Mobile Stroke Unit in the UK Healthcare System: Avoidance of Unnecessary Accident and Emergency Admissions

BACKGROUND

Acute stroke patients are usually transported to the nearest hospital regardless of their required level of care. This can lead to increased pressure on emergency departments and treatment delay.

OBJECTIVE

The aim of the study was to explore the benefit of a mobile stroke unit (MSU) in the UK National Health Service (NHS) for reduction of hospital admissions.

METHODS

Prospective cohort audit observation with dispatch of the MSU in the East of England Ambulance Service area in Southend-on-Sea was conducted. Emergency patients categorized as code stroke and headache were included from June 5, 2018, to December 18, 2018. Rate of avoided admission to the accident and emergency (A&E) department, rate of admission directly to target ward, and stroke management metrics were assessed.

RESULTS

In 116 MSU-treated patients, the following diagnoses were made: acute stroke, n = 33 (28.4%); transient ischaemic attacks, n = 13 (11.2%); stroke mimics, n = 32 (27.6%); and other conditions, n = 38 (32.8%). Pre-hospital thrombolysis was administered to 8 of 28 (28.6%) ischaemic stroke patients. Pre-hospital diagnosis avoided hospital admission for 29 (25.0%) patients. As hospital treatment was indicated, 35 (30.2%) patients were directly triaged to the stroke unit, 1 patient (0.9%) even directly to the catheter laboratory. Thus, only 50 (43.1%) patients required transfer to the A&E department. Moreover, the MSU enabled thrombolysis with a median dispatch-to-needle time of 42 min (interquartile range, 40-60).

CONCLUSION

This first deployment of an MSU in the UK NHS demonstrated improved triage decision-making for or against hospital admission and admission to the appropriate target ward, thereby reducing pressure on strained A&E departments.

Population-based palliative care planning in Ireland: how many people will live and die with serious illness to 2046?

Background: All countries face growing demand for palliative care services.  Projections of need are essential to plan care in an era of demographic change.   We aim to estimate palliative care needs in the Republic of Ireland from 2016 to 2046. Methods: Static modelling of secondary data.  First, we estimate the numbers of people who will die from a disease associated with palliative care need.  We combine government statistics on cause of death (2007-2015) and projected mortality (2016-2046).  Second, we combine these statistics with survey data to estimate numbers of people aged 50+ living and dying with diseases associated with palliative care need.  Third, we use these projections and survey data to estimate disability burden, pain prevalence and health care utilisation among people aged 50+ living and dying with serious medical illness. Results: In 2016, the number of people dying annually from a disease indicating palliative care need was estimated as 22,806, and the number of people not in the last year of life aged 50+ with a relevant diagnosis was estimated as 290,185.  Equivalent estimates for 2046 are up to 40,355 and 548,105, increases of 84% and 89% respectively.  These groups account disproportionately for disability burden, pain prevalence and health care use among older people, meaning that population health burdens and health care use will increase significantly in the next three decades. Conclusion: The global population is ageing, although significant differences in intensity of ageing can be seen between countries. Prevalence of palliative care need will nearly double over 30 years, reflecting Ireland’s relatively young population.  Older people living with a serious disease outnumber those in the last year of life by approximately 12:1, necessitating implementation of integrated palliative care across the disease trajectory. Urgent steps on funding, workforce development and service provision are required to address these challenges.

Population-based palliative care planning in Ireland: how many people will live and die with serious illness to 2046?

Background: All countries face growing demand for palliative care services.  Projections of need are essential to plan care in an era of demographic change.   We aim to estimate palliative care needs in Ireland from 2016 to 2046. Methods: Static modelling of secondary data.  First, we estimate the numbers of people in Ireland who will die from a disease associated with palliative care need.  We combine government statistics on cause of death (2007-2015) and projected mortality (2016-2046).  Second, we combine these statistics with survey data to estimate numbers of people aged 50+ living and dying with diseases associated with palliative care need.  Third, we use these projections and survey data to estimate disability burden, pain prevalence and health care utilisation among people aged 50+ living and dying with serious medical illness. Results: In 2016, the number of people dying annually from a disease indicating palliative care need was estimated as 22,806, and the number of people not in the last year of life aged 50+ with a relevant diagnosis was estimated as 290,185.  Equivalent estimates for 2046 are 40,355 and 548,105, increases of 84% and 89% respectively.  These groups account disproportionately for disability burden, pain prevalence and health care use among older people, meaning that population health burdens and health care use will increase significantly in the next three decades. Conclusion: The global population is ageing, although significant differences in intensity of ageing can be seen between countries. Prevalence of palliative care need in Ireland will nearly double over 30 years, reflecting Ireland's relatively young population.  People living with a serious disease outnumber those in the last year of life by approximately 12:1, necessitating implementation of integrated palliative care across the disease trajectory. Urgent steps on funding, workforce development and service provision are required to address these challenges.

