internal Medicine. Despite its relevance in daily clinical practice, available evidence for the potential impact of this phenomenon is limited. The aim of this study is to evaluate the effects of this situation on patients’ outcomes and possibly identify organizational and managerial aspects related to the presence of outliers. The multicenter, observational, prospective Study Protocol of Safety Issues and SurvIval For Medical Outliers (SISIFO) was promoted by the Italian Federation of Associations of Hospital Doctors on Internal Medicine (FADOI). The primary study endpoint is the evaluation of in-hospital mortality in outliers versus controls. A sample size of 2400 patients has been estimated by assuming a mortality rate of 12% and 8% in outliers and controls, respectively. By virtue of the multicentric dimension, the expected number of patients, and the controlled design, the FADOI-SISIFO study might provide interesting and useful findings to better manage the phenomenon of outliers.
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Abstract
Previous transitional care research has focused on transitions occurring between community and hospital settings. Little is known regarding intrahospital transitions and how they affect care quality. A systematic review was therefore conducted to synthesize the literature regarding clinical outcomes associated with intrahospital transitions. Literature published between January 2003 and December 2018 and indexed in Medline/PubMed, CINAHL, and PsychINFO were reviewed using PRISMA guidelines. Articles were limited to English language and peer-reviewed. Articles were excluded if they focused on transitions occurring from or to the hospital, discharge/discharge planning, or postdischarge follow-up. Data abstraction included study characteristics, sample characteristics, and reported clinical outcomes. Fourteen studies met inclusion criteria, primarily using cross-sectional, cohort, or retrospective chart review quantitative designs. Data were analyzed and synthesized based on outcomes reported. Major outcomes emerging from the articles included delirium, hospital length of stay, mortality, and adverse events. Delirium, hospital length of stay, and morbidity and mortality rates were associated with delayed transfers and transfers to inappropriate units. In addition, increased fall risk and infection rates were associated with higher rates of transfer. Intrahospital transitions represent critical periods of time where the quality of care being provided may be diminished, negatively affecting patient safety and outcomes.
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La Regina M, Guarneri F, Romano E, Orlandini F, Nardi R, Mazzone A, Fontanella A, Campanini M, Manfellotto D, Bellandi T, Gussoni G, Tartaglia R, Squizzato A. What Quality and Safety of Care for Patients Admitted to Clinically Inappropriate Wards: a Systematic Review. J Gen Intern Med 2019; 34:1314-1321. [PMID: 31011980 PMCID: PMC6614225 DOI: 10.1007/s11606-019-05008-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/05/2018] [Accepted: 12/27/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND In countries with public health system, hospital bed reductions and increasing social and medical frailty have led to the phenomenon of "outliers" or "outlying hospital in-patients." They are often medical patients who, because of unavailability of beds in their clinically appropriate ward, are admitted wherever unoccupied beds are. The present work is aimed to systematically review literature about quality and safety of care for patients admitted to clinically inappropriate wards. METHODS We performed a systematic review of studies investigating outliers, published in peer-reviewed journals with no time restrictions. Search and screening were conducted by two independent researchers (MLR and ER). Studies were considered potentially eligible for this systematic review if aimed to assess the quality and/or the safety of care for patients admitted to clinically inappropriate units. Our search was supplemented by a hand search of references of included studies. Given the heterogeneity of studies, results were analyzed thematically. We used PRISMA guidelines to report our findings. RESULTS We collected 17 eligible papers and grouped them into six thematic categories. Despite their methodological limits, the included studies show increased trends in mortality and readmissions among outliers. Quality of care and patient safety are compromised as patients and health professionals declare and risk analysis displays. Reported solutions are often multicomponent, stress early discharge but have not been investigated in the control group. CONCLUSIONS Published literature cannot definitely conclude on the quality and safety of care for patients admitted to clinically inappropriate wards. As they may represent a serious threat for quality and safety, and moreover often neglected and under valued, well-designed and powered prospective studies are urgently needed.
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Affiliation(s)
| | - Francesca Guarneri
- Laboratorio Management e Sanita`, Institute of Management of Scuola Superiore Sant'Anna of Pisa, Pisa, Italy
| | - Elisa Romano
- SS Risk Management, ASL5 Liguria, La Spezia, Italy
| | | | | | - Antonino Mazzone
- Dipartimento Medico Ospedale di Legnano, Azienda Socio Sanitaria Territoriale Ovest Milanese, Legnano, MI, Italy
| | - Andrea Fontanella
- Dipartimento di Medicina Interna, Ospedale del Buonconsiglio - Fatebenefratelli Napoli, Naples, NA, Italy
| | - Mauro Campanini
- Dipartimento di Medicina Interna, Azienda Ospedaliera Maggiore della Carità, Novara, Italy
| | - Dario Manfellotto
- UO Medicina Interna, Ospedale Fatebenefratelli Isola Tiberina, Rome, Italy
| | - Tommaso Bellandi
- Centro Gestione Rischio Clinico Regione Toscana, Florence, Italy
| | | | | | - Alessandro Squizzato
- Dipartimento di Medicina Clinica e Sperimentale, Università dell'Insubria, Varese, Italy
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Abstract
The importance of better care integration is emphasized in many national dementia plans. The inherent complexity of organizing care for people with dementia provides both the justification for improving care integration and the challenges to achieving it. The prevention, detection, and early diagnosis of cognitive disorders mainly resides in primary care, but how this is best integrated within the range of disorders that primary care clinicians are expected to screen is unclear. Models of integrated community dementia assessment and management have varying degrees of involvement of primary and specialist care, but share an emphasis on improving care coordination, interdisciplinary teamwork, and personalized care. Integrated care strategies in acute care are still in early development, but have been a focus of investigation in the past decade. Integrated care outreach strategies to reduce transfers from long-term residential care to acute care have been consistently effective. Integrated long-term residential care includes considerations of end-of-life care. Future directions should include strategies for training and education, early detection in anticipation of disease modifying treatments, integration of technological developments into dementia care, integration of dementia care into general health and social care, and the encouragement of a dementia-friendly society.
