Preventable Hospital Admissions Research Articles

Predicting Hospitalization Risk Among Home Care Residents in the United Kingdom: Development and Validation of a Machine Learning-Based Predictive Model

Preventable hospital admissions in elderly home care residents are a major socioeconomic burden, whilst early detection of deterioration may improve outcomes. Our goal was to develop and validate a machine learning-based algorithm to predict hospitalization risk among home care users. Our primary outcome was hospitalization. An existing risk score (1-5) was assessed for its discriminatory capacity over time. We subsequently developed a new machine learning model using carer concerns, service user demographics, and other home care data between January and July 2021. We randomly selected 150 service user records for validation, which were evaluated by both the model and 10 clinicians (9 doctors and 1 nurse) to compare prediction time and accuracy to human experts. Comparison between model and human was via area under the receiver operating characteristic curve (AUC). A score of 5 conferred an 8x higher likelihood of hospitalization in the subsequent 7 days (15.4% vs 1.8%, p < .05), compared to a score of 1. The new model and risk score increased performance, detecting 182 hospitalizations/month (3.7x chance). The AUC for the model was significantly higher than for clinicians (0.87 vs 0.41-0.57, respectively; p < .05). The model took <1 minute, while clinicians typically took over 40 minutes. A risk prediction model using carer concerns and other home care data features detects 3.7x more hospitalizations than chance. The model is faster and more accurate than human clinicians, enabling low-cost scale-up. This study supports linking the model to a triage and intervention service to reduce preventable hospitalizations in the home care sector.

Impact of a health-system specialty pharmacy on time to upadacitinib initiation.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Upadacitinib has been found to improve symptoms as early as day 1 in patients with inflammatory bowel disease. As a result, early and timely initiation of upadacitinib is paramount to prevent hospital admission for an acute flare. The purpose of this study was to identify the time to initiation of upadacitinib, comparing external specialty pharmacies (ESPs) to a health-system specialty pharmacy (HSSP). This was a single-center, retrospective study at the University of Chicago Medicine (UCM) Inflammatory Bowel Disease Center and included patients initiated on upadacitinib between March 1, 2022, and April 1, 2023. Data collected included demographics, prior authorization information, appeal information, insurance type, date the prescription was sent, and date the patient initiated therapy (patients were called to confirm the date). The primary outcome evaluated was the days from prescribing to patient initiation. Secondary outcomes included the total time to initiation and the time to notification from insurance regarding determination of a prior authorization or appeal. Patients were excluded if they were lost to follow-up, initiated therapy through alternative means, or had previously initiated upadacitinib. A total of 107 patients were initiated on upadacitinib during the study period (n = 18 through the UCM HSSP, n = 89 through an ESP). The median number of days to patient initiation was 3 days (interquartile range, 3-6 days) for the UCM specialty pharmacy vs 9 days (interquartile range, 4-13 days) for ESPs (P = 0.003). A total of 88.9% of patients filling through the UCM specialty pharmacy initiated upadacitinib within 7 days, compared to 47.2% of patients filling through an ESP (P = 0.001). Seven patients needed earlier initiation of therapy to prevent hospital admission. This study validates the ability of HSSPs to initiate therapies earlier than ESPs with a particular focus on upadacitinib.

Case Report on a Multidisciplinary Approach to Address Malnutrition and Improve a Patient’s Fitness for Treatment

Approximately 5,700 people are diagnosed with myeloma each year in the UK. The standard of care is to receive an autologous stem cell transplant after completion of induction therapy. There are no specific dietary recommendations for people with myeloma, however they are at risk of malnutrition due to symptoms and side effects of treatments. This report describes the journey of a 73-year-old male diagnosed with immunoglobulin A (IgA) lambda myeloma in April 2021. The patient lost 23% of his body weight during 6 months of systemic anti-cancer treatment (SACT), resulting in postponing his transplant twice due to reduced fitness. This report describes an effective, although late, multidisciplinary intervention which was successful for the patient who managed to reestablish a healthy weight and good quality of life. The patient received his transplant in January 2023. This case highlights two important aspects of patient care that should not be underestimated in dietetic clinical practice: early screening and multidisciplinary collaboration. Monitoring the nutritional status of patients and providing early nutrition support can prevent hospital admissions, treatment delays and reduce the associated costs. Multidisciplinary teamwork can improve patient care and clinical outcomes, and it is fundamental to strengthen communication and collaboration among clinical disciplines.