Interviewing older people about their experiences of emergency hospital admission: methodology in health services research

This essay makes the case for increased use of patient-centred methodologies, which involve patients and the public, in the area of emergency admissions research in the United Kingdom. Emergency admission research has rarely made use of the patient voice when attempting to find a rate of 'inappropriate' admission for older people, instead focusing on professional viewpoints and more abstract tools. We argue for the important insights that patients and their families bring to emergency admissions research and for the need to listen to and use these voices to find more holistic responses to the issue of unplanned admissions to hospital for those aged over 65. This area of health services research is highly complex, but without involving the patient viewpoint we risk not understanding the full story of events leading up to admission and what preventative measures might have helped, and therefore we also risk developing less effective, simplistic solutions. In the face of increasing challenges to the National Health Service's ability to provide safe, effective and affordable care for older people, researchers need to listen to those with direct and longitudinal experience of their ill health and admission.

Characteristics and predictors for hospitalizations of home-dwelling older persons receiving community care: a cohort study from Norway

BACKGROUND

Older persons are substantial consumers of both hospital- and community care, and there are discussions regarding the potential for preventing hospitalizations through high quality community care. The present study report prevalence and factors associated with admissions to hospital for community-dwelling older persons (> 67 years of age), receiving community care in a Norwegian municipality.

METHODS

This was a cohort study of 1531 home-dwelling persons aged ≥67 years, receiving community care. We retrospectively scrutinized admissions to hospital for the study cohort over a one-year period in 2013. The frequency of admissions was evaluated with regard to association with age (age groups 67-79 years, 80-89 years and ≥ 90 year) and gender. The hospital admission incidence was calculated by dividing the number of admissions by the number of individuals included in the study cohort, stratified by age and gender. The association between age and gender as potential predictors and hospitalization (outcome) was first examined in univariate analyses followed by multinomial regression analyses in order to investigate the associations between age and gender with different causes of hospitalization.

RESULTS

We identified a total of 1457 admissions, represented by 739 unique individuals, of which 64% were women, and an estimated mean age of 83 years. Mean admission rate was 2 admissions per person-year (95% confidence interval (CI): 1.89-2.11). The admission rate varied with age, and hospital incidents rates were higher for men in all age groups. The overall median length of stay was 4 days. The most common reason for hospitalization was the need for further medical assessment (23%). We found associations between increasing age and hospitalizations due to physical general decline, and associations between male gender and hospitalizations due to infections (e.g., airways infections, urinary tract infections).

CONCLUSIONS

We found the main reasons for hospitalizations to be related to falls, infections and general decline/pain/unspecified dyspnea. Men were especially at risk for hospitalization as they age. Our study have identified some clinically relevant factors that are vital in understanding what health care personnel in community care need to be especially aware of in order to prevent hospitalizations for this population.

Frailty: a term with many meanings and a growing priority for community nurses

The question of exactly what frailty is and what that may mean for patients is extremely complex. This is a very conceptual problem requiring a broad and long-term solution. It is not a disease or a condition that can be treated in isolation. Frailty is a collection of contributing factors that culminate in an individual being susceptible to poorer outcomes following health-care interventions and minor illness. The solution to such a complex problem lies in engaging and empowering staff to understand and champion frailty. Once better understood, it will be possible to educate and enable this workforce to recognise the signs of frailty, poor prognosis and patients requiring more specialised palliative care. Informing staff working within a health-care economy of this issue must be the first step in a shift towards managing patients with frailty more appropriately, and streaming their care towards the correct care pathways sooner. This article discusses what frailty is, what it may mean for patients, and attempts to expand on why the construct of frailty is a prevalent issue for community nurses. The link between frailty and mortality is discussed and how targeted appropriate advanced care planning may be used to address this demographic challenge.

