Emergency department use among patients from residential aged care facilities under a Hospital in the Nursing Home scheme in public hospitals in Queensland Australia

Thirty-day hospital readmission predictors in older patients receiving hospital-at-home: a 3-year retrospective study in France

OBJECTIVE

This study described older patients receiving hospitalisation-at-home (HaH) services and identified factors associated with 30-day hospital readmission.

DESIGN

3-year retrospective study in 2017-2019 in France.

PARTICIPANTS

75 108 patients aged 75 years and older who were discharged from hospital medical wards (internal medicine and geriatric units) and admitted to HaH.

PRIMARY OUTCOME MEASURE

30-day hospital readmission.

RESULTS

The mean age of patients was 83.4 years (SD 5.7), 52.3% were male and 88.4% lived in a private household. Patients were primarily discharged from the internal medicine unit (85.3%). The top four areas of care in the HaH were palliative care, complex dressing, intravenous therapy and complex nursing care. Overall, 23.5% of patients died during their HaH stay and 27.8% were readmitted to the hospital at 30 days. In the multivariate model, male (OR 1.19, 95% CI 1.16 to 1.23), supportive cancer HaH care (OR 1.78, 95% CI 1.51 to 2.11) and very high intensity care during the previous in-person hospitalisation (OR 1.45, 95% CI 1.34 to 1.57) increased the risk of hospital readmission at 30 days. Older age (OR 0.97, 95% CI 0.97 to 0.98), living in a nursing home (OR 0.51, 95% CI 0.48 to 0.54), postsurgery HaH care (OR 0.49, 95% CI 0.41 to 0.58) and having been previously hospitalised in a geriatric unit (OR 0.81, 95% CI 0.77 to 0.85) decreased the risk of hospital readmission at 30 days.

CONCLUSIONS

HaH provides complex care to very old patients, which is associated with high mortality. Several factors are associated with rehospitalisation within 30 days that could be avoided with better integration of different services with higher geriatric skills.

TRIAL REGISTRATION NUMBER

CNIL:2228861.

Understanding the Clinical Profile and Hospitalisation Patterns of Residents From Aged Care Facilities: A Regional Victorian Hospital Study

Introduction Residents of residential aged care facilities (RACFs) are typically frailer than their community-dwelling counterparts. They often present to the emergency department (ED) with varied health issues, frequently leading to hospital admissions. These admissions can exacerbate patient frailty and strain the healthcare system. Despite global efforts to reduce ED presentations from RACFs, effective strategies still need to be discovered. This study examines the clinical profile and hospitalisation patterns of RACF residents in a regional Victorian town. Aims The study aimed to assess the prevalence of ED presentations and representations from RACFs, investigate the causes and outcomes of hospital admissions stemming from these presentations, and evaluate the prevalence of documented (advanced care directives) ACDs within this patient cohort. Methods Following ethical approval, we conducted a retrospective analysis of 467 ED presentations from 310 RACF patients admitted to Goulburn Valley Health's (GVH) ED from January to June 2022. We collected and examined data on demographics, ACD existence, ED presentation characteristics, and hospital admissions, classifying admission reasons into eleven groups. Statistical analysis was performed with GraphPad Prism and IBM SPSS, using inferential tests and logistic regression to assess readmission odds at a significance threshold of p<0.05. Results Our study encompassed 310 patients from multiple RACFs, yielding 467 ED presentations. These constituted 2.28% of total ED visits and 9.85% of those aged 65 and above. Most of the cohort were females (59.4%), aged between 79 and 91. About 98 patients presented multiple times, and 48.2% of presentations led to hospital admissions, with 6.2% of admitted patients succumbing during the hospital stay. A documented ACD was absent in 42.9% of the cohort. Statistically significant results include a correlation between male sex and an increased frequency of ED representations (p=0.0422) and a longer ED stay duration for admitted patients (p<0.0001). No significant associations were found between ACD presence and ED representations, ACD and sex, or between age and duration of stay in the ED. Age did not differ significantly among patients with single or multiple presentations or between patients with or without ACD. Regarding fall-related presentations, no significant sex-based difference in admission rates was found. The duration of stay between surgical and medical admissions was also statistically indifferent. Conclusion Our study highlights the significant utilisation of ED services by RACF residents, mainly males. The substantial percentage of these presentations resulting in hospital admissions underlines the critical nature of these visits. The absence of ACD in a significant portion of the cohort and the lack of its influence on the frequency of representations signal the need for further exploration. The results underline the ongoing challenge of meeting the complex healthcare needs of RACF residents and emphasise the importance of gender-specific interventions and efficient hospital utilisation strategies to optimise healthcare delivery in this population. Future studies should further investigate the underlying reasons for these findings to inform targeted strategies for reducing unnecessary ED visits and hospital admissions. Furthermore, fall-related presentations necessitate comprehensive ED assessments and integrated management approaches.

