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Albanesi B, Conti A, Politano G, Dimonte V, Gianino MM, Campagna S. Emergency department visits by nursing home residents. A retrospective Italian study of administrative databases from 2015 to 2019. BMC Geriatr 2024; 24:295. [PMID: 38549053 PMCID: PMC10976813 DOI: 10.1186/s12877-024-04912-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 03/21/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Visits to Emergency Departments (ED) can be traumatic for Nursing Home (NH) residents. In Italy, the rate of ED visits by NH residents was recently calculated as 3.3%. The reduction of inappropriate ED visits represents a priority for National Healthcare Systems worldwide. Nevertheless, research on factors associated with ED visits is still under-studied in the Italian setting. This study has two main aims: (i) to describe the baseline characteristics of NH residents visiting ED at regional level; (ii) to assess the characteristics, trends, and factors associated with these visits. METHODS A retrospective study of administrative data for five years was performed in the Piedmont Region. Data from 24,208 NH residents were analysed. Data were obtained by merging two ministerial databases of residential care and ED use. Sociodemographic and clinical characteristics of the residents, trends, and rates of ED visits were collected. A Generalized Linear Model (GLM) regression was used to evaluate the factors associated with ED visits. RESULTS In 5 years, 12,672 residents made 24,609 ED visits. Aspecific symptoms (45%), dyspnea (17%) and trauma (16%) were the most frequent problems reported at ED. 51% of these visits were coded as non-critical, and 58% were discharged to the NH. The regression analysis showed an increased risk of ED visits for men (OR = 1.61, 95% CI 1.51-1.70) and for residents with a stay in NH longer than 400 days (OR = 2.19, 95% CI 2.08-2.31). CONCLUSIONS Our study indicates that more than half of NH residents' ED visits could potentially be prevented by treating residents in NH. Investments in the creation of a structured and effective network within primary care services, promoting the use of health technology and palliative care approaches, could reduce ED visits and help clinicians manage residents on-site and remotely.
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Affiliation(s)
- Beatrice Albanesi
- Department of Sciences of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, Turin, 10126, Italy
| | - Alessio Conti
- Department of Sciences of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, Turin, 10126, Italy.
| | - Gianfranco Politano
- Department of Control and Computer Engineering, Politecnico di Torino, Turin, Italy
| | - Valerio Dimonte
- Department of Sciences of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, Turin, 10126, Italy
| | - Maria Michela Gianino
- Department of Sciences of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, Turin, 10126, Italy
| | - Sara Campagna
- Department of Sciences of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, Turin, 10126, Italy
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Mäki LJ, Kontunen PJ, Kaartinen JM, Castrén MK. Value-based care of older people-The impact of an acute outreach service unit on emergency medical service missions: A quasi-experimental study. Scand J Caring Sci 2024; 38:169-176. [PMID: 37807498 DOI: 10.1111/scs.13220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 08/31/2023] [Accepted: 09/23/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Transfers to the emergency department can be burdensome for the residents of long-term residential care facilities (LTRCFs) and often lead to adverse effects. Since March 2019, a nurse-led acute outreach service unit "Mobile hospital" (in Finnish, Liikkuva sairaala, LiiSa) has been providing on-site care to LTRCF residents to reduce transfers to the emergency department. METHODS This study compares the numbers and acuities of emergency medical service (EMS) missions carried out in the LTRCFs of Espoo and Kauniainen during two six-month periods: before the implementation of LiiSa and with LiiSa in use. In Finland, EMS missions are divided into four categories (A-D), with category A missions being the most urgent. These categories were used to investigate the impact on mission acuities. RESULTS Due to the implementation of LiiSa, the number of EMS missions decreased by 16.8% (95% confidence interval 10.6%-22.6%, p < 0.001), the number of category D missions by 19.8% (7.1%-30.8%, p = 0.003) and the number of category C missions by 30.3% (17.3%-41.3%, p < 0.001). Changes in the numbers of category A and B missions were not statistically significant. CONCLUSIONS LiiSa helped to avoid many transfers of frail LTRCF patients to the emergency department, and it did not hinder the care of patients with true emergencies by EMSs.
