Medical adverse events in elderly hospitalized patients: a prospective study

Inter-Hospital Transfer Is an Independent Risk Factor for Hospital-Associated Infection

Background: Regionalization of surgical care shifts higher acuity patients to larger centers. Hospital-associated infections (HAIs) are important quality measures with financial implications. In our ongoing efforts to eliminate HAIs, we examined the potential role for inter-hospital transfer in our cases of HAI across a multihospital system. Hypothesis: Surgical patients transferred to a regional multihospital system have a higher risk of National Healthcare Safety Network (NHSN)-labeled HAIs. Patients and Methods: The analysis cohort of adult surgical inpatients was filtered from a five-hospital health system administration registry containing encounters from 2014 to 2021. The dataset contained demographics, health characteristics, and acuity variables, along with the NHSN defined HAIs of central line-associated blood stream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and Clostridioides difficile infection (CDI). Univariable and multivariable statistics were performed. Results: The surgical cohort identified 92,832 patients of whom 3,232 (3.5%) were transfers. The overall HAI rate was 0.6% (528): 86 (0.09%) CLABSI, 133 (0.14%) CAUTI, and 325 (0.35%) CDI. Across the three HAIs, the rate was higher in transfer patients compared with non-transfer patients (CLABSI: n = 18 (1.3%); odds ratio [OR], 4.79; CAUTI: n = 25 (1.8%); OR, 4.20; CDI: n = 37 (1.1%); OR, 3.59); p < 0.001 for all. Multivariable analysis found transfer patients had an increased rate of HAIs (OR, 1.56; p < 0.001). Conclusions: There is an increased risk-adjusted rate of HAIs in transferred surgical patients as reflected in the NHSN metrics. This phenomenon places a burden on regional centers that accept high-risk surgical transfers, in part because of the downstream effects of healthcare reimbursement programs.

Global trends and partial forecast of adverse effects of medical treatment from 1990 to 2019: an epidemiological analysis based on the global burden of disease study 2019

BACKGROUND

The possibility of adverse effects of medical treatment (AEMT) is increasing worldwide, but little is known about AEMT in China. This study analyzed the health burden of AEMT in China in recent years through the Global Burden of Disease Study (GBD) 2019 and compared it with the worldwide average level and those in different sociodemographic index (SDI) regions.

METHODS

We calculated the age-standardized rate (ASR) of deaths, disability-adjusted life years (DALYs), years of life lost (YLLs), years lived with disability (YLDs), incidence and prevalence attributed to AEMT in China, worldwide and countries with different sociodemographic indices during 1990-2019 using the latest data and methods from the GBD 2019.

RESULTS

From 1990 to 2019, the global age-standardized death rate (ASDR), DALYs, and YLLs for AEMT showed a significant downward trend and were negatively associated with the SDI. By 2040, the ASDR is expected to reach approximately 1.58 (95% UI: 1.33-1.80). From 1990 to 2019, there was no significant change in the global incidence of AEMT. The occurrence of AEMT was related to sex, and the incidence of AEMT was greater among females. In addition, the incidence of AEMT-related injuries and burdens, such as ASR of DALYs, ASR of YLLs and ASR of YLDs, was greater among women than among men. Very old and very young people were more likely to be exposed to AEMT.

CONCLUSIONS

From 1990 to 2019, progress was made worldwide in reducing the harm caused by AEMT. However, the incidence and prevalence of AEMT did not change significantly overall during this period. Therefore, the health sector should pay more attention to AEMT and take effective measures to reduce AEMT.

Does Case-Finding for Admission to Aged Care Rapid Investigation and Assessment Unit for Older Patients Improve Hospital Length of Stay? Evaluation of ARIA Unit

Introduction

Many older people present to emergency departments annually, often with complex geriatric syndromes, yet current acute care models and traditional admissions process may under-serve their needs. The multidisciplinary Aged Care Rapid Investigation and Assessment (ARIA) Unit seeks to bridge this gap, by actively identifying and assessing patients.

Methods

A prospective case-control study was undertaken at a single-centre tertiary referral institution. Patients were eligible for inclusion in ARIA group if admitted to ARIA via case-finding by the geriatrician or Aged Care Services Emergency Team, whilst standard geriatric admissions formed the control group. This study evaluates whether ARIA reduced hospital length-of-stay (LOS) and representation rates.

Results

370 patients were included (185 each arm) with similar baseline demographics, frailty scores, and Charlson Comorbidity Indices. Patients admitted to ARIA had significantly shorter hospital LOS than those via standard pathway (3.3 days [IQR2.2-5.8] vs 7.5 days [IQR4.2-13.7], p < 0.00001). There were no significant differences in 90-day representation rates (n = 66 [35.7%] vs n = 64 [34.6%], p = 0.82).

Discussion/Conclusion

Introduction of an ARIA unit with a targeted approach to frontline geriatric services and case-finding is associated with improved LOS of older acute hospital patients. An economical cost analysis of this study would be beneficial in exploring potential financial savings.

Trends and all-cause mortality associated with multimorbidity of non-communicable diseases among adults in the United States, 1999-2018: a retrospective cohort study

OBJECTIVES

Multimorbidity of non-communicable diseases (NCDs) has brought enormous challenges to public health, becoming a major medical burden. However, the patterns, temporal trends, and all-cause mortality associated with NCD multimorbidity over time have not been well described in the United States.

