Convalescence Care Research Articles

Resource utilization and convalescent care cost in neonatal opioid withdrawal syndrome.

Neonatal opioid withdrawal syndrome (NOWS) is a growing public health problem associated with complex and prolonged medical care and a significant resource utilization burden. The objective of this study was to compare the cost of different convalescent care settings for infants with NOWS. Retrospective comparison study of infants with NOWS discharged directly from NICU, transferred to an acute care pediatric floor (PPCU) or rehabilitation hospital (PRH). Primary outcomes were length of stay (LOS) and cost of stay (COS). Infants had 1.3 (95% CI: 1.1,1.6) times and 2.5 (95% CI: 2.1,3.1) times significantly longer mean LOS for PPCU and RH discharges compared to NICU discharges. NICU discharged infants had the lowest mean COS ($25,745.00) and PRH the highest ($60,528.00), despite PRH having a lower cost per day. PRH discharged infants had higher rates of methadone and benzodiazepine and less buprenorphine exposure than NICU/PPCU discharged. Infants born to mothers on marijuana and buprenorphine had a 28% lower mean COS compared to unexposed infants. Median treatment cumulative morphine doses were six-fold higher for PRH than NICU discharge. Infants transferred to convalescence care facilities had longer and more costly admissions and received more medication. However, there may be a role for earlier transfer of a subset of infants at-risk for longer LOS as those exposed to methadone and/or benzodiazepines. Further studies exploring differences in resource utilization, convalescent care delivery and cost expenditure are recommended.

Improving blood product utilization at an ambulatory surgery center: a retrospective cohort study on 50 patients with lumbar disc replacement

BackgroundThere is minimal literature discussing anterior lumbar spine surgery in ambulatory surgery centers (ASCs). The main concern with the anterior approach to the lumbar spine is the potential for injury to great vessels. In our facility, there are two units of crossmatched blood available in addition to cell saver during the procedure. We retrospectively looked at 50 cases of lumbar total disc arthroplasty (TDA) in our ASC to determine utilization of blood products.MethodsMedical records of 50 consecutive patients who underwent a lumbar TDA at a single ASC were reviewed. Surgeries completed at the ASC were all transferred from the post anesthesia care unit to an attached convalescence care center which allows up to 3 days of observation. Patients who had either a 1 or 2 level lumbar TDA were included in the study. Data consisting of demographics, American Society of Anesthesiologist Physical Status Classification System, length of stay, estimated blood loss, cell saver volume, transfusion, perioperative and postoperative complications were recorded. Preoperative, perioperative and postoperative medical records were reviewed.ResultsMedical records of 50 consecutive patients were reviewed. The mean age was 40.86 ± 9.45. Of these, 48 (96%) had a 1-level lumbar TDA, 1(2%) had a 2-level lumbar TDA, 1 (2%) had a lumbar TDA at L4/5 and an anterior lumbar interbody fusion at L5/S1. There were no mortalities; no patient had recorded perioperative complications. No patients received allogeneic blood transfusion, 4 (8%) were re-transfused with cell saver (2 receiving approximately 400 ml and 2 receiving approximately 200 ml of re-transfused blood). All 50 (100%) were discharged home in stable condition. We had 30-day follow-up data on 35 of 50 patients. Of the 35 patients reviewed, three (8.5%) of the patients were readmitted to the hospital. One additional patient was seen in the emergency department and discharged home after negative testing. No patient was readmitted for post-operative anemia.ConclusionThe routine use of both cell saver and crossmatched blood in the operating suite for lumbar TDA may be an over-utilization of healthcare resources. In our review of 50 patients, we had no need for transfusion of allogeneic packed red blood cells (PRBCs) and only four of the 50 patients had enough blood output for re-transfusion from the cell saver. This opens the conversation for alternatives to crossmatched PRBCs being held in the operating room. Such alternatives may be the use of cell salvage, only type O blood in a cooler for each patient or keeping type O blood on constant hold in ASCs.

