Discharge interventions for older patients leaving hospital: protocol for a systematic meta-review

Early supported discharge for older adults admitted to hospital after orthopaedic surgery: a systematic review and meta-analysis

BACKGROUND

Early supported discharge (ESD) aims to link acute and community care, allowing hospital inpatients to return home, continuing to receive the necessary input from healthcare professionals that they would otherwise receive in hospital. Existing literature demonstrates the concept having a reduced length of stay in stroke inpatients and medical older adults. This systematic review aims to explore the totality of evidence for the use of ESD in older adults hospitalised with orthopaedic complaints.

METHODS

A literature search of Cochrane Central Register of Controlled Trials in the Cochrane Library (CENTRAL), EMBASE, CINAHL and MEDLINE in EBSCO was carried out on January 10th, 2024. Randomised controlled trials or quasi-randomised controlled trials were the study designs included. For quality assessment, The Cochrane Risk of Bias Tool 2.0 was used and GRADE was applied to evaluate the certainty of evidence. Acute hospital length of stay was the primary outcome. Secondary outcomes included the numbers of fallers and function. A pooled meta-analysis was conducted using RevMan software 5.4.1.

RESULTS

Seven studies with a population of older adults post orthopaedic surgery met inclusion criteria, with five studies included in the meta-analysis. Study quality was predominantly of a high risk of bias. Statistically significant effects favouring ESD interventions were only seen in terms of length of stay (FEM, MD = -5.57, 95% CI -7.07 to -4.08, I2 = 0%). No statistically significant effects favouring ESD interventions were established in secondary outcomes.

CONCLUSION

In the older adult population with orthopaedic complaints, ESD can have a statistically significant impact in reducing hospital length of stay. This review identifies an insufficient existing evidence base to establish the key benefits of ESD for this population group. There is a need for further higher quality research in the area, with standardised interventions and outcome measures used.

Awareness of and subjective needs for post-discharge healthcare services among older adult patients

BACKGROUND

Increasing patient awareness of post-discharge care resources is an effective strategy to reduce rehospitalization rates and medical costs. Therefore, the purpose of this study was to explore hospitalized older adult patients' awareness of and subjective demands for post-discharge healthcare services.

METHODS

A cross-sectional study design was conducted from November 2018 to May 2020. STROBE statement was completed. Participants were inpatients over 65 years of age in the general ward of a medical center in northern Taiwan. A questionnaire was used to collect data by face-to-face interviews. Two hundred and twelve participants were recruited. Home nursing care, home rehabilitation, home respiratory therapy, home services, assistive devices rental, and transportation were the main post-discharge healthcare services in this study.

RESULTS

Overall, 83.5% of older adult patients were aware of and 55.7% of the older adult patients demanded at least one post-discharge healthcare services. Logistic regression results found that, patients experiencing moderate to severe disability and cognitive impairment, and those hospitalized in the past year had significantly higher demands for services.

CONCLUSIONS

Developing post-discharge healthcare services for older adult patients provides continuous patient-centered services for assisting patients and their families in adapting to the transition period of the post-acute stage. Satisfying these demands is beneficial for older adult patients and their families, as well as for reducing readmissions and medical costs.

Investigating areas for improvement in the transition from hospital-to-home for frail older adults: A mixed methods study

Background

The planning and execution of discharge plans to successfully transition frail older adults from hospital-to-home can be a complicated endeavour.

Objective

To identify areas for improvement in the transitional process of frail older adults who were discharged from hospital based, geriatric units to their homes in the community.

Method

A prospective multi-phased mixed methods design was used, and cross-case thematic analysis of Phase 2 data were triangulated with Phase 1 findings.

Results

Thematic analysis findings indicated several related areas of importance within the transitional process: 1) Coordination of discharge; 2) Transition-to-home planning; 3) Home and community care; 4) Following of recommendations; and, 5) Medical follow-up.

Conclusions

Strengthening communication between stakeholders, as well as the implementation of harmonized policies and guidelines are needed to facilitate more consistent care delivery and provide patients and families with information on what to expect during the transitional process.

