Hospital Admissions In Residents Research Articles

Shaping care home COVID-19 testing policy: a protocol for a pragmatic cluster randomised controlled trial of asymptomatic testing compared with standard care in care home staff (VIVALDI-CT)

IntroductionCare home residents have experienced significant morbidity, mortality and disruption following outbreaks of SARS-CoV-2. Regular SARS-CoV-2 testing of care home staff was introduced to reduce transmission of infection, but it...

Healthcare professionals' experience with emergency department-based acute care performed within nursing homes.

Backgroundhospital admissions of residents from nursing homes often lead to delirium, infections, mortality and reduced functional capacity. We initiated a new service, ‘emergency department-based acute care service’, maintained by consultants from an emergency department (ED) moving emergency care from the hospitals into nursing homes.Objectivethis study explored healthcare professionals’ experiences with this service.Designqualitative semi-structured focus group discussions.Intervention/Settingthe new service provides acute on-site evaluation and treatment to nursing home residents following calls to the emergency dispatch centre.Methodswe conducted focus groups with general practitioners, prehospital personnel, municipal acute care nurses, ED staff and nursing home staff. The analysis was performed using the iterative and explorative approach, ‘systematic text condensation’.Resultsthe participants considered the service as a meaningful and appropriate alternative to hospital admission, as the treatment can be tailored to meet the residents’ wishes and daily capabilities. This was experienced to promote dignity for the residents by reducing unnecessary transfers to the ED and the residents could remain in familiar surroundings with staff who knew their habitual behaviour and history. The nursing home staff contributed valuable information to the ED consultants’ decision-making. The service made it possible to base the decision-making on complete patient pictures, as the ED consultants had the time to get to understand the residents.Conclusionacute care at nursing homes provides an alternative to routine admissions to hospitals and enables healthcare professionals to provide more dignity in the care of nursing home residents.

Comparison of health service use trajectories of residential aged care residents reviewed by a hospital avoidance program versus usual care

ObjectiveTo compare health service use trajectories of residential aged care facility (RACF) residents reviewed by the Aged Care Rapid Response Team (ARRT) to RACF residents who received usual care. MethodsA retrospective group-based trajectory analysis of RACF residents aged ≥65 years who were reviewed by ARRT during 1 July 2015 to 30 June 2016 was conducted. Health service use trajectories were followed for two years to 30 June 2018 and compared to RACF residents aged ≥65 years who lived in the same Local Health District and received usual care. ResultsThere were 2,245 ARRT-reviewed resident hospitalisations and 11,892 usual care resident hospital admissions during 2015−16. Trajectory analysis categorised ARRT-reviewed residents into four groups and usual care residents into three groups. Age, comorbid health conditions and dementia were predictors of group membership in both ARRT-reviewed RACF residents and usual care RACF residents. Additionally, gender predicted group membership in ARRT-reviewed RACF residents and fall-related injuries predicted group membership in usual care RACF residents. ConclusionThe identification of health service use trajectories assists in understanding hospital use by older RACF residents and may offer guidance in the design of prevention measures, including hospital avoidance programs.

Developing a Regional Medicines Optimisation Model for Older People in Care Homes: Refinement and Reproducibility