GJ Express: an improvement initiative to decrease sedation and anesthesia for gastrojejunostomy tube exchanges.

Overuse of sedation and anesthesia causes delays in gastrojejunostomy tube (GJ) exchanges, increased risk of complications, unnecessary use of resources, preventable hospital admissions, and an adverse impact on patient and family experience. Our hospital was over-utilizing sedation and anesthesia, and we aimed to decrease this use from 78% to 20% within two years. An interdisciplinary quality improvement team comprehensively evaluated current processes for GJ tube exchanges through a retrospective chart review for baseline data with prospective time series analysis after improvement implementation. The primary outcome measure was the percentage of pediatric patients that utilized sedation or anesthesia for routine GJ tube exchanges. A statistical process control p-chart was used to calculate and show changes over time for patients (n = 45 patients average). The median percent of pediatric GJ tube exchanges performed with sedation or anesthesia decreased from 77.8% to 11.3%. Most patients (76%) were covered by Medicaid programs; with low reimbursement rates, decreased anesthesiologist billing revenue does not have a negative financial impact. An interprofessional improvement initiative that engaged patients and families, incorporated pediatric-specific staff services, and developed systematic weaning was associated with a significant decrease in the overuse of sedation and anesthesia for GJ tube exchanges. We believe that this work is highly relevant and impactful for medical centers caring for children who require gastrojejunostomy tubes, an increasingly common approach to management of children with feeding issues. There is very little literature available on the use of sedation or anesthesia for changing these tubes. While large children's medical centers in the USA usually do not utilize sedation or anesthesia, there are likely many serious outliers, especially when children receive care outside of a pediatric specific institution. This paper brings awareness to this serious issue and provides information about how we changed care to achieve higher patient safety and lower medical costs.

Home care models dedicated to COVID-19 patients: the experience of a Local Health District of Veneto Region (Italy).

During COVID-19 pandemic, health professionals have been working in an extreme uncertainty context. Affected patients needed to be cared at home as long as possible to avoid virus spreading and hospital resources saturation. The Veneto Regional Administration (North-east of Italy) released Regional guidelines about it. The Western Healthcare District of the Local Health Authority of the city of Vicenza (180,000 inhabitants) implemented a healthcare pathway following them. Aim of the study is to describe the results and outcomes of such implementation. In the implemented health care pathway, a new service called "Special Unit of continuity of care" (USCA) with physicians and nurses has been dedicated to the prise en charge at home of patients suffering from Sars-CoV-2. They were referred to the USCA by general practitioners or by hospital specialists, and managed through a daily clinical monitoring by regular home visits and phone calls, specialist consultations and therapy management. In order to prevent hospital admission, an oxygen concentrator when possible has been employed and managed at home by the members of the USCA when the oxygen saturation was below 93%. An observational retrospective study has been conducted using anonymized data from different databases: the USCA activity database (from 12/01/20 to 21/31/21), the hospital and Emergency Department discharge databases, and the "healthcare co-payments exemptions database". The latter database refers to the people excluded - because of their chronicity - from the co-payment of a list of medical exams and services. Descriptive and multivariate logistic regression analyses have been implemented. 1,419 patients suffering from Sars-CoV-2 have been cared and managed by the USCA in the considered period of time (mean 11.4 days), of whom 787 (55.5%) with at least one chronic condition (described in the above quoted "healthcare co-payments exemption database") and 261 provided with oxygen concentrator. 275 (19.4%) needed a hospital admission, 39 (2.8%) in intensive unit; 53 died during hospitalization (3.8%). Out of the 261 patients utilizing oxygen concentrator, 103 have been admitted to hospital (39.5%), 7.3% in intensive unit and 8.0% died. In implemented multivariate analyses, the use of oxygen concentrator, proxy measure of the severity of the condition, is the major determinant for the risk of hospital admission (adj OR: 3.2, CI 2.3-4.3) and of dying within 30 days (adj OR: 2.8 CI 1.5-5.1). Among the 261 patients provided with oxygen concentrator, 158 (60,5%) have been managed at home without any admission to emergency department and/or hospitalization. In an uncertain context such as COVID-19 pandemic, the already-implemented home care model has been modified by integrating the USCA physicians and nurses and specialist care networks to prevent hospitalization and the sense of isolation and abandonment of people as much as possible. Almost 1,500 patients suffering from COVID-19 have been cared for at home over 13 months by such new service with complex and multidisciplinary activities. The risk of hospitalization and death appears determined by the severity of the pathology with high and significant OR 60% of patients with oxygen concentrators who, despite an initial high hyposaturation were not hospitalized, represent, partly, the group of patients who would have been requiring hospital care in the absence of a home care pathway in a standard situation.