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Affiliation(s)
- Brian Draper
- a School of Psychiatry , University of NSW , Sydney , NSW , Australia
| | - Lee-Fay Low
- b Faculty of Health Sciences , University of Sydney , Sydney , NSW , Australia
| | - Henry Brodaty
- c Centre for Healthy Brain Ageing , University of NSW Sydney , Sydney , NSW , Australia
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11
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Fogg C, Griffiths P, Meredith P, Bridges J. Hospital outcomes of older people with cognitive impairment: An integrative review. Int J Geriatr Psychiatry 2018; 33:1177-1197. [PMID: 29947150 PMCID: PMC6099229 DOI: 10.1002/gps.4919] [Citation(s) in RCA: 127] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 04/03/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To summarise existing knowledge of outcomes of older hospital patients with cognitive impairment, including the type and frequency of outcomes reported, and the additional risk experienced by this patient group. METHODS Integrative literature review. Health care literature databases, reports, and policy documents on key websites were systematically searched. Papers describing the outcomes of older people with cognitive impairment during hospitalisation and at discharge were analysed and summarised using integrative methods. RESULTS One hundred four articles were included. A range of outcomes were identified, including those occurring during hospitalisation and at discharge. Older people with a dementia diagnosis were at higher risk from death in hospital, nursing home admission, long lengths of stay, as well as intermediate outcomes such as delirium, falls, dehydration, reduction in nutritional status, decline in physical and cognitive function, and new infections in hospital. Fewer studies examined the relationship of all-cause cognitive impairment with outcomes. Patient and carer experiences of hospital admission were often poor. Few studies collected data relating to hospital environment, eg, ward type or staffing levels, and acuity of illness was rarely described. CONCLUSIONS Older people with cognitive impairment have a higher risk of a variety of negative outcomes in hospital. Prevalent intermediate outcomes suggest that changes in care processes are required to ensure maintenance of fundamental care provision and greater attention to patient safety in this vulnerable group. More research is required to understand the most appropriate ways of doing this and how changes in these care processes are best implemented to improve hospital outcomes.
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Affiliation(s)
- Carole Fogg
- Research and InnovationPortsmouth Hospitals NHS TrustPortsmouthUK
- National Institute of Health Research Collaboration for Leadership in Applied Health Research and CareWessexUK
- School of Health Sciences and Social Work, Faculty of ScienceUniversity of PortsmouthPortsmouthUK
- Faculty of Health SciencesUniversity of SouthamptonSouthamptonUK
| | - Peter Griffiths
- National Institute of Health Research Collaboration for Leadership in Applied Health Research and CareWessexUK
- Faculty of Health SciencesUniversity of SouthamptonSouthamptonUK
| | - Paul Meredith
- Research and InnovationPortsmouth Hospitals NHS TrustPortsmouthUK
- National Institute of Health Research Collaboration for Leadership in Applied Health Research and CareWessexUK
| | - Jackie Bridges
- National Institute of Health Research Collaboration for Leadership in Applied Health Research and CareWessexUK
- Faculty of Health SciencesUniversity of SouthamptonSouthamptonUK
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Stylianou N, Fackrell R, Vasilakis C. Are medical outliers associated with worse patient outcomes? A retrospective study within a regional NHS hospital using routine data. BMJ Open 2017; 7:e015676. [PMID: 28490563 PMCID: PMC5588983 DOI: 10.1136/bmjopen-2016-015676] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To explore the quality and safety of patients' healthcare provision by identifying whether being a medical outlier is associated with worse patient outcomes. A medical outlier is a hospital inpatient who is classified as a medical patient for an episode within a spell of care and has at least one non-medical ward placement within that spell. DATA SOURCES Secondary data from the Patient Administration System of a district general hospital were provided for the financial years 2013/2014-2015/2016. The data included 71 038 medical patient spells for the 3-year period. STUDY DESIGN This research was based on a retrospective, cross-sectional observational study design. Multivariate logistic regression and zero-truncated negative binomial regression were used to explore patient outcomes (in-hospital mortality, 30-day mortality, readmissions and length of stay (LOS)) while adjusting for several confounding factors. PRINCIPAL FINDINGS Univariate analysis indicated that an outlying medical in-hospital patient has higher odds for readmission, double the odds of staying longer in the hospital but no significant difference in the odds of in-hospital and 30-day mortality. Multivariable analysis indicates that being a medical outlier does not affect mortality outcomes or readmission, but it does prolong LOS in the hospital. CONCLUSIONS After adjusting for other factors, medical outliers are associated with an increased LOS while mortality or readmissions are not worse than patients treated in appropriate specialty wards. This is in line with existing but limited literature that such patients experience worse patient outcomes. Hospitals may need to revisit their policies regarding outlying patients as increased LOS is associated with an increased likelihood of harm events, worse quality of care and increased healthcare costs.
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Affiliation(s)
- Neophytos Stylianou
- Centre for Healthcare Innovation & Improvement (CHI2), School of Management, University of Bath, Bath, UK
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Robin Fackrell
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Christos Vasilakis
- Centre for Healthcare Innovation & Improvement (CHI2), School of Management, University of Bath, Bath, UK
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