Transitional Care Facility Research Articles

Single versus dual fixation of distal femur fractures: A retrospective cohort study at a level one trauma centre in New Zealand

Background The study compares single versus combination fixation of distal femur fractures. Method We retrospectively reviewed patients over 60 between January 2016 and December 2022. Union rate, ambulatory status and complication rate were primary outcomes. Secondary outcomes included quality of reduction, operative time and rate of blood transfusion. Results A total of 92 patients received single fixation, and 22 patients received combination fixation. There was no difference in rate or time of fracture union. Patients with dual fixation were allowed to weight bear on discharge significantly more than single fixation patients (50% vs. 18.9%, p = 0.003). Intramedullary nail fixation, as a single method or combined with lateral plating, was associated with earlier weight bearing. Immediate post-operative weight bearing significantly increased the likelihood of discharging to home or rehabilitation versus discharging to a transitional care facility ( p < 0.00001). There was no difference in the rate of blood transfusion, complication or mortality. Medial translation of the distal articular block was significantly lower with dual fixation (1.2% vs. 3.4%, p = 0.021). Operation time was longer with combination fixation (183 min vs. 134 min p < 0.001). Conclusion Combination fixation allows earlier weight bearing, at the cost of longer operation time.

A regional learning health system of congregate care facilities for COVID-19 response.

The COVID-19 pandemic disproportionately affected congregate care (CC) facilities due to communal living, presence of vulnerable populations, inadequate preventive resources, and limited ability to respond to the pandemic's rapidly evolving phases. Most facilities function independently and are not organized for collaborative learning and operations. We formed a learning health system of CC facilities in our 14-county metropolitan region, coordinated with public health and health care sectors, to address challenges driven by COVID-19. A CC steering committee (SC) was formed that represented diverse institutions and viewpoints, including skilled nursing facilities, transitional care facilities, residential facilities, prisons, and shelters. The SC met regularly and was guided by situational awareness and systems thinking. A regional CC COVID-19 dashboard was developed based on publicly available data and weekly data submitted by participating facilities. Those experiencing outbreaks or supply shortages were quickly identified. As the pandemic progressed, the role of the SC shifted to address new and forecasted needs. Over 60 facilities participated in data sharing. The SC shared new guidelines, regulations, educational material, and best practices with the participating facilities. Information about testing sites, supplies, vaccination rollout, and facilities that had the capacity to accept COVID-19 patients was regularly disseminated. The SC was able to direct resources to those facilities experiencing outbreaks or supply shortages. A novel learning health system of regional CC facilities enabled preparedness, situational awareness, collaboration, and rapid dissemination of best practices across pandemic phases. Such collaborative efforts can play an important role in addressing other public and preventive health challenges.

Pilot Study on SAFE Score - A Novel Quantitative Metric for Evaluation of Patient Well-being in Crawfurd Hospital Transitional Care Facility (CFH TCF).

Crawfurd Hospital (CFH) set up a Transitional Care Facility (TCF) in November 2022 as an interim holding facility for medically stable patients awaiting a long-term discharge disposition. The team invented the SAFE score, to monitor 4 main domains commonly impacted in long-term stays - namely Skin, Action (Behaviour), Function and Emotion. A sample size of 50 patients met the inclusion criteria and were scored by the nurses on day 7, day 14, and monthly thereafter during their TCF stay, and once more within 72 h prior to their discharge. There was no significant improvement or worsening noted across all 4 domains in this pilot study, suggesting that the TCF has achieved its goal of maintaining its patients in all these domains. The scores at the various time points were also useful for the team to immediately identify changes in individual patient scores and act on these findings to ensure optimal patient care. Through this pilot study, we identified further minor improvements which can be made to the and the score, and such a scoring system may further be applicable to various intermediate to long-term care homes to oversee these domains of care.

