Subacute Care Facilities Research Articles

The association between rurality, places of care and the location of death of long-term care home residents with dementia: A population-based study.

Most individuals prefer to spend their final moments of life outside a hospital setting. This study compares the places of care and death of long-term care (LTC) home residents in Ontario in the last 90 days of life, according to LTC home rurality. This retrospective cohort study was conducted using health administrative data from ICES (formerly known as the Institute for Clinical Evaluative Sciences). The study population, which was identified through algorithms, included all Ontario LTC home residents with a dementia diagnosis who died between April 1, 2014, and March 31, 2019. The location of death was categorized as in an acute care hospital, an LTC home, a subacute care facility, or the community. Places of care included emergency department visits and hospitalizations in the last 90 days of life. Statistical tests were used to evaluate differences in location of death and places of care by rurality. Of the 65,375 LTC home residents with dementia, 49,432 (75.6%) died in an LTC home. Residents of LTC homes in the most urban areas were less likely to die in an LTC home than those in more rural homes (adjusted relative risk: 0.84; 95% confidence interval: 0.83 to 0.85). A higher proportion of residents of the most urban LTC homes had at least one hospitalization in the last 90 days of life compared with rural residents (23.7% versus 9.9% palliative hospitalizations and 28.3% versus 15.9% non-palliative hospitalizations [p ⟨ 0.001]). Individuals with dementia residing in urban LTC homes are more likely to receive care in the hospital and to die outside a LTC home than their counterparts living in rural LTC homes. The findings of this work will inform efforts to improve end-of-life care for older adults with dementia living in LTC homes.

Defining ready for discharge from sub-acute care: a qualitative exploration from multiple stakeholder perspectives

BackgroundPlanning discharges from subacute care facilities is becoming increasingly complex due to an ageing population and a high demand on services. The use of non-standardised assessments to determine a patient’s readiness for discharge places a heavy reliance on a clinician’s judgement which can be influenced by system pressures, past experiences and team dynamics. The current literature focusses heavily on discharge-readiness from clinicians’ perspectives and in the acute care setting. This paper aimed to explore the perceptions of discharge-readiness from the perspectives of key stakeholders in subacute care: inpatients, family members, clinicians and managers.MethodsA qualitative descriptive study was conducted, exploring the views of inpatients (n = 16), family members (n = 16), clinicians (n = 17) and managers (n = 12). Participants with cognitive deficits and those who did not speak English were excluded from this study. Semi-structured interviews and focus groups were conducted and audio-recorded. Following transcription, inductive thematic analysis was completed.ResultsParticipants identified that there are both patient-related and environmental factors that influence discharge-readiness. Patient-related factors discussed included continence, functional mobility, cognition, pain and medication management skills. Environmental factors centred around the discharge (home) environment, and were suggested to include a safe physical environment alongside a robust social environment which was suggested to assist to fill any gaps in functional capabilities (i.e. patient-related factors).ConclusionsThese findings make a unique contribution to the literature by providing a thorough exploration of determining discharge-readiness as a combined narrative from the perspectives from key stakeholders. Findings from this qualitative study identified key personal and environmental factors influencing patients’ discharge-readiness, which may allow health services to streamline the determination of discharge-readiness from subacute care. Understanding how these factors might be assessed within a discharge pathway warrants further attention.

Hemodialysis Program in a Subacute Care Facility for ESRD Patients With Tracheostomy

Hemodialysis Program in a Subacute Care Facility for ESRD Patients With Tracheostomy

Evaluation of the predictive validity of the Hessisch Oldendorf Risk of Falling Scale (HOSS)

