[The short stay unit as an alternative to conventional hospitalisation in the treatment of community acquired pneumonia in the over 75 year-old population]

Hospitalisation in short-stay units for adults with internal medicine diseases and conditions

BACKGROUND

Short-stay units are hospital units that provide short-term care for selected patients. Studies have indicated that short-stay units might reduce admission rates, time of hospital stays, hospital readmissions and expenditure without compromising the quality of care. Short-stay units are often defined by a target patient category, a target function, and a target time frame. Hypothetically, short-stay units could be established as part of any department, but this review focuses on short-stay units that provide care for participants with internal medicine diseases and conditions.

OBJECTIVES

To assess beneficial and harmful effects of short-stay unit hospitalisation compared with usual care in people with internal medicine diseases and conditions.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to 13 December 2017 together with reference checking, citation searching and contact with study authors to identify additional studies. We also searched several grey literature sources and performed a forward citation search for included studies.

SELECTION CRITERIA

We included randomised trials and cluster-randomised trials, comparing hospitalisation in a short-stay unit with usual care (hospitalisation in a traditional hospital ward or other services). We defined a short-stay unit to be a hospital ward where the targeted length of stay in hospital for patients was five days or less. We included both multipurpose and specialised short-stay units. Participants were adults admitted to hospital with an internal medicine disease or condition. We excluded surgical, obstetric, psychiatric, gynaecological, and ambulatory participants. Trials were included irrespective of publication status, date, and language.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently extracted data and assessed the risk of bias of each included trial. We measured intervention effect sizes by meta-analyses for two primary outcomes, mortality and serious adverse events, and one secondary outcome, hospital readmission. We narratively reported the following important outcomes: quality of life, activities of daily living, non-serious adverse events, and costs. We used risk ratio differences of 15% for mortality and of 20% for serious adverse events for minimal relevant clinical consideration. We rated the certainty of the evidence and the strength of recommendations of the outcomes using the GRADE approach.

MAIN RESULTS

We included 19 records reporting on 14 randomised trials with a total of 2872 participants. One trial was ongoing. Thirteen trials evaluated short-stay unit hospitalisation for six specific conditions (acute decompensated heart failure (one trial), asthma (one trial), atrial fibrillation (one trial), chest pain (seven trials), syncope (two trials), and transient ischaemic attack (one trial)) and one trial investigated participants presenting with miscellaneous internal medicine disease and conditions. The components of the intervention differed among the trials as dictated by the trial participants' condition. All included trials were at high risk of bias.The certainty of the evidence for all outcomes was very low. Consequently, it is uncertain whether hospitalisation in short-stay units compared with usual care reduces mortality (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.47 to 1.15) 5 trials (seven additional trials reporting on 1299 participants reported no deaths in either group)); serious adverse events (RR 0.95, 95% CI 0.59 to 1.54; 7 trials (one additional trial with 108 participants reported no serious adverse events in either group)), and hospital readmission (RR 0.80, 95% CI 0.54 to 1.19, 8 trials (one additional trial with 424 participants did not report results for participants)). There was not enough information to confirm or refute that short-stay unit hospitalisation had relevant effects on quality of life, activities of daily living, non-serious adverse events, and costs.

AUTHORS' CONCLUSIONS

Overall, the quantity and the certainty of the evidence was very low. Consequently, it is uncertain whether there are any beneficial or harmful effects of short-stay unit hospitalisation for adults with internal medicine diseases and conditions - more trials comparing the effects of short-stay units with usual care are needed. Such trials ought to be conducted with low risk of bias and low risks of random errors to improve the overall confidence in the evidence.

[Are short-stay units an appropriate resource for hospitalising elderly patients with infection?]

OBJECTIVE

To describe the clinical characteristics and outcomes of elderly patients (≥ 75 years) with suspected infection attending the emergency department (ED) and to compare patients admitted to a short-stay unit (SSU) with those admitted to a conventional hospital unit (CHU).

MATERIAL AND METHODS

Prospective cohort study including, using opportunity sampling, patients ≥75 years treated for infection in the ED of 3 Spanish university hospitals (2013). Demographic variables, comorbidity, baseline performance status, presence of sepsis, infection type, destination on discharge, and mortality at 30 days were collected.

