Predictive validity of the BRASS index in screening patients with post-discharge problems. Blaylock Risk Assessment Screening Score

Predictive Power of Dependence and Clinical-Social Fragility Index and Risk of Fall in Hospitalized Adult Patients: A Case-Control Study

OBJECTIVES

Accidental falls are among the leading hospitals' adverse events, with incidence ranging from 2 to 20 events per 1.000 days/patients. The objective of this study is to assess the relationship between in-hospital falls and the score of 3 DEPendence and Clinical-Social Fragility indexes.

METHODS

A monocentric case-control study was conducted by retrieving data of in-hospital patients from the electronic health records.

RESULTS

Significant differences between the mean scores at the hospital admission and discharge were found. The BRASS scale mean (SD) values at the admission and at the discharge were also significantly higher in cases of in-hospital falls: at the admission 10.2 (±7.7) in cases versus 7.0 (±8.0) in controls ( P = 0.003); at the discharge 10.0 (±6.4) versus 6.7 (±7.5) ( P = 0.001). Barthel index mean (SD) scores also presented statistically significant differences: at the admission 60.3 (±40.6) in cases versus 76.0 (±34.8) in controls ( P = 0.003); at discharge 51.3 (±34.9) versus 73.3 (±35.2) ( P = 0.000).Odds ratios were as follows: for Barthel index 2.37 (95% CI, 1.28-4.39; P = 0.003); for Index of Caring Complexity 1.45 (95% CI, 0.72-2.91, P = 0. 255); for BRASS index 1.95 (95% CI, 1.03-3.70, P = 0.026). With BRASS index, the area under the curve was 0.667 (95% CI, 0.595-0.740), thus indicating a moderate predictive power of the scale.

CONCLUSIONS

The use of only Conley scale-despite its sensitivity and specificity-is not enough to fully address this need because of the multiple and heterogeneous factors that predispose to in-hospital falls. Therefore, the combination of multiple tools should be recommended.

Thirty-day mortality in hospitalised patients with lung cancer: incidence and predictors

OBJECTIVES

Patients with lung cancer experience high rates of hospitalisation, mainly due to the high risk of complications that emerge during the natural history of the disease. We designed a retrospective, single-centre, observational study aimed at defining the clinical predictors of 30-day mortality in hospitalised patients with lung cancer.

METHODS

Clinical records from the first admission of patients with lung cancer to the oncology ward of the University Hospital of Parma from 1 January 2017 to 1 January 2022 were collected.

RESULTS

251 consecutive patients were enrolled at the time of data cut-off. In the univariate analysis, baseline clinical predictors of 30-day mortality were Eastern Cooperative Oncology Group performance status (ECOG PS) (≥2 vs 0-1: 27.5% vs 14.8%, p=0.028), high Blaylock Risk Assessment Screening Score (BRASS) (high vs intermediate-low: 34.3% vs 11.9%, p<0.001), presence of pain (yes vs no: 24.4% vs 11.7%, p=0.009), number of metastatic sites (≥3 vs <3: 26.5% vs 13.4%, p=0.017) and presence of bone metastases (yes vs no: 29.0% vs 10.8%, p=0.001). In the multivariate analysis, high BRASS remained significantly associated with increased 30-day mortality (high vs intermediate-low; OR 2.87, 95% CI 1.21 to 6.78, p=0.016).

CONCLUSION

Our results suggest that baseline poor ECOG PS, high BRASS, presence of pain, high tumour burden and presence of bone metastases could be used as clinical predictors of 30-day mortality in hospitalised patients with lung cancer. In particular, the BRASS scale should be used as a simple tool to predict 30-day mortality in hospitalised patients with lung cancer.

Exploration of risk factors for high-risk adverse events in elderly patients after discharge and comparison of discharge planning screening tools

OBJECTIVES

Discharge planning is an effective strategy to prevent adverse health events and reduce medical expenditures. The high-risk target populations of discharged elderly patients and important predictors for the occurrence of adverse events are still not clear. Therefore, the purposes of this study were to examine the validity of discharge planning screening tools in sufficiently identifying high-risk adverse events to health after discharge and to compare two screening tools with our study model.

DESIGN

We conducted a prospective study and recruited elderly patients who had had no hospitalization within 3 months before admission to 13 general wards of a medical center in northern Taiwan from November 2018 to May 2020.

METHODS

Elderly patients were randomly selected during the study period. Within 24 h of admission, patients were asked to consent to join this study. After the patient was discharged, the patient's health and hospitalization for the next year were tracked by telephone interviews.

RESULTS

In total, 300 participants were recruited for this study. Incidences of high-risk adverse events within 30 days, 60 days, and 12 months after discharge were 20.3%, 25.7%, and 48.7% respectively. A logistic regression showed that an increased age, physical or mental disabilities or a major illness, a low body-mass index, and having been hospitalized in the past year were significantly related to the occurrence of high-risk events among elderly discharge patients. The pooled sensitivity of the P_ra was 52% and the specificity was 72%; the pooled sensitivity of the LACE index was 67% and the specificity was 36%. The predictive model of this study had a higher discriminatory power than the P_ra and LACE index for high-risk events after discharge.

CONCLUSIONS

Elderly patients are more vulnerable to high-risk adverse events after discharge. Both the LACE index and P_ra are useful discharge planning screening tools to screen for high-risk adverse events after discharge. Elderly patients need more-active and complete continuity of care plans and discharge planning services to ensure that the overall quality of patient care can be improved and readmissions and mortality reduced.

CLINICAL RELEVANCE

The findings of this study can provide information for discharge planning managers to identify high-risk elderly patients during hospitalization and promptly offer care education or resources to improve care management.

Hospital discharge: testing the "Blaylock Risk Assessment Screening Score" in a surgical department

Background and aim of the work Standardizing patients' assessment to identify individuals at greater risk in encountering difficulties at discharge may help to assist healthcare professionals in clinical decision making and address the gaps in quality that negatively affect continuity of care. We analyzed the predictive validity and the test-retest reliability of the BRASS index in surgical inpatients. Moreover, we evaluated the association between other variables and length of stay or location at discharge. Methods A prospective observational study was conducted. Four hundred twenty-eight patients (≥18 years old) hospitalized in the surgical department of Vimercate hospital were recruited. Data were collected using BRASS index within 48 hours from admission and before discharge. Results We found a high specificity for BRASS in identifying patients discharged to their home with assistance or to residential care. The hospital stay for medium and high-risk patients was significantly longer than those in the low-risk group. There was no statistically significant difference of the BRASS scores during hospitalization. Type of admission, pressure ulcers, ASA score, multidrug-resistant bacterial infections, medical complications and Intensive Unit Care stay showed a significant correlation with longer hospitalization and increased probability to be discharged to their home with assistance or to residential care. Conclusions The BRASS Index may support healthcare professionals to identify surgical inpatients requiring a discharge planning and needs to be completed just once at admission. The inclusion of other patient-specific factors in the assessment process could be valuable for targeting the at-risk population.

Developing a predictive model for hospital-associated disability among older patients hospitalized for an acute illness: the HAD-FREE Score

PURPOSE

To develop a predictive model to identify hospitalized older patients at risk of functional decline.

METHODS

This retrospective cohort study recruited participants aged 65 years and over admitted to internal medicine wards of a tertiary medical center in Taiwan during May to October 2017 for developing predictive model (n = 1698) and those admitted during November to December 2017 for validation study (n = 530) of the model. Demographic data, geriatric assessments and hospital conditions (admission route and length of hospital stay) were collected for analysis.