Objective: This study aims to further validate the Hessisch Oldendorf Risk of Falling Scale (HOSS) for neurological rehabilitation patients. Design: The overall scale performance and fall rate was calculated in a retrospective data analysis. Setting: The study was performed in a subacute care facility during inpatient neurological rehabilitation. Subjects: The study population (n = 512) included neurological and neurosurgical patients with heterogeneous levels of disability. Main measures: The HOSS total score and the suspected risk of falling were compared with the number of falls. Characteristics of fallers and non-fallers were compared using non-parametric group comparisons. Overall scale performance was assessed by calculating the area under the receiver operating characteristic curve of the HOSS as well as by calculating the sensitivity and specificity. Results: A total of 82 (16%) patients experienced at least one fall. Fallers were characterized by an older age, a longer length of stay, a more severe impairment in the activities of daily living upon admission, a hemiparesis, an orientation disorder, a need of a walking aid device and an urinary incontinence. The number of falls was associated with the HOSS total score. Sixty-four fallers and two hundred seventy-four non-fallers were correctly categorized leading to a sensitivity of 78.0% and a specificity of 63.7%. The area under the receiver operating characteristic curve of the HOSS was 0.778 ± 0.25 (CI = 0.729–0.828, P < 0.001). Conclusion: The scale performance of the HOSS showed a good sensitivity and an adequate specificity to identify neurological patients who are at high risk of falling during inpatient rehabilitation.

Effectiveness of an infection prevention strategy to limit exposure of high-risk patients to COVID-19 in a hospital-based subacute unit: a descriptive report.

The coronavirus (COVID-19) epidemic has put unprecedented stress on hospitals as well as skilled nursing facilities, where reside some of the most vulnerable individuals at high risk of mortality and complications of this infection. This report highlights the strategy and success of hospital infection prevention efforts to protect the residents of an in-hospital subacute unit with 24 at-risk patients with chronic pulmonary disease in northern California. Specific efforts are detailed, with results of surveillance testing reported, including both viral PCR and serological IgG assays. Implications for other long-term subacute care facilities are discussed, as well as advantages and specific challenges for 'distinct part' versus 'free-standing' subacute care units.

Examining subacute nurses' roles in a changing healthcare context.

To explore and describe nurses' role in the rehabilitation and care of patients in one subacute care facility in Melbourne, Australia. The role of nurses in subacute care and within the rehabilitation team is evolving and remains unclear. Mixed methods. Fourteen nurses from seven rehabilitation and geriatric evaluation and management wards in one subacute facility in Melbourne, Australia, were observed in practice for two hours and then interviewed. Activities were recorded electronically. Interviews were audio-recorded and transcribed. Data were analysed using content analysis. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ). Three main themes are as follows: (a) Nurses as rehabilitators; (b) Teamwork in rehabilitation; and (c) The changing context of subacute care. Nurses prioritised patient personal and clinical care above other responsibilities. They were largely excluded from team decision-making because clinical responsibilities precluded them from attending team meetings. Unsuitable buildings, increased patient acuity and time constraints were further challenges. Nurses have a multifaceted role in patient rehabilitation that is poorly understood. An evaluation of the nursing role within the interdisciplinary team, skills and processes of care may increase understanding, and improve communication and relationships between disciplines potentially benefiting patients. Role clarity and differentiation in nursing skills are required within the nursing workforce. Nurses have a unique role in both clinical care and rehabilitation of patients, and as part of the interdisciplinary team. Respectful professional relationships need fostering within the interdisciplinary team to achieve optimal patient outcomes. The way that team meetings and decision-making occur in the subacute wards requires adjustment to ensure that the valuable contribution of nurses, both to the interdisciplinary team and to the rehabilitation of patients, is used and acknowledged to improve patient care.