Introduction & Practice Change: In 2012, the Northern Health and Social Care Trust (NHSCT) implemented consultant pharmacist led trust outreach medicines optimisation clinics for care home patients. This model required the consultant pharmacist to conduct clinics either alone or in collaboration with a consultant geriatrician with recommendations being communicated to General Practitioners (GPs) via a letter. This service resulted in a 14% reduction in Emergency Department (ED) admissions together with improved appropriateness of prescribing and drug cost savings1. Results (2012-2014) indicated the pharmacist working alone produced similar outcomes as to when working together with the geriatrician; the decision was therefore made for pharmacists to conduct clinics alone and to refer complex patients to a medical specialist only when deemed necessary. Aim: The aim of this work is to refine the medicines optimisation care home model and reproduce it in another trust, thereby informing the potential to roll out this new pharmacy service throughout care homes in Northern Ireland. Target Population: Patients aged ≥65 years residing in residential and nursing homes (care homes). Timeline: In August 2015 two older people specialist independent prescribing pharmacists were recruited into the NHSCT service under the mentorship of the consultant pharmacist. The Western Health and Social Care Trust (WHSCT) recruited two similar full time pharmacists who have delivered the same consultant pharmacist led model to care homes since September 2015. Data collection for patients seen over a 12-month period and followed up for 90 days is ongoing with full results to be reported early 2017. Highlights: Interim results (February 2016) revealed improved appropriateness of prescribing [measured via the medication appropriateness index (MAI)2] with associated annual drug cost savings estimated at £273k to £382k across the two trusts representing an ‘invest to save’ return of £1.51 - £2.12 per £1 invested in drug cost savings alone. Post clinic healthcare resource usage is being measured and an economic model is being developed to quantify the impact of the pharmacy service on these; interim analysis suggests reduced attendance at hospital ED and decreased GP callouts. Sustainability/Transferability: Preliminary evaluation of the service suggests it is both reproducible and sustainable. Discussion/Lessons Learnt: The WHSCT pharmacists tested different GP communication models where interventions may be actioned via letter, teleconference or direct access into GP systems. The method of communicating recommended clinical interventions between the trust pharmacist and GP can vary depending upon the size and location of the care home and the wishes of the GP responsible for patient care. Conclusion: Consultant pharmacist led medicines optimisation trust outreach services for care homes are reproducible with positive clinical and economic outcomes achievable when transferring the service into another geographical area.

Living in areas with different levels of earthquake damage and association with risk of cardiovascular disease: a cohort-linkage study

Cardiovascular disease rates are known to increase immediately after a severe earthquake. However, less is known about the magnitude of this increase over time in relation to the amount of housing damage. We assessed the effect of area housing damage from a major earthquake sequence in Christchurch, Canterbury province, New Zealand, on cardiovascular disease-related hospital admissions and deaths. For this cohort-linkage study, we used linked administrative datasets from the Statistics New Zealand Integrated Data Infrastructure to identify individuals aged 45 years or older living in Christchurch from the date of the first earthquake on Sept 4, 2010. Individuals were assigned the average damage level for their residential meshblock (small neighbourhood generally comprising 10-50 dwellings) using the insurance-assessed residential building damage costs obtained from the Earthquake Commission as a proportion of property value. We calculated the rates of cardiovascular disease-related hospital admissions (including myocardial infarction) and cardiovascular disease-related mortality and rate ratios (adjusted for age, sex, ethnicity, small-area deprivation index, and personal income) by level of housing damage in the first year and the 4 subsequent years after the earthquake. The rate ratio association between earthquake housing damage and cardiovascular event was examined by Poisson regression, and linear test of trends across damage categories was done by regression modeling. We identified 179 000 residents living in the earthquake-affected region of Christchurch, of whom 148 000 had complete data. For the first 3 months after the Feb 22, 2011 earthquake, the Poisson regression-adjusted rate ratio (RR) for cardiovascular disease-related hospital admissions for residents from areas that were most damaged (compared with residents from the least damaged areas) was 1·12 (95% CI 0·96-1·32; test for linear trend p=0·239). In the first year after the earthquake sequence, for residents from areas that were most damaged (vs the least damaged areas), Poisson regression-adjusted RRs were 1·10 (1·01-1·21; test for linear trend p=0·068) for cardiovascular disease-related hospital admissions, 1·22 (1·00-1·48; p=0·036) for myocardial infarction-related hospital admissions, and 1·25 (1·06-1·47; p=0·105) for cardiovascular disease-related mortality, corresponding to an excess of 66 (95% CI 7-125) cardiovascular disease-related hospital admissions, including 29 (0-53) additional myocardial infarction-related hospital admissions and 46 (13-73) additional deaths from cardiovascular disease. In the 4 subsequent years, we found no evidence of an association of these outcomes with earthquake damage. Rates of cardiovascular disease and myocardial infarction were increased in people living in areas with more severely damaged homes in the first year after a major earthquake. Policy responses to reduce the effect of earthquake damage on cardiovascular disease could include pre-earthquake measures to minimise building damage, early wellbeing interventions within the first year to address post-earthquake stress, and enhanced provision of cardiovascular disease prevention and treatment services. Healthier Lives National Science Challenge and Natural Hazards Research Platform, Ministry of Business, Innovation and Employment.