RESULTS

Overall, of the 1698 participants (mean age 75.8 ± 7.9 years, 60.9% male) enrolled in the development study, 20.1% had functional decline. Results of multivariate logistic regression showed that older age, hearing impairment, history of falls within one year, risk of malnutrition, physical restraint, admission via emergency department and hospital stay ≥ 5 days were independent predictive factors for decline. A scoring system, HAD-FREE Score, constructed from the above predictive factors ranged from 0 to 18 points and ≥ 6 points was chosen as the cut-off point. The area under the receiver operating characteristic analysis was 0.748 (95% confidence interval: 0.720-0.776), the sensitivity was 65.3% and the specificity was 71.3%. Validation of the HAD-FREE Score showed moderate discriminative ability in the validation study.

CONCLUSION

A HAD-FREE Score developed from seven independent factors could predict functional decline with moderate discriminative ability and good validation. This scoring system can be the basis of an automatic dynamic tracking within the electronic medical record to identify those older patients at risk of functional decline during hospitalization.

Factors Associated With Discharge Destination in Community-Dwelling Adults Admitted to Acute General Medical Units

BACKGROUND AND PURPOSE

General medical patients often present to the hospital with medical, social, cognitive, and functional issues that may impact discharge destination. The aim of this study was to investigate the association between patient factors at hospital admission and discharge destination in general medical patients.

METHODS

This was a prospective, single-site observational study conducted on the general medical wards at a tertiary hospital. Inpatients admitted to the general medical unit and referred to physical therapy were included. Patients admitted from residential care were excluded.

MAIN OUTCOME MEASURES

Data were collected a median of 2 days (interquartile range: 1-3) from hospital admission and included demographics, comorbidities (Charlson Comorbidity Index), premorbid physical function (Blaylock Risk Assessment Screening Score, BRASS), current function (de Morton Mobility Index, DEMMI and Alpha Functional Independence Measure, AlphaFIM), and cognition (Rowland Universal Dementia Assessment Scale, RUDAS).

RESULTS

Between July 2016 and August 2017, 417 patients were recruited (53% female, median age: 81 years (interquartile range: 76-86). Of these, 245 patients were discharged directly home; 172 were not discharged home of whom 140 were discharged to a subacute temporary facility providing further opportunity for therapy and discharge planning. Patients discharged directly home had higher functional, mobility, and cognitive scores. Data were partitioned into training, validation, and test sets to provide unbiased estimates of sensitivity, specificity, receiver operating characteristic curve, and area under the curve. Models best associated with discharge were "DEMMI and toilet transfers" (sensitivity 82.1%, specificity 66.2%, area under the curve 83.8%, 95% confidence interval: 76.4-91.2) and "AlphaFIM and walking independence" (sensitivity: 66.7%, specificity: 83.1%, area under the curve: 81.5, 95% confidence interval: 73.2-89.7).

CONCLUSION

Two models were created that differentiated between discharge home and not home and had similar statistical measures of validity. Although the models require further validation, clinicians should consider whether identification of patients likely to be discharged home or not home is of greater relevance for their clinical setting.

Patients recovering from COVID-19 pneumonia in sub-acute care exhibit severe frailty: Role of the nurse assessment

AIMS AND OBJECTIVES

To document the level of frailty in sub-acute COVID-19 patients recovering from acute respiratory failure and investigate the associations between frailty, assessed by the nurse using the Blaylock Risk Assessment Screening Score (BRASS), and clinical and functional patient characteristics during hospitalisation.

BACKGROUND

Frailty is a major problem in patients discharged from acute care, but no data are available on the frailty risk in survivors of COVID-19 infection.

DESIGN

A descriptive cross-sectional study (STROBE checklist).

METHODS

At admission to sub-acute care in 2020, 236 COVID-19 patients (median age 77 years - interquartile range 68-83) were administered BRASS and classified into 3 levels of frailty risk. The Short Physical Performance Battery (SPPB) was also administered to measure physical function and disability. Differences between BRASS levels and associations between BRASS index and clinical parameters were analysed.

RESULTS

The median BRASS index was 14.0 (interquartile range 9.0-20.0) denoting intermediate frailty (32.2%, 41.1%, 26.7% of patients exhibited low, intermediate and high frailty, respectively). Significant differences emerged between the BRASS frailty classes regards to sex, comorbidities, history of cognitive deficits, previous mechanical ventilation support and SPPB score. Patients with no comorbidities (14%) exhibited low frailty (BRASS: median 5.5, interquartile range 3.0-12.0). Age ≥65 years, presence of comorbidities, cognitive deficit and SPPB % predicted <50% were significant predictors of high frailty.

CONCLUSIONS

Most COVID-19 survivors exhibit substantial frailty and require continuing care after discharge from acute care.

RELEVANCE TO CLINICAL PRACTICE

The BRASS index is a valuable tool for nurses to identify those patients most at risk of frailty, who require a programme of rehabilitation and community reintegration.

Assessment tools and factors used to predict discharge from acute general medical wards: a systematic review

PURPOSE

To identify assessment tools and patient factors statistically associated with discharge destination in general medical inpatients.

MATERIALS AND METHOD

A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Four electronic databases were searched. Studies were eligible if they were a quantitative study design, had adult acute general medical inpatients and published in English. Outcomes of interest were tools or factors with statistical correlations with discharge destination (home, subacute or residential care). Articles were screened by two independent assessors. Data were extracted by one reviewer and independently checked by a second reviewer. Data were analysed/described descriptively.

RESULTS

Twenty-three studies were included. Twenty-three tools and 44 factors were identified, which spanned Health Condition, Body Structure and Function, Activity, Participation, Environment and Personal concepts of the World Health Organisation International Classification of Function, Disability and Health (WHO ICF).

CONCLUSIONS

The large number of tools and factors found and their distribution across several WHO ICF concepts exemplifies the complexities of predicting discharge. No single assessment tool that best predicts discharge destination was identified, but rather there were a variety of potential tools identified. Further research is needed to determine the psychometric properties of the identified assessment tools as well as additional predictors of subacute care (including rehabilitation). This is important as it may allow for timely clinical decision making.

TRIAL REGISTRATION

A priori, PROSPERO (CRD42017064209).IMPLICATIONS FOR REHABILITATIONThis systematic review identified a large number of assessment tools and patient factors associated with discharge destination (home, subacute and residential care) in general medical inpatients.All of the domains of the WHO ICF framework are associated with discharge destination and must be considered.Clinicians in the acute setting can use these findings to assist selection of assessment tools to identify patients likely to need rehabilitation or subacute care.Early identification of patients who are unable to return to their place of residence is essential as it allows for provision of early rehabilitation and subsequent discharge planning.

In pursuit of enhanced recovery after total joint replacement: a narrative review of drivers of length of stay

A continual increase in the prevalence of osteoarthritis drives growing demand for total joint arthroplasty. So far, a decrease in length of stay has been the target for health professionals globally. However, a consensus pathway of achieving this has not yet been reached. This article reviews recent advances in pre-operative and perioperative factors impacting length of stay.

Barthel Index: creation and validation of two cut-offs using the BRASS Index

BACKGROUND AND AIM

Hospital discharge should be planned during the first days of stay to avoid an inappropriate length of stay and an early rehospitalization. Blaylock Risk Assessment Screening Score Index (BRASS index) evaluates the risk of difficult discharge, Barthel Index the level of autonomy in "activities of daily living" (ADL). This is a prospective observational study, performed in Padua's Hospital (Italy), with the purpose of validating two cut-offs in the Barthel Index using the BRASS Index, in order to find three bands for difficult discharges: low, medium and high risk.

METHODS

Two studies have been conducted: a pilot study in 2017 with 153 patients and a validation study in 2018 with 253 patients, in order to validate data emerged from the pilot study. Using a statistical method, two cut-offs have been identified in the Barthel Index.