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Affiliation(s)
- Lauri J Mäki
- Department of Emergency Medicine and Services, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Perttu J Kontunen
- Department of Emergency Medicine and Services, Helsinki University and Helsinki University Hospital, Helsinki, Finland
- Päijät-Häme Social and Health Care, Lahti, Finland
| | - Johanna M Kaartinen
- Department of Emergency Medicine and Services, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Maaret K Castrén
- Department of Emergency Medicine and Services, Helsinki University and Helsinki University Hospital, Helsinki, Finland
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Langhoop K, Habbinga K, Greiner F, Hoffmann F. [Characteristics of older versus younger emergency patients : Analysis of over 356,000 visits from the AKTIN German emergency department data registry]. Med Klin Intensivmed Notfmed 2024; 119:18-26. [PMID: 36331564 PMCID: PMC10803396 DOI: 10.1007/s00063-022-00968-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/22/2022] [Accepted: 09/23/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND This nationwide study aims to analyze age-specific differences and characteristics of emergency patients with a special focus on older patients. METHOD In 2019, data were obtained from 11 emergency departments (EDs), all part of the German Emergency Department Data (AKTIN) registry. All patients 18 years and older visiting the EDs were included. In addition to demographic data, variables such as referral, type of transport, primary assessment, diagnoses, length of stay and type of transfer were recorded and compared by age group and specifically by younger (18-64 years) and older patients (65+ years). RESULTS Data from 356,354 patients (39.1% were aged 65+ years) were included. Compared to younger patients, older ED patients were more likely to be accompanied by emergency medical services (15.4 vs. 34.3%) and almost twice as often by an emergency physician (6.4 vs. 12.2%). The need for treatment increased with age; 47.1% of younger and 66.1% of older people were classified as yellow, orange or red. The proportion of patients with internal diseases was higher for patients 65+ years (22.5 vs. 38.8%). Older patients were more often hospitalized (27.5 vs. 60.3%) and were more frequently transferred to an intensive care unit (4.5 vs. 11.9%). CONCLUSION About 40% of adult emergency patients are 65+ years. They require more urgent treatment and are more often hospitalized than younger patients. In older patients, internal diseases were more common.
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Affiliation(s)
- Katharina Langhoop
- Department für Versorgungsforschung, Fakultät VI - Medizin und Gesundheitswissenschaften, Carl von Ossietzky Universität Oldenburg, Ammerländer Heerstraße 114-118, 26129, Oldenburg, Deutschland.
| | - Kirsten Habbinga
- Medizinischer Campus Universität Oldenburg, Pius-Hospital Oldenburg, Oldenburg, Deutschland
| | - Felix Greiner
- Universitätsklinik für Unfallchirurgie, Otto-von-Guericke-Universität Magdeburg, Magdeburg, Deutschland
- Zentralinstitut für Arbeitsmedizin und Maritime Medizin (ZfAM), Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg, Deutschland
| | - Falk Hoffmann
- Department für Versorgungsforschung, Fakultät VI - Medizin und Gesundheitswissenschaften, Carl von Ossietzky Universität Oldenburg, Ammerländer Heerstraße 114-118, 26129, Oldenburg, Deutschland
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Özkaytan Y, Schulz-Nieswandt F, Zank S. Acute Health Care Provision in Rural Long-Term Care Facilities: A Scoping Review of Integrated Care Models. J Am Med Dir Assoc 2023; 24:1447-1457.e1. [PMID: 37488029 DOI: 10.1016/j.jamda.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 07/26/2023]
Abstract
OBJECTIVES We aimed to map integrated care models for acute health care in rural long-term care facilities (LTCFs) for future investigation. DESIGN Systematic scoping review. SETTING AND PARTICIPANTS Residential LTCFs in rural areas worldwide. METHODS The common health-related online databases were systematically searched complemented by a manual search of gray literature. Following the 5-stage framework of Arksey and O'Malley, the extent of included literature was identified and findings were summarized using qualitative meta-summary. RESULTS A total of 35 references were included for synthesis, predominantly primary research on completed and ongoing projects reporting on integrated health care services in rural LTCFs. Incorporating previous research, we extracted 5 approaches of integrated acute-health care models: (1) Availability of Specialists, (2) Networks, (3) Quality Management (QM) and Organization, (4) Telemedicine, and (5) Telehealth. CONCLUSIONS AND IMPLICATIONS This research presents the result of a literature review examining integrated care models as a way to improve acute health care in LTCFs in rural areas. Integrated care models in rural settings can help face the challenging situation and fulfil the complex health care needs of LTCF residents by reducing fragmentation and thereby improve continuity and coordination of acute health care services. These results can guide policy making in creating interventions and support adequate implementation of care models by knowledge translation in health care.
