Acute Day Hospital Research Articles

Modern Innovative Solutions in Improving Outcomes in Chronic Obstructive Pulmonary Disease (MISSION COPD): Mixed Methods Evaluation of a Novel Integrated Care Clinic.

BackgroundChronic obstructive pulmonary disease (COPD) is the second-leading cause of death in the United Kingdom and accounts for 1.7% of bed days in acute hospitals. An estimated two-third of patients with COPD remain undiagnosed.ObjectiveModern Innovative Solutions in Improving Outcomes in Chronic Obstructive Pulmonary Disease (MISSION COPD) aimed to proactively identify patients from primary care who were undiagnosed or had uncontrolled COPD and to provide a comprehensive integrated multidisciplinary clinic to address the needs of this complex group for improving diagnosis, personalizing therapy, and empowering patients to self-manage their condition.MethodsThis clinic was led by a respiratory specialist team from Portsmouth Hospitals NHS Trust working with five primary care surgeries in Wessex. A total of 108 patients were reviewed, with 98 patients consenting to provide additional data for research. Diagnoses were changed in 14 patients, and 32 new diagnoses were made.ResultsReductions were seen across all aspects of unscheduled care as compared to the prior 12 months, including in emergency general practitioner visits (3.37-0.79 visits per patient, P<.001), exacerbations (2.64-0.56 per patient, P=.01), out-of-hours calls (0.16-0.05 per patient, P=.42), and hospital admissions (0.49-0.12 per patient, P=.48). Improvements were observed in the quality of life and symptom scores in addition to patient activation and patient-reported confidence levels.ConclusionsThis pilot demonstrates that the MISSION model may be an effective way to provide comprehensive gold-standard care that is valued by patients and to promote integration across sectors.

Achieving Meaningful Access to Medicaid.

Federal and state budgetary constraints continually challenge Medicaid. The effects of benefit cuts are common: long waiting lists for community-based services, skeletonized drug formularies with unstable access to long-term prescriptions, no psychiatric therapy for people immobilized by depression, and no more than fourteen days of acute hospitalization. Reimbursements may be so low that providers cannot hire qualified staff and must reduce services, close facilities, or refuse to take Medicaid altogether. Misguided efficiency policies may afflict some groups of patients as well. Decisions to narrow access rights to publicly funded health care promote the perception that more broadly inclusive programs would be unwisely and unfairly generous. They also risk characterizing disability rights as "special," confined to a narrow class of people who charitably ought not to be expected to provide for themselves. In contrast, on a philosophical view we have been exploring-one that addresses problems of justice under circumstances of injustice by pursuing rather than reducing inclusion-efforts like these are unjust.

The canary in the coal mine: Continence care for people with dementia in acute hospital wards as a crisis of dehumanization.

Continence is a key moment of care that can tell us about the wider care of people living with dementia within acute hospital wards. The spotlight is currently on the quality of hospital care of older people across the UK, yet concerns persist about their poor treatment, neglect, abuse, and discrimination within this setting. Thus, within hospitals, the care of people living with dementia is both a welfare issue and a human rights issue. The challenge of continence care for people living with dementia can be seen as the ‘canary in the coal mine’ for the unravelling of dignity within the acute setting. This paper draws on an ethnographic study within five hospitals in England and Wales, selected to represent a range of hospital types, geographies and socio‐economic catchments. Observational fieldwork was carried out over 154 days in acute hospitals known to admit large numbers of people living with dementia. This paper starts to fill the gap between theory and data by providing an in‐depth ethnographic analysis examining the ways in which treatment as a person is negotiated, achieved or threatened. We examine how the twin assaults on agency of a diagnosis of dementia and of incontinence threaten personhood. The acute threats to this patient group may then act to magnify perils to treatment as a person. Our findings suggest that personal dignity and the social construction of moral personhood are both threatened and maintained in such a setting. We show how empirical ethnographic data can lend weight to, and add detail to, theoretical accounts of moral personhood and dignity.