RESULTS

Both of study showed that the grade of autonomy is correlated with the risk of difficult discharge. A Barthel score between 0 and 35 corresponds to a high risk, between 35 and 70 to a medium and over 75 to a low.

DISCUSSION

This study suggests that, by the use of only Barthel Index, it may be possible to identify patients who may have difficulty in early discharge. This result suggests that the degree of functional dependence is predictive of the risk of difficult discharge. Further studies are needed to confirm the correlation between these data also in other realities (e.g. outside hospital departments).

CONCLUSION

Nurses could use a single instrument to evaluate the autonomy and the risk of difficult discharge in order to identify early patients that need a discharge plan. (www.actabiomedica.it).

Association between post-discharge secondary care and risk of repeated hospital presentation, entry into long-term care and mortality in older people after acute hospitalization

AIM

Hospitalizations are frequent among acutely ill older people, and might be reduced by post-discharge secondary care (PDSC). We aimed to determine the proportion of older patients planned to receive or attending PDSC after acute hospitalization and the association with undesirable outcomes.

METHODS

A retrospective observational study was carried out using an electronic health record system in two hospitals in New Zealand. Patients were aged ≥75 years, initially presented at an emergency department (ED) and were discharged from medical, surgical, geriatrics or orthopedics wards in three 2-week periods. Planned PDSC at discharge, attended PDSC, ED presentation, long-term care (LTC) admission and death in 90 days after discharge were obtained through the health record system. Proportional hazards regression assessed the associations of planned or attended PDSC with undesirable outcomes (ED presentation, LTC admission and death) within 90 days of discharge.

RESULTS

Clinical records for 1085 patients were extracted, 963 were eligible. Of these, 413 (42.9%) had planned PDSC in discharge summaries, and 573 (59.5%) actually attended in 90 days. Patients planned for PDSC had a similarly adjusted hazard of ED presentation (HR 0.99, P = 0.92), LTC admission (HR 0.73, P = 0.25) and death (HR 0.80, P = 0.34) within 90 days of discharge, compared with those not planned. Similar non-significant associations were observed between attended PDSC and undesirable outcomes.

CONCLUSIONS

In patients aged ≥75 years in New Zealand, we did not find "planned PDSC" at discharge or "attended PDSC" after an acute hospitalization to be associated with ED presentation, LTC admission and death within 90 days after discharge. Other potential benefits of planned or attended PDSC require further investigation. Geriatr Gerontol Int 2019; 19: 1048-1053.

Emergency Department Interventions for Older Adults: A Systematic Review

OBJECTIVES

To evaluate the effect of emergency department (ED) interventions on clinical, utilization, and care experience outcomes for older adults.

DESIGN

A conceptual model informed, protocol-based systematic review.

SETTING

Emergency Department (ED).

PARTICIPANTS

Older adults 65 years of age and older.

METHODS AND MEASUREMENT

Medline, Embase, CINAHL, and PsycINFO were searched for English-language studies published through December 2017. Studies evaluating the use of one or more eligible intervention strategies (discharge planning, case management, medication safety or management, and geriatric EDs including those that cited the 2014 Geriatric ED Guidelines) with adults 65 years of age and older were included. Studies were classified by the number of intervention strategies used (ie, single strategy or multi-strategy) and key intervention components present (ie, assessment, referral plus follow-up, and contact both before and after ED discharge ["bridge"]). The effect of ED interventions on clinical (functional status, quality of life [QOL]), patient experience, and utilization (hospitalization, ED return visit) outcomes was evaluated.

RESULTS

A total of 2000 citations were identified; 17 articles describing 15 unique studies (9 randomized and 6 nonrandomized) met eligibility criteria and were included in analyses. ED interventions showed a mixed pattern of effects. Overall, there was a small positive effect of ED interventions on functional status but no effects on QOL, patient experience, hospitalization at or after the initial ED index visit, or ED return visit.

CONCLUSION

Studies using two or more intervention strategies may be associated with the greatest effects on clinical and utilization outcomes. More comprehensive interventions, defined as those with all three key intervention components present, may be associated with some positive outcomes.

Clinical predictors of protracted length of stay in Ontario Complex Continuing Care hospitals

Background

Post-acute care hospitals are often subject to patient flow pressures because of their intermediary position along the continuum of care between acute care hospitals and community care or residential long-term care settings. The purpose of this study was to identify patient attributes associated with a prolonged length of stay in Complex Continuing Care hospitals.

Methods

Using information collected using the interRAI Resident Assessment Instrument Minimum Data Set 2.0 (MDS 2.0), a sample of 91,113 episodes of care for patients admitted to Complex Continuing Care hospitals between March 31, 2001 and March 31, 2013 was established. All patients in the sample were either discharged to a residential long-term care facility (e.g., nursing home) or to the community. Long-stay patients for each discharge destination were identified based on a length of stay in the 95th percentile. A series of multivariate logistic regression models predicting long-stay patient status for each discharge destination pathway were fit to characterize the association between demographic factors, residential history, health severity measures, and service utilization on prolonged length of stay in post-acute care.

Results

Risk factors for prolonged length of stay in the adjusted models included functional and cognitive impairment, greater pressure ulcer risk, paralysis, antibiotic resistant and HIV infection need for a feeding tube, dialysis, tracheostomy, ventilator or a respirator, and psychological therapy. Protective factors included advanced age, medical instability, a greater number of recent hospital and emergency department visits, cancer diagnosis, pneumonia, unsteady gait, a desire to return to the community, and a support person who is positive towards discharge. Aggressive behaviour was only a risk factor for patients discharged to residential long-term care facilities. Cancer diagnosis, antibiotic resistant and HIV infection, and pneumonia were only significant factors for patients discharged to the community.

Conclusions

This study identified several patient attributes and process of care variables that are predictors of prolonged length of stay in post-acute care hospitals. This is valuable information for care planners and health system administrators working to improve patient flow in Complex Continuing Care and other post-acute care settings such as skilled nursing and inpatient rehabilitation facilities.

Instrumentos de avaliação do risco de prolongamento de internação hospitalar

Resumo Objetivo: Mapear a existência de instrumentos para avaliação do risco de prolongamento do tempo de internação com retardo da alta hospitalar do paciente. Métodos: Efetuada revisão da literatura do tipo scoping de acordo com o proposto pela Joanna Briggs Institute. Efetuada pesquisa na plataforma eletrônica da Ebscohost: Medline, Cinahl, MedicLatina, Cochrane Data Base of Systematic Reviews; na PubMed, em repositórios (RIMAS, RIAP RIUIS, RCAAP e Veritati) e no Google Scholar. Consultadas as referências bibliográficas dos documentos selecionados. Resultados: Da pesquisa efetuada selecionaram-se 7 artigos para análise, que abordavam 4 instrumentos: Patient Status of Continence, Ambulation, Age, Social Background and Thought Processes; 4-Score, Blaylock Risk Assessment Screen e The Multidisciplinary Record. Conclusão: O risco de prolongamento do tempo de internação com retardo da alta hospitalar pode ser avaliado através de 4 tipos de instrumentos. Esta avaliação foca-se principalmente na função cognitiva do paciente, na sua idade, no seu nível de dependência nas atividades de vida diárias, na sua mobilidade e apoio social de que dispõe, apostando-se num planejamento de alta precoce e preventivo.

Development and validation of a simplified BRASS index to screen hospital patients needing personalized discharge planning

BACKGROUND

Discharge planning is an important component of hospital care. The Blaylock Risk Assessment Screening Score (BRASS) index is an instrument used to identify patients requiring complex discharge planning.

OBJECTIVES

(1) Evaluate the ability of the original BRASS index to predict the risk of complex discharge and hospital mortality. (2) Develop and validate a simplified BRASS index by eliminating redundant variables and re-estimating the predictor weights.