SUBSTITUTE PRESCRIBING WITH ANTIPSYCHOTIC REDUCTION

Introduction The Center for Medicare and Medicaid Services (CMS) has called for a reduction in antipsychotic use in the geriatric population, in large part due to the association of these medications with increased mortality. Antipsychotics have significant side effect profiles, including QTc prolongation, weight gain, diabetes mellitus, hypercholesterolemia, and sedation, and may contribute to overall mortality in ways that are not completely understood. As long term care facilities work to decrease their antipsychotic prescribing rates in line with CMS recommendations, they must contend with the challenge of finding alternative treatments for episodes of acute agitation. This observational study aimed to describe the response to this challenge in a geriatric subacute care facility by examining the Medication Administration Record (MAR) to determine if prescribing rates of other medications commonly used to treat agitation increased when antipsychotics were no longer used for this purpose. Methods The study site was a university-affiliated geriatric care facility, which contains long term chronic hospital units, memory support units, and subacute rehabilitation units. Medications were prescribed by geriatric medicine attendings, nurse practitioners, and physician assistants on each unit, with input at times from consulting psychiatrists. Prescribers were employed as members of the facility's closed medical staff. Nursing and administrative staff were generally stable over the time period study. The total census at both sites ranged from 668-725 patients. Over the course of our study, we examined two long term care units at the facility The study units discontinued the use of prescribing antipsychotics on an as needed (PRN) basis and began an initiative modeled after “Appropriate Use of Antipsychotics,” based on the Canadian Foundation for Healthcare Improvement and Appropriate Use of Antipsychotics collaborative. This initiative included a series of interventions to reduce antipsychotic use overall, including staff education and training in specific behavioral interventions. We collected data on the rates of prescribing medications, including antipsychotics, benzodiazepines and trazodone at four time periods: at baseline, some months prior to the start of the initiative (Jan – March 2017), after PRN antipsychotics were discontinued immediately prior to the start of the initiative (July – Sept 2017), during the initiative (January – March 2018) and later after the start of the initiative in follow-up (July – Sept 2018). Six days during each time period (the 15th and last day of the month for each of the 3 months in the period) were selected during which data were collected from the MAR examining the number of medication administrations of each medication. Further analysis was performed looking specifically at the rates of benzodiazepine and trazodone administrations, since these were found to be commonly prescribed medications. Results Administrations of antipsychotics decreased (from 22.0% of the total number of patients at the facility receiving an antipsychotic at time 1 to 19.0% in time 3; to 16.7% at time 4). Concurrently, rates of trazodone prescription rose significantly both by average number of doses per day prescribed (see figure 1; ANOVA for differences between the four time periods F(3,20)=95.43, P Conclusions As rates of antipsychotic prescribing on the units decreased, we observed a phenomenon of substitute prescribing in the form of a significant increase in the amount of trazodone prescribed. At the same time, there was a slight decrease in the amount of benzodiazepines prescribed. Our findings suggest that trazodone was felt by prescribers to be a safer alternative to antipsychotics. The absence of a similar increase in benzodiazepine prescribing suggests that prescribers remained wary of this class of medication because of its longstanding association with adverse effects such as falls. These data also suggest that an ongoing focus on behavioral interventions for agitation in dementia is still needed in order to minimize the phenomenon of substituting one medication with side effects for another with a different set of side effects. Side effects of trazodone include oversedation (which leads to risks of falls), hypotension, QT prolongation, and cognitive effects. A strength of this study is our access to accurate, detailed prescribing data. An additional strength is that the study took place at a facility with stable nursing and medical staffs, thereby decreasing the possibility that staff changes acted as confounders. Limitations of our study include that our data was observational, did not differentiate between PRN doses of a medication and standing doses, did not investigate the symptoms for which each medication was prescribed, and did not compare the effectiveness or adverse effects of these prescriptions. Future research is needed to describe the clinical impact of the phenomenon of medication substitution as antipsychotic prescribing continues to be reduced. This research was funded by: This study took place at Hebrew Rehabilitation Center/Hebrew SeniorLife and was supported by the Canadian Foundation for Healthcare Improvement, a not-for-profit organization funded by Health Canada.

Discharge Delays and Costs Associated With Outpatient Parenteral Antimicrobial Therapy for High-Priced Antibiotics.

Outpatient parenteral antimicrobial therapy (OPAT) is a widely used, safe, and cost-effective treatment. Most public and private insurance providers require prior authorization (PA) for OPAT, yet the impact of the inpatient PA process is not known. Our aim was to characterize discharge barriers and PA delays associated with high-priced OPAT antibiotics. This was an institutional review board-approved study of adult patients discharged with daptomycin, ceftaroline, ertapenem, and novel beta-lactam-beta-lactamase inhibitor combinations from January 2017 to December 2017. Patients with an OPAT PA delay were compared with patients without a delay. The primary endpoint was total direct hospital costs from the start of treatment. Two-hundred patients were included: 141 (71%) no OPAT delay vs 59 (30%) OPAT delay. More patients with a PA delay were discharged to a subacute care facility compared with an outpatient setting: 37 (63%) vs 52 (37%), P = .001. Discharge delays and median total direct hospital costs were higher for patients with OPAT delays: 31 (53%) vs 21 (15%), P < .001 and $19 576 (interquartile range [IQR], 10 056-37 038) vs $7770 (IQR, 3031-13 974), P < .001. In multiple variable regression, discharge to a subacute care facility was associated with an increased odds of discharge delay, age >64 years was associated with a decreased odds of discharge delay. OPAT with high-priced antibiotics requires significant care coordination. PA delays are common and contribute to discharge delays. OPAT transitions of care represent an opportunity to improve patient care and address access barriers.