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Affiliation(s)
- Yasemin Özkaytan
- Faculty of Human Sciences, Graduate School GROW-Gerontological Research on Well-being, University of Cologne, Cologne, Germany.
| | - Frank Schulz-Nieswandt
- Department of Social Policy and Methods of Qualitative Social Research, Faculty of Management, Economics and Social Sciences, University of Cologne, Cologne, Germany
| | - Susanne Zank
- Faculty of Human Sciences, Rehabilitative Gerontology, University of Cologne, Cologne, Germany
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Huang GY, Kumar M, Liu X, Irwanto D, Zhou Y, Chirapa E, Xu YH, Shulruf B, Chan DKY. Telemedicine vs Face-to-Face for Nursing Home Residents With Acute Presentations: A Noninferiority Study. J Am Med Dir Assoc 2023; 24:1471-1477. [PMID: 37419143 DOI: 10.1016/j.jamda.2023.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 07/09/2023]
Abstract
OBJECTIVES Telemedicine and face-to-face outreach services to nursing homes (NHs) have been used to reduce hospital utilization rates for acute presentations. However, how these modalities compare against each other is unclear. This article examines if the management of acute presentations in NHs with care involving telemedicine is noninferior to care delivered face-to-face. DESIGN A noninferiority study was conducted on a prospective cohort. Face-to-face intervention involved on-site assessment by a geriatrician and aged care clinical nurse specialist (CNS). Telemedicine intervention involved on-site assessment by an aged care CNS with telemedicine input by a geriatrician. SETTING AND PARTICIPANTS A total of 438 NH residents with acute presentations from 17 NHs between November 2021 and June 2022. METHODS Between-group differences in proportion of residents successfully managed on-site and mean number of encounters were evaluated using bootstrapped multiple linear regression; 95% CIs were compared against predefined noninferiority margins with noninferiority P values calculated. RESULTS In the adjusted models, care involving telemedicine demonstrated noninferiority in the difference in proportion of residents successfully managed on-site (95% CI lower limit -6.2% to -1.4% vs -10% noninferiority margin; P < .001 for noninferiority) but not in the difference in mean number of encounters (95% CI upper limit 1.42 to 1.50 encounters vs 1 encounter noninferiority margin; P = .7 for noninferiority). CONCLUSIONS AND IMPLICATIONS In our model of care, care that involved telemedicine was noninferior to care delivered face-to-face in managing NH residents with acute presentations on-site. However, additional encounters may be required. Application of telemedicine ought to be tailored to fit the needs and preferences of stakeholders.
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Affiliation(s)
- Gary Y Huang
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Manoj Kumar
- Department of Aged Care and Rehabilitation, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
| | - Xinsheng Liu
- Department of Aged Care and Rehabilitation, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
| | - Deni Irwanto
- Department of Aged Care and Rehabilitation, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
| | - You Zhou
- Department of Aged Care and Rehabilitation, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
| | - Ethel Chirapa
- Department of Aged Care and Rehabilitation, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
| | - Ying H Xu
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia; Department of Aged Care and Rehabilitation, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
| | - Boaz Shulruf
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Daniel K Y Chan
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia; Department of Aged Care and Rehabilitation, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia.
