Hospital Reattendance Research Articles

Are virtual wards for children safe and effective? A 3-year retrospective service evaluation of an urban Hospital at Home service for children and young people

ObjectiveService evaluation of an urban ‘Hospital at Home’ service which provides care in patients’ homes that would traditionally be delivered in the hospital setting.DesignRetrospective longitudinal review of routinely collected data...

A single centre study of the level of parents' satisfaction with the COVID-19 telemedicine consultation.

Telemedicine is an effective tool for video consultation of COVID-19 patients in the setting of the COVID-19 pandemic. Weprospectively determined the level of parents' satisfaction with the COVID-19 telemedicine consultation. This was asingle centre prospective study. COVID-19 paediatric patients who were seen in the children's emergency department of KK Women's and Children's Hospital, Singapore, and deemed fit for home recovery were discharged with a COVID-19 telemedicine follow-up in two to three days' time. Paediatric patients who were seen in the COVID-19 telemedicine visits were included in the parents' satisfaction survey. We excluded patients who defaulted their telemedicine visits. The telemedicine satisfaction survey was conducted using an online form consisting of 16 Likert scale questions, sent via text messaging. Our primary outcome was telemedicine satisfaction scores. Our secondary outcome was children's emergency department reattendance or hospital admission within 10days after the telemedicine consultation. 1238 patients attended the COVID-19 video consultation clinic from 15 December 2021 till 25 March 2022, out of which 476 parents of the COVID-19 patients completed the survey questionnaire. The mean age of the COVID-19 patients was 3.6years. There was a high level of overall satisfaction among parents of the COVID-19 patients, with a mean score of 6.1 out of 7. 12 out of 16 questions had a positive response (mean score of 6 or more). There was a total of 9 reattendances to children's emergency department, out of which 3 cases needed hospital admission. Conclusion: There was a high level of overall satisfaction with the use of telemedicine in symptomatic COVID-19 paediatric patients. What is Known: • Telemedicine is a cost-effective and feasible mode of delivering health care for conditions such as diabetes, heart disease, and depressive disorder, especially in the setting of the COVID-19 pandemic. What is New: • To gauge the parents' satisfaction with the COVID-19 telemedicine visit, in order to improve the patient and caregiver experience with telemedicine, and to improve the telemedicine service delivery. • Information from this study is crucial in order to prevent unnecessary hospital reattendance due to parental concern from poor telemedicine delivery.

Comparison of day-case versus inpatient uni-compartmental knee replacement.

Uni-compartmental knee replacement (UKR) is an alternative to total knee replacement for patients who have isolated compartment osteoarthritis. Studies have demonstrated that UKR can be safely performed as a day-case procedure without a negative impact on complication rates. The aim of this study was to compare the clinical outcomes between day-case and inpatient UKRs. A single surgeon prospective case-controlled study was performed, comparing data between day-case UKRs and inpatient UKRs. This included longitudinal analysis of patient reported outcome measures (PROMs); including the Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score, Short Form 12-item Health Survey, EQ-5D-5L and the Self-administered Comorbidity Questionnaire. Post-operative pain scores (visual analogue scale), unplanned post-operative hospital reattendance rates and complications were also analysed. Overall, 100% of day-case patients were successfully discharged on the same day. Both inpatient (n=23) and day-case (n=23) UKRs demonstrated a significant within group longitudinal improvement of PROM scores (p<0.05) following surgery. However, the post-operative PROM scores were significantly higher in the day-case group as compared to the inpatient group (p<0.05). Both groups had comparable post-operative pain scores, but the day-case group demonstrated fewer unplanned reattendances and post-operative complications. The clinical outcomes of day-case UKR are superior to inpatient UKR. Careful patient selection and a robust multidisciplinary patient pathway are the key components to success of day-case joint replacement surgery. Prospective Case-Control Study, level III.

High-Sensitivity Cardiac Troponin on Presentation to Rule Out Myocardial Infarction: A Stepped-Wedge Cluster Randomized Controlled Trial.