The impact of the 2022 spring COVID-19 booster vaccination programme on hospital occupancy in England: An interrupted time series analysis.

Regular booster vaccination programmes help protect the most vulnerable from COVID-19 and limit pressure on health systems. Existing studies find booster doses to be effective in preventing hospital admissions and deaths but focus on individual effects, failing to consider the population impact of incomplete vaccination coverage and seasonal patterns in disease transmission. We estimated the effectiveness of the 2022 spring booster vaccination programme, available for those aged 75 years and older, residents in care homes, and adults with weakened immune systems, on COVID-19 hospital bed occupancy in England. Booster vaccine coverage in the eligible population increased rapidly in the months after rollout (from 21st March 2022), flattening out just below 80% by July 2022. We used interrupted time series analysis to estimate a 23.7% overall reduction in the rate of hospital occupancy for COVID-19 following the programme, with a statistically significant benefit in the 6-12 weeks following rollout. In the absence of the programme, we calculate that a total of 380,104 additional hospital bed-days would have been occupied by patients with COVID-19 from 4th April to 31st August 2022 (95% CI: -122,842 to 1,034,590). The programme delayed and shortened the duration of the peak while not reducing its magnitude. In sensitivity analyses adjusting the start of the post-intervention period or removing the rate of COVID-19 infection in the over 60s from the model, the effect of the spring booster programme on hospital bed occupancy remained similar. Our findings suggest that timing is a critical consideration in the implementation of COVID-19 booster programmes and that policymakers cannot rely on intermittent booster vaccination of high-risk groups alone to mitigate anticipated peaks in hospital pressure due to COVID-19 epidemics.

Trends in inequalities in avoidable hospitalisations across the COVID-19 pandemic: a cohort study of 23.5 million people in England

ObjectiveTo determine whether periods of disruption were associated with increased ‘avoidable’ hospital admissions and wider social inequalities in England.DesignObservational repeated cross-sectional study.SettingEngland (January 2019 to March 2022).ParticipantsWith the approval of...

Implementation of an asynchronous general practitioner‑to‑specialist  eConsult service (eConsultant) in Australia

Background: With the rise in demand for specialist care across Australia, patients are experiencing excessive delays for specialist input, linked with subsequent deterioration in health. eConsultant is an outpatient substitution model which has been evaluated and implemented extensively internationally. It provides an asynchronous, digital, clinician-to-clinician advice service, giving GPs remote access to specialist support for patient care within 3-business days. This study, the first to track implementation of an eConsultant service in Australia, identifies barriers and enablers to adoption prior to broader implementation. 
 Method: Our prospective mixed-methods observational study included semi-structured interviews with GPs and stakeholders to understand determinants of implementation. GPs send a Request-for-Advice (RFA) to the specialist and advise patients to schedule a timely follow-up appointment to discuss the eConsultant advice. Adoption (program enrolment/usage by GPs & GP practices) was assessed. 
 Results: The study is underway in 12 rural/remote and 10 urban general practices. To date, RFAs have been generated for 178 patients (mean age 59.5yrs, 63% rural, 37% urban). The GPs mean time to response by the eConsultant was 1.7 (SD 2.3) days and patients mean time to specialist input (initial GP to GP follow-up appointment) was 13.0 (SD 2.7) days (well below average waiting times for OPD appointments). Qualitative interviews conducted with 11 GPs and 4 stakeholders highlight the benefits of eConsultant to providing efficient/timely access to specialist support for GPs and their patients. 
 Conclusion: eConsultant is feasible in Australia with benefits to the health system of timely specialist support for patients without the cost of subsidised patient travel, face-to-face visits, and potentially preventable hospital admissions. eConsultant provides GPs with a reliable, auditable record of advice given by specialists, an opportunity for GP practice capacity building and more direct partnership with specialist colleagues. eConsultant offers a streamlined evidence-based option, implementable state-wide, to support patients and primary care providers.