DESIGN

Prospective cohort study.

PARTICIPANTS

Patients admitted at the general internal medicine wards of tertiary referral hospital in Turin, Italy, and screened within 48 h using the BRASS index.

METHODS

The first phase of the study assessed the performance of the original BRASS index in predicting the risk of complex discharge and hospital mortality, then a simplified score was developed. In the second phase, temporal validation of the simplified BRASS index was performed. The probability of each discharge modality (discharged at home without complications, complex discharge, and dead in hospital) was modeled using polytomous logistic regression. The AUC was used to compare the performance of the different models.

KEY RESULTS

Among 6044 patients in the first phase of the study, 63% were discharged at home without complications, 31% had complex discharge, and 6% died during the hospital stay. The AUC of the simplified BRASS index, compared with the original index were 0.71 vs. 0.70 for complex discharge and 0.83 vs. 0.80 for hospital mortality. In the validation set (3325 patients), the simplified BRASS index discriminates the outcome categories with an AUC of 0.69 and 0.81 for complex discharge and hospital mortality, respectively.

CONCLUSION

The new, simplified BRASS index showed a slightly better performance in predicting the risk of complex discharge and hospital mortality than the original tool and takes less time to be applied. These results were also confirmed in the validation set.

Clinical utility of scores on the Blaylock Risk Assessment Screen (BRASS): An analysis of administrative data

PURPOSE

Project was undertaken to examine the utility of the Blaylock Risk Assessment Screen (BRASS) in identifying patients who may experience discharge complications as indicated by longer hospital stays or readmission within 30-days of a discharge to home.

BACKGROUND

Before measures can be put in place to facilitate discharge planning and to prevent unplanned readmission by recently discharged patients, those at risk of such events must be identified.

METHODS

Project involved an analysis of 13-months of administrative data from one tertiary care hospital. Utility of the BRASS was examined in terms of its sensitivity and specificity as well as its positive and negative predictive values.

RESULTS

Majority (83%) of hospital discharges were to home. Approximately 7% of patients experienced at least one readmission within 30-days of being discharged to home. Using scores of 10 or higher as an indicator of risk, BRASS exhibited a high degree of specificity suggesting it is useful for 'ruling in' those who have the outcomes-of-interest. However low sensitivity indicates many who experienced the outcomes were incorrectly classified by the BRASS as low risk. The low positive predictive value for 30-day readmission also suggests many who were classified by the BRASS as being 'at risk' were not readmitted.

CONCLUSION

The observed rate of 30-day readmission is likely conservative as the analysis involved data from only one acute care facility. One explanation for the low positive predictive value for 30-day readmission is that completion of the BRASS on admission enabled the implementation of preventive measures.

Management of care transition and hospital discharge

Current demographic and epidemiological trends highlight a growing task in surgical departments by elderly patients, characterized by high prevalence of comorbidity, complexity, and functional disability. Of consequence, discharge of an elderly patient must be considered in a new cultural perspective and should be imagined as a well-structured process starting from admission to surgical department and finishing with the patient discharge in a setting able to support her/him in the best possible way. The lack of a suitable discharge planning and of a proper transition program in the elderly subjects increases the risk of quick re-admission and may negatively affect the functional and the status quality of life of patients and caregivers. To reduce the risk of negative outcome it is essential a hospital organization dedicated to the discharge of frail older patients considering: (1) adequate attention to assess the comprehensive clinical/social/care conditions; (2) respect of the expectations of the patient and her/his relatives; (3) formalization of institutional roles or teams designated to the planning and coordination of discharge; (4) good knowledge of management programs of transitional care, and (5) strong communication/information ability in patients transition between hospital, home care and community settings.

Prediction of post-acute care demand in medical and neurological inpatients: diagnostic assessment of the post-acute discharge score - a prospective cohort study

BACKGROUND

Early identification of patients requiring transfer to post-acute care (PAC) facilities shortens hospital stays. With a focus on interprofessional assessment of biopsychosocial risk, this study's aim was to assess medical and neurological patients' post-acute care discharge (PACD) scores on days 1 and 3 after hospital admission regarding diagnostic accuracy and effectiveness as an early screening tool. The transfer to PAC facilities served as the outcome ("gold standard").

METHODS

In this prospective cohort study, registered at ClinicalTrial.gov (NCT01768494) on January 2013, 1432 medical and 464 neurological patients (total n = 1896) were included consecutively between February and October 2013. PACD scores and other relevant data were extracted from electronic records of patient admissions, hospital stays, and interviews at day 30 post-hospital admission. To gauge the scores' accuracy, we plotted receiver operating characteristic (ROC) curves, calculated area under the curve (AUC), and determined sensitivity and specificity at various cut-off levels.

RESULTS

Medical patients' day 1 and day 3 PACD scores accurately predicted discharge to PAC facilities, with respective discriminating powers (AUC) of 0.77 and 0.82. With a PACD cut-off of ≥8 points, day 1 and 3 sensitivities were respectively 72.6% and 83.6%, with respective specificities of 66.5% and 70.0%. Neurological patients' scores showed lower accuracy both days: using the same cut-off, respective day 1 and day 3 AUCs were 0.68 and 0.78, sensitivities 41.4% and 68.7% and specificities 81.4% and 83.4%.

CONCLUSION

PACD scores at days 1 and 3 accurately predicted transfer to PAC facilities, especially in medical patients on day 3. To confirm and refine these results, PACD scores' value to guide discharge planning interventions and subsequent impact on hospital stay warrants further investigation.

TRIAL REGISTRATION

ClinialTrials.gov Identifier, NCT01768494 .

BRASS score and complex discharge: a pilot study

Aims:

A highly functional continuity of patient care, which is linked to the reduction of the risk of long-term hospitalization, above all for ‘at-risk’ patients. Research into an objective, reliable instrument for redirecting individual results to organizational aims to extend the entire country, is a fundamental step to move from a reactive assistance approach to a pro-active one.

Methods:

An observational and descriptive retrospective study was carried out July - November 2014 in two Italian state hospitals, completing the BRASS Index within 48/72 hours of admission.

Results:

The study group consisted of 122 inpatients. A correlation presented itself, albeit low (ρ=0.05191), between age and the number of ‘revolving door’ admissions; a medium correlation (ρ=0.485131) between age and risk band (according to BRASS).

Conclusions:

The BRASS Index is straightforward and swift, and can prove a valuable tool in directing nurses’ attention to those patients most at risk of prolonged hospitalization. (www.actabiomedica.it)

Caregivers' misperception of the severity of hip fractures

PURPOSE

The aim of our study was to evaluate how the caregiver of a hip fracture patient perceives the patient's health status and autonomy in the period immediately preceding the acute event and whether these judgments are actually in line with the prognosis predicted by the medical team caring for the patient in the rehabilitation structure.

PATIENTS AND METHODS

We enrolled 147 patients of both sexes, aged ≥65 years, who were referred to our center following surgical treatment of hip fractures of various nature. At the beginning of the rehabilitation program, each patient's caregiver was asked to complete the Blaylock Risk Assessment Screening Score (BRASS) questionnaire. The same questionnaire was compiled contemporaneously by the doctor taking care of the patient.

RESULTS

Analysis of the data shows that the caregivers tend to assign lower scores than the doctor, with a mean difference in agreement with the Bland-Altman plot of -2.43, 95% CI=-2.93 to -1.93, t-test P<0.001. Furthermore, differences in objectivity emerge in the evaluation of the clinical problems of the patient in a borderline clinical condition.

CONCLUSION

This study revealed that caregivers systematically misperceive the clinical situation of hip fracture patients prior to the acute event. Altered perception of such an important factor can lead to a general lack of satisfaction with the outcome achieved by the patient at the end of the rehabilitation process. We therefore believe that an adequate, effective communication between the people making up the health care team and the patient's social and family network is the foundation of the rehabilitation process. It is precisely on this foundation that the individual's care and assistance need to be assembled.