Nursing Home Outreach Clinics show an improvement in patient safety and reduction in hospital admissions in residents with chronic conditions

Background: In an environment of an ageing population, with patients exhibiting multiple co-morbidities and taking multiple drugs, as well as attending emergency departments with preventable admissions, the project team aimed to implement and evaluate nursing home outreach clinics. Objectives: To demonstrate the benefit of holding consultant pharmacist-led medication review clinics in nursing homes; improve medication appropriateness and assess if a reduction in the number of hospital admissions was achievable. Methods: Patients were reviewed in outreach clinics in the nursing homes. Data on patient age, number of drugs taken and clinical interventions made was collected for all patients seen. Monthly emergency department attendances were tracked and hospital admissions monitored. More detailed data was collected for 100 patients on type and significance of clinical interventions made, medication appropriateness, using the medication appropriateness index (MAI) and drug costs. Results: Over a 12-month period, in 16 homes, 727 patients were reviewed and an average of 2.9 clinical interventions made per patient. Over the project duration, the average number of hospital admissions from these homes dropped from approximately 3.5 to 1.5 per month. Total estimated drug cost savings for the project over a 2-year time period were estimated at £213k. Individual and total MAI scores for 100 patients, evaluated in more detail, showed a highly significant improvement after clinic review (Wilcoxon Signed Rank test, p<0.001), indicative of more appropriate prescribing. Discussion: Nursing home outreach clinics have resulted in cost-effective and safer patient care via significant clinical interventions and increased appropriateness of drugs prescribed for vulnerable older patients with complex needs.

PC-FACS

PC-FACS

Socioeconomic status and hospitalization in the very old: a retrospective study

BackgroundSocioeconomic status could affect the demand for hospital care. The aim of the present study was to assess the role of age, socioeconomic status and comorbidity on acute hospital admissions among elderly.MethodsWe retrospectively examined the discharge abstracts data of acute care hospital admissions of residents in Rome aged 75 or more years in the period 1997–2000. We used the Hospital Information System of Rome, the Tax Register, and the Population Register of Rome for socio-economic data. The rate of hospitalization, modified Charlson's index of comorbidity, and level of income in the census tract of residence were obtained. Rate ratios and 95% confidence limits were computed to assess the relationship between income deciles and rate of hospitalization. Cross-tabulation was used to explore the distribution of the index of comorbidity by deciles of income. Analyses were repeated for patients grouped according to selected diseases.ResultsAge was associated with a marginal increase in the rate of hospitalization. However, the hospitalization rate was inversely related to income in both sexes. Higher income was associated with lower comorbidity. The same associations were observed in patients admitted with a principal diagnosis of chronic condition (diabetes mellitus, heart failure, chron obstructive pulmonary disease) or stroke, but not hip fracture.ConclusionLower social status and associated comorbidity, more than age per se, are associated with a higher rate of hospitalization in very old patients.

Trends in event rate and case fatality of patients hospitalized with myocardial infarction between 1984 and 2001This paper is one of a selection of papers published in this Special Issue, entitled Young Investigator's Forum.