High-sensitivity cardiac troponin assays enable myocardial infarction to be ruled out earlier, but the safety and efficacy of this approach is uncertain. We investigated whether an early rule-out pathway is safe and effective for patients with suspected acute coronary syndrome. We performed a stepped-wedge cluster randomized controlled trial in the emergency departments of 7 acute care hospitals in Scotland. Consecutive patients presenting with suspected acute coronary syndrome between December 2014 and December 2016 were included. Sites were randomized to implement an early rule-out pathway where myocardial infarction was excluded if high-sensitivity cardiac troponin I concentrations were <5 ng/L at presentation. During a previous validation phase, myocardial infarction was ruled out when troponin concentrations were <99th percentile at 6 to 12 hours after symptom onset. The coprimary outcome was length of stay (efficacy) and myocardial infarction or cardiac death after discharge at 30 days (safety). Patients were followed for 1 year to evaluate safety and other secondary outcomes. We enrolled 31 492 patients (59±17 years of age [mean±SD]; 45% women) with troponin concentrations <99th percentile at presentation. Length of stay was reduced from 10.1±4.1 to 6.8±3.9 hours (adjusted geometric mean ratio, 0.78 [95% CI, 0.73-0.83]; P<0.001) after implementation and the proportion of patients discharged increased from 50% to 71% (adjusted odds ratio, 1.59 [95% CI, 1.45-1.75]). Noninferiority was not demonstrated for the 30-day safety outcome (upper limit of 1-sided 95% CI for adjusted risk difference, 0.70% [noninferiority margin 0.50%]; P=0.068), but the observed differences favored the early rule-out pathway (0.4% [57/14 700] versus 0.3% [56/16 792]). At 1 year, the safety outcome occurred in 2.7% (396/14 700) and 1.8% (307/16 792) of patients before and after implementation (adjusted odds ratio, 1.02 [95% CI, 0.74-1.40]; P=0.894), and there were no differences in hospital reattendance or all-cause mortality. Implementation of an early rule-out pathway for myocardial infarction reduced length of stay and hospital admission. Although noninferiority for the safety outcome was not demonstrated at 30 days, there was no increase in cardiac events at 1 year. Adoption of this pathway would have major benefits for patients and health care providers. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03005158.

110 A Single Centre Study on the Thirty-Day Hospital Reattendance and Readmission of Older Patients During the SARS-CoV-2 Pandemic

IntroductionHospital and social care suffered major alterations during the SARS-CoV-2 pandemic in the UK. Older adults were disproportionally affected by routine care disruption. To our knowledge, no data has been published so far on the impact of service disruption on 30-day readmission.MethodsWe performed a retrospective observational study of all patients admitted to a single east London hospital with laboratory-confirmed or clinical diagnosis of COVID-19 between 16th March and 6th April 2020. Older patients were defined as aged 80 years and over. Readmission was captured within 30 days of discharge. Comparator defined as the same period in 2019. Descriptive statistics were used.ResultsThree hundred and ninety-three patients were included. The majority survived to discharge (69.7%). Positive laboratory testing was similar between older and younger patients (85.7% vs 84.7%, p = NS). Mortality was significantly higher for older patients on index presentation (60.2% vs 20.3%, p < 0.001). Length of stay was also significantly longer for these patients (median 9 vs 7 days, p = 0.00694). The readmission rate for the 274 individuals discharged after index admission was 11.3% (n = 31). Amongst older patients, readmission rate during the study period was slightly higher than the same period in 2019 (17.9% vs 14.8%, p = 0.36). The median time interval between discharge and re-attendance was 8 [1–29]days. All re-attending older patients were re-admitted, whereas 54.2% of younger patients were sent home directly from the emergency department. Only 1 of the 31 patients re-attended because of insufficient social care.ConclusionsOur data shows that readmission rates in the older population of East London during the SARS-CoV-2 pandemic were largely similar to non-pandemic periods. During this period, readmission rates appear to have been driven by clinical rather than social imperatives. This suggests that adapted social care services performed well and should be reinforced for future surges.

The Use of Tranexamic Acid to Reduce the Need for Nasal Packing in Epistaxis (NoPAC): Randomized Controlled Trial