Timely identification of frailty &amp; comprehensive multidisciplinary assessment on a newly established specialist geriatric ward

Introduction: Beaumont Hospital catchment area has a 20% higher proportion of over 65’s and over 85’s than the national average. Between 2011 and 2026 it is predicted that there will be 44% increase in the population of North Dublin over 65 years of age 1. Older people are admitted to hospital more frequently, have longer length of stay and occupy more bed days in acute hospitals than any other patient group. Many older people are frail and present to hospital with acute or sub-acute illnesses often accompanied by functional and/or cognitive deteriorations. Furthermore, once hospitalised frail older people are at huge risk of further hospital based deconditioning due to reduction in habitual activity and sleep deprivation. Once identified, the gold standard for the acute management of frailty in older people is early multidisciplinary team (MDT) assessment and delivery of high quality care with an emphasis on reduction in unnecessary delays and proactive case-management.Extensive research has shown that frail older patients who receive timely access to coordinated care under specialist geriatric teams (SGT) on a specialist geriatric ward (SGW), in the form of comprehensive geriatric assessment, have an increased likelihood of returning home, as well as reduced mortality rate following acute hospital admission 2. Aim and practice change implemented: This change management project was completed in conjunction with the SGT on a newly established SGW (Hardwicke ward). It was carried out as part of a larger ward redevelopment project. This particular project took place over a 4 week period in April/May 2016. The following key stakeholders were involved; patients, MDT, Clinical Nurse Managers, Geriatricians, Project Sponsor (Physiotherapy Manager). This project utilised quality improvement (QI) methodology incorporating; process mapping, development of a driver diagram, data collection and implementing multiple plan-do-study-act cycles to rapidly test changes (IHI, 2016). The following project aim was established: To standardise a process to identify 100% of frail patients over 75 years of age who are admitted to Hardwicke ward under the care of a Geriatrician and ensure referral to all relevant multidisciplinary team members within 24 hours of admission by May 13th 2016. Highlights: (innovation, impact and outcomes) A number of standardised processes have now been successfully implemented on Hardwicke ward for frailty triage, prompt referral to MDT and completion of common MDT assessment documentation. These standardised processes have led to 100% of new patients over 75 years of age being screened for frailty and all relevant MDT referrals being sent via a standardised method (electronic referral) within 24 hours of admission to the ward. This has increased from a baseline of 40% at initial data collection on week one. The result is a more efficient, standardised, co-ordinated and patient-focused process which has led to a reduction in unnecessary wait times and thus a reduction in the risk of hospital-associated de-conditioning in frail older people. The use of QI methodology and interdisciplinary working were key factors in the success of this project. A clear line of sight with the National Clinical Programme for Older People 3 was also crucial to its success. Sustainability and trasferability: Future areas for further development are focused on the following; Stabilise and embed the current standardised processes into practice on Hardwicke ward (incorporating succession planning and ongoing training for Junior rotational staff) Further streamline the processes to reduce inefficiencies utilising QI methodology Spread the learning to other acute wards & MDTs initially focusing on a 2nd SGW

Collaborative recovery: an intergrative model for an acute day hospital and home care team

Collaborative recovery: an intergrative model for an acute day hospital and home care team

The current economic burden of illness of osteoporosis in Canada.

We estimate the current burden of illness of osteoporosis in Canada is double ($4.6 billion) our previous estimates ($2.3 billion) due to improved data capture of the multiple encounters and services that accompany a fracture: emergency room, admissions to acute and step-down non-acute institutions, rehabilitation, home-assisted or long-term residency support. We previously estimated the economic burden of illness of osteoporosis-attributable fractures in Canada for the year 2008 to be $2.3 billion in the base case and as much as $3.9 billion. The aim of this study is to update the estimate of the economic burden of illness for osteoporosis-attributable fractures for Canada based on newly available home care and long-term care (LTC) data. Multiple national databases were used for the fiscal-year ending March 31, 2011 (FY 2010/2011) for acute institutional care, emergency visits, day surgery, secondary admissions for rehabilitation, and complex continuing care, as well as national dispensing data for osteoporosis medications. Gaps in national data were supplemented by provincial and community survey data. Osteoporosis-attributable fractures for Canadians age 50+ were identified by ICD-10-CA codes. Costs were expressed in 2014 dollars. In FY 2010/2011, the number of osteoporosis-attributable fractures was 131,443 resulting in 64,884 acute care admissions and 983,074 acute hospital days. Acute care costs were $1.5 billion, an 18% increase since 2008. The cost of LTC was 33.4 times the previous estimate ($31 million versus $1.03 billion) because of improved data capture. The cost for rehabilitation and secondary admissions increased 3.4 fold, while drug costs decreased 19%. The overall cost of osteoporosis was over $4.6 billion, an increase of 83% from the 2008 estimate. Since the 2008 estimate, new Canadian data on home care and LTC are available which provided a better estimate of the burden of osteoporosis in Canada. This suggests that our previous estimates were seriously underestimated.