Taxonomy of Interventions to Reduce Acute Care Transfers From Long-term Care Homes: A Systematic Scoping Review

OBJECTIVE

To develop a taxonomy of interventions aimed at reducing emergency department (ED) transfers and/or hospitalizations from long-term care (LTC) homes.

DESIGN

A systematic scoping review.

SETTING AND PARTICIPANTS

Permanent LTC home residents.

METHODS

Experimental and comparative observational studies were searched in MEDLINE, CINAHL, Embase Classic + Embase, the Cochrane Library, PsycINFO, Social Work Abstracts, AMED, Global Health, Health and Psychosocial Instruments, Joanna Briggs Institute EBP Database, Ovid Healthstar, and Web of Science Core Collection from inception until March 2020. Forward/backward citation tracking and gray literature searches strengthened comprehensiveness. The Mixed Methods Appraisal Tool was used to assess study quality. Intervention categories and components were identified using an inductive-deductive thematic analysis. Categories were informed by 3 intervention dimensions: (1) "when/at what point(s)" on the continuum of care they occur, (2) "for whom" (ie, intervention target resident populations), and (3) "how" these interventions effect change. Components were informed by the logistical elements of the interventions having the potential to influence outcomes. All interventions were mapped to the developed taxonomy based on their categories, components, and outcomes. Distributions of components by category and study year were graphically presented.

RESULTS

Ninety studies (25 randomized, 23 high quality) were included. Six intervention categories were identified: advance care planning; palliative and end-of-life care; onsite care for acute, subacute, or uncontrolled chronic conditions; transitional care; enhanced usual care (most prevalent, 31% of 90 interventions); and comprehensive care. Four components were identified: increasing human resource capacity (most prevalent, 93%), training or reorganization of existing staff, technology, and standardized tools. The use of technology increased over time. Potentially avoidable ED transfers and/or hospitalizations were measured infrequently as primary outcomes.

CONCLUSIONS AND IMPLICATIONS

This proposed taxonomy can guide future intervention designs. It can also facilitate systematic reviews and precise effect size estimations for homogenous interventions when outcomes are comparable.

English language proficiency and hospital admissions via the emergency department by aged care residents in Australia: A mixed-methods investigation

Residents of Residential Age Care Facilities (RACFs) have particularly high rates of Emergency Department (ED) visits, with up to 55% being potentially avoidable (e.g. not resulting in a hospital admission). This is concerning as ED visits by RACF residents are associated with negative outcomes including longer hospital stays, iatrogenic illness, complications and mortality. Limited English proficiency (LEP) has significant negative impacts on the healthcare quality and outcomes for older people but has not been studied as a factor in ED visits from RACFs. This study aimed to examine if RACF residents with LEP have a lower rate of hospital admission via the ED compared to non-LEP controls and identify any associated factors. We hypothesised that LEP-related communication difficulties would reduce the ability to manage minor health issues in the RACF, leading to a lower proportion of LEP ED transfers being admitted. We used a parallel mixed-methods design, comprising a quantitative matched cohort study of ED visit data from two Local Hospital Networks (LHNs) in South-East Melbourne, Australia and secondary thematic analysis of 25 interviews with LEP residents, family carers and staff from two RACFs in the same region. We found no differences in the proportion of hospital ED transfers that led to admission (LHN1, 87.1% LEP, 85.6% non-LEP controls, p = 0.57; LHN2, 76.0% LEP, 76.9% non-LEP controls, p = 0.41) and no direct qualitative evidence suggesting that resident LEP affected decisions to transfer residents to ED, despite communication difficulties being reported during the transfer process. These results may be due to the high level of family carer involvement in residents' care identified in the qualitative study. However, additional research using different measures of LEP is recommended to further explore a broader range of cultural and linguistic factors in both rates of ED presentations and the decision-making processes underpinning resident transfers to ED.

Actual drug-related harms in residential aged care facilities: a narrative review

INTRODUCTION

Older people in residential aged care facilities (RACFs) have a high risk of safety issues and concerns about the potential quality of care received. This narrative review investigates the types of actual drug-related harms, their prevalence, reporting of any standard definitions for these harms, and their identification methods.