METHODS

All adult participants were sourced from nationally representative data from the National Health and Nutrition Examination Survey. In total, 55,081 participants were included in trend analysis, and 38,977 participants were included in Cox regression.

RESULTS

The 5 NCDs with the largest increases over the study period were diabetes, osteoporosis, obesity, liver conditions, and cancer. The estimated prevalence of multimorbidity increased with age, especially for middle-aged participants with 5 or more NCDs; in general, the prevalence of NCD multimorbidity was higher among females than males. Participants with 5 or more NCDs were at 4.49 times the risk of all-cause mortality of participants without any diseases. Significant interactions were found between multimorbidity and age group (p for interaction <0.001), race/ethnicity (p for interaction<0.001), and educational attainment (p for interaction=0.010).

CONCLUSIONS

The prevalence of multiple NCDs significantly increased from 1999 to 2018. Those with 5 or more NCDs had the highest risk of all-cause mortality, especially among the young population. The data reported by this study could serve as a reference for additional NCD research.

Implementation of the Frailty Care Bundle (FCB) to promote mobilisation, nutrition and cognitive engagement in older people in acute care settings: protocol for an implementation science study

Background: Older people are among the most vulnerable patients in acute care hospitals. The hospitalisation process can result in newly acquired functional or cognitive deficits termed hospital associated decline (HAD).  Prioritising fundamental care including mobilisation, nutrition, and cognitive engagement can reduce HAD risk. Aim: The Frailty Care Bundle (FCB) intervention aims to implement and evaluate evidence-based principles on early mobilisation, enhanced nutrition and increased cognitive engagement to prevent functional decline and HAD in older patients. Methods: A hybrid implementation science study will use a pragmatic prospective cohort design with a pre-post mixed methods evaluation to test the effect of the FCB on patient, staff, and health service outcomes.  The evaluation will include a description of the implementation process, intervention adaptations, and economic costs analysis. The protocol follows the Standards for Reporting Implementation Studies (StaRI). The intervention design and implementation strategy will utilise the behaviour change theory COM-B (capability, motivation, opportunity) and the Promoting Action on Research Implementation in Health Services (i-PARIHS). A clinical facilitator will use a co-production approach with staff. All patients will receive care as normal, the intervention is delivered at ward level and focuses on nurses and health care assistants (HCA) normative clinical practices. The intervention will be delivered in three hospitals on six wards including rehabilitation, acute trauma, medical and older adult wards. Evaluation: The evaluation will recruit a volunteer sample of 180 patients aged 65 years or older (pre 90; post 90 patients). The primary outcomes are measures of functional status (modified Barthel Index (MBI)) and mobilisation measured as average daily step count using accelerometers. Process data will include ward activity mapping, staff surveys and interviews and an economic cost-impact analysis. Conclusions: This is a complex intervention that involves ward and system level changes and has the potential to improve outcomes for older patients.

In-hospital complications in an acute care geriatric unit

Introduction: In-hospital complications frequently occur in hospitalized people over 65 worsening their clinical outcomes. There are, however, few studies on the factors associated with in-hospital complications in elderly patient care. Objective: To evaluate factors associated with in-hospital complications in a geriatric acute care unit in Bogotá, Colombia. Materials and methods: We conducted an analytical, observational, retrospective study in a cohort of 1,657 patients over 65 years of age who received care in the geriatric unit of a high complexity hospital in Bogotá, Colombia. The dependent variable was in-hospital complications and the independent variables, the degree of functional dependence on admission, dementia, nutritional status, social support, comorbidity, and polypharmacy. We used Poisson’s linear regression model to identify associated variables. Results: The bivariate analysis showed that functional dependence (PR=2.092, p≤0.001) and malnutrition (PR=2.850, p≤0.001) were associated with a higher rate of hospital-acquired infection. In the multivariate analysis, functional dependence (PR=1.931, p=0.003) and malnutrition (PR=2.502, p=0.002) remained independent factors for in-hospital complications. Conclusion: In acute care centers, integral assessment at admission to identify functional dependence and malnutrition predicts in-hospital complications.

The Incidence and Preventability of Adverse Events in Older Acutely Admitted Patients: A Longitudinal Study With 4292 Patient Records

OBJECTIVES

Acute care crowding is a global issue, jeopardizing patient safety. An important cause of crowding is the growing number of older, vulnerable, and complex patients. This group is at higher risk of experiencing (preventable) adverse events (AEs) than younger patients.This study aimed to identify the incidence, preventability, nature, and prevention strategies of AEs in older patients during an acute hospital admission and to assess changes over time.

METHODS

We analyzed data of 4292 acutely admitted patients (70+) who died in the hospital, using data of a multicenter Dutch AE record review study (2008, 2012, 2016). Multilevel logistic regression analyses were performed to adjust for patient-mix differences and clustering on department/hospital level per year.