Discharge interventions from inpatient child and adolescent mental health care: a scoping review

The post-discharge period is an extremely vulnerable period for patients, particularly for those discharged from inpatient children and adolescent mental health services (CAMHS). Poor discharge practices and discontinuity of care can put children and youth at heightened risk for readmission, among other adverse outcomes. However, there is limited understanding of the structure and effectiveness of interventions to facilitate discharges from CAMHS. As such, a scoping review was conducted to identify the literature on discharge interventions. This scoping review aimed to describe key components, designs, and outcomes of existing discharge interventions from CAMHS. Nineteen documents were included in the final review. Discharge interventions were extracted and summarized for pre-discharge, post-discharge, and bridging elements. Results of this scoping review found that intervention elements included aspects of risk assessment, individualized care, discharge preparation, community linkage, psychoeducation, and follow-up support. Reported outcomes of discharge interventions were also extracted and included positive patient and caregiver satisfaction, improved patient health outcomes, and increased cost effectiveness. Literature on discharge interventions from inpatient CAMHS, while variable in structure, consistently underscore the role of such interventions in minimizing patient and family vulnerability post-discharge. However, findings are limited by inadequate reporting and heterogeneity across studies. There is a need for further research into the design, implementation, and evaluation of interventions to support successful discharges from inpatient child and adolescent mental health care.

Exploration of risk factors for high-risk adverse events in elderly patients after discharge and comparison of discharge planning screening tools

OBJECTIVES

Discharge planning is an effective strategy to prevent adverse health events and reduce medical expenditures. The high-risk target populations of discharged elderly patients and important predictors for the occurrence of adverse events are still not clear. Therefore, the purposes of this study were to examine the validity of discharge planning screening tools in sufficiently identifying high-risk adverse events to health after discharge and to compare two screening tools with our study model.

DESIGN

We conducted a prospective study and recruited elderly patients who had had no hospitalization within 3 months before admission to 13 general wards of a medical center in northern Taiwan from November 2018 to May 2020.

METHODS

Elderly patients were randomly selected during the study period. Within 24 h of admission, patients were asked to consent to join this study. After the patient was discharged, the patient's health and hospitalization for the next year were tracked by telephone interviews.

RESULTS

In total, 300 participants were recruited for this study. Incidences of high-risk adverse events within 30 days, 60 days, and 12 months after discharge were 20.3%, 25.7%, and 48.7% respectively. A logistic regression showed that an increased age, physical or mental disabilities or a major illness, a low body-mass index, and having been hospitalized in the past year were significantly related to the occurrence of high-risk events among elderly discharge patients. The pooled sensitivity of the P_ra was 52% and the specificity was 72%; the pooled sensitivity of the LACE index was 67% and the specificity was 36%. The predictive model of this study had a higher discriminatory power than the P_ra and LACE index for high-risk events after discharge.

CONCLUSIONS

Elderly patients are more vulnerable to high-risk adverse events after discharge. Both the LACE index and P_ra are useful discharge planning screening tools to screen for high-risk adverse events after discharge. Elderly patients need more-active and complete continuity of care plans and discharge planning services to ensure that the overall quality of patient care can be improved and readmissions and mortality reduced.

CLINICAL RELEVANCE

The findings of this study can provide information for discharge planning managers to identify high-risk elderly patients during hospitalization and promptly offer care education or resources to improve care management.

Interventions to improve physical performances of older people with cancer before complex medico-surgical procedures: Protocol for an umbrella review of systematic reviews and meta-analyses

BACKGROUND

Current demographics lead increasing older cancer patients to undergo complex medico-surgical procedures, with substantial risk of decompensations and deconditioning. The Prehabilitation & Rehabilitation in Oncology: Adaptation to Disease and Accompaniment of Patients' Trajectories (PROADAPT) project is currently being developed with the aim of improving care, through standardized care pathways guided by existing evidence and implementation programs. A working group will specifically focus on improvement of physical performances before such procedures. These interventions may have been developed in different contexts: before surgery in large, before carcinologic surgery or complex medical interventions (chemotherapy, radiotherapy), or in primary care for elderly patients to prevent sarcopenia and frailty. Post-surgical interventions are out of the scope of this review. The objective of this review is to summarize the level of evidence to support physical reconditioning interventions and identify areas where further work is required.

METHODS

This umbrella review will include moderate to high quality systematic reviews, meta-analysis, and pre-existing umbrella or meta-reviews. Two reviewers will independently search the following databases: PubMed/MedLine, Cochrane Library, Embase, and CINAHL. Research strategy will use diverse keywords used to refer to the concepts of "prehabilitation," "preoperative exercise," or "preoperative rehabilitation," with prespecified inclusion and exclusion criteria and only systematic reviews selection. The distinct types of interventions presented using PRISMA guidelines and a narrative reporting of results. A focus will be made on outcomes such as physical performances, quality of life, autonomy in everyday activities, or number of hospital bed days.