Interprofessional Collaboration to Support Person-centered Care: Implementation of an Integrated Surgical Pathway for Complex Foot and Ankle Patients

Introduction: Traditionally foot and ankle patients have high medical and social complexities that require additional support and care navigation following surgery to improve transitions out of hospital into the community for recovery at home. We explored implementation of an integrated surgical pathway that included an interprofessional, centralized intake model for surgical consult, pre-operative mobility assessment to assess post-operative supports and potential barriers to successful discharge home, and creation of a partnership with transitional care, while providing person-centered care to improve patient experience and surgical recovery. 
 Aims, Objectives and Methodology: Our objective was to develop and implement an integrated surgical pathway for complex foot and ankle patients to support seamless transitions in care from acute to recovery at home following surgery. 
 A working group was formed with members spanning operational and clinical roles across the care continuum including: physiotherapist practitioner, surgeon administrative support, clinical managers, inpatient physiotherapists, social work, nurse practitioners and transitional care program managers. A 2-hour process mapping session was conducted outlining the current state surgical pathway and potential barriers to successful discharge were identified. Standard care path guidelines were developed with decision tree clinical resources to assist the care team in facilitating referrals to transitional care pre-operatively to ensure seamless transition for the patient after surgery. 
 Highlights and Key Findings: The patient population supported by this integrated pathway were those with complex foot and ankle surgical procedures including: ankle and midfoot fusion, ligament reconstruction, ankle osteotomy, total ankle replacement and triple arthrodesis. Fairly equal distribution was seen between male and female (48% and 52% respectively), and the average age was 54 years. The addition of an interprofessional consult offered more robust patient education, pre and post surgical planning and expectation setting. A pre-op mobility assessment optimized post-operative care coordination. This was illustrated by a reduction in the acute length of stay from an average of 8.2 days in 19/20 to 3.4 days in 20/21. From 2018 to 2022 the discharge disposition of this patient cohort remained consistent with the majority of patients (66%) supported to return home with outpatient physiotherapy, 24% of patients were discharged home with homecare services coordinated and a small proportion (<10%) were transferred to a transitional care, inpatient or residential care facility. Qualitative report from patient's revealed that supports provided eased anxiety and improved post-operative transitions home for recovery.
 Conclusions: Implementation of an integrated surgical pathway for complex foot and ankle patients that maximize pre-operative care planning and leveraging existing community partnerships, both in-home and institutional; enable the delivery of person-centred care, facilitating seamless transitions from acute care to community for patients while optimizing hospital resource utilization.
 Implications for applicability/transferability, sustainability and limitations: Expansion of collaborative integrated models that support additional orthopedic surgical patient populations from hospital to recovery within the community are critical in providing person-centered care. Sustainability of these models will rely on securing the resources required for pre-surgical patient education, expectation setting and care and resource planning for seamless post-operative transitions. 

Hospital discharge for stroke patients: Transitional Care is Brain

Abstract Background Among cerebrovascular disease, stroke is a life-threatening neurological event and a main cause of serious long-term disability, with relevant healthcare and economic burden. Treatment of stroke is time dependent and organised integrated stroke care enables quick and effective responses to reduce stroke-related death and disability. This study aimed at evaluating the amount of hospital discharge to transitional care facilities for stroke patients to support integrated care models in the city of Pavia (Italy). Methods In 2017 in Pavia, Fondazione IRCCS Policlinico San Matteo started a partnership with Fondazione Mondino to build a specific stroke pathway, becoming a leading centre for stroke treatment. We conducted a retrospective chart review (RCR) of patient-centred data to quantify the volume of discharge for stroke patients. Two trained public health residents reviewed medical records with stroke admission diagnosis during 2021, analysing onset (e.g., Emergency Room, other hospital, emergency network), ward, treatment and discharge types (e.g., home, death, transitional care facility). Results Our RCR found 669 patients with a stroke diagnosis treated at San Matteo hospital in 2021, the vast majority of which were admitted to the neurology ward (375 patients, 56%). The recanalization rate was 32% (150 on 464 ischemic stroke patients). Regarding the discharge type, 299 patients (45%) were sent home, while 297 patients (44%) needed transfer to rehabilitation or long-term care facilities. About 8% (52 patients) of the overall sample died in hospital. Conclusions Our analysis showed that, while most stroke patients were discharged and sent home, more than two-third need to be transferred to continue to get the right healthcare from the right professional. Transitional care facilities should receive the greatest consideration by systems and providers seeking to implement care models to reduce residual neurological disabilities for stroke patients. Key messages • A fast and accessible emergency chain is essential to reduce residual neurological disabilities and the related healthcare and economic burden in stroke patients. • Extending the stroke path model to other time-dependent diseases is increasingly high-priority to shape a strong and resilient healthcare system, ensuring qualified health coverage.