Epistaxis is a common emergency department (ED) presentation and, if simple first aid measures fail, can lead to a need for anterior nasal packing. Tranexamic acid is an agent that contributes to blood clot stability. The aim of this study is to investigate the effectiveness of topical intranasal tranexamic acid in adult patients presenting to the ED with persistent epistaxis, and whether it reduces the need for anterior nasal packing. From May 5, 2017, to March 31, 2019, a double-blind, placebo-controlled, multicenter, 1:1, randomized controlled trial was conducted across 26 EDs in the United Kingdom. Participants with spontaneous epistaxis, persisting after simple first aid and the application of a topical vasoconstrictor, were randomly allocated to receive topical tranexamic acid or placebo. The primary outcome was the need for anterior nasal packing of any kind during the index ED attendance. Secondary outcome measures included hospital admission, need for blood transfusion, recurrent epistaxis, and any thrombotic events requiring any hospital reattendance within 1 week. The study sample consisted of 496 participants with spontaneous epistaxis, persisting after simple first aid and application of a topical vasoconstrictor. In total, 211 participants (42.5%) received anterior nasal packing during the index ED attendance, including 111 of 254 (43.7%) in the tranexamic acid group versus 100 of 242 (41.3%) in the placebo group. The difference was not statistically significant (odds ratio 1.107; 95% confidence interval 0.769 to 1.594; P=.59). Furthermore, there were no statistically significant differences between tranexamic acid and placebo for any of the secondary outcome measures. In patients presenting to an ED with atraumatic epistaxis that is uncontrolled with simple first aid measures, topical tranexamic acid applied in the bleeding nostril on a cotton wool dental roll is no more effective than placebo at controlling bleeding and reducing the need for anterior nasal packing.

Feasibility of Using a Risk Assessment Tool to Predict Hospital Transfers or Death for Older People in Australian Residential Aged Care. A Retrospective Cohort Study.

Residents of Aged Care Facilities (RACF) experience burdensome hospital transfers in the last year of life, which may lead to aggressive and potentially inappropriate hospital treatments. Anticipating these transfers by identifying risk factors could encourage end-of-life discussions that may change decisions to transfer. The aim was to examine the feasibility of identifying an end-of-life risk profile among RACF residents using a predictive tool to better anticipate predictors of hospital transfers, death or poor composite outcome of hospitalisation and/or death after initial assessment. A retrospective cohort study of 373 permanent residents aged 65+ years was conducted using objective clinical factors from records in nine RACFs in metropolitan Sydney, Australia. In total, 26.8% died and 34.3% experienced a composite outcome. Cox proportional hazard regression models confirmed the feasibility of estimating the level of risk for death or a poor composite outcome. Knowing this should provide opportunities to initiate advance care planning in RACFs, facilitating decision making near the end of life. We conclude that the current structure of electronic RACF databases could be enhanced to enable comprehensive assessment of the risk of hospital re-attendance without admission. Automation tools to facilitate the risk score calculation may encourage the adoption of prediction checklists and evaluation of their association with hospital transfers.

Improving antimicrobial stewardship in an Acute Medical Unit (AMU) during patient discharge following introduction of an antimicrobial information card

Patients who initially present to the emergency department are often streamlined to an Acute Medical Unit (AMU). A quality improvement project was developed to introduce a new "Antibiotic Information Card" for patients discharged home from the AMU. Aims were to reduce 30-day readmission and reattendance rates due to the same infection after initial discharge by 75%, as well as improving patient education regarding their antibiotic prescription to 75%. Two Plan Do Study Act cycles were implemented in a busy AMU. Data were collected using electronic discharge software and patient records, as well as individual patient telephone questionnaires. Statistical analysis used run chart analysis. Baseline findings showed a variable level of patient knowledge on their antibiotic prescriptions (14%-70%) and fluctuations in 30-day reattendance rates (0%-50%). After the initial introduction of the Antibiotic Information Card, run chart analysis showed a shift in patient knowledge, significantly increasing to over 75%, and special cause variation which was not sustained. There were no significant changes in 30-day hospital reattendance and readmission rates throughout the intervention; however, there was a significant improvement in patient knowledge of their antibiotic prescription and management. Staff engagement is encouraged for sustainability of quality improvement changes to promote antimicrobial stewardship within the AMU.

Association between the level of municipality healthcare services and outcome among acutely older patients in the emergency department: a Danish population-based cohort study

ObjectivesThis study aims to describe the association between use of municipality healthcare services before an emergency department (ED) contact and mortality, hospital reattendance and institutionalisation.DesignPopulation-based prospective cohort study.SettingED of a...

Disability and morbidity among older patients in the emergency department: a Danish population-based cohort study

ObjectivesThe objective was to describe the prevalence of geriatric conditions among older medical patients in the emergency department (ED) and the association with admission, mortality, reattendance and loss of independency.DesignPopulation-based...