Rotavirus Vaccination Coverage During a Rotavirus Outbreak Resulting in a Fatality at a Subacute Care Facility.

The introduction of rotavirus vaccine in the United States has reduced rotavirus disease burden, but outbreaks still occur. Complete-series rotavirus vaccination coverage is <75% in the United States, and it might be lower among vulnerable populations. We describe here the clinical characteristics and vaccination status of children during a rotavirus outbreak in a pediatric subacute care facility in 2017. Clinical history, signs and symptoms, and vaccination history were abstracted for the 26 patients residing in the facility during the time of the outbreak. A case-patient was defined as one who experienced 3 or more loose stools in a period of 24 hours with onset between April 17 and May 17, 2017. Stool samples from 14 resident patients were tested for rotavirus with reverse-transcription polymerase chain reaction. The median patient age at the facility was 2.9 years. Of the 26 resident patients, 22 (85%) met the case definition. One child died. Stool samples from 11 case-patients were positive according to reverse-transcription polymerase chain reaction for rotavirus. Fifteen case-patients were unvaccinated against rotavirus; 3 were partially vaccinated, and 2 were fully vaccinated. Vaccination status could not be completely determined in 2 cases. An outbreak of rotavirus affected nearly all resident patients of a subacute care facility and caused 1 death. Because of recommendations against giving rotavirus vaccine in an intensive care setting, infants who require a prolonged intensive care stay might age out of rotavirus vaccine eligibility (the first dose must be given before 15 weeks of age according to Advisory Committee on Immunization Practices recommendations). The result is a vulnerable population of unvaccinated infants who might later congregate in another care setting.

Initial Assessment of the Risk Assessment and Prediction Tool in a Heterogeneous Neurosurgical Patient Population.

Bundled care payments are increasingly being explored for neurosurgical interventions. In this setting, skilled nursing facility (SNF) is less desirable from a cost perspective than discharge to home, underscoring the need for better preoperative prediction of postoperative disposition. To assess the capability of the Risk Assessment and Prediction Tool (RAPT) and other preoperative variables to determine expected disposition prior to surgery in a heterogeneous neurosurgical cohort, through observational study. Patients aged 50 yr or more undergoing elective neurosurgery were enrolled from June 2016 to February 2017 (n=623). Logistic regression was used to identify preoperative characteristics predictive of discharge disposition. Results from multivariate analysis were used to create novel grading scales for the prediction of discharge disposition that were subsequently compared to the RAPT Score using Receiver Operating Characteristic analysis. Higher RAPT Score significantly predicted home disposition (P<.001). Age 65 and greater, dichotomized RAPT walk score, and spinal surgery below L2 were independent predictors of SNF discharge in multivariate analysis. A grading scale utilizing these variables had superior discriminatory power between SNF and home/rehab discharge when compared with RAPT score alone (P=.004). Our analysis identified age, lower lumbar/lumbosacral surgery, and RAPT walk score as independent predictors of discharge to SNF, and demonstrated superior predictive power compared with the total RAPT Score when combined in a novel grading scale. These tools may identify patients who may benefit from expedited discharge to subacute care facilities and decrease inpatient hospital resource utilization following surgery.

The perspective of allied health staff on the role of nurses in subacute care.