Characterization of temporal relationships of comorbidities developed following cancer diagnoses in veterans.

e18049 Background: Understanding patient trajectories and common sequences of comorbidity accrual among those newly diagnosed with cancer is critical for precision approaches to care and prevention. The Veterans Affairs (VA) Cooperative Studies Program (CSP) #380 cohort includes 3,121 healthy asymptomatic veterans who underwent screening colonoscopy and were followed for at least ten years. The current analysis leverages computational approaches to characterize the temporal relationships of diagnoses in CSP #380 participants following diagnosis of colorectal or other cancers. Methods: Patients enrolled in CSP #380 with at least 5 years of linked electronic health record data from the VA Corporate Data Warehouse (October 1999-December 2015) were included. Cancer diagnoses and their most common subsequent new diagnoses were identified per patient by the first instance of each three-digit ICD-9 diagnosis affecting at least 50 patients. Pairwise chronological relative risks (RR) between subsequent diagnoses were represented as a directed network graph, which maps the probability of developing a diagnosis following a prior diagnosis. Results: A total of 2,210 patients were included. The most common cancer diagnoses were prostate (436), thoracic (169), bladder (120), colon (72), and kidney cancers (65). Most first diagnoses following a cancer diagnosis were related to progressive cancer or acute/subacute treatment toxicity. For prostate cancer, comorbidities with greatest RR were carcinoma in situ (RR 6.85), unspecified (NOS) metastases (2.75), and urethral stricture (2.53). For lung cancer, they were metastases of respiratory and digestive sites (12.24), lymph nodes (6.47), and NOS (5.68), pneumothorax and air leak (4.16), and convalescence and palliative care (3.07). In bladder cancer, they were carcinoma in situ (9.00), cystitis (6.78), kidney or other urinary cancer (6.19), attention to artificial openings (3.40), and urethral stricture (2.78). These and other results were visualized with network graphs. Conclusions: Computational techniques can identify and visualize future health concerns following cancer diagnoses. In this cohort of initially healthy and asymptomatic veterans on a prospective screening colonoscopy study, most subsequent diagnoses were related to cancer or toxicities of therapy, as might be expected in an aging cohort. Future work may focus on streamlining in-clinic identification of potential high likelihood comorbidities.

Complejidad y prevalencia de síndromes geriátricos de los pacientes atendidos en unidades sociosanitarias en Catalunya. Estudio multicéntrico del proyecto XARESS

BackgroundDescriptive study is presented on the complexity and prevalence of geriatric syndromes (GS) in Intermediate Care Units in Catalonia. MethodsA retrospective study was conducted on 6471 stays completed during the year 2014 in the participating centres of the XARESS network. Data was obtained by extracting the information routinely collected on the CMBD-RSS registry (Minimum Basic Dataset for the Intermediate Care Resources). The prevalence and associations between geriatric síndromes (resource group) RG category, length of stay, and destination at discharge is described. Results were stratified by type of unit (convalescence or long stay). ResultsParticipants presented a median of 3 GS at admission in long stay units, and 2 GS at admission in convalescence units. The number of GS varied with RG category, although in all RG categories, there were patients without complexity (no SG), and patients with extreme complexity (up to 9 GS). Patients with geriatric syndromes had a longer mean length of stay and greater dependence than patients without syndromes, although with great variability across GS. However, the presence of geriatric syndromes had no impact on the destination at discharge. ConclusionsThe population cared for in intermediate care units have high complexity and a high prevalence of geriatric syndromes at admission. The CMBD-RSS registry allows the characterisation of complexity of the population admitted to the Catalan convalescence and long term intermediate care units.

Differences in risk factors among early and late readmission of elderly patients from convalescence care unit and 30 and 90 days outcome: A cohort study

Differences in risk factors among early and late readmission of elderly patients from convalescence care unit and 30 and 90 days outcome: A cohort study

“The place is a prison, and you can’t change it”

Speedwell Military Hospital was a hospital for veterans of the Canadian Expeditionary Force located in the newly-built Ontario Reformatory in Guelph. Speedwell was part of a nation-wide program administered by the Department of Soldiers’ Civil Re-Establishment (DSCR) during the First World War intended to neutralize some of the social dangers associated with demobilization. As the health of individual veterans at Speedwell became closely associated with the nation’s economic strength, the ultimate goal of hospitals like Speedwell was the transformation of sick and wounded veterans into healthy and productive workers. However, as the needs of patients changed after the war, the initial promise of Speedwell as a site of rehabilitative labour made it clearly unsuitable for veterans in need of long-term convalescence care.