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Kristensen GS, Kjeldgaard AH, Søndergaard J, Andersen-Ranberg K, Pedersen AK, Mogensen CB. Associations between care home residents' characteristics and acute hospital admissions - a retrospective, register-based cross-sectional study. BMC Geriatr 2023; 23:234. [PMID: 37072701 PMCID: PMC10114422 DOI: 10.1186/s12877-023-03895-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/15/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Care home residents are frail, multi-morbid, and have an increased risk of experiencing acute hospitalisations and adverse events. This study contributes to the discussion on preventing acute admissions from care homes. We aim to describe the residents' health characteristics, survival after care home admission, contacts with the secondary health care system, patterns of admissions, and factors associated with acute hospital admissions. METHOD Data on all care home residents aged 65 + years living in Southern Jutland in 2018-2019 (n = 2601) was enriched with data from highly valid Danish national health registries to obtain information on characteristics and hospitalisations. Characteristics of care home residents were assessed by sex and age group. Factors associated with acute admissions were analysed using Cox Regression. RESULTS Most care home residents were women (65.6%). Male residents were younger at the time of care home admission (mean 80.6 vs. 83.7 years), had a higher prevalence of morbidities, and shorter survival after care home admission. The 1-year survival was 60.8% and 72.3% for males and females, respectively. Median survival was 17.9 months and 25.9 months for males and females, respectively. The mean rate of acute hospitalisations was 0.56 per resident-year. One in four (24.4%) care home residents were discharged from the hospital within 24 h. The same proportion was readmitted within 30 days of discharge (24.6%). Admission-related mortality was 10.9% in-hospital and 13.0% 30 days post-discharge. Male sex was associated with acute hospital admissions, as was a medical history of various cardiovascular diseases, cancer, chronic obstructive pulmonary disease, and osteoporosis. In contrast, a medical history of dementia was associated with fewer acute admissions. CONCLUSION This study highlights some of the major characteristics of care home residents and their acute hospitalisations and contributes to the ongoing discussion on improving or preventing acute admissions from care homes. TRIAL REGISTRATION Not relevant.
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Affiliation(s)
- Gitte Schultz Kristensen
- Emergency Department, Aabenraa Hospital, Department of Regional Health Research, Faculty of Health Science, University Hospital of Southern Jutland, University of Southern Denmark, Odense, Denmark.
| | | | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Karen Andersen-Ranberg
- Geriatric Research Unit, Department of Clinical Research, Department of Public Health, Department of Regional Health Research, Faculty of Health Science, Clinical research Department, Aabenraa Hospital, University of Southern Denmark University Hospital of Southern Denmark, Odense, Denmark
| | - Andreas Kristian Pedersen
- Department of Regional Health Research, Faculty of Health Science, Emergency Department, Aabenraa Hospital, The University of Southern Denmark, University Hospital of Southern Denmark, Odense, Denmark
| | - Christian Backer Mogensen
- Department of Regional Health Research, Faculty of Health Science, Emergency Department, Aabenraa Hospital, The University of Southern Denmark, University Hospital of Southern Denmark, Odense, Denmark
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Marincowitz C, Preston L, Cantrell A, Tonkins M, Sabir L, Mason S. What influences decisions to transfer older care-home residents to the emergency department? A synthesis of qualitative reviews. Age Ageing 2022; 51:6834152. [PMID: 36413591 PMCID: PMC9681131 DOI: 10.1093/ageing/afac257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND care home residents aged over 65 have disproportionate rates of emergency department (ED) attendance and hospitalisation. Around 40% attendances may be avoidable, and hospitalisation is associated with harms. We synthesised the evidence available in qualitative systematic reviews of different stakeholders' experiences of decisions to transfer residents to the ED. METHODS six electronic databases, references and citations of included reviews and relevant policy documents were searched. Reviews of qualitative studies exploring factors that influenced care home staff, medical practitioners, residents' family or residents' experiences and factors influencing decisions to transfer residents to the ED were included. Thematic analysis was used to synthesise findings. RESULTS six previous reviews were included, which synthesised the findings of 34 primary studies encompassing 152 care home residents, 283 resident family members or carers and 447 care home staff. Of the primary studies, 19 were conducted in the North America, seven in Australia, five were conducted in Scandinavia, two in the United Kingdom and one in Holland. Three themes were identified: (i) power dynamics between residents, family members, care home staff and health care professionals (external to the care home) influence decisions; (ii) admission can be necessary; however, (iii) some decisions may be driven by factors other than clinical need. CONCLUSION transfer decisions are complex and are determined not just by changes in health status interventions aimed at reducing avoidable transfers need to address the key role family members have in transfer decisions, the medical legal fears of care home staff and barriers to accessing community services.