The Transition of Care Between Emergency Department and Primary Care: A Scoping Study

OBJECTIVES

Patients with chronic diseases are often forced to seek emergency care for exacerbations. In the face of large predicted increases in the prevalence of chronic diseases, there is increased pressure to avoid hospitalizing these patients at the end of the ED visit, if they can obtain the care they need in the outpatient setting. We performed this scoping study to provide a broad overview of the published literature on the transition of care between ED and primary care following ED discharge.

METHODS

We performed a MEDLINE search of English-language articles published between 1990 and March 2015. We created a data-charting form a priori of the search. Papers were organized into themes, with new themes created when none of the existing themes matched the paper. Papers with multiple themes were assigned preferentially to the theme that was consistent with their primary objectives. We created a descriptive numerical summary of the included studies.

RESULTS

Of 1,138 titles, there were 252 potentially relevant abstracts, and among those 122 met criteria for full paper review. An additional 11 papers were acquired from reference review. From the 133 papers, 85 were included in the study. The papers were categorized into seven themes. These included Follow-up compliance and its predictors (38 studies), Telephone calls to discharged ED patients (15 studies), ED navigators (14 studies), The current system (nine studies), Ways to alert primary care providers (PCPs) of the ED visit (seven studies), and Patient views and PCP information requirements (one each). In the Follow-up compliance and predictors theme, the two most frequently identified significant predictors for increasing the frequency of follow-up care were the provision of a follow-up appointment time prior to ED departure and the presence of health insurance. Follow-up telephone calls to patients resulted in better follow-up rates, but increased ED return visits in some studies. In the current system patients themselves are the conduit, and the barriers to follow-up care can be high. E-mail and/or electronic medical record alerts to the PCP are relatively new, and no studies limited the alerts to patients who had a defined need for follow-up care.

CONCLUSIONS

A plethora of work has been published on the transition of care from ED to primary care. To decrease hospitalizations among the upcoming wave of patients with chronic diseases, it appears that the two most efficient areas to target are a primary care follow-up appointment system and health insurance. Further research is needed in particular to identify the patients who actually need follow-up care and to develop information technology solutions that can be effectively implemented within the current emergency healthcare system.

The Impact of Introducing Restorative Care on Client Outcomes and Health System Effectiveness in an Integrated Health Authority

To support the transition from hospital to community for adults 65 years and older, a restorative care unit was introduced within a regional health authority in Newfoundland and Labrador. A pre-post study design was used to evaluate the impacts of restorative care. This article describes the impact of restorative care on client outcomes and health system utilization. All patients discharged from restorative care during the first year of operation were included in the study. A total of 54 clients were discharged during the first year, with 70% being discharged to a community setting. Consistent with previous studies, statistically significant improvements were noted in function as measured using the modified Barthel Index of Activities of Daily Living and fear of falling as measured using the Fall Efficacy Scale–International. The number of alternate level of care patients in acute care and their length of acute care stay did not decrease during our study period. However, an interesting change was observed: The number of applications for long-term care initiated in acute care decreased. Further examination of the long-term outcomes of discharged patients and of the factors influencing health system outcomes is suggested.

Factors affecting in-hospital informal caregiving as decided by families: findings from a longitudinal study conducted in acute medical units

BACKGROUND

Informal caregiving offered by family members has been widely studied in the community setting, but little attention to date has been dedicated to that offered at the hospital level.

AIMS

To describe the proportion of patients admitted to acute medical units receiving care from informal caregivers as decided by the family and to identify the factors affecting the numbers of care shifts performed by informal caregivers.

DESIGN AND METHODS

A longitudinal study was performed involving 12 acute medical units located in 12 northern Italian hospitals.

RESULTS

All patients (N = 1464) admitted to medical units were included, and 77.1% of them received at least one shift of informal care during their in-hospital stay, especially during the mornings and afternoons. At the patient level, those at higher risk of prolonged hospitalisation and difficult discharge at admission, and those reporting higher occurrence of adverse events, such as pressure sores, confusion events and use of physical restraints during hospitalisation, were more likely receiving informal care. At the nursing care level, a higher amount of missed nursing care was associated with an increased number of care shifts offered by informal caregivers during patient hospitalisation, whereas the amount of care offered by staff was a protective factor.

CONCLUSIONS

Families play a care role in the care of older patients admitted to acute medical units. They contribute substantially to the care of patients, especially during morning and afternoon shifts.

A comorbidity prognostic effect on post-hospitalization outcome in a geriatric rehabilitation setting: the pivotal role of functionality, assessed by mediation model, and association with the Brass index

BACKGROUND

Discharge planning is a critical feature of hospital's care in geriatric rehabilitation centers. The aim of this study was to evaluate the effects of comorbidity and functionality in identifying patients who are at risk of discharge problems. We also evaluate the association between Blaylock Risk Assessment Screening Score, BRASS index (BI), and post-hospitalization outcome (PHO).

METHODS

Eighty patients (58 women and 22 men, with mean age equal to 83.28 ± 6.77 years) at geriatric rehabilitation division admission were screened with Geriatric Multidimensional Assessment (GMA). Then, BI and PHO were evaluated (mean follow-up time was 205.1 ± 95.8 days). By Structural Equation Model, we evaluated the existing causal relationships between comorbidity, functionality and PHO, elements of GMA, and the association between PHO and BI.

RESULTS

Comorbidity acted on PHO through functionality with indirect effect only (+0.703, P = 0.019). So, the functionality assumes a pivotal role of the causal relationship comorbidity to PHO. BI is positively associated with PHO: correlation returned was equal to +0.313 (P = 0.019).

CONCLUSIONS

The comorbidity has a role in getting worse PHO, but its effect is possible only through the mediation of functional status. The study also demonstrated the positive association between BI and PHO.

Moderate efficiency of clinicians' predictions decreased for blurred clinical conditions and benefits from the use of BRASS index. A longitudinal study on geriatric patients' outcomes

OBJECTIVES

Accurate prognosis is an essential aspect of good clinical practice and efficient health services, particularly for chronic and disabling diseases, as in geriatric populations. This study aims to examine the accuracy of clinical prognostic predictions and to devise prediction models combining clinical variables and clinicians' prognosis for a geriatric patient sample.

STUDY DESIGN AND SETTING

In a sample of 329 consecutive older patients admitted to 10 geriatric units, we evaluated the accuracy of clinicians' prognosis regarding three outcomes at discharge: global functioning, length of stay (LoS) in hospital, and destination at discharge (DD). A comprehensive set of sociodemographic, clinical, and treatment-related information were also collected.

RESULTS

Moderate predictive performance was found for all three outcomes: area under receiver operating characteristic curve of 0.79 and 0.78 for functioning and LoS, respectively, and moderate concordance, Cohen's K = 0.45, between predicted and observed DD. Predictive models found the Blaylock Risk Assessment Screening Score together with clinicians' judgment relevant to improve predictions for all outcomes (absolute improvement in adjusted and pseudo-R(2) up to 19%).

CONCLUSION

Although the clinicians' estimates were important factors in predicting global functioning, LoS, and DD, more research is needed regarding both methodological aspects and clinical measurements, to improve prognostic clinical indices.

Efficacy of emergency department-based interventions designed to reduce repeat visits and other adverse outcomes for older patients after discharge: A systematic review

AIM

There is an urgent need for effective geriatric interventions to meet the health service demands of the growing older population. In this paper, we systematically review and update existing literature on interventions within emergency departments (ED) targeted towards reducing ED re-visits, hospitalizations, nursing home admissions and deaths in older patients after initial ED discharge.