A generalizable unsupervised graph‐based approach for anomalous event detection in people living with dementia

AbstractBackgroundSensor‐based remote health monitoring of persons living with dementia (PLwD) can be used to monitor the progression of their condition with minimal intrusion. This helps minimize preventable hospital admissions, while allowing researchers to improve their understanding of dementia. Existing approaches for detecting anomalies in activity and behavior in PLwD are challenged by data noise, drift, label reliance, and poor explainability and generalizability due to wide inter‐individual variability.MethodWe propose and evaluate a solution that combines graph learning with the Contextual Matrix Profile (CMP), an ultra‐fast distance‐based discord detection technique. Daily household movement data collected via passive infrared sensors are used to generate multivariate CMP. This is encoded as a set of time‐evolving graphs. A self‐supervised graph model is trained to separate graphs by distance, so discordant time blocks show up as anomalous graphs. Differences between successive graph embeddings are subject to moving average thresholding to detect anomaly. We compare our method to four state‐of‐the‐art outlier detection algorithms, and demonstrate the generalizability of a distance‐based graph model trained on one cohort, to anomaly detection in unseen individuals.ResultGraph‐enhanced CMP models outperform state‐of‐the‐art algorithms, yielding 74% recall with a 5.7% alert rate and 88% household‐level validity when evaluated on 13,426 days’ data from 42 households with 145 agitation events, collected by the UK Dementia Research Institute between August 2019 and April 2022. Similar results are obtained for a 23‐participant, 5284‐day Falls cohort: 72% recall, 5.85% alert rate and 83% household‐level validity. Pretrained models yield similarly high performance for unseen households in both cohorts. Experiments on the publicly available PAMAP dataset reveal superior top‐k alert performance. Explainability is achieved via the CMP that is the source for graphs.ConclusionWe address the need for generalizable anomaly detection models for multivariate time series sensor data in remote health monitoring. While the CMP allows the ability to denoise and detect patterns at a household level, a graph model constructed in the distance space is generalizable across households. With higher sensitivity, fewer alerts than state‐of‐the‐art methods and inherent explainability, graph‐CMP models offer a clinically meaningful unsupervised anomaly detection technique for dementia and beyond.

The clinical impact of a crisis resolution home treatment team.

To evaluate the impact of treatment provided by a Crisis Resolution Home Treatment Team (CRHTT) in terms of preventing hospital admission, impact on service user's symptoms and overall functioning, as well as service user's satisfaction with the service. Secondary objectives were to evaluate the patient characteristics of those attending the CRHTT. All the service users treated by the CRHTT between 2016 and 2020 were included. Service users completed the Brief Psychiatric Rating Scale (BPRS), the Health of the Nation Outcome Scale (HoNOS), and the Client Satisfaction Questionnaire-version 8 (CSQ-8) before and after treatment by the CRHTT. Admission rates were compared between areas served by the CRHTT and control, before and after the introduction of the CRHTT, using two-way ANOVA. Between 2016 and 2020, 1041 service users were treated by the service. Inpatient admissions in the areas served by the CRHTT fell by 38.5% after its introduction. There was a statistically significant interaction between CRHTT availability and time on admission rate, F (1,28) = 8.4, p = .007. BPRS scores were reduced significantly (p < .001), from a mean score of 32.01 before treatment to 24.64 after treatment. Mean HoNOS scores were 13.6 before and 9.1 after treatment (p < .001). Of the 1041 service users receiving the CSQ-8, only 180 returned it (17.3%). Service users' median responses were "very positive" to all eight items on the CSQ-8. Although our study design has limitations this paper provides some support that CRHTT might be effective for the prevention of inpatient admission. The study also supports that CRHTT might be an effective option for the treatment of acute mental illness and crisis, although further research is needed in this area.

Using an electronic diary and wristband accelerometer to detect exacerbations and activity levels in COPD: a feasibility study.