To explore allied health staff perceptions on the role of nurses in subacute care wards. A consequence of earlier discharge from acute hospitals is higher acuity of patients in subacute care. The impact on nurses' roles and required skill mix remains unknown. In the same way, nurses' integration into the rehabilitation team is ambiguous. Descriptive qualitative inquiry. Semistructured interviews conducted with 14 allied health staff from one subacute care facility in Melbourne, Australia. Interviews were audio-recorded and transcribed verbatim. Analysis using the framework approach. Three main themes were evident: (a) the changing context of care: patient acuity, rapid patient discharge and out-dated buildings influenced care; (b) generalist as opposed to specialist rehabilitation nurses: a divide between traditional nursing roles of clinical and personal care and a specialist rehabilitation role; and (c) interdisciplinary relations and communication demonstrated lack of respect for nurses and integrating holistic care into everyday routines. Allied health staff had limited understanding of nurses' role in subacute care, and expectations varied. Power relationships appeared to hamper teamwork. Failure to include nurses in team discussions and decision-making could hinder patient outcomes. Progressing patients to levels of independence involves both integrating rehabilitation into activities of daily living with nurses and therapy-based sessions. Promotion of the incorporation of nursing input into patient rehabilitation is needed with both nurses and allied health staff. Lack of understanding of the nurses' role contributes to lack of respect for the nursing contribution to rehabilitation. Nurses have a key role in rehabilitation sometimes impeded by poor teamwork with allied health staff. Processes in subacute care wards need examination to facilitate more effective team practices inclusive of nurses. Progressing patients' independence in rehabilitation units involves activities of daily living with nurses as much as therapy-based sessions.

Hospital discharge documentation of a designated clinician for follow-up care and 30-day outcomes in hip fracture and stroke patients discharged to sub-acute care

BackgroundTransitions to sub-acute care are regularly complicated by inadequate discharge communication, which is exacerbated by a lack of clarity regarding accountability for important follow-up care. Patients discharged to sub-acute care often have complex medical conditions and are at heightened risk for poor post-hospital outcomes, yet many do not see a provider until 30 days post discharge due to current standards in Medicare regulations. Lack of designation of a responsible clinician or clinic for follow-up care may adversely impact patient outcomes, but the magnitude of this potential impact has not been previously studied.MethodsWe examined the association of designating a responsible clinician/clinic for post-hospital follow-up care within the hospital discharge summary on risk for 30-day rehospitalization and/or death in stroke and hip fracture patients discharged to sub-acute care. This retrospective cohort study used Medicare Claims and Electronic Health Record data to identify non-hospice Medicare beneficiaries with primary discharge diagnoses of stroke/ or hip fracture discharged from one of two urban hospitals to sub-acute care facilities during 2003–2008 (N = 1130). We evaluated the association of omission of the designation of a responsible clinician/clinic for follow-up care in the hospital discharge summary on the composite outcome of 30-day rehospitalization and/or death after adjusting for patient characteristics and utilization. We used multivariate logistic regression robust estimates clustered by discharging hospital.ResultsPatients whose discharge summaries omitted designation of a responsible clinician/clinic for follow-up care were significantly more likely to experience 30-day rehospitalization and/or death (OR: 1.51, 95% CI 1.07–2.12, P = 0.014).ConclusionsThe current study found a strong relationship between the omission of a responsible clinician/clinic for follow-up care from the hospital discharge summary and the poor outcomes for patients transferred to sub-acute care. More research is needed to understand the role and impact of designating accountability for follow-up care needs on patient outcomes.

Flooded with evidence: using a 'spillway' model to improve research implementation in nursing practice

Objective: To identify barriers to implementing evidence-based practice initiatives in small to medium sub-acute facilities in Queensland. Design: The study uses a qualitative methodology in which field observations and convergent interviews were employed to generate data. Setting: Four south-east Queensland sub-acute care facilities participated in the study. Observational and interview data were collected. Subjects: Field observations were recorded across the sites. Five research fellows collected observational data on evidencebased practice implementation across a period of six months. Nine clinicians participated in in-depth, convergent interviews at the end of the period of observation. Main outcome measures: The authors analysed observational and interview data using qualitative thematic analysis. Results: Three themes emerged which described the needs of clinicians when evidence-based practice initiatives were being implemented: (1) valuing evidence; (2) risk prioritisation; and (3) controlling the flow of evidence. A ‘Spillway Model’ is proposed as a mechanism for targeting clinical priorities using integrated risk management. Conclusion: This study supports the use of integrated risk management as part of a Spillway Model to guide the introduction of evidence-based practice initiatives in the clinical setting.