RESULTS

The incidence of AEs in this group declined significantly (χ2(1) = 8.78, P = 0.003) from 10.7% (95% confidence interval [CI] =8.2-13.9) in 2008, 7.4% (95% CI = 5.6-9.7) in 2012, to 7.2% (95% CI = 5.5-9.3) in 2016. The relative preventability showed a significant parabolic trend (χ2(1) = 4.86, P = 0.027), from 46.2% (95% CI = 34.1-58.7), to 32.4% (95% CI = 21.1-46.1), to 44.6% (95% CI = 32-58). Adverse events were often related to medication (26.3% in 2008, 35.1% in 2012, and 39.5% in 2016), and the preventability in AEs related to diagnosis was highest (88.3%, 70.8%, and 79.9%).

CONCLUSIONS

The incidence of AEs in older acutely admitted patients declined over the years; however, the preventability increased again after an initial decline. This could be related to crowding or increasing complexity in the acute care chain. Further monitoring and improvement in (preventable) AE rates are necessary to pinpoint areas of improvement to make hospital care for this vulnerable group safer.

Clinical impact of compound sarcopenia in hospitalized older adult patients with heart failure

OBJECTIVES

Skeletal muscle loss or sarcopenia is a frequent complication in heart failure (HF) and contributes to adverse clinical outcomes. We evaluated if age (primary) and chronic disease (secondary) related sarcopenia, that we refer to as compound sarcopenia, impacts clinical outcomes in hospitalized patients with HF.

DESIGN

Cross-sectional study using hospitalized patient data.

SETTING

Data from the Agency for Healthcare Research and Quality through the Healthcare Cost and Utilization Project (HCUP).

PARTICIPANTS

Hospitalized adult patients with a primary or secondary diagnosis of HF (n = 64,476) and a concurrent random 2% sample of general medical population (GMP; n = 322,217) stratified by age (<50 years of age [y], 51-65y, >65y) from the Nationwide Inpatient Sample (NIS) database (years 2010-2014).

MEASUREMENTS

In-hospital mortality, length of stay (LoS), cost of hospitalization per admission (CoH), comorbidities and discharge disposition, with and without muscle loss phenotype, were analyzed. Muscle loss phenotype was defined using a comprehensive code set from international classification of diseases-9 (ICD-9).

RESULTS

Muscle loss phenotype was observed in 8673 (13.5%) patients with HF compared to 5213 (1.6%) GMP across all age strata. In patients with HF, muscle loss phenotype was associated with higher mortality, LoS, and CoH. Patients with HF (>65y) and muscle loss phenotype had higher mortality (adjusted OR: 1.81; 95% CI 1.56-2.10), CoH (adjusted OR 1.48; 95% CI 1.44-1.1.52), and LoS (adjusted OR 1.40; 95% CI 1.37-1.43) compared to >65y GMP with muscle loss phenotype.

CONCLUSION

Muscle loss phenotype is more commonly associated with increasing age in hospitalized patients with HF. Clinical outcomes were significantly worse in patients with HF aged >65y compared to younger patients with HF and all age strata in GMP with and without a muscle loss phenotype.

Medication review interventions to reduce hospital readmissions in older people

Objective

To assess the efficacy of medication review as an isolated intervention and with several co‐interventions for preventing hospital readmissions in older adults.

Methods

Ovid MEDLINE, Embase, The Cochrane Central Register of Controlled Trials and CINAHL were searched for randomized controlled trials evaluating the effectiveness of medication review interventions with or without co‐interventions to prevent hospital readmissions in hospitalized or recently discharged adults aged ≥65, until September 13, 2019. Included outcomes were “at least one all‐cause hospital readmission within 30 days and at any time after discharge from the index admission.”

Results

Twenty‐five studies met the inclusion criteria. Of these, 11 studies (7,318 participants) contributed to the network meta‐analysis (NMA) on all‐cause hospital readmission within 30 days. Medication review in combination with (a) medication reconciliation and patient education (risk ratio (RR) 0.45; 95% confidence interval (CI) 0.26–0.80) and (b) medication reconciliation, patient education, professional education and transitional care (RR 0.64; 95% CI 0.49–0.84) were associated with a lower risk of all‐cause hospital readmission compared to usual care. Medication review in isolation did not significantly influence hospital readmissions (RR 1.06; 95% CI 0.45–2.51). The NMA on all‐cause hospital readmission at any time included 24 studies (11,677 participants). Medication review combined with medication reconciliation, patient education, professional education and transitional care resulted in a reduction of hospital readmissions (RR 0.82; 95% CI 0.74–0.91) compared to usual care. The quality of the studies included in this systematic review raised some concerns, mainly regarding allocation concealment, blinding and contamination.

Conclusion

Medication review in combination with medication reconciliation, patient education, professional education and transitional care, was associated with a lower risk of hospital readmissions compared to usual care. An effect of medication review without co‐interventions was not demonstrated. Trials of higher quality are needed in this field.

The geriatric emergency literature 2019

Geriatric Emergency Medicine is an important frontier for study and innovation by emergency practitioners. The rapid growth of this patient population combined with complex medical and social needs has prompted research ranging from which tests and screening tools are most effective for geriatric evaluation to how we can safely manage pain in the elderly or address goals of care in the Emergency Department. This review summarizes emergency medicine articles focused on the older patient population published in 2019, which the authors consider critical to the practice of geriatric emergency medicine.

Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting?

