Reduced hospitalization rates are not associated with increased mortality or readmission rates in an emergency department in Israel

Implementation of a program for treatment of acute infections in nursing homes without hospital transfer

Background

Nursing care residents have high hospitalization rates. To address this, we established a unique virtual geriatric unit that has developed a program aimed at providing support to nursing homes.

Aims

We aimed to evaluate effectiveness of in-house intravenous antibiotic treatment in nursing hospitals after the implementation of the specially designed training program.

Methods

A cohort study of nursing home residents to evaluate a training program for providers, designed to increase awareness and give practical tools for in-house treatment of acute infections. Data obtained included types of infections, antibiotics used, hospital transfer, and length of treatment. Primary outcomes were in-house recovery, hospitalization and mortality. Univariate analysis and multivariable logistic regression analysis to assess association between different factors and recovery.

Results

A total of 890 cases of acute infections were treated with intravenous antibiotics across 10 nursing homes over a total of 4,436 days. Of these cases, 34.8% were aged 90 years or older. Acute pneumonia was the most prevalent infection accounted for 354 cases (40.6%), followed by urinary tract infections (35.7%), and fever of presumed bacterial infection (17.1%). The mean duration of intravenous antibiotic treatment was 5.09 ± 3.86 days. Of the total cases, 800 (91.8%) recovered, 62 (7.1%) required hospitalization and nine (1.0%) resulted in mortality. There was no significant difference observed in recovery rates across different types of infections.

Discussion

Appling a simple yet unique intervention program has led to more "in-house" residents receiving treatment, with positive clinical results.

Conclusion

Treating in-house nursing home residents with acute infections resulted in high recovery rates. Special education programs and collaboration between healthcare organizations can improve treatment outcomes and decrease the burden on the healthcare system.

Evaluating the consequences of health policy decisions

Uncertainty about intended and possible unintended side effects makes it important to evaluate changes following health policy decisions. A recent IJHPR article by Greenberg et al. evaluated changes in emergency department care following a directive of the Israeli Ministry of Health to limit occupancy in internal medicine wards. Over a six-year observation period, they found that one-month mortality and one-week readmissions after ED visits remained unchanged, while increases in average ED visit length, as well as increased delay time from ED admission to ward were observed. These findings help to assess the impact of the occupancy limit directive and may support future health policy decisions.

However, the study by Greenberg et al. was limited by the unavailability of diagnostic data, and this illustrates a significant issue that transcends this particular study. In many countries, policy-relevant administrative data are not sufficiently available on a timely basis. Data availability is the prerequisite for monitoring developments in patterns of care following health policy changes. Besides conducting retrospective studies, timely availability of data makes it possible to establish monitoring systems which may help decision makers assess the impact of policy changes, identify undesired developments early, and recognize changes in need or demand of health services within the population.

Usefulness of bounce-back admission in monitoring the quality of practice in the emergency department

Background: Recently, unscheduled readmissions after discharge from the emergency department (ED) (bounce-back admissions, BBAs) have been monitored as a hospital performance measure in countries other than Japan. It has been suggested that BBAs may be caused by errors in diagnoses or treatments.

Purpose: This retrospective cohort study aimed to evaluate BBAs and improve the quality of medical care in the ED of Showa University Hospital by analyzing the data of adult patients (≥18 years) with index visits to the ED of Showa University Hospital between June 2011 and May 2013 (n=15,069).

Patients and methods: Patients were registered and followed up for unscheduled admissions to this hospital within 7 days. In order to understand the reasons for BBAs, individual diagnoses upon BBA were compared to the corresponding diagnoses upon discharge.

Results: Among the 11,669 discharged patients, 180 patients were admitted within 3 days after discharge (3-day BBAs), and 257 were admitted within 7 days after discharge (7-day BBAs). The main diagnoses upon admission (BBA) were pneumonia or exacerbation of chronic obstructive pulmonary disease (COPD) or asthma (n=40, 16%), cholecystitis or cholangitis (n=21, 8.2%), and urinary tract infection (n=16, 6.2%). Among the 7-day BBA cases, 117 patients had similar and 110 patients had different diagnoses upon discharge and admission; in the remaining 30 cases, the results could not be ascertained owing to incomplete diagnostic data. In the cases of pneumonia, exacerbation of COPD or asthma, and colitis or enterocolitis, there was a significantly higher “similar” diagnoses than “different”, while the reverse was true for cases of stroke, ileus or bowel obstruction, and meningitis. These results were shared with the ED staff, and similar surveillances were periodically conducted. The frequency of admission within 7 days after discharge continuously declined from 2013 to 2016.

Conclusion: Analyzing the discharge and admission diagnoses may help ED staff to understand the reasons for common errors in order to follow the plan-do-check-act cycle of medical care in the ED.