Mealtime interruptions, assistance and nutritional intake in subacute care

Protected mealtimes is an initiative to support increased nutritional intake for all hospitalised patients, particularly those who are malnourished. The increased focus on maximising independence of patients in the subacute setting may provide a supportive environment for implementing these strategies. The aim of the present study was to gain insight into subacute ward practices at mealtimes under usual conditions (i.e. at baseline) where no protected mealtimes policy was implemented. Participants were patients aged ≥65 years recruited from subacute care facilities at a large healthcare network in Victoria, Australia. Participants were observed at mealtimes and mid meals (i.e. morning tea, afternoon tea and supper) to determine daily energy and protein intake, provision of mealtime assistance and mealtime interruptions. Almost all participants received assistance when it was needed, with positive and negative interruptions experienced by 56.2% and 76.2% of participants, respectively. There was an energy deficit of approximately 2 MJ per day between average intake and estimated requirements. In conclusion, mealtime practices were suboptimal, with particularly high rates of negative interruptions. Protected mealtimes is one strategy that may improve the mealtime environment to support patients' dietary intake. Prospective studies are needed to evaluate its implementation and effects.

Omission of Physical Therapy Recommendations for High-Risk Patients Transitioning From the Hospital to Subacute Care Facilities

ObjectivesTo assess the quality and explore the potential impact of the communication of physical therapy (PT) recommendations in hospital discharge summaries/orders for high-risk subacute care populations, specifically targeting recommendations for (1) maintenance of patient safety, (2) assistance required for mobility, and (3) use of assistive devices. DesignMedical record abstraction of retrospective cohort comparing discharge recommendations made by inpatient PT to orders included in written hospital discharge summaries/orders, the primary form of hospital-to-subacute care communication. Data were linked to Medicare outcomes from corresponding years for all Medicare beneficiaries in the cohort. SettingAcademic hospital. ParticipantsAll hospitalized patients (N=613 overall) 18 years and older with primary diagnoses of stroke or hip fracture, with an inpatient PT consultation and discharged to subacute care during the years 2006 to 2008; 366 of these were Medicare beneficiaries. InterventionsNot applicable. Main Outcome MeasuresCombined rehospitalization, emergency department visit, and/or death within 30 days of discharge. ResultsOmission of recommendations for maintaining patient safety occurred in 54% (316/584) of patients; for assistance required for mobility, in approximately 100% (535/537); and for use of assistive devices, in 77% (409/532). As compared with those without patient safety restriction/precaution omissions, Medicare beneficiaries with such omissions demonstrated a trend toward more negative 30-day outcomes (26% vs 18%, P=.10). Similar, albeit nonsignificant, outcome trends were observed in the other omission categories. ConclusionsPT recommendations made during a hospital stay in high-risk patients are routinely omitted from hospital discharge communications to subacute care facilities. Interventions to reliably improve this communication are needed.

Incorporating ADA Best Practice Guidelines in Electronic Medical Records to Improve Glycemic Management in Health Care Facilities

Aggressive management of diabetes using American Diabetes Association (ADA) best practice guidelines in hospitalized patients reduces morbidity and mortality. Inpatient electronic medical records systems improve care in chronic diseases by identifying care needs and improving the data available for decision making and disease management. The purpose of this quality improvement project was to evaluate the impact of ADA best practice guidelines of glycemic management once they have been entered into the electronic medical record (EMR) of hospitalized diabetics. Kotter’s organizational change process guided the project. The project question investigated whether nurses’ use of ADA Best Practice Guidelines incorporated into the EMR improves glycemic management in hospitalized patients. A quality improvement project pretestposttest design evaluated the intervention to assess whether the program goals were met. A convenience sample of 8 nurses practicing in a subacute health care facility participated in the program with data obtained from a convenience sampling of diabetic patients admitted to the facility (n=50). A1C, diabetes types, and hypo/hyperglycemic treatment event data were compared 30 days pre- and post-intervention. Outcome data calculated using descriptive statistics revealed improved documentation for A1C results (4% to 96%), the different types of diabetes (from 100% documented as Type 1 to 28 % documented as Type2) and increased corrective measures for abnormal glycemic events (increased 16% to 44%). EMR alerts and reminders provided timely information to health care practitioners, resulting in better management for the diabetic patient, thus affecting social change of diabetes care.