Early and accurate identification of acute exacerbations of COPD may lead to earlier treatment and prevent hospital admission. Electronic diaries have been developed for symptom monitoring and accelerometers to monitor activity. However, it is unclear whether this technology is usable in the COPD population. This study aimed to assess the feasibility of an electronic diary (eDiary) for symptom reporting using the MoreCare app and activity monitoring with the Garmin Vivofit 2 in COPD. Participants were recruited from the London COPD Cohort. Participants were provided a Garmin Vivofit 2 activity monitor and an android tablet with the MoreCare app for a period of 3 months. 25 COPD patients were recruited (mean±sd age 70.8±7.1 years, forced expiratory volume in 1 s (FEV1) 49.8±14.8% predicted). Age, gender, disease severity and exacerbation frequency had no impact on eDiary compliance. There was a moderate positive correlation between median daily very active minutes and FEV1 % pred (ρ=0.62, p=0.005). Daily step counts decreased during the initial 7 days of exacerbation and recovery compared to a pre-exacerbation baseline. A decision-tree model identified change in sputum colour, change in step count, severity of cold, exacerbation history and use of rescue medication as the most important predictors of acute exacerbations of COPD in this cohort. Symptom and activity monitoring using digital technology is feasible in COPD. Further large-scale digital health studies are needed to assess whether eDiaries can be used to identify patients at risk of exacerbation and guide early intervention.

Severe and common mental disorders and risk of emergency hospital admissions for ambulatory care sensitive conditions among the UK Biobank cohort.

People with mental disorders have worse physical health compared with the general population, which could be attributable to receiving poorer quality healthcare. To examine the relationship between severe and common mental disorders and risk of emergency hospital admissions for ambulatory care sensitive conditions (ACSCs), and factors associated with increased risk. Baseline data for England (N = 445 814) were taken from UK Biobank, which recruited participants aged 37-73 years during 2006-2010, and linked to hospital admission records up to 31 December 2019. Participants were grouped into those with a history of either schizophrenia, bipolar disorder, depression or anxiety, or no mental disorder. Survival analysis was used to assess the risk of hospital admission for ACSCs among those with mental disorders compared with those without, adjusting for factors in different domains (sociodemographic, socioeconomic, health and biomarkers, health-related behaviours, social isolation and psychological). People with schizophrenia had the highest (unadjusted) risk of hospital admission for ACSCs compared with those with no mental disorder (hazard ratio 4.40, 95% CI 4.04-4.80). People with bipolar disorder (hazard ratio 2.48, 95% CI 2.28-2.69) and depression or anxiety (hazard ratio 1.76, 95% CI 1.73-1.80) also had higher risk. Associations were more conservative when including all admissions, as opposed to first admissions only. The observed associations persisted after adjusting for a range of factors. People with severe mental disorders have the highest risk of preventable hospital admissions. Ensuring people with mental disorders receive adequate ambulatory care is essential to reduce the large health inequalities they experience.

SAT294 Effectiveness Of Electronic Consults For Immune Related Endocrine Toxicities In Reducing Appointment Access Time And Preventing Hospital Admissions

Abstract Disclosure: A.I. Shariff: Consulting Fee; Self; Bristol-Myers Squibb. Speaker; Self; Merck. Background: Endocrine irAEs are noted in 4% to 14.6% of ICI treated patients leading to 12.2% of irAE related admissions.1Delayed access, diagnosis and management are often causes of preventable hospital admissions in cancer patient.2 3 Herein, we describe a single-institution experience with an e- consult platform from oncology to endocrinology as a cost effective and high impact solution to this limitation. Methods: Between 5/1/2020 to 11/1/2021 patients who received ICI were included in a retrospective observational cohort study. Data collection included patient demographic, cancer, treatments, irAE and appointment specifics. Results: 102 e-consults were reviewed during the study period. Thyroiditis was noted as the most common irAE while NSCLC, and pembrolizumab use were most commonly noted in the cohort. 88 and 60 consults received diagnostic and treatment recommendations respectively. Reduction in median time to appointment was lowered from 60.5 days to 38.50 days. Among e-consulted patients, 2 (2.23%) required hospitalization for further evaluation and management. This is a reduction from previous data at the same institution (2007- 2017) where 11% endocrine toxicities were admitted. With an average length of stay approximated to 6.4 days at $3,142 per day, a total of $100,544 was saved as a result of the consult service.1 We also noted that these e-consults were poorly reimbursed by all payers, and current average reimbursement ranged from $15- $32/ consult.4Conclusion: This study underscores the impact and effectiveness of e consults as a tool for timely recommendations and improving access leading to reduction in health care utilization. To support e-consults, the effort-payment mismatch must be addressed by health systems and payers that can propel integration and scalability of these effective services across oncology and other subspecialty practices to enhance access and mitigate gaps in specialty care provided to cancer patients. Presentation Date: Saturday, June 17, 2023