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Affiliation(s)
- Carl Marincowitz
- Address correspondence to: Carl Marincowitz, Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK.
| | - Louise Preston
- Health Economics and Decision Science, Health Services Research School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Anna Cantrell
- Health Economics and Decision Science, Health Services Research School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Michael Tonkins
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
| | - Lisa Sabir
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
| | - Suzanne Mason
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, S1 4DA, UK
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Long KM, Haines TP, Clifford S, Sundram S, Srikanth V, Macindoe R, Leung W, Hlavac J, Enticott J. English language proficiency and hospital admissions via the emergency department by aged care residents in Australia: A mixed-methods investigation. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e4006-e4019. [PMID: 35318761 PMCID: PMC10078708 DOI: 10.1111/hsc.13794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 11/25/2021] [Accepted: 03/02/2022] [Indexed: 06/14/2023]
Abstract
Residents of Residential Age Care Facilities (RACFs) have particularly high rates of Emergency Department (ED) visits, with up to 55% being potentially avoidable (e.g. not resulting in a hospital admission). This is concerning as ED visits by RACF residents are associated with negative outcomes including longer hospital stays, iatrogenic illness, complications and mortality. Limited English proficiency (LEP) has significant negative impacts on the healthcare quality and outcomes for older people but has not been studied as a factor in ED visits from RACFs. This study aimed to examine if RACF residents with LEP have a lower rate of hospital admission via the ED compared to non-LEP controls and identify any associated factors. We hypothesised that LEP-related communication difficulties would reduce the ability to manage minor health issues in the RACF, leading to a lower proportion of LEP ED transfers being admitted. We used a parallel mixed-methods design, comprising a quantitative matched cohort study of ED visit data from two Local Hospital Networks (LHNs) in South-East Melbourne, Australia and secondary thematic analysis of 25 interviews with LEP residents, family carers and staff from two RACFs in the same region. We found no differences in the proportion of hospital ED transfers that led to admission (LHN1, 87.1% LEP, 85.6% non-LEP controls, p = 0.57; LHN2, 76.0% LEP, 76.9% non-LEP controls, p = 0.41) and no direct qualitative evidence suggesting that resident LEP affected decisions to transfer residents to ED, despite communication difficulties being reported during the transfer process. These results may be due to the high level of family carer involvement in residents' care identified in the qualitative study. However, additional research using different measures of LEP is recommended to further explore a broader range of cultural and linguistic factors in both rates of ED presentations and the decision-making processes underpinning resident transfers to ED.