Burden of community-onset bloodstream infections, Western Interior, British Columbia, Canada.

Although community-onset bloodstream infection (BSI) is recognized as a major cause of morbidity and mortality, its epidemiology has not been well defined in non-selected populations. We conducted population-based surveillance in the Interior Health West region of British Columbia, Canada in order to determine the burden associated with community-onset BSI. A total of 1088 episodes were identified for an overall annual incidence of 117·8/100 000 of which 639 (58·7%) were healthcare-associated (HA) and 449 (41·3%) were community-associated (CA) BSIs for incidences of 69·2 and 48·6/100 000, respectively. The incidence of community-onset BSI varied by age and gender and elderly males were at the highest risk. Overall 964 (88·6%) episodes resulted in hospital admission for a median length of stay of 8 days; the total days of acute hospitalization associated with community-onset BSI was 13 530 days or 1465 days/100 000 population per year. The in-hospital mortality rate was 10·6% (102/964) and this was higher for HA-BSI (72/569, 12·7%) compared to CA-BSI (30/395, 7·6%, P = 0·014) episodes. Community-onset BSI, especially HA-BSI, is associated with a major burden of illness.

Use of hospital and long-term institutional care services in relation to proximity to death among older people in Finland

Using nationally-representative register data for older people in Finland in period 1998–2003 we study how the number of days in acute hospital and long term institutional care services varies by age and proximity to death and how these use patterns change as mortality improves. Acute health care use depends more on proximity to death than on age, a finding often interpreted as showing that the need for care services among older people will be substantially less than would be expected based on the likely increase in population numbers. We show that this assumption is too optimistic for three reasons: (1) the increase in population numbers will be concentrated mainly among the “old old” where use of services is substantial; (2) earlier findings of much lower use of acute care services by older than younger people who are close to death are not observed; and (3) any savings in acute care are more than offset by greater use of residential long-term care (LTC). The main consequences of improving mortality are: (1) to postpone rather than to reduce overall demand for health care; (2) to shift the balance of care from acute to long-term care services; and (3) to increase considerably the average age of time spent in care. We further construct a new indicator “care-free life expectancy” based on number of days in hospital and long-term care to summarise care use patterns for cohorts under a range of plausible mortality assumptions. As mortality improves, lifetime use of acute hospital and long-term care after age 65 and the proportion of life spent in LTC increases for later cohorts, but the proportion spent in acute care decreases slightly.

Acute care inpatients with long-term delayed-discharge: evidence from a Canadian health region