50 Employing Shared Decision Making (SDM) to reduce NSAID-related harm and hospitalisations, in at-risk patients in primary care

Abstract Background 10% of hospital admissions in Ireland are Adverse Drg Reaction (ADR) related, and 71% of these are potentially avoidable. NSAID-related ADRs have been implicated in up to 30% of all ADR-related admissions. Addressing NSAID related STOPP criteria may prevent hospital admissions with bleeding, Cerebrovascular (CV) events and renal impairment. If stopping NSAID is not possible, dose reductions or drug switches can minimise the risk of harm. Preferred NSAIDs are naproxen (lower CV risk) or ibuprofen &amp;lt;1,200 mg/day (lower CV and gastrointestinal bleed risk). Methods Patients aged ≥65 years with valid prescriptions for NSAIDs were identified via software search using the M01 ATC classification system code. Each patients file was reviewed for NSAID related STOPP criteria. Specific software searches using additional ATC classification system codes were undertaken to identify those at high risk of harm e.g. NSAID with anticoagulant. Patients were engaged in Shared Decision Making (SDM) with the practice pharmacist and prescription changes were agreed and enacted by the GP. Results 63 patients&amp;gt;65 yrs had a valid prescription for an NSAID. 42 had ≥1 NSAID related STOPP criteria. 35 were deemed appropriate for intervention. 7 were prescribed a preferred NSAID and had mild hypertension only. 23 were deemed at high risk of harm. Software searches identified the same 23 high risk patients. 35 patients were engaged in SDM. 100% of these agreed to a change to their prescription. 51% stopped their NSAID whilst 40% changed or dose reduced their NSAID and 9% agreed to addition of gastroprotection. This achieved an overall 60% STOPP resolution rate. A higher average 91% resolution rate was achieved in the higher-risk patients. Conclusion SDM achieves higher STOPP resolution rates in patients at higher risk of harm who are identifiable though specific GP practice software searches. These software searches can be employed annually to effectively and efficiently prioritise patients for SDM interventions.

58 Review of a pilot Reablement Team service

Abstract Background A Reablement Team (RT) was established in a level two hospital for patients who are medically fit for discharge from either Medical Assessment Unit (MAU) or in-patient care, to prevent hospital admission and to support early discharge, through the provision of home rehabilitation. The team consists of senior grade medical social worker, occupational therapist, speech and language therapist, physiotherapist and a rehabilitation assistant. Intensive rehabilitation is provided in the home for up to 6 weeks. This study sought to evaluate service impact and performance in 2022. Methods A mixed method design was employed. Quantitative data was used by analysing number and nature of patients seen, discharge outcomes and pre and post outcome measures to determine goals achieved, quality of life and independence levels. Qualitative data included patient satisfaction questionnaires. Results In 2022, 78 patients were seen, 41 female and 37 male. Mean age of 79 years. Of the total number of patients, 59 (76%) were discharged early from hospital and 19 (24%) avoided hospital admission after attending the MAU. Underlying diagnosis of patients comprised Stroke (n = 29), progressive neurological disorders (n = 11), respiratory disorders (n = 2) orthopaedic/musculoskeletal (n = 13), falls (n = 20), patients medically unwell (n = 3). Of the patients discharged, 86% remained at home (n = 67), while 14% were readmitted. Using pre/post outcome measures, 89% reported an improvement in quality of life as measured by the ICECAP assessment and the mean increase of all patients in independence was 5.4% measured on the modified Barthel index. 91% of patients achieved one or more primary rehabilitation goals. All patients rated service satisfaction as high. Conclusion Findings indicate that a RT service can reduce LOS and prevent unnecessary admissions when intensive rehabilitation is provided by a dedicated team of HSCPs in the home. Additional benefits include reduction of primary care waiting list and integrated home care.