ETHICS AND DISSEMINATION

Ethical approval is not required for such an umbrella review. Our review will be submitted for publication in a peer-reviewed international journal using open access option if available. It will be complementary to reviews focused on hospital discharge of older people.

PROSPERO REGISTRATION NUMBER

CRD42020100110.

Implementation of a systematic comprehensive geriatric assessment for elderly patients suspected of pulmonary hypertension

BACKGROUND

The phenotype of patients seen for a suspicion of pulmonary hypertension has changed, with an increasing age and frequency of comorbidities. Selection of elderly patients, in whom a classical work-up is mandatory, is challenging. Comprehensive geriatric assessment (CGA) has modified the management of elderly patients with cancer. Pulmonary hypertension (PH) shares with cancer a functional impact and may evolve rapidly, depending on the group of PH. We assessed the impact of a systematic CGA in patients over 70 years old referred for a suspicion of PH.

METHODS

A standardised CGA was performed on every patient older than 70 years old, referred for a PH suspicion, before considering invasive tests for diagnosis and treatment, between July 2014 and May 2019. Our primary aim was to describe the impact of CGA on the decision to stop or pursue the recommended diagnostic work-up for PH.

RESULTS

Among the thirty-one patients evaluated [mean age 81,5 (72-91) years], a negative CGA leads to stop the diagnostic work-up in eleven patients. Among the nineteen remaining patients, sixteen had confirmed PH, with half being chronic thromboembolic pulmonary hypertension.

CONCLUSIONS

Our study indicates that comprehensive geriatric assessment could be an excellent first screen for elderly patients referred for a PH suspicion. Involving a geriatric physician stopped the investigations in one third of patients. In patients with a favourable CGA, PH was confirmed in most of the cases, with chronic thromboembolic pulmonary hypertension being the first cause of PH.

Supporting at-risk older adults transitioning from hospital to home: who benefits from an evidence-based patient-centered discharge planning intervention? Post-hoc analysis from a randomized trial

BACKGROUND

Subgroups of older patients experience difficulty performing activities of daily living (ADL) following hospital discharge, as well as unplanned hospital readmissions and emergency department (ED) presentations. We examine whether these subgroups of "at-risk" older patients benefit more than their counterparts from an evidence-based discharge planning intervention, on the following outcomes: (1) independence in ADL, (2) participation in life roles, (3) unplanned re-hospitalizations, and (4) ED presentations.

TRIAL DESIGN AND METHODS

This study used data from a randomized control trial involving 400 hospitalized older patients with acute and medical conditions, recruited through 5 sites in Australia. Participants receive either HOME, a patient-centered discharge planning intervention led by an occupational therapist; or a structured in-hospital consultation. HOME uses a collaborative approach for goal setting and includes pre and post-discharge home visits as well as telephone follow-up. Characteristics associated with higher risks of adverse outcomes were recorded and at-risk subgroups were created (mild cognitive impairment, walking difficulty, comorbidity, living alone and no support from family). Independence in ADL and participation in life roles were assessed with validated questionnaires. The number of unplanned re-hospitalizations and ED presentations were extracted from medical files. Linear regression models were conducted to detect variation in response to the intervention at 3-months, according to patients' characteristics.

RESULTS

Analyses revealed significant interaction effects for intervention by cognitive status for unplanned re-hospitalization (p = 0.003) and ED presentations (p = 0.021) at 3 months. Within the at-risk subgroup of mild cognitively impaired, the HOME intervention significantly reduced unplanned hospitalizations (p = 0.027), but the effect did not reach significance in ED visits. While the effect of HOME differed according to support received from family for participation in life roles (p = 0.019), the participation observed in HOME patients with no support was not significantly improved.

CONCLUSIONS

Findings show that hospitalized older adults with mild cognitive impairment benefit from the HOME intervention, which involves preparation and post-discharge support in the environment, to reduce unplanned re-hospitalizations. Improved discharge outcomes in this at-risk subgroup following an occupational therapist-led intervention may enable best care delivery as patients transition from hospital to home.

TRIAL REGISTRATION

The trial was registered before commencement (ACTRN12611000615987).