Subacute Care Wards Research Articles

P086 Measurement of Environmental Factors affecting Sleep within Rehabilitation Wards, Sub-acute Care Wards, and Aged Care Facilities: A Scoping Review

Abstract Introduction Unfamiliar environments are often poorly conducive to adequate sleep, especially for patients within different care settings, where proper sleep is vital for recovery and overall health. This scoping review thus aims to synthesise the evidence around which aspects of the sleep environment are measured within rehabilitation, sub-acute and aged care settings, how they are being measured, and to identify if there are any ‘gold standards’ against which the environmental factor measurements are compared. Method A search was conducted from inception to May 2023 within PubMed, EMBASE, Cochrane Library, Cumulated Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and Web of Science. Eligibility criteria included full length original studies of any design reporting on the measurement properties of environmental factors affecting sleep of adult patients admitted to rehabilitation/sub-acute wards and aged care facilities. Results This scoping review identified 2185 studies after duplicate removal, of which 82 studies have been admitted for data extraction following review from two authors. Data will be sought for the following variables: publication year, country, study aim, study design, care setting, population characteristics, environmental factors studied, unit of measurement, specific measure, measurement method, gold standard comparators (if any). Discussion It is anticipated that this review will be completed by August 2023 and will identify the most common methods used to measure environmental factors affecting sleep outcomes within the literature. This study will thereby inform and aid researchers and clinicians with developing future environmental interventions and measuring their impact within rehabilitation, subacute and aged care settings.

Meals beyond the bedside: An ethnographic exploration of staffs' perspectives and experiences of communal dining in subacute care.

Communal dining offers multiple benefits for hospital patients, yet dining rooms may be underutilized in practice. This study aimed to understand and explore staffs' perspectives and experiences of communal dining in subacute care, and the impacts on staff mealtime practice. Using qualitative, ethnographic methodology, 94 hours of fieldwork were conducted across two subacute care wards. Participants were staff involved in nutrition care or present on the ward at mealtimes. Ninety-one semistructured and ethnographic interviews were conducted with 59 staff, and 54 episodes of observation captured more than 190 staff. Interviews and field notes were thematically analyzed using an inductive approach. Three themes were identified: (i) benefits to patients; (ii) logistical and practical challenges; and (iii) supportive cultural factors. While staff recognized how communal dining benefited patients, logistical and practical challenges impacted their ability to facilitate it in practice. Healthcare organizations seeking to embed communal dining into the mealtime routine should recognize that clear delineation of staff roles and responsibilities, and cultural change involving normalization, setting expectations, and collective advocacy may be needed to optimize benefits for patients.

Direct Admission from the Emergency Department to a Subacute Care Ward: An Alternative to Acute Hospitalization

In recent years, subacute care units (SCUs) have emerged as alternatives to acute hospitalization for selected emergency department (ED) patients who might benefit from a short period of inpatient stay within a less acute setting. We developed a new protocol to directly admit selected older patients from our acute hospital's (AH) ED to the SCU of a partner community hospital, making use of our ED's short-stay ward as a transit area to overcome administrative, financial, and clinical barriers. The new protocol has removed the need for intervening stays of longer than 24 hours at our AH, reduced overall length of stay across both institutions, decreased hospital admissions, and reduced the number of patient hand-offs.

A Framework for Supporting Post-acute Care Transitions of Older Patients With Hip Fracture

ObjectiveImproving care transitions is of critical importance for older patients, especially those with complex care needs. Our study examined the “Transitions of Care” (ToC) of complex, post-acute older adults at multiple time points. The objective of this article is to identify domains relevant to health care transitions of post-acute older patients with hip fracture so as to inform future ToC interventions. DesignHere we conducted a framework-based synthesis of the 12 peer-reviewed manuscripts that were published from our multisite, ethnographic study. Setting and participantsAll 12 manuscripts were based on 1 study, described here. Data were collected in multiple regions, in acute and sub-acute care wards, rehabilitation programs, home care agencies, long-term care and assisted living facilities, and patients' private homes. We completed 51 interviews with 23 postoperative hip fracture patients aged ≥65 years, 24 interviews with 19 family caregivers, and 96 interviews with 92 health care providers. Interviews with patients, family caregivers, and health care providers were conducted at each transition point for a total of 171 individual interviews. ResultsTaken together, our framework analysis of the 12 manuscripts identified 8 themes related to ToC. Two themes, patient complexity and system constraints, are contextual factors that tend to impede ToC and may be less amenable to change. The remaining 6 themes, patient involvement and choice, family caregiver roles, strong relationships, coordination of roles, documentation, and information sharing, have the potential to support and improve ToC. Conclusions and implicationsWith comprehensive data from a range of stakeholders, collected at multiple transition points along the health care continuum, in our final 6 themes we identify potential points of intervention for clinicians and teams seeking to improve ToC for older complex patients.