Bundled approaches for surgical site infection prevention: the continuing quest to get to zero.

Although awell-timed operation can enhance both duration andqualityof life, postoperative complications, including surgical site infections (SSIs), can offset some of the benefits of the operation. In addition to functional loss and mortality, SSIs are associated with increased length of stay and higher health care costs.1,2 SSIs are the most common reason for readmission after surgery,3 accounting for nearly 20% of unplanned readmissions.Among infectingorganisms,Staphylococcusaureusconsistently ranksas themostprevalentpathogen associatedwith SSIs, particularly after cardiac and orthopedicprocedures.4SaureusSSIs canbedevastating, especially when a prosthetic device is involved. Although the results vary, several prior investigations suggest that perioperative use of topical mupirocin along with chlorhexidine gluconate bathing amongpatients known tobe colonized with methicillin-susceptible S aureus (MSSA) or methicillin-resistant S aureus (MRSA) may reduce the risk of SSIs.5,6 The evidence for benefit ismost robust for cardiac and orthopedic procedures.7 Yet decolonization protocols are not consistently applied in US hospitals.8 In this issueof JAMA, Schweizerandcolleagues9 report the results of the Study to Optimally Prevent SSIs in Select Cardiac and Orthopedic Procedures (STOP-SSI), a multicenter, pragmatic study that examined the implementation of a bundled intervention of screening, decolonization, and targeted antimicrobial prophylaxis to prevent complex S aureus SSIs (deep incisional or organ space infections) among patients undergoing cardiac surgery andhip or knee arthroplasties. The specific interventions were simple and included screening and then decolonizing individuals who were positive for either MSSA orMRSA using intranasal mupirocin and chlorhexidine bathing, both for 5 days. In addition, the standardsurgicalprophylaxis regimenwasmodifiedto includevancomycin (along with the usual firstor second-generation β-lactam) for individuals known to be colonized with MRSA. The study took place in 20 hospitals across the United States and included 42 534 unique operations, consisting of 10 833 cardiac procedures and 31 701 hip or knee arthroplasties. Use of the bundlewas associatedwith adecrease in complex S aureus SSIs. Overall, 101 complex S aureus SSIs occurred after 28 218 operations during the preintervention period compared with 29 SSIs after 14 316 operations during the intervention; mean SSI rate per 10 000 operations decreased from36 for thepreinterventionperiod to 21 for the intervention period; rate ratio (RR), 0.58 (95% CI, 0.37-0.92). Although the absolute difference of 15 infections per 10 000 operations seemsmodest, eachcomplexSSIprevented is clinically meaningful. For the individual patient, development of a serious SSI after cardiac or orthopedic surgeryusually translates into months of parenteral antibiotics, additional surgical procedures, and extended inpatient and subacute care facility stays. The lengthy recovery can negate any benefit provided by the original operation. In a substantial portion, S aureus SSI will contribute to death.10,11 Given the considerable clinical and economic consequences of SSIs, some have suggested that the goal for the US health care system is zero tolerance of adverse events.12 The study by Schweizer et al has a number of notable strengths. For example, the inclusion of patients undergoing emergency or urgent operations, a population recognized as at high risk for SSI, improves the generalizability of the findings. In addition, the primary study outcome was limited to complex S aureus SSIs, eliminating much of the subjectivity of infection surveillance. Even though surveillance practices variedamongparticipatinghospitals, complicatedSaureusSSIs arenot clinically subtle andcanbe identifiedeasily byany surveillance system. The pragmatic nature of this investigation is reflected in reported bundle compliance; even after a 3-month phase-in period,bundleadherencewas83%,withonly39%implementing all components of the bundled intervention (fully adherent). The authors observed a “dose-response” association for bundle adherence; rates of complex SSIs decreased significantly among patients in the fully adherent group (RR, 0.26 [95% CI, 0.10-0.69]) but not in the partially adherent or nonadherent groups. Although a matter of speculation, improved adherence to thebundlemayproducebetter results in other settings,particularly if baseline infection rates arehigher than those reported in this study. Moving forward, efforts to promote andmaintain adherence topreventionprotocolswill remain important. Leveraging the potential of the electronic medical record through the use of automated reminders and checklists is one approach. Adherence rateswere particularly low in urgent and emergency operations in which nearly half of surgeons and sites were not adherent. Given the experience reportedbySchweizer et al, universal decolonizationand routine use of vancomycin may be a suitable alternative for urgent operations. The authors tested 36 infecting isolates for evidence of high-level resistance to mupirocin or chlorhexidine gluconate; 1 isolate demonstrated high-level mupirocin resistance, and none carried qac genes. Although these results are Related article page 2162 Opinion

Multisite analysis of the timing and outcomes of unplanned transfers from subacute to acute care.