BACKGROUND

Elderly patients presenting to the emergency department (ED) with nonspecific complaints (NSCs) often undergo troponin testing to assess for atypical acute coronary syndrome (ACS). However, the rate of ACS and utility of troponin testing in this population is unknown. We sought to determine the rate of ACS and diagnostic yield of troponin testing in elderly patients with NSCs.

METHODS

We retrospectively identified all patients aged ≥ 65 years triaged in the ED with NSCs from January 1, 2017, to June 30, 2017. NSCs were defined a priori and included complaints such as weakness, dizziness, or fatigue. NSCs were verified in ED provider notes by trained abstractors blind to testing results. Exclusions were focal chief complaint in provider notes, fever, and no troponin ordered. ACS was strictly defined and independently adjudicated by two trained physician researchers blind to the study hypothesis. We calculated the proportion of patients with ACS within 30 days and the test characteristics of troponin to diagnose ACS.

RESULTS

Screening identified 1,146 encounters, and 552 were excluded for fever or focal chief complaints in the provider notes. Of the remaining 594 patients, troponin was ordered in 412 (69%), comprising the study cohort. The mean (±SD) age was 78.7 (±8.3) years, with 58% female and 75% admitted. Troponin elevation occurred in 81 patients (20%). ACS occurred in 5 of 412 (1.2%). Troponin was 100% sensitive (95% confidence interval [CI] = 48% to 100%) and 81% specific (95% CI = 77% to 85%) for ACS. Of patients with elevated troponin, 93.8% were false positives (no ACS). All patients with troponin elevation were admitted, but only one underwent angiography and no patients received reperfusion therapy.

CONCLUSIONS

While consideration for ACS is prudent in selected elderly patients with NSCs, ACS was rare and no patients received reperfusion therapy. Given the false-positive rate in our study, our results may not support routine troponin testing for ACS in this population.

Carbapenem-Resistant Enterobacteriaceae Outbreak in a Medical Ward in Spain: Epidemiology, Control Strategy, and Importance of Environmental Disinfection

Introduction: Carbapenem-resistant Enterobacteriaceae (CRE) are a growing public health problem. We describe an outbreak by CRE and the measures to control it in a hospitalization unit in Spain. Methods: In June 2015, the system of prevention and control of CRE implemented in the hospital detected an increase in the incidence of patients with CRE in a mixed hospitalization facility (geriatrics, internal medicine, and pneumology), with the appearance of four related patients in 2 weeks, three of them being nosocomial cases. A multidisciplinary group was created and carried out: weekly screenings, general cleaning, four training sessions for personnel, two hand hygiene observation studies and environmental sampling. A higher incidence of new cases was detected in three adjoining rooms, in which environmental decontamination was performed with vaporized hydrogen peroxide. Results: In 5 months, a total of 18 cases were detected, 14 of them were nosocomial. Four different clones of Klebsiella pneumoniae OXA-48 were responsible for 83.3% of the cases. Adherence to hand hygiene increased from 36% to 85% after the training sessions. Seven percent of the environmental samples were positive for CRE in rooms with high incidence, moving to 0% after decontamination with hydrogen peroxide. Three patients died, one of them possibly associated with clinical infection due to CRE. Conclusions: Multidisciplinary information strategies, personnel training, and control of environmental reservoirs are effective to address outbreaks of CRE.

Clinical characteristics of heart failure associated with functional dependence at admission in hospitalized elderly

Objective

to identify which clinical features of heart failure are associated with a greater chance of functional dependence for the basic activities of daily living in hospitalized elderly.

Method

cross-sectional study conducted with elderly hospitalized patients. The clinical characteristics of heart failure were assessed by self-report, medical records and scales. Dependency was assessed by the Katz Index. The Fisher’s Exact Test was used to analyze associations between the nominal variables, and logistic regression to identify factors associated with dependence.

Results

the sample consisted of 191 cases. The prevalence of functional dependence was 70.2%. Most of the elderly were partially dependent (66.6%). Clinical characteristics associated with dependence at admission were dyspnea (Odds Ratio 8.5, Confidence Interval 95% 2.668-27.664, p <0.001), lower limb edema (Odds Ratio 5.7, 95% Confidence Interval 2.148-15.571, p <0.001); cough (Odds Ratio 9.0, 95% confidence interval 1.053-76.938, p <0.045); precordial pain (Odds Ratio 4.5, 95% confidence interval 1.125-18.023, p <0.033), and pulmonary crackling (Odds Ratio 4.9, 95% Confidence Interval 1.704-14.094, p <0.003).

Conclusion

functional dependence in admitted elderly patients with heart failure is more associated with congestive signs and symptoms.

Enhanced supervision: new ways to promote safety and well-being in patients requiring one-to-one or cohort nursing

The number of older people with multiple co-morbidities and cognitive impairment being admitted to hospital is increasing, and behavioural disturbances, such as confusion, agitation and delirium, are becoming commonplace. The need for nursing teams to manage the patients with such disturbances has led to the proliferation of one-to-one nursing or close observation, anecdotally known as 'specialing'. This article describes the implementation and outcomes of a new framework for providing enhanced supervision of patients in clinical wards run by the Cardiff and Vale University Health Board, one of the largest acute providers of care in Wales.