Epidemiology of vancomycin-resistant enterococci in postacute care facility and predictors of clearance: A 5-year retrospective cohort study

BackgroundThere have been no local studies on the duration and risk factors for vancomycin-resistant enterococcus (VRE) colonization in a postacute convalescence hospital. Our aim was to investigate the duration of VRE colonization and risk factors for prolonged carriage among patients admitted to a convalescence hospital. MethodsThe case records of patients admitted to a 400-bed convalescence care hospital with rectal swab or stool culture samples positive for VRE from January 2010 to December 2014 were retrieved. The clinical characteristics associated with clearance of colonization within the hospitalization period were analyzed, and logistic regression was set up to detect for factors associated with inpatient and 1-year mortality. ResultsA total of 121 patients (mean age, 81.45 years) were colonized with VRE. The inpatient clearance rate was only 35.5%. The median time to VRE clearance during the hospital stay was 43 days. The independent predictors for VRE colonization during hospitalization were old-age-home residents [odds ratio (OR)=2.72; 95% confidence interval (CI), 1.14–6.48] and antibiotics use (OR=4.27; 95% CI, 1.89–9.62). Inpatient mortality was higher among those with persistent VRE colonization upon discharge (39.7% vs. 18.6%, p=0.017). Presence of wound or bed sores (OR=4.58; 95% CI, 1.16–13.2), chair/bed bound status (OR=3.64; 95% CI, 1.27–10.46), and persistent VRE colonization (OR=12.4; 95% CI, 3.16–42.52) were predictors for 1-year mortality. ConclusionThe strongest risk factor for prolonged VRE carriage was old-age-home residents. Survival is adversely affected by VRE carriage and functional mobility. Patients with these factors should be managed more carefully, and active surveillance should be focused on this high-risk group to prevent spread of transmission.

Standardized technique for single port laparoscopic ileostomy and colostomy

Single site laparoscopic techniques and technology exploit maximum usefulness from confined incisions. The formation of an ileostomy or colostomy seems very applicable for this modality as the stoma occupies the solitary incision obviating any additional wounds. Here we detail the principles of our approach to defunctioning loop stoma formation using single port laparoscopic access in a stepwise and standardized fashion along with the salient specifics of five illustrative patients. No specialized instrumentation is required and the single access platform is established table-side using the 'glove port' technique. The approach has the intra-operative advantage of excellent visualization of the correct intestinal segment for exteriorization along with direct visual control of its extraction to avoid twisting. Postoperatively, abdominal wall trauma has been minimal allowing convalescence and stoma care education with only one parietal incision. Single incision stoma siting proves a ready, robust and reliable technique for diversion ileostomy and colostomy with a minimum of operative trauma for the patient.

Mortality and Life Expectancy in Homeless Men and Women in Rotterdam: 2001–2010

BackgroundData on mortality among homeless people are limited. Therefore, this study aimed to describe mortality patterns within a cohort of homeless adults in Rotterdam (the Netherlands) and to assess excess mortality as compared to the general population in that city.MethodsBased on 10-year follow-up of homeless adults aged ≥ 20 years who visited services for homeless people in Rotterdam in 2001, and on vital statistics, we assessed the association of mortality with age, sex and type of service used (e.g. only day care, convalescence care, other) within the homeless cohort, and also compared mortality between the homeless and general population using Poisson regression. Life tables and decomposition methods were used to examine differences in life expectancy.ResultsDuring follow-up, of the 2096 adult homeless 265 died. Among the homeless, at age 30 years no significant sex differences were found in overall mortality rates and life expectancy. Compared with the general Rotterdam population, mortality rates were 3.5 times higher in the homeless cohort. Excess mortality was larger in women (rate ratio [RR] RR 5.56, 95% CI 3.95–7.82) as compared to men (RR 3.31, 95% CI 2.91–3.77), and decreased with age (RR 7.67, 95% CI 6.87–8.56 for the age group 20–44 and RR 1.63, 95% CI 1.41–1.88 for the age group 60+ years). Life expectancy at age 30 years was 11.0 (95% CI 9.1–12.9) and 15.9 (95% CI 10.3–21.5) years lower for homeless men and women compared to men and women in the general population respectively.ConclusionHomeless adults face excessive losses in life expectancy, with greatest disadvantages among homeless women and the younger age groups.