Applying the consolidated framework for implementation research to evaluate the community rapid intervention service

BackgroundDeveloped in 2019, the Community Rapid Intervention Service (CRIS) is a community intervention service aiming to prevent hospital admissions. CRIS provides a response within two hours to patients with sub-acute medical needs in their usual place of residence. This evaluation aimed to identify challenges and facilitators to implementation of the service, with a view to informing future service development, optimising patient care and disseminating learning to other areas looking to implement similar services.MethodsThis study used the Consolidated Framework for Implementation Research (CFIR) as an evaluation framework. We conducted semi-structured interviews with local healthcare system leaders, clinicians that worked within the CRIS, and clinicians who interfaced with the CRIS. The CFIR was used to guide data collection and analysis. Two Community of Practice (CoP) meetings were held to gather stakeholders’ perspectives of the evaluation.ResultsThree key themes were identified from the analysis of 13 interviews: contextual factors influencing implementation, service identity and navigating complexity. Contextual factors such the influence of the Covid 19 pandemic upon health services and the expansion of the CRIS were discussed by participants. The adaptability of the service was deemed both a facilitator and challenge of implementation. Ways to build-on and improve the existing CRIS model were suggested.ConclusionThis evaluation has shown that the CRIS may need to be redefined with clarity provided as to how the service interfaces with other urgent and planned care offered in acute, primary, community and social services. Structuring the evaluation around the CFIR was helpful in identifying facilitators and challenges that influenced the implementation of the CRIS.

Associations between self-reported healthcare disruption due to covid-19 and avoidable hospital admission: evidence from seven linked longitudinal studies for England

ObjectivesTo examine whether there is an association between people who experienced disrupted access to healthcare during the covid-19 pandemic and risk of an avoidable hospital admission.DesignObservational analysis using evidence from...

Geographic Variation in Preventable Hospitalizations among US Children with Autism.

There is a limited amount of research on geographic differences in preventable hospitalizations for ambulatory care sensitive conditions (ACSCs) among children with autism. The purpose of this study was to examine US regional differences in potentially preventable hospital admissions for pediatric inpatients diagnosed with autism. Hospital discharge data for six pediatric preventable conditions were obtained from the 2016-2019 National Inpatient Sample (NIS) under the US Agency for Healthcare Research and Quality. Geographic differences in preventable hospitalizations for children with autism were examined by US census regions and divisions. Multiple logistic regression analyses were conducted to examine child and clinical characteristics associated with ACSCs hospitalization across four US regions; the dependent variable was the likelihood of ACSCs hospitalization. Additionally, this study further explored the variation in preventable hospitalization among racial and ethnic groups for each region or division. Of the 138,305 autistic inpatients aged 2-17 years, about 10% had a primary diagnosis related to ACSCs. The results showed that the highest proportion of preventable hospitalizations for autistic children occurred in the middle Atlantic division of the northeast region. Racial differences were observed across all US regions, particularly in the northeast and south regions. Black children with autism were more likely to be hospitalized for ACSCs compared to White children with autism in three of the four US regions. Our results highlight the significant racial disparities in potentially avoidable hospitalizations among US children with autism. Examining geographic and racial differences in potentially avoidable hospitalizations could inform policy and practice while gaining a better understanding of pediatric patients with autism and where their families access health services. The findings of this study may help policymakers to identify where intervention is needed to tackle health inequities in the accessibility to quality primary care in the US. Further studies with more detailed investigation are recommended to better understand the mechanisms underlying these disparities, and to formulate effective regional policy and clinical practices while considering the unique needs and challenges of underserved children with autism.

Recognising and responding to acute deterioration in care home residents: a scoping review