Evaluating the Impact of the Dementia Care in Hospitals Program (DCHP) on Hospital-Acquired Complications: Study Protocol

Despite the increasing number of older people, many with cognitive impairment (CI), in hospitals, there is yet to be an evaluation of hospital-wide interventions improving the management of those with CI. In hospitalized patients with CI, there are likely to be associations between increased complications that impact on outcomes, length of stay, and costs. This prospective study will evaluate the effectiveness of an established hospital CI support program on patient outcomes, patient quality of life, staff awareness of CI, and carer satisfaction. Using a stepped-wedge, continuous-recruitment method, the pre-intervention patient data will provide the control data for usual hospital care. The intervention, the Dementia Care in Hospitals Program, provides hospital-wide CI awareness and support education, and screening for all patients aged 65+, along with a bedside alert, the Cognitive Impairment Identifier. The primary outcome is a reduction in hospital-acquired complications: urinary tract infections, pressure injuries, pneumonia and delirium. Secondary outcome measures include cost effectiveness, patient quality of life, carer satisfaction, staff awareness of CI, and staff perceived impact of care. This large-sample study across four sites offers an opportunity for research evaluation of health service functioning at a whole-of-hospital level, which is important for sustainable change in hospital practice.

Prevalence of Multiple Chronic Conditions Among Older Adults in Florida and the United States: Comparative Analysis of the OneFlorida Data Trust and National Inpatient Sample

Background

Older patients with multiple chronic conditions are often faced with increased health care needs and subsequent higher medical costs, posing significant financial burden to patients, their caregivers, and the health care system. The increasing adoption of electronic health record systems and the proliferation of clinical data offer new opportunities for prevalence studies and for population health assessment. The last few years have witnessed an increasing number of clinical research networks focused on building large collections of clinical data from electronic health records and claims to make it easier and less costly to conduct clinical research.

Objective

The aim of this study was to compare the prevalence of common chronic conditions and multiple chronic conditions in older adults between Florida and the United States using data from the OneFlorida Clinical Research Consortium and the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS).

Methods

We first analyzed the basic demographic characteristics of the older adults in 3 datasets—the 2013 OneFlorida data, the 2013 HCUP NIS data, and the combined 2012 to 2016 OneFlorida data. Then we analyzed the prevalence of each of the 25 chronic conditions in each of the 3 datasets. We stratified the analysis of older adults with hypertension, the most prevalent condition. Additionally, we examined trends (ie, overall trends and then by age, race, and gender) in the prevalence of discharge records representing multiple chronic conditions over time for the OneFlorida (2012-2016) and HCUP NIS cohorts (2003-2013).

Results

The rankings of the top 10 prevalent conditions are the same across the OneFlorida and HCUP NIS datasets. The most prevalent multiple chronic conditions of 2 conditions among the 3 datasets were—hyperlipidemia and hypertension; hypertension and ischemic heart disease; diabetes and hypertension; chronic kidney disease and hypertension; anemia and hypertension; and hyperlipidemia and ischemic heart disease. We observed increasing trends in multiple chronic conditions in both data sources.

Conclusions

The results showed that chronic conditions and multiple chronic conditions are prevalent in older adults across Florida and the United States. Even though slight differences were observed, the similar estimates of prevalence of chronic conditions and multiple chronic conditions across OneFlorida and HCUP NIS suggested that clinical research data networks such as OneFlorida, built from heterogeneous data sources, can provide rich data resources for conducting large-scale secondary data analyses.

COMPARAÇÃO ENTRE GRAVIDADE DO PACIENTE E CARGA DE TRABALHO DE ENFERMAGEM ANTES E APÓS A OCORRÊNCIA DE EVENTOS ADVERSOS EM IDOSOS EM CUIDADOS CRÍTICOS

RESUMO Objetivo: comparar a gravidade do paciente e a carga de trabalho de enfermagem antes e após a ocorrência de evento adverso moderado e grave em idosos internados em unidades de terapia intensiva. Método: estudo comparativo, realizado em nove unidades de terapia intensiva de um Hospital Universitário de São Paulo. Os eventos foram coletados dos prontuários dos pacientes e classificados em moderados e graves segundo a Organização Mundial de Saúde. A análise da gravidade foi realizada segundo o Symplified Acute Phsiologic Score II e a carga de trabalho segundo o Nursing Activities Score, 24 horas antes e depois do evento moderado e grave. O teste t, com significância de 5%, foi utilizado para a comparação das médias da gravidade clínica e da carga de trabalho, antes e após o evento. Resultados: a amostra foi composta por 315 idosos, sendo que 94 (29,8%) sofreram eventos moderados e graves nas unidades. Dos 94 eventos, predominou o tipo processo clínico e procedimento (40,0%). A instalação e manutenção de artefatos terapêuticos e cateteres foram as intervenções prevalentes que resultaram em danos fisiopatológicos (66,0%), de grau moderado (76,5%). A média de pontuação da carga de trabalho (75,19%) diminuiu 24 horas após a ocorrência do evento (71,97%, p=0,008) e, a gravidade, representada pela probabilidade de morte, aumentou de 22,0% para 29,0% depois do evento (p=0,045). Conclusão: no contexto da segurança do paciente, a identificação das alterações nas condições clínicas e na carga de trabalho de enfermagem em idosos que sofrem eventos subsidiam a prevenção dessas ocorrências.