Impact of completing a psychosocial rehabilitation programme on inpatient service utilisation in South Africa.

Deinstitutionalisation refers to the process of transferring most of the psychiatric care provision from inpatient state-run institutions to community-based care. However, it has proven difficult to implement and failed to reach its desired targets. New Beginnings (NB) is a transitional care facility that facilitates the transition from in- to outpatient care. To date, no data exist as to whether the intervention provided at NB is effective in reducing psychiatric readmissions. To determine if completing a psychosocial rehabilitation (PSR) programme reduces acute inpatient service utilisation and if this is influenced by sociodemographic or clinic factors. New Beginnings transitional care facility in South Africa. A record review of all NB admissions between January 2011 and December 2015. Demographic and clinical data were collected, including readmissions and days-in-hospital (DIH), 36 months pre- and postindex admission. Patients were divided into a completer group (CG) and a noncompleter group (NCG) for the eight-week PSR programme, and comparative statistical analysis was performed. Completion of the 8-week voluntary inpatient PSR programme led to a significant decrease (p = 0.017) (CG vs. NCG) in DIH during the 36-month period postindex admission. In addition, both groups showed significantly decreased (p < 0.001) DIH postindex in comparison to pre-index admission. This study's findings support that transitional care facilities offering an inpatient PSR programme may reduce inpatient service utilisation for all attendees but especially for those who complete the program. This highlights the need for such facilities that offer interventions tailored for patients with mental illness. This is the first local study highlighting the potentially important role transitional care facilities could play in reducing readmissions.

Geriatric Social Workers in Adult Day Care Facilities: Meditation, Worker Resilience, and Job Satisfaction.

This article reports a wait list control design study on the influence of an online meditation training program for geriatric social workers (GSWs) in a range of adult day care facilities across eight Asian and African cities. Results indicated that the online program was effective in building resilience and promoting job satisfaction among the intervention group. The program was more effective for participants from Asian cities, women, Hindus, and Buddhists working in transitional day care facilities and regularly logging into the self-practice sessions. Self-practice was an important mediator determining the relationship between demographic predictors and outcomes. This synchronous and asynchronous online program can be used by GSWs with some modifications for participants from African cities; men; Muslims and Christians; and those working in active adult, palliative, and memory care facilities. Refinements may entail adding familiar spiritual ideologies, some activities for men involving greater verbalization of feelings and emotions linked to the work, and intensive exercises addressing specific challenges of workers in palliative and memory care facilities.

The passage of a painting: The learning process of students creating art for people with dementia

Making Art for Making Place, a joint education and research project, engaged post-secondary fine arts students in the creation of paintings for residents of a transitional care facility. The purpose of the project was to explore how improving the living environment through art could benefit the residents with dementia while considering the impact this had on the students themselves. This article draws from participant observations and follow-up interviews to examine the learning experiences of students who created paintings for the facility. Further, it explores the impact on their learning through interactions with nurses and expert researchers who joined the class to participate in group discussions and share their expertise working with people living with dementia. The research revealed that the project fostered positive community building; engaged students in discussions and reflections about how art affects people; prompted consideration of experiences of the elderly – particularly those with dementia; and expanded understandings of the roles of art in the society.

Attributable Delay of Discharge for Children with Long-Term Mechanical Ventilation

To assess the reasons for discharge delays for children with long-term mechanical ventilation. Charts of children (0-18years of age) with a new tracheostomy in the Pulmonary Habilitation Program at the Ann and Robert H. Lurie Children's Hospital of Chicago were retrospectively reviewed for demographic information, medical diagnoses, medical stability, discharge to home, reasons for discharge delay, and hours of staffed home nursing. All patients were discharged on mechanical ventilation. Discharge delay was defined as >10days after medical stability. Hospital charges were analyzed and excess charges quantified beginning with the date of delay. Descriptive statistics and Pearson χ2 tests were used to compare nursing hours and demographics. Of 72 patients, 55% were male with mean age 1.8years (SD 3.8) at tracheostomy placement. The most common long-term mechanical ventilation indication was chronic lung disease (n=47, 65%); 54% had discharge delays, the majority were primarily due to lack of home nursing (62%), followed by delay of caregiver training (18%), caregiver health and social issues (8%), and delay in a transitional care facility bed (8%). Of the 39 delayed patients, 10% ($13 217 889) of hospital charges occurred during excess days with a median of $186 061 (IQR $117 661-$386 905) per patient. Over one-half of children discharged to the community from a large inpatient pediatric long-term mechanical ventilation program had a nonmedical delay of discharge home, most commonly because of home nurse staffing. This case series provides further evidence that limited availability of home nursing impedes efficient discharge and prolongs hospitalizations.