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Affiliation(s)
- Katrina M. Long
- School of Primary and Allied Health CareMonash UniversityFrankstonVictoriaAustralia
| | - Terry P. Haines
- School of Primary and Allied Health CareMonash UniversityFrankstonVictoriaAustralia
| | - Sharon Clifford
- Department of General PracticeSchool of Public Health and Preventive MedicineMonash UniversityNotting HillVictoriaAustralia
| | - Suresh Sundram
- Department of PsychiatrySchool of Clinical SciencesMonash UniversityClaytonVictoriaAustralia
- Mental Health ProgramMonash HealthClaytonVictoriaAustralia
| | - Velandai Srikanth
- Peninsula HealthFrankstonVictoriaAustralia
- Peninsula Clinical SchoolCentral Clinical SchoolMonash UniversityFrankstonVictoriaAustralia
- National Centre for Healthy AgeingFrankstonVictoriaAustralia
| | - Rob Macindoe
- SEHCP Inc. (t/a enliven)DandenongVictoriaAustralia
| | - Wing‐Yin Leung
- Department of Psychological SciencesSchool of Health SciencesSwinburne University of TechnologyHawthornVictoriaAustralia
- National Ageing Research InstituteParkvilleVictoriaAustralia
| | - Jim Hlavac
- Translation and Interpreting StudiesSchool of Languages, Literatures, Cultures and LinguisticsMonash UniversityClaytonVictoriaAustralia
| | - Joanne Enticott
- Monash Centre for Health Research and ImplementationClaytonVictoriaAustralia
- Southern SynergyDepartment of PsychiatrySchool of Clinical Sciences, Monash UniversityClaytonVictoriaAustralia
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Cen Z, Li J, Hu H, Lei KC, Loi CI, Liang Z, Chan TF, Ung COL. Exploring the implementation of an outreach specialist program for nursing home residents in Macao: A multisite, qualitative study. Front Public Health 2022; 10:950704. [PMID: 36249183 PMCID: PMC9558699 DOI: 10.3389/fpubh.2022.950704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/25/2022] [Indexed: 01/22/2023] Open
Abstract
Background The "Specialist Medical Outreach Project (SMOP)" involving inter-disciplinary hospital-based healthcare professionals is a government initiative that aims to provide integrative specialist care to high-risk residents at the nursing homes. However, research exploring the implementation and impact of SMOP is lacking. This study aimed to evidence the impact of SMOP on the quality of care at the nursing home and the key contextual determinants influencing SMOP outcomes. Method Semi-structured key informant audio-recorded face-to-face interviews were conducted with eight managers, six doctors, 28 nursing staff, and seven pharmacy staff at the nursing homes participating in the SMOP to collect insights about how SMOP was operated and performed, and the impact of SMOP as observed and expected. Participants were recruited with purposive sampling. A thematic analysis approach was employed and key themes were identified using open coding, grouping, and categorizing. Results Forty-nine interviews were conducted. Thematic analysis identified three principal themes: the overall perception about SMOP, the benefits as observed; and the areas of improvement. Together with the 10 subthemes, the results highlighted the expectations for SMOP to address the unmet needs and promote patient-centered care, and the benefits of SMOP in supporting effective use of resources for the nursing home, reducing the risks of adverse events for the residents, promoting communication and capacity building for the healthcare providers and facilitating efficient use of healthcare resources for the health system. Requests for more frequent visits by a larger inter-disciplinary specialist team were raised. Careful staff and workflow planning, and mechanisms for data-sharing and communication across care settings were deemed the most important actions for improvement. Conclusion It is a general perception that the SMOP is beneficial in enhancing the quality of care for high-risk residents in the nursing home in Macao. Cross-sector inter-disciplinary collaboration and efficient data-sharing and communication mechanism play a crucial role in ensuring the success of the program. A robust assessment framework to monitor and evaluate the cost-effectiveness of the program is yet to be developed.