One-Year Mortality Rates Before and After Implementing Quality-Improvement Initiatives to Prevent Inpatient Falls (2012⁻2016)

Single-room ward design has previously been associated with increased risk of inpatient falls and adverse outcomes. However, following quality initiatives, the incidence of inpatient falls has shown a sustained reduction. Benefits have also been observed in the reduction of hip fractures. However, one-year mortality trends have not been reported. The aim of this observational study is to report the trends in one-year mortality rates before and after implementing quality-improvement initiatives to prevent inpatient falls over the last 5 years (2012⁻2016). This retrospective observational study was conducted for all patients who had sustained an inpatient fall between January 2012 and December 2016. All the incident reports in DATIX patient-safety software which were completed for each inpatient fall were studied, and the clinical information was extracted from Clinical Work Station software. Mortality data were collected on all patients for a minimum of one year following the discharge from the hospital. The results show that 95% patients were admitted from their own homes; 1704 patients had experienced 3408 incidents of an inpatient fall over 5 years. The mean age of females (82.61 ± 10.34 years) was significantly higher than males (79.36 ± 10.14 years). Mean falls/patient = 2.0 ± 2.16, range 1⁻33). Mean hospital stay was 45.43 ± 41.42 days. Mean hospital stay to the first fall was 14.5 ± 20.79 days, and mean days to first fall prior to discharge was 30.8 ± 34.33 days. The results showed a significant and sustained reduction in the incidence of inpatient falls. There was a downward trend in the incidence of hip fractures over the last two years. There was no significant difference in the inpatient and 30-day mortality rate over the last five years. However, mortality trends appear to show a significant downward trend in both six-month and one-year mortality rates over the last two years following the implementation of quality initiatives to prevent inpatient falls. A significant reduction in the incidence of inpatient falls following quality initiatives initially has been observed, followed by a downward trend in the incidence of hip fractures. We have just started to observe a significant reduction in the 6-month and one-year mortality. We propose prompt completion of multifactorial falls risk assessments, and every possible quality initiative should be taken to prevent a 'first inpatient fall', which should result in the sustained improvement of clinical outcomes.

Factors associated with the occurrence of adverse events in critical elderly patients

Objective:

to identify the factors associated with the occurrence of adverse events in critical elderly patients admitted to intensive care unit according to demographic and clinical characteristics.

Method:

a retrospective cohort study was conducted in nine units of a teaching hospital. Data were collected from medical records and from monitoring of nursing shift change. We used the t-test/Mann-Whitney, chi-square and logistic regression to test associations. Significance level of 5% was used.

Results:

out of the 315 elderly, 94 experienced events. Those who experienced events were men (60.6%) with mean age of 70.7 years, length of hospital stay of 10.6 days and survivors (61.7%). Most of the 183 events were clinical processes and procedures (37.1%). There was an association between adverse event and length of hospital stay in the unit (p=0.000; OR=1.10, 95% CI [1.06, 1.14]).

Conclusion:

the identification of associated events and factors in the elderly subsidize the prevention of these occurrences before the vulnerability of this age group.

Clinicians' perceptions and recognition of practice improvement strategies to prevent harms to older people in acute care hospitals

AIMS AND OBJECTIVES

Explore clinicians' perceptions of practice improvement strategies used to prevent harms to older people during acute hospitalisation.

BACKGROUND

Older people are vulnerable to many interrelated preventable harms during acute care hospitalisation. Improvement strategies recommend standardisation of practices to assist healthcare staff to mitigate risk; however, older people continue to suffer preventable harms in acute hospitals.

METHODS

A qualitative exploratory descriptive design was used to collect data using focus groups and individual interviews from a purposive sample of 33 participants. Participants represented a wide range of clinicians from four diverse healthcare organisations. Qualitative content analysis used a framework informed by common preventable harms derived from key literature and policy documents.

RESULTS

Participants' perceptions of practice improvement strategies varied depending on their role within their organisational hierarchy. Recognition of preventable harms was guided by standard risk assessment and management tools used in their organisations. Preventable harms relating to skin integrity and falls were universally recognised across all sites and roles. Alternatively, there was variability in participant recognition of preventable harms related to nutrition, continence, medications and cognition; pain was consistently overlooked as a contributor to preventable harms.

CONCLUSIONS

Hospital staff perceived standard clinical risk assessment and management tools as the main practice improvement strategy to prevent harms. These tools prompted staff recognition of preventable harms to older people during acute hospitalisation. Variability in the recognition of some preventable harms was attributed to variable use of standard assessment tools. Pain was unlikely to be recognised as contributing to preventable harms.

RELEVANCE TO CLINICAL PRACTICE

Clinical Risk Management tools may assist clinicians in recognising and responding to preventable harms to older people during hospitalisation. These tools provide critical resources for consistent and timely assessment and evaluation of risk for preventable harms.

What is inappropriate hospital use for elderly people near the end of life? A systematic review

BACKGROUND

Older people with advance chronic illness use hospital services repeatedly near the end of life. Some of these hospitalizations are considered inappropriate.