BackgroundAcute hospital discharge delays are a pressing concern for many health care administrators. In Canada, a delayed discharge is defined by the alternate level of care (ALC) construct and has been the target of many provincial health care strategies. Little is known on the patient characteristics that influence acute ALC length of stay. This study examines which characteristics drive acute ALC length of stay for those awaiting nursing home admission.MethodsPopulation-level administrative and assessment data were used to examine 17,111 acute hospital admissions designated as alternate level of care (ALC) from a large Canadian health region. Case level hospital records were linked to home care administrative and assessment records to identify and characterize those ALC patients that account for the greatest proportion of acute hospital ALC days.ResultsALC patients waiting for nursing home admission accounted for 41.5% of acute hospital ALC bed days while only accounting for 8.8% of acute hospital ALC patients. Characteristics that were significantly associated with greater ALC lengths of stay were morbid obesity (27 day mean deviation, 99% CI = ±14.6), psychiatric diagnosis (13 day mean deviation, 99% CI = ±6.2), abusive behaviours (12 day mean deviation, 99% CI = ±10.7), and stroke (7 day mean deviation, 99% CI = ±5.0). Overall, persons with morbid obesity, a psychiatric diagnosis, abusive behaviours, or stroke accounted for 4.3% of all ALC patients and 23% of all acute hospital ALC days between April 1st 2009 and April 1st, 2011. ALC patients with the identified characteristics had unique clinical profiles.ConclusionsA small number of patients with non-medical days waiting for nursing home admission contribute to a substantial proportion of total non-medical days in acute hospitals. Increases in nursing home capacity or changes to existing funding arrangements should target the sub-populations identified in this investigation to maximize effectiveness. Specifically, incentives should be introduced to encourage nursing homes to accept acute patients with the least prospect for community-based living, while acute patients with the greatest prospect for community-based living are discharged to transitional care or directly to community-based care.

Population-based laboratory assessment of the burden of community-onset bloodstream infection in Victoria, Canada

Although community-onset bloodstream infection (BSI) is recognized as a major cause of morbidity and mortality, its epidemiology has not been well defined in non-selected populations. We conducted population-based laboratory surveillance in the Victoria area, Canada during 1998-2005 in order to determine the burden associated with community-onset BSI. A total of 2785 episodes were identified for an overall annual incidence of 101·2/100,000. Males and the very young and the elderly were at highest risk. Overall 1980 (71%) episodes resulted in hospital admission for a median length of stay of 8 days; the total days of acute hospitalization associated with community-onset BSI was 28 442 days or 1034 days/100,000 population per year. The in-hospital case-fatality rate was 13%. Community-onset BSI is associated with a major burden of illness. These data support ongoing and future preventative and research efforts aimed at reducing the major impact of these infections.

Use of Inappropriate Medications and Their Prognostic Significance Among In-Hospital and Nursing Home Patients with and without Dementia in Finland

Although the Beers criteria have been frequently utilised to describe the use of inappropriate medications in various elderly populations, less is known about the use of such medications among patients with dementia, and nor have many studies dealt with their impact on mortality or use of healthcare services. This study examines the use of inappropriate drugs and their impact on mortality and use of health services among Finnish elderly nursing home and hospital patients. Patients with dementia were studied as a special subgroup. A total of 425 patients consecutively admitted to seven Finnish nursing homes and two hospitals in 1999-2000 were examined. Details of all medications prescribed and administered were retrieved from medical records and coded according to the Beers 1997 criteria. Mortality data as well as days in acute hospital were obtained from central registers and all area hospitals during 2 years of follow-up. The entire population was old and frail (mean age 86 years, 82% females), 60% had dementia and 36.2% received at least one potentially inappropriate drug (PID). No differences existed in the proportion of users of PIDs among those 60% of patients with dementia compared with those without. The most common PID was temazepam, with 14% of all patients on high doses. Other commonly used PIDs were oxybutynin and dipyridamole. Amitriptyline was more commonly used among patients without dementia (4.7%) compared with those with dementia (0.8%). Nevertheless, in this very old and frail study population, use of inappropriate drugs did not predict mortality or use of health services. Use of PIDs is common in nursing homes and hospitals in Finland but has no impact on mortality or hospital admissions. Use of high-dose temazepam as a hypnotic accounted for most of the high use of PIDs.