Transcatheter Aortic Valve Replacement: OPTIMIZING OUTCOMES FOR HEALTHY RECOVERY.

Transcatheter aortic valve replacement (TAVR) has been approved in the United States for intermediate and high-risk patients with severe symptomatic aortic stenosis. More than 80 000 TAVR procedures have been performed in the United States and the number is growing every year. Two valve designs are approved in the United States including the balloon expandable Edwards Sapien prosthesis and self-expanding CoreValve prosthesis. The PARTNER trial of the Sapien valve, involving patients who were considered inoperable, reported a 19% absolute risk reduction in mortality compared with medical therapy, with a number needed to treat of 5. Randomized controlled trials in patients with high and intermediate risk of inhospital mortality based on the Society of Thoracic Surgeons score showed noninferiority of TAVR compared with surgical aortic valve replacement. Major complications associated with TAVR include a 2% to 3% risk of stroke at 30 d, 8% to 25% risk of permanent pacemaker implantation depending on valve design, and 6% risk of major vascular complications. There are some concerns regarding valve durability as this technology is extended to younger patients with lower risk. Five-year follow-up data from the initial PARTNER trials noted appropriate valve performance and hemodynamics in survivors; however, longer follow-up is required to assess the true incidence of structural deterioration. Approximately one-third of TAVR patients are transferred to a transitional care facility after TAVR, and more than 50% of the patients are frail. Cardiac rehabilitation has been reported to be safe in post-TAVR patients and was associated with significant improvements in exercise capacity, functional independence, and frailty.

Robotic-Assisted, Video-Assisted Thoracoscopic and Open Lobectomy: Propensity-Matched Analysis of Recent Premier Data

Robotic-assisted lobectomy (RL) is becoming a popular alternative technique to video-assisted thoracoscopic lobectomy (VL), although open lobectomy (OL) remains the most common approach. The objective of this study is to provide a comparative analysis of perioperative clinical outcomes from elective RL, VL, and OL. The Premier Healthcare Database was analyzed for lobectomies performed from January 1, 2011, to September 30, 2015. International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes were used to identify surgical approaches, complications, and mortality. Propensity score matching (1:1) for patient and hospital characteristics allowed comparison of RL versus OL (n= 2,775 each) and RL versus VL (n= 2,951 each). Compared with OL in propensity matched analysis, RL was associated with a lower postoperative complication rate (p < 0.0001), shorter hospital stay (p < 0.0001), and lower mortality rate (p= 0.0282). Patients in the RL group were more likely to be discharged home than to a transitional health care facility (p < 0.0001). Compared with VL, the RL group had a lower conversion rate to thoracotomy (p < 0.0001), lower overall postoperative complication rate (p= 0.0061), and shorter hospital stay (p= 0.006). The RL patients also were more likely to be discharged home than to a transitional health care facility (p= 0.0108). The postoperative mortality rates of RL and VL were similar (p= 0.44). There was no difference in iatrogenic injuries when comparing RL with OL and RL with VL (p= 0.1284 and p= 0.5477, respectively). Robotic-assisted lobectomy was associated with improved outcomes for certain perioperative clinical variables, including shorter length of stay and lower complication rates. It was also was associated with a lower conversion rate to OL compared with VL.

Leading by walking around in long-term care and transitional care facilities.

Nursing staff in long-term care/transitional care (LTC/TC) facilities in the US work in unique environments that can be stressful and demanding. There is much in the literature that describes different leadership styles in nursing, but a limited amount on leadership in LTC/TC environments. This article explores the concept of leading by walking around (LBWA), also known as leadership by walking, to cultivate therapeutic work environments in LTC/TC facilities in the US. It defines therapeutic work environments and describes the specific environment of LTC/TC facilities. It also briefly describes the nursing hierarchy and nurse education in the US. Finally, it describes the cultivation of therapeutic work environments by using LBWA and includes two examples of the concept in action.