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Affiliation(s)
- Zhifeng Cen
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao SAR, China
| | - Junlei Li
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao SAR, China
| | - Hao Hu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao SAR, China,Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Taipa, Macao SAR, China
| | - Ka Cheng Lei
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao SAR, China
| | - Cheng I Loi
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao SAR, China
| | - Zuanji Liang
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao SAR, China
| | - Tek Fai Chan
- Macao Society for Medicinal Administration, Taipa, Macao SAR, China
| | - Carolina Oi Lam Ung
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao SAR, China,Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Taipa, Macao SAR, China,*Correspondence: Carolina Oi Lam Ung
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Marincowitz C, Preston L, Cantrell A, Tonkins M, Sabir L, Mason S. Factors associated with increased Emergency Department transfer in older long-term care residents: a systematic review. THE LANCET. HEALTHY LONGEVITY 2022; 3:e437-e447. [PMID: 36098321 DOI: 10.1016/s2666-7568(22)00113-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 01/15/2023] Open
Abstract
The proportion of adults older than 65 years is rapidly increasing. Care home residents in this age group have disproportionate rates of transfer to the Emergency Department (ED) and around 40% of attendances might be avoidable. We did a systematic review to identify factors that predict ED transfer from care homes. Six electronic databases were searched. Observational studies that provided estimates of association between ED attendance and variables at a resident or care home level were included. 26 primary studies met the inclusion criteria. Seven common domains of factors assessed for association with ED transfer were identified and within these domains, male sex, age, presence of specific comorbidities, polypharmacy, rural location, and care home quality rating were associated with likelihood of ED transfer. The identification of these factors provides useful information for policy makers and researchers intending to either develop interventions to reduce hospitalisations or use adjusted rates of hospitalisation as a care home quality indicator.
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Affiliation(s)
- Carl Marincowitz
- Centre for Urgent and Emergency Care Research (CURE), Health Services Research, School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Louise Preston
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Michael Tonkins
- Centre for Urgent and Emergency Care Research (CURE), Health Services Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Lisa Sabir
- Centre for Urgent and Emergency Care Research (CURE), Health Services Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Suzanne Mason
- Centre for Urgent and Emergency Care Research (CURE), Health Services Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
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11
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Giacomini G, Minutiello E, Politano G, Dalmasso M, Albanesi B, Campagna S, Gianino MM. Trajectories and determinants of emergency department use among nursing home residents: a time series analysis (2012-2019). BMC Geriatr 2022; 22:418. [PMID: 35549898 PMCID: PMC9101855 DOI: 10.1186/s12877-022-03078-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background Emergency department (ED) use among nursing home (NH) residents is an internationally-shared issue that is understudied in Italy. The long term care in Italy is part of the health system. This study aimed to assess trajectories of ED use among NH residents and determinants between demographic, health supply, clinical/functional factors. Methods A pooled, cross-sectional, time series analysis was performed in an Italian region in 2012/2019. The analysis measured the trend of ED user percentages associated with chronic conditions identified at NH admission. A GLM multivariate model was used to evaluate determinants of ED use. The variables collected were sex, age, assistance intensity, destination after discharge from NH, chronic conditions at NH admission, need for daily life assistance, degree of mobility, cognitive impairments, behavioural disturbances and were taken from two databases of the official Italian National Information System (FAR and C2 registries) that were combined to create a unique and anonymous code for each patient. Results A total of 37,311 residents were enrolled; 55.75% (20,800 residents) had at least one ED visit. The majority of the residents had cardiovascular (25.99%) or mental diseases (24.37%). In all pathologies, the percentage of ED users decreased and the decrease accelerated over time. These results were confirmed in the fixed effects regression model (coefficient for linear term (b = − 3.6177, p = 0, 95% CI = [− 5.124, − 2.1114]); coefficient for quadratic term = − 0.7691, p = 0.0046, 95% CI = [− 1.2953, − 0.2429]). Analysis showed an increased odds of ED visits involving males (OR = 1.27, 95% CI 1.24;1.30) and patients affected by urogenital diseases (OR = 1.16, 95% CI [1.031–1.314]). The lowest odds of ED visits were observed among subjects aged > 90 years (OR = 0.64, 95% CI [0.60–0.67]), who required assistance for their daily life activities (OR = 0.86; 95% CI = [0.82, 0.91]), or with serious cognitive disturbances (OR = 0.86; 95% CI = [0.84, 0.89]), immobile (OR = 0.93; 95% CI = [0.89, 0.96]), or without behavioural disturbances (OR = 0.92; 95% CI = [0.90, 0.94]). Conclusions The percentage of ED users has decreased, through support from the Italian disciplinary long-term care system. The demographic, clinical/functional variables associated with ED visits in this study will be helpful to develop targeted and tailored interventions to avoid unnecessary ED use.