Tensions and constraints for nurses in hospital‐in‐the‐home programmes

Economic necessity constrains health-care expenditure and waiting lists for hospital treatments remain high. As a result, more care is delivered via alternative means, such as same-day surgery initiatives and home-care programmes. Acute care delivered in the home to patients who would otherwise require hospitalization is becoming an increasingly acceptable means of treatment. These Hospital-in-the-Home programmes offer increased comfort while delivering comparable outcomes to many patient groups. The purpose of this paper is to generate discussion concerning the tensions that exist for nurses who practice in the home under the auspices of acute-care institutions. Data drawn from field work that formed part of a critical ethnography is used to generate the discussion. The larger research project explored the constructions of the role of the nurse in four Hospital-in-the-Home programmes in Victoria, Australia. It will be argued that there is significant pressure exerted upon nurses to support the imperative to reduce bed days in acute hospitals by transferring people to their home. At times, this agenda clashes with the nurses' professional commitment to provide holistic patient care, yet the dilemmas are largely unacknowledged and/or unrecognized by the nurses despite the tension they generate.

Provision of high-protein supplement for patients recovering from hip fracture

Objective We compared clinical outcomes with a standard (Ensure) or a high-protein (Boost HP) liquid nutritional supplement for older adults recovering from hip fracture surgery in a rehabilitation hospital. Methods This randomized, double-blind, parallel-group study compared the clinical effectiveness of a standard (Ensure) with a high-protein (Boost HP) liquid nutritional supplement among patients ( n = 46) 60 y or older who recently underwent surgical repair of a hip fracture. Patients were encouraged to drink at least two 8-oz cans (17.8 g/d protein for Ensure versus 30 g/d protein for Boost HP) per day for 28 d. Study measurements included change in Functional Independence Measure between rehabilitation admission and discharge, length of rehabilitation stay, laboratory measures (i.e., serum albumin, prealbumin, and C-reactive protein), physical activity energy expenditure by 7-d triaxial accelerometry, and dietary intake by three random, telephonic, 24-h dietary recalls. Results There were no significant group differences with respect to age, sex, acute hospital days, hip fracture assessment parameters, or surgical treatment. Consumption of supplement (260 oz/28 d of Ensure versus 239 oz/28 d of Boost HP) was comparable. There were no differences in complication or adverse event rates during the study. The Boost HP group consumed more protein than the Ensure group (63 versus 50 g, P < 0.048) and had a greater improvement in serum albumin over the 28-d supplementation period (+0.7 versus +0.2 g/dL, P < 0.019). The Boost HP group also consumed more fiber (12 versus 8 g), calcium (821 versus 639 mg), vitamin K (66 versus 45 μg), and phosphorus (1035 versus 833 mg) than did the Ensure group. Rehabilitation length of stay was shorter in the Boost HP than in the Ensure group, although this trend did not reach statistical significance (23 versus 28 d, P = 0.27). Outcome differences were not detected in the Functional Independence Measure. Conclusions Supplementation was well tolerated in this population and contributed significantly to total dietary intake. Consumption of a high-protein liquid nutritional supplement may offer some benefits by improving visceral protein status.

Two knees or not two knees?: Patient costs and outcomes following bilateral and unilateral total knee joint replacement surgery for OA

Aims: This study aims to address medical and non-medical direct costs and health outcomes of bilateral and unilateral total knee replacement from the patients’ perspective during the first year post-surgery. Methods: Osteoarthritis patients undergoing primary unilateral total knee or bilateral total knee replacement (TKR) surgery at three Sydney hospitals were eligible. Patients completed questionnaires pre-operatively to record expenses during the previous three months and health status immediately prior to surgery. Patients then maintained detailed prospective cost diaries and completed SF-36 and WOMAC Index each three months for the first post-operative year. Results: Pre-operatively, no significant differences in health status were found between patients undergoing unilateral TKR and bilateral TKR. Both unilateral and bilateral TKR patients showed improvements in pain, stiffness and function from pre-surgery to 12 months post-surgery. Patients who had bilateral TKR spent an average of 12.3 days in acute hospital and patients who had unilateral TKR 13.6 days. Totally uncemented prostheses were used in 6% of unilateral replacements and 48% of bilateral replacements. In hospital, patients who had bilateral TKR experienced significantly more complications, mainly thromboembolic, than patients who had unilateral TKR. Regression analysis showed that for every one point increase in the pre-operative SF-36 physical score (i.e. improving physical status) out-of-pocket costs decreased by 94%. Out-of-pocket costs for female patients were 3.3 times greater than for males. Conclusion: Patients undergoing bilateral TKR and unilateral TKR had a similar length of stay in hospital and similar out-of-pocket expenditures. Bilateral replacement patients reported better physical function and general health with fewer health care visits one year post procedure. Patients requiring bilateral TKR have some additional information to aid their decision making. While their risk of peri-operative complications is higher, they have an excellent chance of good health outcomes at 12 months and are not going to be doubly ‘out-of-pocket’ for the experience.

