Unplanned readmissions in younger and older adult patients: the role of healthcare-related adverse events

How do we identify acute medical admissions that are suitable for same day emergency care?

Medical emergencies causing unplanned hospital admission place considerable demands on acute healthcare services. Some patients can be assessed and treated through ambulatory pathways without inpatient admission, via same day emergency care (SDEC), potentially benefiting patients and reducing demands on inpatient services. There is currently considerable variation within acute medicine in aspects of SDEC delivery ranging from overall service design to patient selection methods. Scoring systems identifying patients likely to be successfully managed through SDEC services have been suggested, but evidence of utility in diverse populations is lacking. Specific scoring systems exist for some common medical problems, including cardiac chest pain and pulmonary embolism, but further research is needed to demonstrate how these are most effectively incorporated into SDEC services. This review defines SDEC and describes the variation in services nationally. It reviews the evidence for their clinical impact, tools to screen patients for SDEC and current gaps in our knowledge regarding service deployment.

Potentially modifiable risk factors for 30-day unplanned hospital readmission preventive intervention-A data mining and statistical analysis

Unplanned hospital readmissions have a high prevalence and substantial healthcare costs. Preventive intervention during hospitalization holds the potential for reducing readmission risk. However, it is challenging to develop individualized interventions during hospitalization because the causes of readmissions have not been clearly known and because patients are heterogeneous. This work aimed to identify potentially modifiable risk factors of readmission to help clinicians better plan and prioritize interventions for different patient subgroups during hospitalization. We performed the analysis of associations between the changes of potentially modifiable risk factors and the change of readmission status with association rule mining and statistical methods. Twenty-nine risk factors were identified from the association rules, and twenty-five of them were potentially modifiable. The association rules with potentially modifiable risk factors can be recommended to different patient subgroups to support the development of customized readmission preventive interventions.

Everyday activities at home: Experiences of older repeatedly readmitted people

INTRODUCTION

Limitations in everyday activities are a risk factor for hospital readmission. Despite this, few studies have focussed on everyday activities of repeatedly readmitted older people. The experiences and specific needs of this group have been poorly described regarding their everyday activities at home. A deeper understanding may help occupational therapists and other health professions to facilitate readiness for this group at and after discharge. The aim of this study was, therefore, to describe the experiences of performing everyday activities of older people repeatedly readmitted to hospital and discharged to home.

METHODS

A qualitative interview study was used to collect data from sixteen participants (75 years and older). Data were analysed using qualitative content analysis.

RESULTS

One theme 'trying to manage an unpredictable everyday life' and two categories describe experiences of everyday activities at home. The participants expressed the importance of continuing everyday activities after discharge where support from relatives and healthcare seemed to be of importance.

CONCLUSION

It was found that performance of everyday activities and contact with family members were of importance in their everyday life. Therefore, assessments and support were of particular importance for the group of older people who do not have close social relations at home.

Admission Decision-Making in Hospital Emergency Departments: The Role of the Accompanying Person

In resource-stretched emergency departments, people accompanying patients play key roles in patients’ care. This article presents analysis of the ways health professionals and accompanying persons talked about admission decisions and caring roles. The authors used an ethnographic case study design involving participant observation and semi-structured interviews with 13 patients, 17 accompanying persons and 26 health care professionals in four National Health Service hospitals in south-west England. Focused analysis of interactional data revealed that professionals’ standardization of the patient–carer relationship contrasted with accompanying persons’ varied connections with patients. Accompanying persons could directly or obliquely express willingness, ambivalence and resistance to supporting patients’ care. The drive to avoid admissions can lead health professionals to deploy conversational skills to enlist accompanying persons for discharge care without exploring the meanings of their particular relationship with the patients. Taking a relationship-centered approach could improve the attention to accompanying persons as co-producers of health care and participants in decision-making.

A new simplified model for predicting 30-day mortality in older medical emergency department patients: The rise up score

BACKGROUND/OBJECTIVES

Currently, accurate clinical models that predict short-term mortality in older (≥ 65 years) emergency department (ED) patients are lacking. We aimed to develop and validate a prediction model for 30-day mortality in older ED patients that is easy to apply using variables that are readily available and reliably retrievable during the short phase of an ED stay.

METHODS

Prospective multi-centre cohort study in older medical ED patients. The model was derived through logistic regression analyses, externally validated and compared with other well-known prediction models (Identification of Seniors at Risk (ISAR), ISAR-Hospitalised Patients, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Modified Early Warning Score (MEWS)).

RESULTS

Within 30 days after presentation, 66 (10.9%) of 603 patients in the derivation cohort and 105 (13.3%) of 792 patients in the validation cohort died. The newly developed model included 6 predictors: age, ≥2 abnormal vital signs, serum albumin, blood urea nitrogen, lactate dehydrogenase, and bilirubin. The discriminatory value of the model for mortality was very good with an AUC of 0.84 in the derivation and 0.83 in the validation cohort. The final model was excellently calibrated (Hosmer-Lemeshow p-value 0.89). The discriminatory value of the model was significantly higher than that of the four risk stratification scores (highest AUC of 0.69 for ISAR score, p-value 0.007).

CONCLUSION

We developed and externally validated an accurate and simplified prediction model for 30-day mortality in older ED patients. This model may be useful to identify patients at risk of short-term mortality and to apply personalised medical care.

Study protocol for a multicentre prospective cohort study to identify predictors of adverse outcome in older medical emergency department patients (the Risk Stratification in the Emergency Department in Acutely Ill Older Patients (RISE UP) study)

BACKGROUND

Older patients (≥65 years old) experience high rates of adverse outcomes after an emergency department (ED) visit. Reliable tools to predict adverse outcomes in this population are lacking. This manuscript comprises a study protocol for the Risk Stratification in the Emergency Department in Acutely Ill Older Patients (RISE UP) study that aims to identify predictors of adverse outcome (including triage- and risk stratification scores) and intends to design a feasible prediction model for older patients that can be used in the ED.