BackgroundAcute deterioration describes a rapid change in physical and/or mental health resulting from an acute illness – e.g., heart attack or infection. Older people in care homes are some of the frailest and vulnerable in society. They have complex health needs, experience multiple long-term conditions (MLTC) and have weakened immune systems due to the ageing process. They are more susceptible to acute deterioration and delayed recognition and response, is linked to poorer health outcomes, adverse events and death. Over the past five years, the need to manage acute deterioration in care homes and prevent hospital admissions has led to development and implementation of improvement projects, including the use of hospital derived practices and tools to identify and manage this condition. This is potentially problematic as care homes are different from hospitals—options to escalate care vary throughout the UK. Further, hospital tools have not been validated for use in care homes and have shown to be less sensitive in older adults living with frailty.ObjectivesTo collate the available evidence on how care home workers recognise and respond to acute deterioration in residents using published primary research, non-indexed and grey literature, policies, guidelines and protocols.MethodsA systematic scoping review was conducted following Joanna Briggs Institute (JBI) scoping review methodology. Searches were conducted using: CINAHL (EBSCOhost), EMCARE (OVID), MEDLINE (OVID) and HMIC (OVID). Snowball searches of included studies’ reference lists were conducted. Studies that featured care homes with or without nursing and provided 24/7 care to residents were included.ResultsThree hundred and ninety-nine studies were identified. After reviewing all studies against inclusion criteria, n = 11 were included in the review. All studies used qualitative methods and were conducted in Australia, UK, South Korea, USA and Singapore. Four themes were generated from the review: identifying residents with acute deterioration; managing acute deterioration, care home policies and procedures, and factors affecting recognition and response to acute deterioration.FindingsRecognition and response to acute deterioration in residents is determined by multiple factors and is context sensitive. There are several interrelated factors within and external to the care home that contribute to how acute deterioration is recognised and managed.Conclusions and ImplicationsThe available literature on how care home workers recognise and respond to acute deterioration is limited and often subtends other areas of interest. Recognising and responding to acute deterioration in care home residents is reliant on a complex and open system encompassing multiple interrelated components. The phenomenon of acute deterioration remains underexplored and further research is required to examine contextual factors that accompany identification and management of this condition in care home residents.

#6672 THE DEVELOPMENT OF A COMMUNITY-NEPHROLOGY, MULTI-DISCIPLINARY SERVICE

Abstract Background and Aims The Walsall Together clinical and operational leads constructed a collaborative initiative between nephrology and community services. Driven to provide multi-agency, patient-focused care. The aim of the community nephrology MDT service is to identify and optimally manage individuals with acute nephrological presentations and optimally manage individuals with secondary complications of chronic kidney disease (CKD) at home, while maximally utilising outpatient community services to prevent hospital admissions. Method Nephrology and community teams, including rapid-response, complex-case management, enhanced-care and frailty teams devised a MDT service for individuals with either community-acquired acute kidney injury (AKI) or complications of CKD. The MDT can consist of; a nephrologist, community-CKD nurse, a member from each of the above teams, a community pharmacist and an MDT coordinator. Patients are identified from the MDT attendee's caseload, from the community heart failure and the community geriatrician patient cohort. A weekly MDT meeting is held on Microsoft Teams, this allows for efficient working across a large geographical area. The MDT coordinator is essential for the efficient performance of the community nephrology MDT. They are responsible for: organising meetings, producing minutes, requesting laboratory investigations (including urine album in creatinine ratio), chasing results from clinical investigations and finally ensuring that the actions generated from the MDT are completed. The community pharmacist is an independent prescriber and immediately actions any medication changes. The community teams consist of advanced clinical practitioners or band 7/above nurse prescribers. All clinical staff perform home visits and fully utilise outpatient services including ambulatory-care-unit services for medical assessment, urgent imaging and intravenous electrolyte replacement. The medical-day-case unit services for the administration of blood transfusions. The community outpatient access team services for intravenous iron therapy and antibiotic therapy. Results Currently, the community nephrology MDT is actively managing over 60 patients. This excludes patients who have been successfully managed and discharged from the community MDT service. The multimorbid, patient cohort with recurrent hospital admissions appear to have benefited the most. A reduction and/or cessation is noted, in hospital admissions after the introduction of interventions from the community nephrology MDT. The service allows the nephrology team to easily monitor and manage housebound, individuals with CKD. This reduces the number of admissions related to secondary complications of CKD. Furthermore, by managing acute illness in the community, the service reduces the number of individuals admitted to hospital with community acquired AKI. Finally, in the unfortunate event of terminal, irreversible pathology, the MDT service allows for advanced care planning and referral to community palliative care services. Conclusion The Walsall Together collaboration has demonstrated that utilising a multi-agency approach to managing acute and chronic renal disease, can result in a reduction in hospital admissions. Furthermore, the cooperative multi-speciality approach, has led to improved monitoring and management of housebound individuals with CKD.