Shelter-based convalescence for homeless adults in Amsterdam: a descriptive study

BackgroundAdequate support for homeless populations includes shelter and care to recuperate from illness and/or injury. This is a descriptive analysis of diagnoses and use of shelter-based convalescence in a cohort of homeless adults in Amsterdam.MethodsDemographics of ill homeless adults, diagnoses, referral pattern, length of stay, discharge locations, and mortality, were collected by treating physicians during outreach care provision in a shelter-based convalescence care facility in Amsterdam, from January 2001 through October 2007.Results629 individuals accounted for 889 admissions to the convalescence care facility. 83% were male and 53% were born in the Netherlands. The mean age was 45 years (SD 10 years). The primary physical problems were skin disorders (37%), respiratory disorders (33%), digestive disorders (24%) and musculoskeletal disorders (21%). Common chronic conditions included addictions 78%, mental health disorders 20%, HIV/AIDS 11% and liver cirrhosis 5%. Referral sources were self-referred (18%), general hospitals (21%) and drug clinics (27%). The median length of stay was 20 days. After (self)discharge, 63% went back to the previous circumstances, 10% obtained housing, and 23% went to a medical or nursing setting. By March 2008, one in seven users (n = 83; 13%) were known to have died, the Standard Mortality Ratio was 7.5 (95% CI: 4.1-13.5). Over the years, fewer men were admitted, with significantly more self neglect, personality disorders and cocaine use. Lengths of stay increased significantly during the study period.ConclusionOver the last years, the shelter-based convalescence care facility users were mainly homeless single males, around 45 years of age, with chronic problems due to substance use, mental health disorders and a frail physical condition, many of whom died a premature death. The facility has been flexible and responsive to the needs of the users and services available.

Subsyndromal delirium in the ICU: evidence for a disease spectrum

ICU delirium is common and adverse. The Intensive Care Delirium Screening Checklist (ICDSC) score ranges from 0 to 8, with a score of 4 or higher indicating clinical delirium. We investigated whether lower (subsyndromal) values affect outcome. 600 patients were evaluated with the ICDSC every 8[Symbol: see text]h. Of 558 assessed patients 537 noncomatose patients were divided into three groups: no delirium (score = 0; n = 169, 31.5%), subsyndromal delirium (score = 1-3; n = 179, 33.3%), and clinical delirium (score >or=4; n = 189, 35.2%). ICU mortality rates were 2.4%, 10.6%, and 15.9% in these three groups, respectively. Post-ICU mortality was significantly greater in the clinical delirium vs. no delirium groups (hazard ratio = 1.67) after adjusting for age, APACHE II score, and medication-induced coma. Relative ICU length of stay was: no delirium < subsyndromal delirium < clinical delirium and hospital LOS: no delirium < subsyndromal delirium approximately clinical delirium. Patients with no delirium were more likely to be discharged home and less likely to need convalescence or long-term care than those with subsyndromal delirium or clinical delirium. ICDSC score increments higher than 4/8 were not associated with a change in mortality or LOS. Clinical delirium is common, important and adverse in the critically ill. A graded diagnostic scale permits detection of a category of subsyndromal delirium which occurs in many ICU patients, and which is associated with adverse outcome.

Shelter-based Convalescence for Homeless Adults

Homelessness is associated with increased hospital costs and length of stay, and medical or surgical conditions are typically complicated by secondary diagnoses of substance abuse or mental illness. Convalescence care to provide timely treatment has not been analyzed. This is a retrospective study of diagnoses and utility of shelter-based convalescence in a cohort of homeless subjects.A 20-bed shelter-based unit providing up to 3 months stay post hospital discharge, or for treatment of addictions or for those too ill to remain in the general shelter was studied. Charting was by the use of an electronic health record developed for the project. Demographics, reason for admission and outcomes are retrospectively described.140 men had 181 admissions from July 2000-April 2003; 23.8% were post hospital discharge, 57.4% were from the general shelter. Average length of stay was 40 days. 83.4% were treated for a medical or surgical condition, 83.6% for psychiatric disease and 29.8% for addictions. Medication adherence was >80% in the majority. During admission, 20% obtained a new health card, 43.6% a new drug card, 89.3% received transportation to appointments, 60% applied for housing and 24.3% obtained housing.A shelter-based convalescence unit can provide health care to homeless persons, treat medical and mental illness, ensure adherence to treatment regimes, decrease substance abuse and assist with housing.

Shelter-based convalescence for homeless adults.