AIM

To investigate extent and causes of inappropriate hospital admission among older patients near the end of life.

METHODS

English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995-December 2016) covering community and nursing home residents aged ≥60years admitted to hospital.

OUTCOMES

measurements of inappropriateness. A 17-item quality score was estimated independently by two authors.

RESULTS

The definition of 'Inappropriate admissions' near the end of life incorporated system factors, social and family factors. The prevalence of inappropriate admissions ranged widely depending largely on non-clinical reasons: poor availability of alternative sites of care or failure of preventive actions by other healthcare providers (1.7-67.0%); family requests (up to 10.5%); or too late an admission to be of benefit (1.7-35.0%). The widespread use of subjective parameters not routinely collected in practice, and the inclusion of non-clinical factors precluded the true estimation of clinical inappropriateness.

CONCLUSIONS

Clinical inappropriateness and system factors that preclude alternative community care must be measured separately. They are two very different justifications for hospital admissions, requiring different solutions. Society has a duty to ensure availability of community alternatives for the management of ambulatory-sensitive conditions and facilitate skilling of staff to manage the terminally ill in non-acute settings. Only then would the evaluation of local variations in clinically inappropriate admissions and inappropriate length of stay be possible to undertake.

Impact of Hospital Design on Acutely Unwell Patients with Dementia

Increasing emphasis on patient privacy and satisfaction has seen more 100% single-room hospitals opened across the UK. Few studies have addressed the impact of these new hospital designs (single rooms) on clinical outcomes specifically for acutely unwell frail patients with dementia. The objective of this study was to profile and compare the clinical outcomes of acutely unwell patients with dementia admitted to two different hospital environments. This prospective observation study was conducted for 100 dementia patients admitted at Ysbyty Ystrad Fawr (hospital with 100% single rooms) and Royal Gwent Hospital (traditional multi-bed wards) under the same University Health Board. The length of stay (LoS) was significantly longer for patients admitted to single rooms. The clinical profile of the patients was similar in both hospitals and has no association with LoS. There was no significant difference in terms of incidence of inpatient falls, fall-related injury, discharge to a new care home, 30-day readmission, or mortality. The single room environment appears to influence LoS, as previously reported; however, following the introduction of quality improvement initiatives to prevent inpatient falls, single rooms do not appear to be associated with higher inpatient fall incidence. We propose more research to understand the relationship between single rooms and LoS.

VITAL SIGNS MEASUREMENT: AN INDICATOR OF SAFE CARE DELIVERED TO ELDERLY PATIENTS

ABSTRACT The study's aim was to analyze the importance assigned by the nursing staff to the recording of vital signs of elderly inpatients, as well as perceived barriers and benefits. Data were collected through interviews held with 13 nurses and the reports were analyzed using content analysis, considering the health belief model proposed by Rosenstock. The categories that emerged from the analysis indicate barriers that interfere in the proper monitoring of vital signs, namely: workload, lack of availability and accessibility of basic equipment such as thermometers, stethoscopes and sphygmomanometers, which compromises the nursing assessment and leads to a greater susceptibility to incidents. Although the facility does not provide conditions to measure vital signs properly, the nursing staff attempts to do what is feasible given their current knowledge and context to achieve the best outcome possible in view of the resources available.

The cost of hospital-acquired complications for older people with and without dementia; a retrospective cohort study

BACKGROUND

Increased length of stay and high rates of adverse clinical events in hospitalised patients with dementia is stimulating interest and debate about which costs may be associated and potentially avoided within this population.

METHODS

A retrospective cohort study was designed to identify and compare estimated costs for older people in relation to hospital-acquired complications and dementia. Australia's most populous state provided a census sample of 426,276 discharged overnight public hospital episodes for patients aged 50+ in the 2006-07 financial year. Four common hospital-acquired complications (urinary tract infections, pressure areas, pneumonia, and delirium) were risk-adjusted at the episode level. Extra costs were attributed to patient length of stay above the average for each patient's Diagnosis Related Group, with separate identification of fixed and variable costs (all in Australian dollars).

RESULTS

These four complications were found to be associated with 6.4% of the total estimated cost of hospital episodes for people over 50 (A$226million/A$3.5billion), and 24.7% of the estimated extra cost of above-average length of stay spent in hospital for older patients (A$226million/A$914million). Dementia patients were more likely than non-dementia patients to have complications (RR 2.5, p <0.001) and these complications comprised 22.0% of the extra costs (A$49million/A$226million), despite only accounting for 10.4% of the hospital episodes (44,488/426,276). For both dementia and non-dementia patients, the complications were associated with an eightfold increase in length of stay (813%, or 3.6 days/0.4 days) and doubled the increased estimated mean episode cost (199%, or A$16,403/A$8,240).

CONCLUSION

Urinary tract infections, pressure areas, pneumonia and delirium are potentially preventable hospital-acquired complications. This study shows that they produce a burdensome financial cost and reveals that they are very important in understanding length of stay and costs in older and complex patients. Once a complication occurs, the cost is similar for people with and without dementia. However, they occur more often among dementia patients. Advances in models of care, nurse skill-mix and healthy work environments show promise in prevention of these complications for dementia and non-dementia patients.