Postgraduate Education for Pediatricians

Thank you very much for inviting me to start off the discussions today on postgraduate medical education. Historically, postgraduate education has always been grounded in the perception of the specific health care needs of patients. Therefore, I'm first going to address some of the more important health care needs of children, emphasizing the unmet needs which future pediatricians must be prepared to meet. Then I'd like to move on from these discrete problems to several very difficult fundamental challenges that cut across rotations and the residency years. There is a saying attributed to Mark Twain that might well have been directed to us as educators. “It is noble to teach oneself; it is still nobler to teach others—and a lot more trouble.”1 These cross-cutting challenges are a lot of trouble to address. But to begin, let's consider the health needs of children. Many groups of children deserve attention; however, 6 subsets, in particular, stand out. I'm going to comment briefly on each of these from the perspective of residency training. First, there are those children and youth requiring hospitalization for high levels of care. The numbers of children and youth receiving tertiary and quartinary care have been relatively stable for several years.2 It is unlikely that the number of acute hospital days of care for these children will increase. The trend to diagnose and treat more and more of these children in ambulatory settings is likely to offset the introduction of new hospital-based diagnostic and treatment modalities. These patients are usually the recipients of the mainstream of direct services and research provided by the faculties of academic pediatric departments and, not surprisingly, academic departments across the country care for a large proportion of this total group. Participation in the care of these children also constitutes a major part …

Cost of nosocomial infection: Relative contributions of laboratory, antibiotic, and per diem costs in serious Staphylococcus aureus infections

This study reports an analysis of the relative importance of laboratory antibiotic, and per diem costs of caring for 58 patients with serious Staphylococcus aureus nosocomial infections. Laboratory costs accounted for 2%, antibiotics for 21%, and per diem costs for 77% of total infection-related costs. Only 45% of patients were hospitalized for additional days specifically because of infection, but these patients stayed an average of 18 extra days. Nosocomial infections with S. aureus resistant to penicillinase-resistant penicillins (PRP) were more frequently associated with additional infection-related days of hospitalization than were PRP-susceptible infections. The cost of PRP-resistant infections was also significantly greater than PRP-susceptible infections, primarily because of the costs of additional days of hospitalization. Rational strategies to control costs of nosocomial infection should focus on two approaches: (1) prevention and (2) reduction of acute hospital days attributable to infections.

Relating mental health and physical function at discharge to rehabilitation status at three months postburn.

Preinjury mental health is said to be a major predictive factor in the rehabilitation progress of burn patients. However, it is unclear which component of rehabilitation (emotional v physical) is predicted by this variable; furthermore, the predictive validity of preinjury mental health has not been compared with physical variables. The present study compared preinjury mental health, physical variables, and length of hospitalization in predicting the rehabilitation progress of 59 major burn patients at three-month follow-up. Preinjury mental health was assessed by the Rand Mental Health Form; physical status, by the Upper Extremity Index (standard measures of upper limb joint mobility); and hospital stay, by the number of days of acute hospitalization. These variables were assessed at the time of discharge. Three-month rehabilitation outcome was measured by the Sickness Impact Profile, a self-report inventory that evaluates patient outcome in 12 different areas. These areas were in turn placed in the categories of disability (ie, difficulties in functioning in activities of daily living; eating) handicap (ie, difficulties in functioning in general areas of living; employment) and mental health status. In predicting mental health status at three months, preinjury mental health was significantly correlated. In predicting physical disability, physical factors were found to be important. Conversely, physical status was not significantly related to mental health outcome, and preinjury mental health was not related to physical disability. The results indicate the importance of defining outcome when attempting to predict rehabilitation progress of burn patients.