Homelessness is associated with increased hospital costs and length of stay, and medical or surgical conditions are typically complicated by secondary diagnoses of substance abuse or mental illness. Convalescence care to provide timely treatment has not been analyzed. This is a retrospective study of diagnoses and utility of shelter-based convalescence in a cohort of homeless subjects. A 20-bed shelter-based unit providing up to 3 months stay post hospital discharge, or for treatment of addictions or for those too ill to remain in the general shelter was studied. Charting was by the use of an electronic health record developed for the project. Demographics, reason for admission and outcomes are retrospectively described. 140 men had 181 admissions from July 2000-April 2003; 23.8% were post hospital discharge, 57.4% were from the general shelter. Average length of stay was 40 days. 83.4% were treated for a medical or surgical condition, 83.6% for psychiatric disease and 29.8% for addictions. Medication adherence was >80% in the majority. During admission, 20% obtained a new health card, 43.6% a new drug card, 89.3% received transportation to appointments, 60% applied for housing and 24.3% obtained housing. A shelter-based convalescence unit can provide health care to homeless persons, treat medical and mental illness, ensure adherence to treatment regimes, decrease substance abuse and assist with housing.

Convalescence care for seniors of lower Manhattan: an interdisciplinary outreach, rehabilitation, and education model

The purpose of this study was to test the efficacy of an interdisciplinary geriatric outreach, rehabilitation, and education program for seniors. Community-dwelling Chinese seniors in lower Manhattan were recruited through outreach activities (17 educational workshops, three community health fairs, media interviews) and community physician referrals to offer rehabilitation services. The instrument administered at entry and exit included questions about pain intensity, quality of life, activities of daily living (ADLs), and an assessment of a variety of intrinsic and extrinsic barriers to life participation. The sample included 70 seniors (53 women) with a mean age of 70.5 +/- 7.48 years (range 60-93 years old) of whom 86% were Cantonese-speaking Chinese. The barriers-to-life participation assessment revealed cultural, communication, transportation, and physical environmental barriers as well as insufficient financial resources. Thirty-four patients who completed the program showed a significant improvement in quality of life. Patients' reports reflected a high degree of satisfaction with the program. Interdisciplinary team-oriented patient care, including a physiatrist, social worker, and rehabilitation staff, may result in good outcomes and high patient satisfaction in ambulatory community seniors.

Convalescence Care for Seniors in Lower Manhattan

Convalescence Care for Seniors in Lower Manhattan

Nurses as hotel hostesses: a future path in nursing?

On a recent trip to Hengelo, Holland, I discovered that nurses are functioning as hotel hostesses in a hospital experiment. With the decline in convalescence care, escalating inpatient hospital treatment and patient demands for a more flexible and dynamic healthcare service, this recent initiative in Holland could catch on in the UK.

Emerging patterns in transitional care.

Prologue: The subject of long-term care in the American health care system has been widely discussed in public policy circles because an increasing proportion of the population is growing old, because Congress has structured new Medicare incentives that encourage providers to minimize the lengths of acute hospital stays, and because coverage is limited for such services. Much of the attention paid this subject has focused on institutional long-term care rather than postacute convalescence, rehabilitation, and psychiatric care within both acute and chronic care facilities. This paper sketches the shape that these “transitional care” services are taking. Herbert Traxler, who holds a doctorate in economics from Florida State University, has been with the National Center for Health Services Research and Health Care Technology Assessment (NCHSR) since 1982 and has observed trends in the health care industry for more than a decade. Before joining the NCHSR, Traxler spent four years with Florida's Bureau of State Planning and Development Agency, where, as he says, “the future of aging in America is happening.” Given that nearly 20 percent of Florida's population is sixty-five and older—the same proportion that will exist nationally in the year 2000—Traxler recognized that many of the problems faced by the Sunshine State today will confront the whole country tomorrow. Thomas Dunaye is a professor of health services administration at Florida International University where he has served on the faculty since 1978. Prior to that, he was an assistant professor at Yale University and at State University of New York at Stony Brook. Dunaye holds a doctorate in public health from the University of California, Los Angeles.

Development and use of home-care services. Suggestions for physicians.

The changing age-composition of the US population and the proportionate increase in long-term illness and disability have resulted in increased recognition by the medical profession of the need to reexamine and improve traditional methods of delivering healthcare services. Over the past half century, the increase in prevalence of such chronic diseases as hypertensive and arteriosclerotic heart disease, cerebrovascular disease, arthritis, neurological disorders, malignancies, and pulmonary disorders has expanded demand for long-term medical and supportive care. Many of these diseases after a dramatic, acute phase, are followed by long periods of convalescence, rehabilitation, and supportive care, often punctuated by additional acute episodes. Other medical problems have a less acute onset phase which requires definitive diagnosis followed by a long course of definitive therapy. Congenital defects (in structure or metabolism) and disabilities resulting from accidents also contribute their share of long-term-care problems. These diseases or disabilities present difficult problems of medical, social,