SA62. The Auditory Brainstem Response to Complex Sounds (cABR) Indexes Cognitive Network Function in Schizophrenia

Abstract Background: The auditory brain stem response to complex sounds (cABR) is an event-related potential (ERP) biomarker that quantifies sound encoding in the brain stem and midbrain. Although it has not yet been thoroughly investigated in schizophrenia (SZ), the cABR has demonstrated sufficient sensitivity for predicting response to at least one form of auditory-targeted cognitive training. We therefore aimed to examine whether the efficiency and accuracy of auditory encoding would be associated with the perception of speech-in-noise (SIN) and other higher order cognitive abilities that are commonly impaired in SZ. Methods: Thirty-one SZ patients in a transitional care facility underwent electroencephalography (EEG) testing with the cABR paradigm which consisted of 40 msec /da/ speech stimulus, presented binaurally with a 50 msec interstimulus interval (ISI). cABR onset (Peak A) latency and stimulus-to-response cross-correlations were calculated as an index of speech encoding timing and accuracy. Participants also completed the MATRICS Consensus Cognitive Battery (MCCB) and a modified version of QuickSIN, a measure of speech-in-noise perception. Results: Faster cABR peak A latency (mean = 7.93, SD = 1.41 msec) was associated with better speech-in-noise discriminability (r = −.47), CPT-IP attention (r = −.40), working memory (r = −.54 to r = −.62), and global cognition (r = −.44). Stimulus-to-response cABR encoding was positively associated with verbal learning and memory performance (r = .38, P < .05); its relationship with speech-in-noise discriminability trended toward significance (r = .33, P = .07). Conclusion: The cABR provides important information about the accuracy and efficiency of sound encoding within the brain stem. Its amplitude and timing appear to reflect functioning of the neural networks underlying speech perception and other functionally significant cognitive domains in SZ. Ongoing studies will assess whether these and other cABR parameters can be used to predict and monitor response to procognitive interventions in SZ.

Senescence, Alzheimer’s Dementia, and the Semi-Subjective in Ignacio Ferreras’s Film Arrugas

Based on the acclaimed graphic novel of the same name, the animated feature film Arrugas (Wrinkles) (Ferreras 2011) captures the everyday lives and frustrations of elderly residents in a transitional care facility. The film’s central protagonist is the recent arrival Emilio, who has Alzheimer’s disease, but Arrugas addresses not only his blossoming friendships and newfound hardships, but also a range of characters and everyday situations that characterize the textures of senescence. Building on recent scholarship on senescence and intellectual disability in Spanish film, cultural studies of Alzheimer’s dementia, and work on interdependency within disability studies approaches more broadly, the article explores key formal cinematic aspects of the feature. In particular, the semi-subjective shot is employed in the film as a way of linking the individual experience of dementia with the social processes that inform it.

Abstract TP381: Evaluation Of A Modified Home Care Intervention For Stroke Patients In Transition From Hospital To Home

Introduction: In the past two decades, there has been 84% increase of stroke prevalence in China. Since transitional care facilities are lacking in China, most of the stroke survivors return home after discharged from acute hospital setting. Routine disease-oriented discharge planning does not match individual home care needs. Objective: To evaluate the effectiveness of a modified home care (HC) intervention to facilitate the transition of care for stroke survivors from hospital to home. Methods: Using a quasi-experimental study design, stroke survivors from a 115-bed stroke unit in teaching hospital in China were recruited. HC subjects (n=168) received nurse-led pre-discharge preparation and post-discharge follow-ups, which beganon admission until 30-days post hospital discharge(a total of 4 hours,5 sessions,48 minutes on average). Hospital length of stay (LOS), stroke-related readmission rates, ability to perform activities of daily living (ADLs), and medication adherence were assessed at 30-days post-discharge. Historical controls (n=173)that received routine discharge planning, including standardized patient education about stroke and one telephone follow-up, were used as the comparison group (CG). Results: Subjects were on average 65.10 years old, 51% women, 74% ischemic stroke, 26% hemiparesis. The HC group had significantly better outcomes with a reduced hospital LOS(HC=11.3±2.2days vs.CG=12.4±4.3 days, p = 0.03), decreased stroke-related readmission rate(HC=1.2% vs.CG=6.4%, p = 0.02), increased ability to perform ADLs observed by Barthel Index. (HC=38.3±10.2vs.CG=32.1±10.3, p = 0.03) and medication adherence (HC=95.8%vs.CG=53.2%, p = 0.004), compared to CG. Conclusions: Our findings suggest that the modified HC intervention, incorporating nursing care planning and follow-ups across care settings, is effective in enhancing the transition from hospital to home, in terms of hospital care utilization and patient outcomes.