Changes in disability levels among older adults experiencing adverse events in postacute rehabilitation care: a prospective observational study

This study aimed to assess the relationship between adverse events (AEs) and changes in the levels of disability from admission to discharge during inpatient rehabilitation programs. A prospective cohort study was conducted among a cohort of inpatients (216 older adults) admitted to a rehabilitation unit. The occurrences of any AE were reported. The level of disability regarding mobility activities was estimated using the disability qualifiers from the International Classification of Functioning, Disability, and Health. Changes in the levels of disability between admission and discharge were assessed. Baseline-measured covariates were also selected. Regarding all 4 disability levels ("no limitation," "mild," "moderate," "severe," and "complete disability"), a total of 159 participants experienced an improvement at discharge (126 participants progressed 1 level, whereas 33 improved 2 disability levels), 56 made no change, and no participants experienced a decline. The occurrence of fall-related events and the diagnostic group (musculoskeletal system) are specific predictive factors of change in the level of disability. The odds of undergoing a change in any disability level between admission and discharge decreases by 68% (1-0.32) when patients experience fall-related events (odds ratio [OR] = 0.32, 95% confidence interval [CI] = 0.11-0.97, P = 0.041) and increases for individuals with musculoskeletal conditions (OR = 3.91, 95% CI = 1.34-11.38, P = 0.012). Our findings suggest that increased efforts to prevent the occurrence of these AEs, together with early interventions suited to the diagnosis of the affected system, may have a positive influence on the improvement of disability. Further studies should evaluate disability over time after discharge to obtain a better sense of how transient or permanent the associated disability may be.

Factors affecting mortality in elderly patients hospitalized for nonmalignant reasons

Elderly population is hospitalized more frequently than young people, and they suffer from more severe diseases that are difficult to diagnose and treat. The present study aimed to investigate the factors affecting mortality in elderly patients hospitalized for nonmalignant reasons. Demographic data, reason for hospitalization, comorbidities, duration of hospital stay, and results of routine blood testing at the time of first hospitalization were obtained from the hospital records of the patients, who were over 65 years of age and hospitalized primarily for nonmalignant reasons. The mean age of 1012 patients included in the study was 77.8 ± 7.6. The most common reason for hospitalization was diabetes mellitus (18.3%). Of the patients, 90.3% had at least a single comorbidity. Whilst 927 (91.6%) of the hospitalized patients were discharged, 85 (8.4%) died. Comparison of the characteristics of the discharged and dead groups revealed that the dead group was older and had higher rates of poor general status and comorbidity. Differences were observed between the discharged and dead groups in most of the laboratory parameters. Hypoalbuminemia, hypertriglyceridemia, hypopotassemia, hypernatremia, hyperuricemia, and high TSH level were the predictors of mortality. In order to meet the health necessities of the elderly population, it is necessary to well define the patient profiles and to identify the risk factors.

What justifies a hospital admission at the end of life? A focus group study on perspectives of family physicians and nurses

BACKGROUND

Despite a majority preferring not to die in hospital and health policies aimed at increasing home death, the proportion of hospital deaths remains high. Gaining insight into professional caregiver perspectives about what justifies them could be helpful in understanding the persistently high rates of such hospital admissions and hospital deaths.

AIM

To explore the perspectives of nurses from nursing homes, home care and hospitals, and family physicians concerning hospital admissions at the end of life and the circumstances in which they consider them to be justified.

DESIGN

Focus groups, transcribed verbatim and analysed using a constant comparative approach.

SETTING/PARTICIPANTS

Five focus groups were held with family physicians (n = 39), two focus groups (n = 16) with nurses from different care settings (nursing home, home care and hospital) and one with nursing home nurses (n = 7) in Belgium.

RESULTS

Participants indicated that although they considered death at home or in the nursing home of residence the most preferable outcome, there are a number of scenarios that they consider to justify a hospital admission at the end of life: when the patient prefers a hospital admission, when the caring capacity of the care setting is considered to be inadequate and when one of a number of acute medical situations occurs.

CONCLUSION

A number of situations have been identified in which nurses and family physicians consider a hospital admission to be justified. Adequate advance care planning and improved psychosocial support to both family and professional caregivers could reduce the number of hospital deaths.

The differential effects of surgical harm in elderly populations. Does the adage: "they tolerate the operation, but not the complications" hold true?

BACKGROUND

Elderly patients are thought to tolerate surgical complications poorly because of low physiologic reserve. The purpose of the study was to evaluate the differential effects of surgical harm in patients over 80 years old.

METHODS

Three years of data from a harm-reduction campaign were used to identify inpatient surgeries performed on patients older than 50. The rates of harm, death, cost, and length of stay (LOS) were analyzed using SPSS 21 (IBM, New York, NY).

RESULTS

A total of 22,710 patients were identified. Rates of harm and mortality increased with increasing age. Harmed patients over age 80 had increased mortality (9.5% vs 7%), but lower cost, intensive care unit days, and LOS versus those aged 50 to 80. Linear regression showed increased cost with harm ($24,000) and decreased cost with age above 80 (-$7,000).

CONCLUSIONS

In the elderly surgical population, there is more harm and harm events are associated with higher mortality rates, but less additional cost and LOS. Differing goals or aggressiveness of care may explain cost avoidance in the elderly.