RESULTS

During the study period, 330 patients ≥75 years (mean age 83.8±7.3) were evaluated for a suspected infection in the ED, and 306 (93%) were admitted to the hospital, 175 (53%) to the CHU and 87 (26%) to the SSU. Medical history included hypertension (74.5%), arrhythmia (30%), chronic obstructive pulmonary disease (28%), and diabetes mellitus (26%), and risk factors for multidrug resistance, such as antibiotic treatment in 3 months prior to admission (48%), and institutionalisation (26%). A classic sepsis syndrome was found to be the source of infection in 53%, and was respiratory in half of patients. When comparing patients admitted to SSU and CHU, statistically significant differences (p<.05) were found in the Charlson index (1.95 vs. 2.51), Glasgow coma scale (14.6 vs. 14.3), classic sepsis syndrome (67% vs. 53%), severe sepsis (2.3% vs. 18%), length of stay (4.2 vs. 10.4 days), and mortality within 30 days (3.4% vs. 18%), respectively.

CONCLUSIONS

SSU may be an adequate alternative to CHU for elderly patients requiring admission with suspected infection.

Short-term prognostic factors in the elderly patients seen in emergency departments due to infections

OBJECTIVES

To analyse factors associated with short-term mortality in elderly patients seen in emergency departments (ED) for an episode of infectious disease.

MATERIALS AND METHODS

A prospective, observational, multicentre, analytical study was carried out on patients aged 75years and older who were treated in the ED of one of the eight participating hospitals. An assessment was made of 26 independent variables that could influence mortality at 30days. They covered epidemiological, comorbidity, functional, clinical and analytical factors. Multivariate logistic regression analysis was performed.

RESULTS

The study included 488 consecutive patients, 92 (18.9%) of whom died within 30days of visiting the ED. Three variables were significantly associated with higher mortality: severe functional dependence, with Barthel index ≤60 [odds ratio (OR) 8,92; 95% confidence interval (CI): 4.98-15.98, P=.003], systolic blood pressure <90mmHg [OR 7.34; 95%CI: 4.39-12.26, P=.005] and serum lactate >4mmol/l [OR 21.14; 95%CI: 8.94-49.97, P=.001]. The area under the curve for the model was 0.971 (95%CI: 0.951-0.991; P<.001).

CONCLUSIONS

Several factors evaluated in an initial assessment in the ED, including the level of functional dependence, systolic blood pressure and, especially, serum lactate, were found to determine a poor short-term prognosis in the elderly patients who presented with an episode of an infectious disease.

Guía de consenso para el abordaje de la neumonía adquirida en la comunidad en el paciente anciano

La incidencia de la neumonía adquirida en la comunidad se incrementa con la edad y se asocia a una elevada morbimortalidad debido a los cambios fisiológicos asociados al envejecimiento y a una mayor presencia de enfermedades crónicas. Debido a la importancia que tiene desde un punto de epidemiológico y pronóstico, y a la enorme heterogeneidad descrita en el manejo clínico, creemos que existía la necesidad de realizar un documento de consenso específico para este perfil de paciente. El propósito de este fue realizar una revisión de las evidencias en relación con los factores de riesgo para la etiología, la presentación clínica, el manejo y el tratamiento de la neumonía adquirida en la comunidad en los ancianos con el fin de elaborar una serie de recomendaciones específicas basadas en el análisis crítico de la literatura. Este documento es fruto de la colaboración de diferentes especialistas en representación de la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), Sociedad Española de Geriatría y Gerontología (SEGG), Sociedad Española de Quimioterapia (SEQ), Sociedad Española de Medicina Interna (SEMI), Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Sociedad Española de Hospitalización a Domicilio (SEHAD) y Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC).

[Impact of short-stay units on the quality of medical care in Spain]

OBJECTIVE

Short-stay units (SSUs) have been developed as an alternative to conventional hospitalisation. The aim of this study is to analyse the impact of short-stay units on the quality of medical care in Spain.

MATERIAL AND METHODS

A systematic review was performed by retrieving studies that analysed the results of SSUs in Spain, in terms of clinical effectiveness, efficiency and satisfaction among patients, using an electronic database search (Pubmed/Medline and Spanish Medical Index) and a review of selected references. The data collected included, mortality, length of stay and re-admission rates, as well as other variables.

RESULTS

Twenty-seven articles were found, with a great heterogeneity in both study design and type of SSU analysed. After analysing results, it was observed that SSUs in Spain provided effective clinical care. Low-quality evidence was also found supporting the hypothesis that SSUs are able to reduce overall length of stay in the whole hospital or department where they were created. There are not enough data to support any other advantages or benefits of SSUs, when compared with other hospitalisation units.

CONCLUSIONS

SSUs may be able to effectively improve clinical care in selected patients, and may help to shorten overall length of stay. Further research is needed in order to define their exact role and to establish their optimal model.