METHODS

Databases Medline, CINAHL, Embase and Web of Science were searched to identify all articles published up to June 2012 that focused on older adults in the ED, included a comparison group, and reported quantitative results in four primary outcomes: ED re-visits, hospitalizations, nursing home admissions and death after initial ED discharge.

RESULTS

Of the 2826 titles screened, just nine studies met our inclusion criteria. The studies varied in their design and outcome measurements such that results could not be combined. Two trends surfaced: (i) more intensive interventions more frequently resulted in reduced adverse outcomes than did simple referral intervention types; and (ii) among the lowest intensity, referral-based interventions, studies that used a validated prediction tool to identify high-risk patients more frequently reported improved outcomes than those that did not use such a tool.

CONCLUSION

Of the few studies that met the inclusion criteria, there was a lack of consistency and clarity in study designs and evaluative outcomes. Despite this, more intensive interventions that followed patients beyond a referral and the use of a clinical risk prediction tool appeared to be associated with improved outcomes. The dearth of rigorous evaluations with standardized methodologies precludes further recommendations.

Can the Blaylock Risk Assessment Screening Score (BRASS) predict length of hospital stay and need for comprehensive discharge planning for patients following hip and knee replacement surgery? Predicting arthroplasty planning and stay using the BRASS

BACKGROUND

Knee and hip arthroplasty constitutes a large percentage of hospital elective surgical procedures. The Blaylock Risk Assessment Screening Score (BRASS) was designed to identify patients in need of discharge planning. The purpose of this study was to evaluate whether the BRASS was associated with length of stay (LOS) in hospital following elective arthroplasty.

METHODS

We retrospectively reviewed the charts of individuals undergoing primary elective arthroplasty for knee or hip osteoarthritis who had a documented BRASS score.

RESULTS

In our study cohort of 241, both BRASS (p < 0.001) and replacement type (hip v. knee; p = 0.048) were predictive of LOS. Higher BRASS was associated with older patients (p < 0.001), higher American Society of Anesthesiologists score (p < 0.001) and longer LOS (p < 0.001). We found a specificity of 83% for a BRASS greater than 8 and a hospital stay longer than 5 days and a specificity of 92% for a BRASS greater than 10.

CONCLUSION

The BRASS represents a novel and significant predictor of LOS following elective arthroplasty. Patients with higher BRASS are more likely to stay in hospital 5 days or more and should receive pre-emptive social work consultations to facilitate timely discharge planning and hospital resources.

Hospital discharge: results from an Italian multicenter prospective study using Blaylock Risk Assessment Screening Score

PURPOSE

To analyze the predictive validity and reliability of the Blaylock Risk Assessment Screening Score (BRASS) Index in a large group of patients.

METHODS

Prospective multicenter observational study was conducted in six Italian hospitals. Data were collected in three phases.

FINDINGS

Seven hundred eleven patients were recruited. The mean length of hospitalization for low-risk patients was significantly shorter than those in the medium and high-risk groups. Patients with a BRASS Index lower than 10, unlike those with a higher BRASS Index, were mainly discharged home.

CONCLUSIONS

Our results indicate that the BRASS Index is useful to identify patients at risk for prolonged hospitalization.

CLINICAL RELEVANCE

The use of a validated BRASS instrument can be useful to screen the patients, improving individual discharge planning.

Measurement properties of the occupational therapy discharge needs screen

BACKGROUND

Pre-discharge home assessments are integral to discharge planning; however, there is no screening tool identifying clients with complex needs.

PURPOSE

To determine the inter- and intrarater reliability and predictive and concurrent validity of the Occupational Therapy Discharge Needs Screen (OTDNS), a screening tool that identifies clients with more complex discharge needs.

METHODS

The OTDNS Functional Independence Measure (FIM) and Functional Autonomy Measurement System (SMAF) were administered to 89 participants.

FINDINGS

Intrarater reliability was ICC = 0.93 (95% CI 0.90 - 0.96) (n = 89). Interrater reliability was ICC = 0.53 (95% CI 0.27- 0.70) (n = 89) with the initial OTDNS instructions, and ICC = 0.91 (95% CI 0.62 - 0.96) (n = 10) with revised OTDNS instructions. The OTDNS had an inverse relationship with the FIM (r = -0.51; p < 0.001) and a positive relationship with the SMAF (r = 0.64; p < 0.001). A score of > 7/28 had a sensitivity = 75% and specificity = 40% when predicting occupational therapy home assessment post-discharge.

IMPLICATIONS

The OTDNS has potential to contribute to continuity and efficiency of the discharge-planning process.

The impact of early emergency department allied health intervention on admission rates in older people: a non-randomized clinical study

BACKGROUND

This study sought to determine whether early allied health intervention by a dedicated Emergency Department (ED) based team, occurring before or in parallel with medical assessment, reduces hospital admission rates amongst older patients presenting with one of ten index problems.

METHODS

A prospective non-randomized trial in patients aged sixty five and over, conducted in two Australian hospital EDs. Intervention group patients, receiving early comprehensive allied health input, were compared to patients that received no allied health assessment. Propensity score matching was used to compare the two groups due to the non-randomized nature of the study. The primary outcome was admission to an inpatient hospital bed from the ED.

RESULTS

Of five thousand two hundred and sixty five patients in the trial, 3165 were in the intervention group. The admission rate in the intervention group was 72.0% compared to 74.4% in the control group. Using propensity score probabilities of being assigned to either group in a conditional logistic regression model, this difference was of borderline statistical significance (p = 0.046, OR 0.88 (0.76-1.00)). On subgroup analysis the admission rate in patients with musculoskeletal symptoms and angina pectoris was less for those who received allied health intervention versus those who did not. This difference was significant.

CONCLUSIONS

Early allied health intervention in the ED has a significant but modest impact on admission rates in older patients. The effect appears to be limited to a small number of common presenting problems.

Relationship between pre-discharge occupational therapy home assessment and prevalence of post-discharge falls

RATIONALE, AIMS AND OBJECTIVE

Pre-discharge occupational therapy home assessments are common practice, and considered important for falls prevention in older people. This prospective, observational cohort study describes the association between pre-discharge home assessment and falls in the first month post-discharge from a rehabilitation hospital.

METHODS

342 inpatients were recruited and followed up 1 month post-discharge. Patients were classified into diagnostic groups (cardiac, orthopaedic trauma, spinal, peripheral joint surgery, neurological and deconditioned). Age, gender, falls risk [Falls Risk Assessment Scoring System (FRASS)], functional independence scores (FIM™) and receipt (or not) of a home assessment were recorded. Patients completed a diary to document post-discharge falls. Logistic regression analysis tested the effect on falling of receiving a home assessment, age, gender, diagnostic group, FRASS and FIM™.

RESULTS

Considering all subjects, not receiving a home assessment increased the risk of falling 1 month post-discharge [odds ratio (OR) 2.6, 95% confidence interval (CI) 1.4-4.7, P=0.003]. Neurological and orthopaedic trauma patients had significantly elevated risks of falling [OR (95% CI), respectively, 12.5 (4.7-33.2), 3.4 (1.4-8.4)] relative to the orthopaedic joint group. For all diagnostic groups except neurological, falls risk was mitigated by a home assessment. In non-neurological patients, adjusting for the effect of diagnostic group, FRASS and FIM™ scores indicated a significant association between not receiving a home assessment and falling (OR 4.2, 95% CI 2.1-8.2, P<0.001).

CONCLUSIONS

Pre-discharge occupational therapy home assessments are sound post-discharge falls-prevention strategies in non-neurological patients. The decision to conduct a home assessment should consider diagnosis, falls risk and functional independence.