METHODS

The RISE UP study is a prospective observational multicentre cohort study in older (≥65 years of age) ED patients treated by internists or gastroenterologists in Zuyderland Medical Centre and Maastricht University Medical Centre+ in the Netherlands. After obtaining informed consent, patients characteristics, vital signs, functional status and routine laboratory tests will be retrieved. In addition, disease perception questionnaires will be filled out by patients or their caregivers and clinical impression questionnaires by nurses and physicians. Moreover, both arterial and venous blood samples will be taken in order to determine additional biomarkers. The discriminatory value of triage- and risk stratification scores, clinical impression scores and laboratory tests will be evaluated. Univariable logistic regression will be used to identify predictors of adverse outcomes. With these data we intend to develop a clinical prediction model for 30-day mortality using multivariable logistic regression. This model will be validated in an external cohort. Our primary endpoint is 30-day all-cause mortality. The secondary (composite) endpoint consist of 30-day mortality, length of hospital stay, admission to intensive- or medium care units, readmission and loss of independent living. Patients will be followed up for at least 30 days and, if possible, for one year.

DISCUSSION

In this study, we will retrieve a broad range of data concerning adverse outcomes in older patients visiting the ED with medical problems. We intend to develop a clinical tool for identification of older patients at risk of adverse outcomes that is feasible for use in the ED, in order to improve clinical decision making and medical care.

TRIAL REGISTRATION

Retrospectively registered on clinicaltrials.gov ( NCT02946398 ; 9/20/2016).

Factors associated with unplanned readmissions within 1 day of acute care discharge: a retrospective cohort study

BACKGROUND

Unplanned hospital readmissions are a quality and safety indicator. In Australian, 8% to 11.1% of unplanned readmissions occur ≤1 day of acute care discharge. The aim of this study was to explore the reasons for unplanned hospital readmissions ≤1 day of acute care discharge, and determine what proportion of such unplanned hospital readmissions were potentially preventable.

METHODS

A retrospective exploratory cohort design was used to conduct this two phase study. In Phase 1, organisational data from 170 readmissions ≤1 day and 1358 readmissions between 2 and 28 days were compared using the Cochran-Mantel-Haenszel test. Binary logistic regression was used to examine factors associated with unplanned readmission ≤1 day. In Phase 2, a medical record audit of 162 Phase 1 readmissions ≤1 day was conducted and descriptive statistics used to summarise the study data. Index discharges occurred between 1 August and 31 December 2015.

RESULTS

In Phase 1, unplanned readmissions ≤1 day were more likely in paediatric patients (< 0.001); index discharges on weekends (p = 0.006), from short stay unit (SSU) (p < 0.001) or against health professional advice (p = 0.010); or when the readmission was for a Diagnosis Related Group (p < 0.001). The significant predictors of unplanned readmission ≤1 day were index discharge against advice or from SSU, and 1-5 hospital admissions in the 6 months preceding index admission. In Phase 2, 88.3% readmissions were unpreventable and 11.7% were preventable. The median patient age was 57 years and comorbidities were uncommon (3.1%). Most patients (94.4%) lived at home and with others (78.9%). Friday was the most common day of index discharge (17.3%) and Saturday was the most common day of unplanned readmission (19.1%). The majority (94.4%) of readmissions were via the emergency department: 58.5% were for a like diagnosis and pain was the most common reason for readmission.

CONCLUSIONS

Advanced age, significant comorbidities and social isolation did not feature in patients with an unplanned readmission ≤1 day. One quarter of patients were discharged on a Friday or weekend, one quarter of readmissions occurred on a weekend, and pain was the most common reason for readmission raising issues about access to services and weekend discharge planning.

Patients' and providers' perceptions of the preventability of hospital readmission: a prospective, observational study in four European countries

OBJECTIVES

Because of fundamental differences in healthcare systems, US readmission data cannot be extrapolated to the European setting: To investigate the opinions of readmitted patients, their carers, nurses and physicians on predictability and preventability of readmissions and using majority consensus to determine contributing factors that could potentially foresee (preventable) readmissions.

DESIGN

Prospective observational study. Readmitted patients, their carers, and treating professionals were surveyed during readmission to assess the discharge process and the predictability and preventability of the readmission. Cohen's Kappa measured pairwise agreement of considering readmission as predictable/preventable by patients, carers and professionals. Subsequently, multivariable logistic regressionidentified factors associated with predictability/preventability.

SETTING

15 hospitals in four European countries PARTICIPANTS: 1398 medical patients readmitted unscheduled within 30 days MAIN OUTCOMES AND MEASURES: (1) Agreement between the interviewed groups on considering readmissions likely predictable or preventable;(2) Factors distinguishing predictable from non-predictable and preventable from non-preventable readmissions.

RESULTS

The majority deemed 27.8% readmissions potentially predictable and 14.4% potentially preventable. The consensus on predictability and preventability was poor, especially between patients and professionals (kappas ranged from 0.105 to 0.173). The interviewed selected different factors as potentially associated with predictability and preventability. When a patient reported that he was ready for discharge during index admission, the readmission was deemed less likely by the majority (predictability: OR 0.55; 95% CI 0.40 to 0.75; preventability: OR 0.35; 95% CI 0.24 to 0.49).

CONCLUSIONS

There is no consensus between readmitted patients, their carers and treating professionals about predictability and preventability of readmissions, nor associated risk factors. A readmitted patient reporting not feeling ready for discharge at index admission was strongly associated with preventability/predictability. Therefore, healthcare workers should question patients' readiness to go home timely before discharge.