Room for one more? A review of the literature on 'inappropriate' admissions to hospital for older people in the English NHS

This paper reports the findings of a review of the literature on emergency admissions to hospital for older people in the UK, undertaken between May and June 2014 at the Health Services Management Centre, University of Birmingham. This review sought to explore: the rate of in/appropriate emergency admissions of older people in the UK; the way this is defined in the literature; solutions proposed to reduce the rate of inappropriate admissions; and the methodological issues which particular definitions of 'inappropriateness' raise. The extent to which a patient perspective is included in these definitions of inappropriateness was also noted, given patient involvement is such a key policy priority in other areas of health policy. Despite long-standing policy debates, relatively little research has been published on formal rates of 'inappropriate' emergency hospital admissions for older people in the UK NHS in recent years. What has been produced indicates varying rates of in/appropriateness, inconsistent ways of defining appropriateness and a lack of focus on the possible solutions to address the problem. Significantly, patient perspectives are lacking, and we would suggest that this is a key factor in fully understanding how to prevent avoidable admissions. With an ageing population, significant financial challenges and a potentially fragmented health and social care system, the issue of the appropriateness of emergency admission is a pressing one which requires further research, greater focus on the experiences of older people and their families, and more nuanced contextual and evidence-based responses.

How Professionals Share an E-Care Plan for the Elderly in Primary Care: Evaluating the Use of an E-Communication Tool by Different Combinations of Professionals

BACKGROUND

Home-dwelling elderly patients with multimorbidity are at risk of fragmentation of care because of the many different professionals involved and a potentially unclear level of communication. Multidisciplinary communication seems to occur incidentally. Mutual feedback is needed for a professional team to provide consistent care and adequate support to the patient system. eHealth technology can improve outcomes.

OBJECTIVE

The aim of this study was to evaluate the use of a tool, Congredi, for electronic communication by professionals for the care of home-dwelling elderly patients.

METHODS

The research group was recruited through general practices and home care organizations. Congredi, a tool designed for multidisciplinary communication, was made available for professionals in primary care. It consists of a care plan and a communication channel (secure emailing). Professionals opened Congredi records for elderly patients who had 2 or more professionals involved. The records were the unit of analysis. Data were gathered from the Congredi system over a period of 42 weeks.

RESULTS

An inclusion rate of 21.4% (203/950) was achieved; nearly half of the participants were nurses. During the study, professionals were active in 448 patient records; female professionals were prevalent. In the patient records, 3 types of actions (care activities, emailing, and process activities) were registered. Most activities occurred in the multidisciplinary records (mean 12.2), which had twice the number of activities of monodisciplinary records (6.35), and solo records had a mean of 3.43 activities. Most activities were care activities (mean 9.14), emailing had a mean of 0.89 activities, and process activities had a mean of 0.29.

CONCLUSIONS

An e-communication tool (Congredi) was usable for improving multidisciplinary communication among professionals. It even seemed to yield results for 40% of the professionals who used the e-care plan on their own. The content of the tool provided an active communication practice, with significant increases observed in the actions that must be shared for the effective coordination of care.

In Hospital We Trust: Experiences of older peoples' decision to seek hospital care

The purpose of this study was to explore how older people experience and perceive decisions to seek hospital care while receiving home health care. Twenty-two Swedish older persons were interviewed about their experiences of decision to seek hospital while receiving home health care. The interviews were analyzed using qualitative content analysis. The findings consist of one interpretative theme describing an overall confidence in hospital staff to deliver both medical and psychosocial health care, In Hospital We Trust, with three underlying categories: Superior Health Care, People's Worries, and Biomedical Needs. Findings indicate a need for establishing confidence and ensuring sufficient qualifications, both medical and psychological, in home health care staff to meet the needs of older people. Understanding older peoples' arguments for seeking hospital care may have implications for how home care staff address individuals' perceived needs. Fulfillment of perceived health needs may reduce avoidable hospitalizations and consequently improve quality of life.

The second national audit of intermediate care

Intermediate care services have developed internationally to expedite discharge from hospital and to provide an alternative to an emergency hospital admission. Inconsistencies in the evidence base and under-developed governance structures led to concerns about the care quality, outcomes and provision of intermediate care in the NHS. The National Audit of Intermediate Care was therefore established by an interdisciplinary group. The second national audit reported in 2013 and included crisis response teams, home-based and bed-based services in approximately a half of the NHS. The main findings were evidence of weak local strategic planning, considerable under-provision, delays in accessing the services and lack of mental health involvement in care. There was a very high level of positive patient experience reported across all types of intermediate care, though reported involvement with care decisions was less satisfactory.