Between 1984 and 1993, prevalence and case fatality of hospitalized acute myocardial infarction (AMI) had declined in the population of Halifax County. We aimed to determine whether these trends continued into the 21st century by investigating patient characteristics, treatment methods, and fatality for hospital admissions of residents of Halifax County, aged 25-74, during 1984-1989 (period 1), 1990-1993 (period 2), and 1998-2001 (period 3) and diagnosed as AMI that were extracted from databases for the Halifax County MONICA and ICONS (Improving Cardiovascular Outcomes in Nova Scotia) Studies. Trends in patient characteristics and treatment methods were assessed by chi2 statistics. Their association with 28-day fatality was determined by logistic regression. Event rate declined during 1984-1993 but not into 1998-2001 (p = 0.206). Compared with 1990-1993, fewer AMI patients during 1998-2001 were > or = 55 years (73.3% vs. 69.9%), cigarette smokers (49.8% vs. 42.9%), had a history of myocardial infarction (28.9% vs. 24.9%), and had an admission heart rate >100 (34.8% vs. 17.4%). Additionally, more patients had a history of diabetes (22.5% vs. 28.1%). Case fatality declined progressively over the 3 study time periods (16.6%, 13.1%, and 9.4%, respectively). Changes also occurred in prevalence of Killip class 4 status during admission (20.2%, 10.3%, and 13.3%, respectively), use of thrombolysis (9.0%, 30.9, and 32.6%, respectively), and percutaneous coronary intervention (PCI) (4.3%, 11.2%, and 22.4%, respectively) in the different periods. Significant associations were found between case fatality and patient history of diabetes, history of MI, age, elevated admission heart rate, Killip class 4 impairment, thrombolysis, and PCI. The ICONS registry of hospitalized acute myocardial infarctions was used to compare case fatality during 1998-2001 with that reported by the Halifax County MONICA Project for 1984-1993. Whereas the population rate of myocardial infarctions had declined between 1984-1993 but not subsequently, case fatality declined significantly throughout the study period. The continued decline in case fatality is likely explained by changes in patient profile on presentation and medical therapies, including the increased use of thrombolysis and PCI.

The use of acute hospital services by elderly residents of nursing and residential care homes.

The objective of this study was to compare hospitalisation rates by cause of admission, hospital death rates and length of stay for residents from nursing and residential care homes with those in the community. This is a retrospective study of acute hospital emergency admissions in one health district, Merton, Sutton and Wandsworth between April 1996 and March 1997. Data linkage and manual look up were used to derive emergency hospital admissions for residents of care homes aged 65 and over. Admission rates were calculated for cause, length of stay and hospital death for residents of care homes and in the community with relative risks. The relative risk of emergency admission from a care home compared with the community was 1.39 for all diagnoses, 2.68 for all injuries, and 3.96 for fracture of neck of femur. The relative risk of dying in hospital for care home residents was 2.58 overall, and 3.64 in the first 48 hours of a hospital stay (all P-values <0.0001). Admission rates were higher from residential than from nursing homes. There was some increase in admissions from homes during holiday periods and over Christmas. In conclusion, there are major difficulties in monitoring admissions from nursing and residential care homes due to poor quality recording and inaccuracies in NHS coding. This was compounded by an absence of data on the age and sex profile and healthcare needs of the resident population in care homes. Prospective studies are required to ascertain when admission is avoidable and when it is appropriate. The information strategy needs to ensure that routine data sources are capable of monitoring the use of hospital services by residents of care homes.

Small Area Variation in Hospital Admission Rates: Bayesian Adjustment for Primary Care and Hospital Factors

SUMMARY Hospital admission rates are often used as a proxy to reflect patterns of morbidity or health need in population subgroups or across geographic areas. This paper considers the estimation of small area variations in relative health need, as measured by routinely collected hospital admissions data, after allowing for variation in general practice (primary care) and hospital (supply) effects. A fully Bayesian hierarchical modelling framework is adopted, using combinations of electoral ward populations and general practice patients’ lists to define catchment groups for analysis. Hospitals create a further stratum, with flows of patients between catchment groups and hospitals being represented by a gravity model. Variations in health outcomes are modelled by using a range of random-effects structures for each cross-classification of strata, together with a consideration of ward, practice, hospital and crossed level covariates. The approach is applied to case-studies of child respiratory and total emergency hospital admissions for residents in a London health authority.

Impact of a psychiatric outreach service for homeless persons with schizophrenia

Since 1988 a 24-hour psychiatric out reach service has been in operation in the inner city of Sydney to provide services to residents of refuges for the homeless. A total of 506 homeless persons with schizophrenia were referred to the outreach service between April 1988 and mid-1992, of whom 91 failed to attend. Hospitalization data were collected for the four years before and the four years after each individual's referral to the service. After the introduction of the service, the rate and duration of psychiatric hospital admissions for residents with schizophrenia who were treated by the outreach service decreased significantly, whereas those who failed to attend showed no such decrease.