Predicting functional adverse outcomes in hospitalized older patients: a systematic review of screening tools

BACKGROUND

Functional decline frequently occurs following hospitalisation in older people and may be prevented or minimized by specific management. Such care processes needs appropriate early screening of older hospitalized patients.

OBJECTIVE

To identify instruments able to detect on admission older hospitalized patients at risk of functional decline at and after discharge.

METHODS

Functional decline is defined as loss of independence in activities of daily living (functional decline) or admission in nursing home. The systematic search used Medline 1970-2007, Web of Science 1981-2007 and references list of relevant papers. An independent epidemiologist assessed methodological quality of the retained articles.

RESULTS

We found 12 studies developing predictive tools, including 7145 patients. Functional outcomes were assessed at or after discharge. Preadmission functional status, cognition, and social support were major components for prediction of functional evolution. Few instruments are fully validated and data concerning reliability are often lacking. Operational characteristics are moderate (sensitivity 29-87%, negative likelihood ratio 0.2-0.8).

CONCLUSIONS

Instruments predicting functional adverse outcomes are difficult to compare due to heterogeneity of functional outcomes and hospital settings. The reason why so many tools have been developed is probably because none gives full satisfaction: their general predictive validity and performances are insufficient. Further research is needed to improve the screening of frail older patients admitted to hospital with standardized and validated tools.

Factors influencing hospital readmission rates after acute medical treatment

It is a concern that increasing pressure to diagnose, treat and discharge patients rapidly is leading to unacceptably high readmission rates. Readmissions were studied over a two-month period. Patients were identified through the hospital coding system, and electronic discharge summaries provided details of each admission. In total, 69 readmissions were identified, representing 4.34% of medical admissions. Readmitted patients were older than those with single admissions (median age 75 and 71 years, respectively; p < 0.05). Initial length of stay was greater in those patients who would go on to be readmitted (median six days; single admission, two days; p < 0.0001). Seventy-one per cent of readmissions were deemed avoidable, with discharge before conclusive therapy being the leading factor implicated (56%). Readmission is more likely in older patients with complex care needs. Rapid throughput of patients is not associated with readmission. The majority of readmissions can potentially be avoided with judicious medical care.

Telephone follow-up improves patients satisfaction following hospital discharge

BACKGROUND

Many patients encounter problems in the first weeks after discharge from hospital. Telephone follow-up (TFU) is reputed to be a good tool for providing medical advice, managing symptoms, identifying complications and giving reassurance after discharge. Therefore, we aimed to study whether tight TFU would increase patient satisfaction, improve compliance and reduce re-hospitalization rate.

METHODS

The study population included 400 patients, hospitalized in an Internal Medicine Department, randomly divided into two groups; TFU and control. TFU took place one week and one month after discharge. Three months later, members of both groups were contacted by telephone.

RESULTS

Satisfaction was increased in the TFU group compared with control group by 6-12% in most fields. Notably, 87% of patients in the TFU group indicated that earlier telephone contact increased their satisfaction. In addition, 78.2% of the patients in the control group reported that they performed the tests that were recommended at discharge and 86.5% reported that they received explanations regarding their medications. In the TFU group, this percentage was increased significantly to 86.9% (P=0.02) and 96.7% (P<0.0001), respectively. As to treatment results, 93% of the patients in the TFU group as compared to 84% in the control group reported improvement in their symptoms. A non-significant trend towards fewer readmission was observed in the TFU group (26% vs. 35% P=0.062).

CONCLUSIONS

TFU can improve medical treatment by increasing satisfaction and compliance. A trend towards decreased readmission rates was observed, which may lead to a reduction in the burden on the medical system.

A predictive score to identify hospitalized patients' risk of discharge to a post-acute care facility

BACKGROUND

Early identification of patients who need post-acute care (PAC) may improve discharge planning. The purposes of the study were to develop and validate a score predicting discharge to a post-acute care (PAC) facility and to determine its best assessment time.

METHODS

We conducted a prospective study including 349 (derivation cohort) and 161 (validation cohort) consecutive patients in a general internal medicine service of a teaching hospital. We developed logistic regression models predicting discharge to a PAC facility, based on patient variables measured on admission (day 1) and on day 3. The value of each model was assessed by its area under the receiver operating characteristics curve (AUC). A simple numerical score was derived from the best model, and was validated in a separate cohort.

RESULTS

Prediction of discharge to a PAC facility was as accurate on day 1 (AUC: 0.81) as on day 3 (AUC: 0.82). The day-3 model was more parsimonious, with 5 variables: patient's partner inability to provide home help (4 pts); inability to self-manage drug regimen (4 pts); number of active medical problems on admission (1 pt per problem); dependency in bathing (4 pts) and in transfers from bed to chair (4 pts) on day 3. A score > or = 8 points predicted discharge to a PAC facility with a sensitivity of 87% and a specificity of 63%, and was significantly associated with inappropriate hospital days due to discharge delays. Internal and external validations confirmed these results.

CONCLUSION

A simple score computed on the 3rd hospital day predicted discharge to a PAC facility with good accuracy. A score > 8 points should prompt early discharge planning.

Early prediction of the need for non-routine discharge planning for the elderly

Successful home return from hospital admission is a key issue to provide quality healthcare in a society with numerous older subjects. Therefore, a screening method for early identification of patients who require intensive, non-routine discharge planning needs to be established. We have developed a 7-item screening sheet (the screening sheet at admission: SSA) and conducted a prospective cohort study to examine its usefulness in predicting the need for non-routine discharge planning. The SSA score yielded an area under receiver operating characteristic curve of 0.82. Moreover, a cutoff score of 2 or higher gave sensitivity, specificity and positive and negative predictive values of 0.82, 0.72, 0.13 and 0.99, respectively. A stepwise logistic regression model demonstrated that age of 75 years or more and impairment in basic activities of daily living (ADL) were significantly associated with requirement for non-routine discharge planning in surgical patients, while living alone or with a spouse aged 75 or older and readmission within 1 month were also significant predictors in medical patients. The SSA score may be useful in identifying patients who need further assessment and planning. While the four items were particularly important predictors, differences between medical and surgical patients should also be considered.

Emergency department case-finding for high-risk older adults: the Brief Risk Identification for Geriatric Health Tool (BRIGHT)

OBJECTIVE

The objective was to test the ability of the Brief Risk Identification for Geriatric Health Tool (BRIGHT) to identify older emergency department (ED) patients with functional and physical impairment.

METHODS

This was a cross-sectional study in which 139 persons > or = 75 years, who presented to an urban New Zealand ED over a 12-week period, completed the 11-item BRIGHT case-finding tool. Then, within 10 days of their index ED visit, 114 persons completed a comprehensive geriatric assessment. A "yes" response to at least 3 of the 11 BRIGHT items was considered "positive." Primary outcome measures were instrumental activities of daily living (IADL), cognitive performance scale (CPS), and activities of daily living (ADL).

RESULTS

The BRIGHT-identified IADL deficit (64% prevalence) with a sensitivity of 0.76, specificity of 0.79, and receiver operating characteristic (ROC) of 0.83 (95% confidence interval [CI] = 0.74 to 0.91, p < 0.01); cognitive deficit (35% prevalence) sensitivity of 0.78, specificity of 0.54, and ROC of 0.66 (95% CI = 0.55 to 0.76, p = 0.006); and ADL deficit (29% prevalence) sensitivity of 0.83, specificity of 0.53, and ROC of 0.64 (95% CI = 0.53 to 0.75, p = 0.020). Positive likelihood ratios (LR+) for the three outcomes of interest were 3.6, 1.7, and 1.8, respectively. Negative likelihood ratios (LR-) were 0.3, 0.4, and 0.3.

CONCLUSIONS

The 11-item BRIGHT successfully identifies older adults in the ED with decreased function and may be useful in differentiating elder patients in need of comprehensive assessment.

