Indicators of home-based hospitalization model and strategies for its implementation: a systematic review of reviews

BACKGROUND

Home-based hospitalization (HBH) offers an alternative delivery model to hospital care. There has been a remarkable increase in pilot initiatives and deployment of this model to optimize services offered to a population with a variety of progressive and chronic diseases. Our objectives were to systematically summarize the indicators of HBH as well as the factors associated with the successful implementation and use of this model.

METHODS

We used a two-stage process. First, five databases were consulted, with no date delimitation. We included systematic reviews of quantitative, qualitative, and mixed studies published in English, French, Spanish, or Portuguese. We followed guidance from PRISMA and the Cochrane Collaboration. Second, we used the Nursing Care Performance Framework to categorize the indicators, a comprehensive grid of barriers and facilitators to map the factors affecting HBH implementation, and a thematic synthesis of the qualitative and quantitative findings.

RESULTS

Fifteen reviews were selected. We identified 26 indicators related to nursing care that are impacted by the use of HBH models and 13 factors related to their implementation. The most frequently documented indicators of HBH were cost of resources, problem and symptom management, comfort and quality of life, cognitive and psychosocial functional capacity, patient and caregiver satisfaction, hospital mortality, readmissions, and length of stay. Our review also highlighted new indicators, namely use of hospital beds, new emergency consultations, and use of healthcare services as indicators of resources of cost, and bowel complications, caregiver satisfaction, and survival time as indicators of change in the patient's condition. The main facilitators for HBH implementation were related to internal organizational factors (multidisciplinary collaboration and skill mix of professionals) whereas barriers were linked to the characteristics of the HBH, specifically eligibility criteria (complexity and social situation of the patient).

CONCLUSION

To the best of our knowledge, this is the first review that synthesizes both the types of indicators associated with HBH and the factors that influence its implementation. Considering both the processes and outcomes of HBH will help to identify strategies that could facilitate the implementation and evaluation of this innovative model of care delivery.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018103380.

Incidence of delirium in the Canadian emergency department and its consequences on hospital length of stay: a prospective observational multicentre cohort study

OBJECTIVE

We aim to determine the incidence of delirium and describe its impacts on hospital length of stay (LOS) among non-delirious community-dwelling older adults with an 8-hour exposure to the emergency department (ED) environment.

DESIGN

This is a prospective observational multicentre cohort study (March-July 2015). Patients were assessed two times per day during their entire ED stay and up to 24 hours on hospital ward.

SETTING

The study took place in four Canadian EDs.

PARTICIPANTS

338 included patients: (1) aged ≥65 years; (2) who had an ED stay ≥8 hours; (3) were admitted to hospital ward and (4) were independent/semi-independent.

MAIN OUTCOMES AND MEASURES

The primary outcomes of this study were incident delirium in the ED or within 24 hours of ward admission and ED and hospital LOS. Functional and cognitive status were assessed using validated Older Americans Resources and Services and the modified Telephone Interview for Cognitive Status tools. The Confusion Assessment Method was used to detect incident delirium. Univariate and multivariate analyses were conducted to evaluate outcomes.

RESULTS

Mean age was 76.8 (±8.1), 17.7% were aged >85 years old and 48.8% were men. The mean incidence of delirium was 12.1% (n=41). Median IQR ED LOS was 32.4 (24.5-47.9) hours and hospital LOS was 146.6 (75.2-267.8) hours. Adjusted mean hospital LOS was increased by 105.4 hours (4.4 days) (95% CI 25.1 to 162.0, P<0.001) for patients who developed an episode of delirium compared with non-delirious patient.

CONCLUSIONS

An incident delirium was observed in one of eight independent/semi-independent older adults after an 8-hour ED exposure. An episode of delirium increases hospital LOS by 4 days and therefore has important implications for patients and could contribute to ED overcrowding through a deleterious feedback loop.

[Making a safe transition home after a meningioma resection: The impact of nursing care]

INTRODUCTION

This study originated from patients' demands that they be better informed and that their meningioma diagnosis be considered serious. Meningioma are brain tumours that represent about 30% of all primary brain tumours. In 90% of the cases, they are non-cancerous. The objective was to identify whether educational intervention by nurses would have a positive impact on transition.

METHOD

The study lasted 12 months and included two groups: intervention and control. Intervention involved the verbal and written delivery of answers to frequently asked questions, as well as patient follow-up for six weeks post-surgery. Nurses were available during the preparation for discharge, as well as the follow-up call 48-72 hours later.

RESULTS

Educational nursing care had no demonstrable effect.

DISCUSSION

Differences between the groups might have influenced the effect of educational intervention. Our results suggest certain lines of thought as to the doses of information that should be given based on stages of care and individual particularities.

Secondary care clinic for chronic disease: protocol

Background

The complexity of chronic disease management activities and the associated financial burden have prompted the development of organizational models, based on the integration of care and services, which rely on primary care services. However, since the institutions providing these services are continually undergoing reorganization, the Centre hospitalier affilié universitaire de Québec wanted to innovate by adapting the Chronic Care Model to create a clinic for the integrated follow-up of chronic disease that relies on hospital-based specialty care.

Objective

The aim of the study is to follow the project in order to contribute to knowledge about the way in which professional and management practices are organized to ensure better care coordination and the successful integration of the various follow-ups implemented.

Methods

The research strategy adopted is based on the longitudinal comparative case study with embedded units of analysis. The case study uses a mixed research method.

Results

We are currently in the analysis phase of the project. The results will be available in 2015.

Conclusions

The project’s originality lies in its consideration of the macro, meso, and micro contexts structuring the creation of the clinic in order to ensure the integration process is successful and to allow a theoretical generalization of the reorganization of practices to be developed.

Aortic flow velocity indices during upright exercise: reliability and relationship to cardiac output

OBJECTIVE

To determine the intra- and interobserver reproducibility of Doppler-derived ascending aortic flow velocity measurements at rest and during upright exercise of increasing intensity; and to determine the relationship between Doppler-derived measurements and cardiac output obtained by the indirect Fick carbon dioxide rebreathing method in the same conditions.

SUBJECTS

Twenty young healthy adults participated in the study; eight participated in the first part and 12 in the second.

DESIGN

For the intra-observer study, subjects were submitted to three workloads (50, 100 and 150 W) of 5 mins duration on two occasions, seven days apart. The intra-observer reproducibility was determined by two technicians taking the Doppler measurements within 90 s during the steady state of each workload during the first session. The relationship between cardiac output and aortic flow velocities was studied by measuring cardiac output by carbon dioxide rebreathing and flow velocities by continuous wave Doppler ultrasound simultaneously at rest as well as during the last minute of the three workloads (50, 100 and 150 W) of 5 mins duration.

RESULTS

The interobserver reproducibility was very good, with r values of 0.87 for peak velocity (PV) and 0.97 for peak acceleration (PA). The intra-observer reproducibility at the seventh day interval showed r values of 0.93 for PV and 0.96 for PA for one of the technicians. PV and PA of the ascending aortic flow correlated well with cardiac output (r = 0.85 and 0.82, respectively, P < 0.01). ANOVA showed that PV and PA increase proportionately with exercise intensity.

CONCLUSION

PV and PA of ascending aortic flow are reproducible and reflect changes in left ventricular function during exercise.