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.

Characteristics and outcomes of emergency interhospital transfers from subacute to acute care for clinical deterioration

To describe characteristics and outcomes of emergency interhospital transfers from subacute to acute hospital care and develop an internally validated predictive model to identify features associated with high risk of emergency interhospital transfer. Prospective case-time-control study. Acute and subacute healthcare facilities from five health services in Victoria, Australia. Cases were patients with an emergency interhospital transfer from subacute to acute hospital care. For every case, two inpatients from the same subacute care ward on the same day of emergency transfer were randomly selected as controls. Admission episode was the unit of measurement and data were collected prospectively. Patient and admission characteristics, transfer characteristics and outcomes (cases), serious adverse events and mortality. Data were collected for 603 transfers in 557 patients and 1160 control patients. Cases were significantly more likely to be male, born in a non-English speaking country, have lower functional independence, more frequent vital sign assessments and experience a serious adverse event during first acute care or subacute care admissions. When adjusted for health service, cases had significantly higher inpatient mortality, were more likely to have unplanned intensive care unit admissions and rapid response team calls during their entire hospital admission. Patients who require an emergency interhospital transfer from subacute to acute hospital care have hospital admission rates and in-hospital mortality. Clinical instability during the first acute care admission (serious adverse events or increased surveillance) may prompt reassessment of patient suitability for movement to a separate subacute care hospital.

How does nutritional state change during a subacute admission? Findings and implications for practice.

Nutritional status influences patients' clinical and functional outcomes. The aims were to identify changes in nutritional state during subacute care and associated participant characteristics. A longitudinal study was undertaken with consecutive patients admitted to subacute care wards during a 3-month period. Participants were recruited under a waiver of consent to reflect the usual demographic. Change in classification (malnourished, at risk of malnutrition, well nourished) of the full Mini Nutritional Assessment (full MNA) between admission and discharge was the primary outcome. Weight (kg), mid-arm and calf circumference (cm) change were secondary outcomes. Hand grip strength (kg) and fat-free mass (kg) (assessed using bioelectrical impedance analysis) were measured for a consenting subgroup. Participants (n=248, 36.7% male) had a median age of 80 years and a length of stay of 17 days. On admission, 29.1% were classified as malnourished. By discharge, nutritional classification remained stable for 62.0% of participants (n=132), declined for 10.3% (n=22) and improved for 27.7% (n=59, including 52.5% malnourished on admission). Impaired cognition (odds ratio (OR)=0.169, P=0.002) and higher full MNA score at admission (OR=0.870, P=0.001) reduced odds of improvement in full MNA. There was no change in hand grip strength (n=46), but there was a decline in mean fat-free mass (-1.1 kg, 95% confidence interval: -0.1 to -2.2 kg, P=0.043, n=24). Multidisciplinary care supports the nutritional state of most patients admitted to subacute care. Those with cognitive impairments or at risk of malnutrition were less likely to demonstrate improvement and may benefit from more intensive or tailored nutritional care.

A novel organizational model to face the challenge of multimorbid elderly patients in an internal medicine setting: a case study from Parma Hospital, Italy.

Continuous increase of elderly patients with multimorbidity and Emergency Department (ED) overcrowding are great challenges for modern medicine. Traditional hospital organizations are often too rigid to solve them without consistently rising healthcare costs. In this paper we present a new organizational model achieved at Internal Medicine and Critical Subacute Care Unit of Parma University Hospital, Italy, a 106-bed internal medicine area organized by intensity of care and specifically dedicated to such patients. The unit is partitioned into smaller wards, each with a specific intensity level of care, including a rapid-turnover ward (mean length of stay <4days) admitting acutely ill patients from the ED, a subacute care ward for chronic critically ill subjects and a nurse-managed ward for stable patients who have socio-economic trouble preventing discharge. A very-rapid-turnover ("come'n'go") ward has also been instituted to manage sudden ED overflows. Continuity, effectiveness, safety and appropriateness of care are guaranteed by an innovative figure called "flow manager," with skilled clinical experience and managerial attitude, and by elaboration of an early personalized discharge plan anticipating every patient's needs according to lean methodology principles. In 2012-2014, this organizational model, compared with other peer units of the hospital and of other teaching hospitals of the region, showed a better performance, efficacy and effectiveness indexes calculated on Regional Hospital Discharge Records database system, allowing a capacity to face a massive (+22%) rise in medical admissions from the ED. Further studies are needed to validate this model from a patient outcome point of view.