Clostridium difficile Incidence and Severity in Transitional Long-Term Care Facility Patients With Fecal Management Systems

Clostridium difficile Incidence and Severity in Transitional Long-Term Care Facility Patients With Fecal Management Systems

Care of children with medical complexity in the hospital setting.

Children with medical complexity are a subset of patients with special health care needs whose "health and quality of life depend on integrating health care between a primary care medical home, tertiary care services, and other important loci of care such as transitional care facilities, rehabilitation units, the home, the school, and other community based settings," according to Cohen et al. These children are characterized by (1) substantial health care service needs, (2) one or more severe chronic clinical condition(s), (3) severe functional limitations, and (4) high projected use of health resources that may include frequent or prolonged hospitalization, multiple surgeries, or the ongoing involvement of multiple subspecialty services and providers. Children with medical complexity are an important population for pediatric hospitalists, particularly those practicing in tertiary care settings. Recent studies describe the increasing prevalence of complex chronic conditions among all pediatric hospitalizations in the United States. This article reviews the definitions of children with medical complexity and recent studies describing the changes in hospital utilization for this group. We discuss issues in their inpatient care, including (1) intensive care coordination needs, (2) critical decision-making that occurs in the inpatient setting, (3) common clinical issues that occur with technology dependence (tracheostomies, feeding tubes, and cerebrospinal fluid shunts), and (4) common reasons for admission (eg, perioperative care, aspiration pneumonia, seizures, and feeding intolerance). Finally, we present a few important clinical questions regarding inpatient care for children with medical complexity that will require research in the coming years.

From the President: The Power of Early Identification

From the President: The Power of Early Identification

From Trauma Quality Improvement Project to the Geriatric Trauma Institute: Developing an Innovative Care Model for the Coming Storm

ABSTRACT Background The US geriatric population is projected to steadily increase to approximately 20% by 2030, thereby significantly increasing the burden to trauma services. This study sought to transform the geriatric trauma care model into one more effective, efficient, financially sustainable, and capable of absorbing the anticipated increased demand. Study design The goals were to improve the geriatric trauma care process—for patient and hospital, detail its evolution, and provide a formative evaluation of the result. A multidisciplinary team, internal and external to the hospital, was assembled including clinical, administrative, and technical staff. Over 18 months, application of Lean Six Sigma tools/concepts produced a novel care model, the Geriatric Trauma Institute (GTI). Retrospectively, formative evaluation was accomplished by comparing pre-GTI data time-matched with that from the first 8 months post-GTI initiation. Results The GTI has achieved 100% involvement of institution orthopedists with 100% of geriatric trauma admissions being converted to the GTI. Eight months post-GTI, geriatric trauma service admissions increased 26.6%, while non-trauma admissions decreased 78.2%. Out-transfers declined by 28.2%. Patients dispositioned to home increased 26.1% alongside decreases to rehabilitation (47.2%), skilled nursing, and transitional care facilities. Conclusion Geriatric trauma institute success is evidenced by the quantifiable benefits to patient and hospital. During development, new work processes, tools, and staff training helped boost the utilization of the trauma service regarding geriatric trauma care via the novel multidisciplinary approach. The GTI has demonstrated sustained quality improvement in geriatric trauma care maintained through the trauma service performance improvement initiative. How to cite this article DeLa'O CM, Rodriguez A, Boer J, Simunich T, Dumire R. From Trauma Quality Improvement Project to the Geriatric Trauma Institute: Developing an Innovative Care Model for the Coming Storm. Panam J Trauma Crit Care Emerg Surg 2014;3(3):105-108.

The Therapeutic Value of Adversity

The Therapeutic Value of Adversity