Discharge planning: communication, education and patient participation

For the most part, discharge from hospital is routine and uneventful. However, for a percentage of people, discharge from acute care requires careful planning to ensure continuity of care. This is particularly the case with older patients who have complex medical needs. This literature review reveals that the essential elements for discharge planning are: communication, coordination, education, patient participation and collaboration between medical personnel. Outcomes measures of successful discharge planning include patient satisfaction and quality of life. Smooth and efficient coordination of this process reduces stress and anxiety for the patient, family, nurse, doctor, hospital and community services.

Interventions aimed at reducing problems in adult patients discharged from hospital to home: a systematic meta-review

BACKGROUND

Many patients encounter a variety of problems after discharge from hospital and many discharge (planning and support) interventions have been developed and studied. These primary studies have already been synthesized in several literature reviews with conflicting conclusions. We therefore set out a systematic review of the reviews examining discharge interventions. The objective was to synthesize the evidence presented in literature on the effectiveness of interventions aimed to reduce post-discharge problems in adults discharged home from an acute general care hospital.

METHODS

A comprehensive search of seventeen literature databases and twenty-five websites was performed for the period 1994-2004 to find relevant reviews. A three-stage inclusion process consisting of initial sifting, checking full-text papers on inclusion criteria, and methodological assessment, was performed independently by two reviewers. Data on effects were synthesized by use of narrative and tabular methods.

RESULTS

Fifteen systematic reviews met our inclusion criteria. All reviews had to deal with considerable heterogeneity in interventions, populations and outcomes, making synthesizing and pooling difficult. Although a statistical significant effect was occasionally found, most review authors reached no firm conclusions that the discharge interventions they studied were effective. We found limited evidence that some interventions may improve knowledge of patients, may help in keeping patients at home or may reduce readmissions to hospital. Interventions that combine discharge planning and discharge support tend to lead to the greatest effects. There is little evidence that discharge interventions have an impact on length of stay, discharge destination or dependency at discharge. We found no evidence that discharge interventions have a positive impact on the physical status of patients after discharge, on health care use after discharge, or on costs.

CONCLUSION

Based on fifteen high quality systematic reviews, there is some evidence that some interventions may have a positive impact, particularly those with educational components and those that combine pre-discharge and post-discharge interventions. However, on the whole there is only limited summarized evidence that discharge planning and discharge support interventions have a positive impact on patient status at hospital discharge, on patient functioning after discharge, on health care use after discharge, or on costs.

Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home

BACKGROUND

It is known that many patients encounter a variety of problems in the first weeks after they have been discharged from hospital to home. In recent years many projects have addressed discharge planning, with the aim of reducing problems after discharge. Telephone follow-up (TFU) is seen as a good means of exchanging information, providing health education and advice, managing symptoms, recognising complications early, giving reassurance and providing quality aftercare service. Some research has shown that telephone follow-up is feasible, and that patients appreciate such calls. However, at present it is not clear whether TFU is also effective in reducing postdischarge problems.

OBJECTIVES

To assess the effects of follow-up telephone calls in the first month post discharge, initiated by hospital-based health professionals, to patients discharged from hospital to home.

SEARCH STRATEGY

We searched the following databases from their start date to July 2003, without limits as to date of publication or language: the Cochrane Consumers and Communication Review Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), PubMed, EMBASE (OVID), BiomedCentral, CINAHL, ERIC (OVID), INVERT (Dutch nursing literature index), LILACS, Picarta (Dutch library system), PsycINFO/PsycLIT (OVID), the Combined Social and Science Citation Index Expanded (SCI-E), SOCIOFILE. We searched for ongoing research in the following databases: National Research Register (http://www.update-software.com/nrr/); Controlled Clinical Trials (http://www.controlled-trials.com/); and Clinical Trials (http://clinicaltrials.gov/). We searched the reference lists of included studies and contacted researchers active in this area.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of TFU initiated by a hospital-based health professional, for patients discharged home from an acute hospital setting. The intervention was delivered within the first month after discharge; outcomes were measured within 3 months after discharge, and either the TFU was the only intervention, or its effect could be analysed separately.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and for methodological quality. The methodological quality of included studies was assessed using the criteria from the Cochrane Effective Practice and Organisation of Care Review Group. The data-extraction form was based on the template developed by the Cochrane Consumers and Communication Review Group. Data was extracted by one review author and checked by a second author. For as far it was considered that there was enough clinical homogeneity with regard to patient groups and measured outcomes, statistical pooling was planned using a random effects model and standardised mean differences for continuous scales and relative risks for dichotomous data, and tests for statistical heterogeneity were performed.

MAIN RESULTS

We included 33 studies involving 5110 patients. Predominantly, the studies were of low methodological quality. TFU has been applied in many patient groups. There is a large variety in the ways the TFU was performed (the health professionals who undertook the TFU, frequency, structure, duration, etc.). Many different outcomes have been measured, but only a few were measured across more than one study. Effects are not constant across studies, nor within patient groups. Due to methodological and clinical diversity, quantitative pooling could only be performed for a few outcomes. Of the eight meta-analyses in this review, five showed considerable statistical heterogeneity. Overall, there was inconclusive evidence about the effects of TFU.

AUTHORS' CONCLUSIONS

The low methodological quality of the included studies means that results must be considered with caution. No adverse effects were reported. Nevertheless, although some studies find that the intervention had favourable effects for some outcomes, overall the studies show clinically-equivalent results between TFU and control groups. In summary, we cannot conclude that TFU is an effective intervention.

Inter-organizational continuity of care and the electronic patient record: A concept development

There is an expectation that the use of electronic patient records will contribute to continuity of care across organizations for the growing number of elderly and chronically ill people who need continuing nursing care after an episode of hospitalization. This article aims to explore the concept of inter-organizational continuity of care and to address the contribution, expectations and promises associated with the advent of the electronic patient record. A content analysis of the literature concerning concept development provided a model which indicates that inter-organizational continuity is a multidimensional concept, comprising individual and organizational perspectives with qualitative and quantitative properties.

Prospective evaluation of a screen for complex discharge planning in hospitalized adults

OBJECTIVES

To test the predictive ability of the Probability of Repeated Admission (PRA) screen for nonroutine discharge planning (requiring new referrals for formal services).

DESIGN

Prospective cohort.

SETTING

Two hospitals within a large Midwestern, tertiary care, referral-based system.

PARTICIPANTS

Nine hundred ninety-one hospitalized adults identified using a systematic sampling strategy.

MEASUREMENTS

The PRA screen was administered, and use of nonroutine discharge planning resources and nonroutine discharge disposition were determined using observation and open record review. Prolonged length of stay was determined by comparing the actual length of stay with the combined average length of stay for diagnosis-related groupings.

RESULTS

Significant differences in PRA scores existed in two of three endpoints, but the differences were small, and the ranges of scores overlapped almost completely. Using, logistic regression, items predicting use of nonroutine discharge-planning resources were self-rated health, caregiver availability, age, and sex (chi-square (chi2) = 105.7, df = 9, P <.001), accounting for 17.9% of the variability and area under receiver operating characteristic curve (AUC) of 0.74. Self-rated health and sex predicted prolonged length of stay (chi2 = 15.3, df = 5, P =.009), but only explained 2.2% of the variability, with an AUC of 0.58. The predictors of nonroutine discharge disposition were self-rated health, caregiver availability, age, sex, and diabetes mellitus (chi2 = 125.8, df = 11, P <.001), accounting for 23.0% of the variability, with an AUC of 0.79.

CONCLUSION

The clinical utility of using the PRA as a screen for early identification of persons who use nonroutine discharge planning is limited, although certain individual items may be useful.