AREAS COVERED

The authors conducted a systematic search on Ovid Embase, Ovid Medline, and PubMed from March 2001 to March 2021. This narrative review included all types of studies targeting aged care residents aged 65 years and above with actual drug-related harms.

EXPERT OPINION

The prevalence of actual drug-related harms in residents ranged from 0.07% to 63.0%. Falls, drug-drug interactions, neuropsychiatric symptoms, anaphylaxis, urinary tract infection, hypoglycemia, hypokalaemia, and acute kidney injury are the most common drug-related harms in older residents. Psychotropic drugs are the most common drug class implicated in these harms. Evidence related to the association between individual psychotropic drugs and injury, or harm is also lacking. Due to the variation in study duration, reported prevalence, identification methods, and absence of a definition for actual drug-related harms in most studies, further research is mandated to understand the prevalence and clinical implications of drug-related harms in older residents.

Emergency department presentations and 30-day mortality in patients from residential aged care facilities

ObjectiveTo describe patterns of emergency department (ED) presentations and predictors of 30-day mortality in patients referred from a residential aged care facility (RACF).MethodsA retrospective analysis of linked state-wide emergency, inpatient and death data from 136 public ED hospitals in New South Wales, Australia. Data were collected from the NSW Emergency Department Data Collection database, the NSW Admitted Patient Data Collection database and the NSW Registry of Births, Deaths and Marriages. All patients aged ≥65 years presenting to the ED from a RACF between January 2017 and July 2018 were included. ED diagnosis categories, re-admission rates within 30 days and 30-day all-cause mortality were measured.ResultsIn total, 43 248 presentations were identified. The most common ED diagnosis categories were: injury (26.48%), respiratory conditions (14.12%) and cardiovascular conditions (10.74%). Prolonged ED length of stay was associated with higher adjusted hazard ratios for 30-day all-cause mortality after adjustments for age Charlson Comorbidity Index, triage category and diagnosis category (HR 1.10 95% CI 1.05-1.14 P < 0.001).ConclusionsA large proportion of ED presentations from RACFs were for injuries associated with falls and chest infections. There was a range of both high- and low-urgency presentations. Both the 30-day mortality and re-admission rates were high. Predictors of increased mortality included prolonged length of stay in the ED and re-admission within 30 days. The findings are useful in informing discussion around improving access to care in RACFs and coordination of healthcare providers in this cohort.

The enigma: Decision-making to transfer residents to the emergency department; communication and care delivery between emergency department staff and residential aged care facilities' nurses

OBJECTIVE

To investigate the experience of nurses involved in decision-making to transfer residents from a residential aged care facility (RACF) to their local hospital emergency department. This paper reports on the findings of the second phase of a two-phase study.

METHODS

Qualitative semi-structured interviews with 19 aged care nurses were conducted. Interviews were audio-taped and transcribed verbatim, and a thematic analysis was carried out.

RESULTS

The analysis revealed five major themes that influenced decision-making in relation to the transfer of a resident from the residential aged care facility to the emergency department: conflict with key stakeholders; knowledge and experience; policy and process; stakeholder perception; and recognition and support.

CONCLUSIONS

Robust outreach programs, support from other health-care professionals, and improving interdisciplinary understanding and communication between aged care nurses, paramedics and the emergency department would be advantageous to ensure effective care delivery and decision-making.

Elderly patients presenting to a rural hospital emergency department in inland Croatia - A retrospective study

BACKGROUND

Emergency departments are faced with a high influx of patients presenting for various complaints. The aim of the present study was to assess the basic characteristics of elderly patients presenting to a rural hospital emergency department in inland Croatia in 2017.

METHODS

Retrospective data collected from the Hospital Information System and by analysis of medical records on patients presenting to emergency department in 2017 were used in the study.

RESULTS

Study results indicated that a lower proportion of elderly individuals aged 65-74 were hospitalized following emergency department workup. A statistically significantly higher proportion of patients older than 74 years was presented to ED due to various discomforts and diseases (ICD-10 group I; χ2 = 324.85; p < 0.01) than due to cardiorespiratory diseases and acute abdomen (χ2 = 285.04; p < 0.01).

CONCLUSION

Our findings highlight the need for a complex approach in care for elderly people, given that they are a fragile population with multiple comorbidities, chronic diseases, atypical symptoms, and often with cognitive and functional impairments.