The aim of the present study was to examine the timing and outcomes of patients requiring an unplanned transfer from subacute to acute care. Subacute care in-patients requiring unplanned transfer to an acute care facility within four Victorian health services from 1 January to 31 December 2010 were included in the study. Data were collected using retrospective audit. The primary outcome was transfer within 24 h of subacute care admission. In all, 431 patients (median age 81 years) had unplanned transfers; of these, 37.8% had a limitation of medical treatment (LOMT) order. The median subacute care length of stay was 43 h: 29.0% of patients were transferred within 24 h and 83.5% were transferred within 72 h of subacute care admission. Predictors of transfer within 24 h were comorbidity weighting (odds ratio (OR) 1.1, P = 0.02) and LOMT order (OR 2.1, P < 0.01). Hospital admission occurred in 87.2% of patients and 15.4% died in hospital. Predictors of in-hospital mortality were comorbidity weighting (OR 1.2, P < 0.01) and the number of physiological abnormalities in the 24 h preceding transfer (OR 1.3, P < 0.01). There is a high rate of unplanned transfers to acute care within 24h of admission to subacute care. Unplanned transfers are associated with high hospital admission and in-hospital mortality rates.

Geriatric small bowel obstruction: an analysis of treatment and outcomes compared with a younger cohort

BackgroundSmall bowel obstruction (SBO) is a common condition, but little is known about its presentation, management, and outcomes in geriatric patients. MethodsA retrospective review was performed comparing geriatric (≥65 years of age) and nongeriatric patients admitted with SBO. Admission characteristics, treatment, and outcomes were compared. Data analysis included Student t test and chi-square test or Fisher’s exact test. ResultsAmong 80 geriatric and 136 nongeriatric patients, no difference was observed among admission characteristics, treatment, time to or type of surgery, length of postoperative stay, or overall complications. Cardiac complications (15% vs 0%, P = .0082) and subacute care facility discharge (29% vs 5%, P < .001) were more common for geriatric patients. ConclusionsCompared with younger adults, elderly patients with SBO have similar presentations and overall outcomes with the exception of cardiac morbidity and discharge disposition. Preoperative attention to cardiac risk profile and discharge disposition discussion should be encouraged.

Hospital readmission in children with complex chronic conditions discharged from subacute care.

Children with complex chronic conditions (CCC) are responsible for a disproportionate number of hospital readmissions. This study sought to determine 30-day hospital readmission rates in children with CCC discharged from a rehabilitation and transitional care hospital and to identify factors associated with increased risk of readmission. We conducted a retrospective cohort study identifying children with CCC discharged over an 18-month period from a subacute care facility staffed by hospitalists from a freestanding children's hospital. The primary outcome measure was readmission to the referring acute care hospital within 30 days of the subacute discharge. Of the 272 discharged patients meeting inclusion criteria as children with at least 1 CCC, 19% had at least 1 readmission within 30 days of discharge. On univariate analysis, readmission was associated with the number of home medications (P = .001), underlying chronic respiratory illness (P < .001), home apnea or pulse oximetry monitor use (P = .02), tracheostomy and/or ventilator dependence (P = .003), length of stay (P = .04), and number of follow-up appointments (P = .02). On multivariate analysis, the number of discharge medications was associated with increased odds of readmission (odds ratio: 1.11 [95% confidence interval: 1.03-1.20]; P = .01). Receiver operating curve analysis identified a cutoff of 8 medications as most associated with readmission; in patients discharged with ≥8 medications, the hospital readmission rate was 29%. This is the first known study that investigated hospital readmission rates in children with CCC discharged from a subacute facility and specifically identified the number of discharge medications as a significant risk factor for readmission.