Is Frailty a Predictor of Outcomes in Elderly Inpatients with Acute Kidney Injury? A Prospective Cohort Study

BackgroundFrailty and acute kidney injury are independently associated with an increased risk of morbidity and mortality. The degree of frailty can be assessed by the Clinical Frailty Score (CFS). This study assessed whether an individual's CFS was associated with acute kidney injury in acute elderly medical admissions and recorded the short-term outcomes. MethodsThis was a single-center prospective observational cohort study. All patients aged ≥65 years admitted under an acute medical take over 12 nonconsecutive days were included. Patient demographics, comorbidities, baseline CFS, and renal status on admission were recorded. Outcomes of death, length of stay, and hospital re-attendance were assessed 2 weeks following admission. ResultsOf 164 patients (77 males), 19% had acute kidney injury on admission and 22% were considered severely frail. Severe frailty was associated with acute kidney injury (P = .01) and death within 2 weeks (P = .01). Two-week mortality was highest among patients with both (36%). ConclusionThe incidence of acute kidney injury in “severely frail” acutely unwell elderly patients is significantly higher and associated with an increased short-term mortality. The CFS may be useful in acute illness to guide clinical decisions in elderly patients.

Impact of combined initial and readmission length of stay following elective colorectal cancer resection on long term survival

Objectives: Hospital readmission within 30 days following surgery can be used as a marker of poor patient care. The aim of this study was to investigate the short and long term impact of patients who are readmitted following elective colorectal cancer resections. Methods: Data was prospectively collected on patients who underwent surgical treatment for colorectal cancer within an enhanced recovery programme at Yeovil District Hospital UK between 2002 and 2015. Data were captured on readmissions (defined as unplanned hospital re-attendance within 30 days of surgery) and overall survival (OS) calculated using Kaplan-Meier methods at 5 years. Results: 1023 patients underwent colorectal cancer resections (median age 73 [25-96], 454 (44%) were female), 423 (41%) were for rectal malignancies. 854 (83.5%) were planned operations and 169 (16.5%) were performed as emergencies. Overall 30-day mortality was 1.4%. 166 (16%) patients were readmitted within 30 days of surgery (median age 71 [25-88], 68 (41%) female). Readmitted patients had a longer initial length of hospital stay (median 10 vs. 8 days, p<0.001). Median readmission length of stay was 3 days (IQR 8, range 0-39 days). Significantly more rectal cancer patients were readmitted (p=0.04). There was no delay in administration of adjuvant chemotherapy within this readmission group. 16 (10%) of the readmissions required return to theatre, 9 of which required intervention of a major nature. Readmission alone did not significantly impact on 5 year overall survival (59% vs. 70%, p=0.092) but in those readmitted, five year overall survival was significantly associated with a shorter combined total length of hospital stay (median 14 vs. 20 days, p=0.04). Conclusion: In patients requiring hospital re-attendance following colorectal cancer surgery, a shorter combined length of stay was associated with long-term survival. Disclosure of interest: None declared.

Acute care of older patients in the emergency department: strategies to improve patient outcomes.

Older patients in the emergency department (ED) are a vulnerable population who are at a higher risk of functional decline and hospital reattendance subsequent to an ED visit, and have a high mortality rate in the months following an ED attendance. The delivery of acute care in a busy environment to this population presents its own unique challenge. The purpose of this review is to detail the common geriatric syndromes encountered in the ED as well as the appropriate strategies and instruments, which can be utilized to support the clinical decision matrix and improve outcomes.

PWE-033 The Incidence and Cost of Unexpected Hospital Attendance Following Elective Outpatient Flexible Sigmoidoscopy

IntroductionOutpatient flexible sigmoidoscopy is an increasingly utilised investigation shown to be effective in the detection and prevention of bowel cancer. The procedure is thought to entail a low risk of...

Reduction in Hospital Reattendance due to Improved Preoperative Patient Education Following Hemorrhoidectomy

To improve quality of healthcare, patient information must be thorough and easy to understand. This is important in day surgery where patients are seen less often by health practitioners. We looked at the impact of improving patient information in the setting of day-case hemorrhoidectomy in terms of patient satisfaction and whether medical attention was sought after the operation. A retrospective, comparative study was performed on 60 patients undergoing day-case hemorrhoidectomy and on 60 patients undergoing the same operation with improved patient information. Comparisons were made between the groups regarding patient satisfaction scores, those seeking medical attention, the numbers of patients requesting a 6-week outpatient follow-up and the reasons for seeking medical advice. There was a significant improvement in the patient satisfaction scores in the second study group who received the improved information. This group sought medical attention significantly less and they felt less need for a routine follow-up. This study has shown that by improving the quality of patient information for day-case hemorrhoidectomy, patient satisfaction was higher and fewer patients sought medical attention, which has beneficial financial indications for the NHS Trust and improvement of healthcare for the patient.