The emergency care model: A new paradigm for skilled nursing facilities

The population of individuals age 65 and older is increasing in the United States. One third of these individuals will utilize nursing home care before death. Nursing home residents ("NHR") average 1.8 emergency department visits annually. Improving the quality of nursing home care is of vital importance. This project describes a new paradigm for the management of acute emergent health issues affecting NHR. The model features a multidisciplinary team coordinated by emergency providers resulting in a 55% reduction in unplanned hospital admissions compared to skilled nursing facility regional data. Additionally, a reduction in ancillary lab costs was observed. Implementation of this paradigm on a national scale could result in a projected cost savings in excess of $10 billion per year for the Center for Medicare and Medicaid Services ("CMS").

Frailty, Hospitalization, and Mortality in Residential Aged Care

Background

Frailty predicts mortality in residential aged care, but the relationship with hospitalization is inconsistent. The purpose of this study was to investigate and compare whether frailty is associated with hospitalization and mortality among residents of aged care services.

Methods

A prospective cohort study of 383 residents aged 65 years and older was conducted in six Australian residential aged care services. Frailty was assessed using the FRAIL-NH scale and a 66-item frailty index.

Results

Overall, 125 residents were hospitalized on 192 occasions and 85 died over the 12-month follow-up. Over this period, less than 3% of the nonfrail/vulnerable residents but more than 20% of the most frail residents died at the facility without hospitalization. Using the FRAIL-NH, residents with mild/moderate frailty had higher numbers of hospitalizations (adjusted incidence rate ratio 1.57, 95% confidence interval [CI] 1.11-2.20) and hospital days (incidence rate ratio 1.48, 95% CI 1.32-1.66) than nonfrail residents. Residents who were most frail had lower numbers of hospitalizations (incidence rate ratio 0.65, 95% CI 0.42-0.99) and hospital days (incidence rate ratio 0.39, 95% CI 0.33-0.46) than nonfrail residents. Similar patterns of associations with number of hospital days were observed for the frailty index. Most frail residents had a higher risk of death than nonfrail residents (for FRAIL-NH, adjusted hazard ratio 2.96, 95% CI 1.50-5.83; for frailty index, hazard ratio 5.28, 95% CI 2.05-13.59).

Conclusions

Residents with mild/moderate frailty had higher risk of hospitalization and death than nonfrail residents. Residents who were most frail had higher risk of death but lower risk of hospitalization than nonfrail residents.

Potentially avoidable hospitalisations of German nursing home patients? A cross-sectional study on utilisation patterns and potential consequences for healthcare

OBJECTIVES

Demand for nursing home (NH) care is soaring due to gains in life expectancy and people living longer with chronic illness and disability. This is dovetailing with workforce shortages across the healthcare profession. Access to timely and appropriate medical care for NH residents is becoming increasingly challenging and can result in potentially avoidable hospitalisations (PAHs). In light of these factors, we analysed PAHs comparing NH patients with non-NH patients.

DESIGN

Cross-sectional study with claims data from 2015 supplied by a large German health insurance company within the federal state of Baden-Wuerttemberg.

SETTING

One-year observation of hospitalisation patterns for NH and non-NH patients.

PARTICIPANTS

3 872 245 of the 10.5million inhabitants of Baden-Wuerttemberg were covered.

METHODS

Patient data about hospitalisation date, sex, age, nationality, level of care and diagnoses were available. PAHs were defined based on international classification of diseases (ICD-10) diagnoses belonging to ambulatory care sensitive conditions (ACSCs). Adjusted ORs for PAHs for NH patients in comparison with non-NH patients were calculated with multivariable regression models.

RESULTS

Of the 933 242 hospitalisations in 2015, there were 23 982 for 13 478 NH patients and 909 260 for 560 998 non-NH patients. Mean age of hospitalised NH patients and level of care were significantly higher than those of non-NH patients. 6449 PAHs (29.6%) for NH patients and 136 543 PAHs (15.02%) for non-NH patients were identified. The adjusted OR for PAHs was significantly heightened for NH patients in comparison with non-NH patients (OR: 1.22, CI (1.18 to 1.26), p<0.0001). Moreover, we could observe that more than 90% of PAHs with ACSCs were unplanned hospitalisations (UHs).

CONCLUSIONS

Large numbers of PAHs for NH patients calls for improved coordination of medical care, especially general practitioner service provision. Introduction of targeted training programmes for physicians and NH staff on health problem management for NH patients could perhaps contribute to reduction of PAHs, predominantly UHs.