Reduction in Hospital Reattendance due to Improved Preoperative Patient Education Following Hemorrhoidectomy

Introduction: To improve quality of healthcare, patient information must be thorough and easy to understand. This is important in day surgery where patients are seen less often by health practitioners. We looked at the impact of improving patient information in the setting of day-case hemorrhoidectomy in terms of patient satisfaction and whether medical attention was sought after the operation. Methods: A retrospective, comparative study was performed on 60 patients undergoing day-case hemorrhoidectomy and on 60 patients undergoing the same operation with improved patient information. Comparisons were made between the groups regarding patient satisfaction scores, those seeking medical attention, the numbers of patients requesting a 6-week outpatient follow-up and the reasons for seeking medical advice. Results: There was a significant improvement in the patient satisfaction scores in the second study group who received the improved information. This group sought medical attention significantly less and they felt less need for a routine follow-up. Conclusions: This study has shown that by improving the quality of patient information for day-case hemorrhoidectomy, patient satisfaction was higher and fewer patients sought medical attention, which has beneficial financial indications for the NHS Trust and improvement of healthcare for the patient.

Venous thromboembolism in emergency department patients with rigid immobilization for lower leg injury: Incidence and risk factors

To determine the incidence and risk factors for symptomatic venous thromboembolism (VTE) in adults who are discharged from the ED with rigid immobilization for lower limb injury. Eligible patients presenting between 1 December 2008 and 31 December 2010 were identified retrospectively from the Southern Health ED (Monash Medical Centre, Dandenong Hospital, Casey Hospital, all located in Melbourne, Australia) information system. Age, sex, diagnosis, type of splint and other defined potential VTE risk factors were recorded. VTE was confirmed from archived diagnostic imaging or hospital re-attendance records. Patients presenting between 1 October 2010 and 31 December 2010 were contacted to detect VTE diagnosed and treated outside of Southern Health. VTE incidence is reported, and comparison of risk factors performed. VTE was initially confirmed in 33 of 1231 patients (2.7%, 95% confidence interval 1.9-3.7). VTE was reported by 3 of 174 in the contacted subgroup (1.7%, 0.4-4.6). Applying this 'missed rate' to the whole sample, the estimated VTE incidence is between 3.1% and 7.1%. Multivariate risk factor analysis found VTE risk to increase with age and a diagnosis of Achilles tendon rupture. The estimated VTE incidence was between 3% and 7% in this ED population with age and diagnosis of Achilles tendon rupture increasing risk. Prospective research to more accurately determine incidence, severity and risk stratification is required before firm recommendations on the likely risk versus benefit profile of thromboprophylaxis can be made for this population.

Emergency department social work in the UK and Sweden: evaluation by older frequent emergency department attendersKuratorsarbete på akutmottagning i förenade kungadömet Storbritannien och Sverige: en utvärdering utifrån brukarperspektivet hos äldre mångbesökare på akutmottagningen

Social work based in hospital emergency departments (EDs) in Sweden and the UK reflects a wider European social/health care policy trend. A key focus is on diverting older frequent ED attenders from ‘inappropriate’ hospital re-attendance or emergency admission, because of social care problems. However, previously there has been no evaluation of the significance of ED social work for health and well-being, from the standpoint of older frequent ED attenders themselves. In a preliminary way, our paper provides this through drawing on a small scale Swedish/UK study. Its comparative account of service user feedback underscores the importance of ED social work as a facet of European social work. It indicates that ED social work contributes to the quality of care within emergency departments, acts as a key access point to social services, and can promote both short and longer-term health. At the same time, some serious shortcomings emerge. These include under-developed referral systems, and limitations to community based services following ED social work assessment, which reflect the under-resourcing of social care provision in both countries. Moreover, service users’ experience in both Sweden and the UK reveals the risk of ED social work with older frequent ED attenders being used as a substitute for follow-up medical/nursing care when that is also required.