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Affiliation(s)
- Gianmarco Giacomini
- Department of Public Health Sciences and Pediatrics, Università di Torino, Via Santena 5 bis, 10126, Torino, Italy
| | - Ettore Minutiello
- Department of Public Health Sciences and Pediatrics, Università di Torino, Via Santena 5 bis, 10126, Torino, Italy
| | - Gianfranco Politano
- Department of Control and Computer Engineering, Politecnico di Torino, Torino, Italy
| | - Marco Dalmasso
- Unit of Epidemiology- Local Health Unit TO3, Via Sabaudia 164, Turin, Grugliasco, Italy
| | - Beatrice Albanesi
- Department of Public Health Sciences and Pediatrics, Università di Torino, Via Santena 5 bis, 10126, Torino, Italy
| | - Sara Campagna
- Department of Public Health Sciences and Pediatrics, Università di Torino, Via Santena 5 bis, 10126, Torino, Italy
| | - Maria Michela Gianino
- Department of Public Health Sciences and Pediatrics, Università di Torino, Via Santena 5 bis, 10126, Torino, Italy.
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12
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Conroy S, Thomas M. Urgent care for older people. Age Ageing 2022; 51:6146885. [PMID: 33620421 DOI: 10.1093/ageing/afab019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Geriatric medicine is the clinical specialty that focuses upon the care of older people-especially those with frailty (a state of increased vulnerability). In hospital, older people living with frailty are at high risk of developing a range of unpleasant outcomes such as delirium, falls, fractures, pressure sores and death. Comprehensive geriatric assessment is a form of holistic care that incorporates a specific set of clinical competencies that are able to reduce these adverse outcomes. Over the years, geriatric medicine has moved from being more of a community-based service towards a more acute specialty-encroaching now upon emergency department care. The challenge now is to work out how best to deliver geriatric care across the whole hospital (older people with frailty are not just cared for in geriatric wards!). The themed collection published on the Age & Ageing journal website outlines key articles that are attempting to develop solutions to this challenging conundrum. We hope that you enjoy reading them.
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Affiliation(s)
- Simon Conroy
- Department of Health Sciences, University of Leicester, Leicester LE1 7RH, UK
| | - Matt Thomas
- Department of Medicine for Older People, Poole Hospital, Poole BH15 2JB, UK
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13
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Hullick C, Conway J, Barker R, Hewitt J, Darcy L, Attia J. Supporting residential aged care through a Community of Practice. Nurs Health Sci 2021; 24:330-340. [PMID: 34939738 DOI: 10.1111/nhs.12917] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 12/12/2021] [Accepted: 12/13/2021] [Indexed: 11/27/2022]
Abstract
Transfers to Emergency Departments and hospitalizations are common for older people living in residential aged care who experience acute deterioration. This paper shares reflections from 10 years of work across a region in New South Wales, Australia, to develop a new model of care in141 residential aged care homes. The model successfully reduced Emergency Department transfers and admissions to hospital. Using an exemplar patient case, the paper describes the Aged Care Emergency Program and associated research outputs. An interprofessional, multi-agency Community of Practice supported this work. The authors reflect on the successes and challenges of using a Community of Practice to implement the model of care. We conclude that the Community of Practice, with its iterative evaluation, facilitated change and provided a mechanism for interprofessional practice. Broader systemic change requires clarity in goals of care, shared decision-making, working across sectors, and appropriate resource allocation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Carolyn Hullick
- Hunter New England Local Health District, Lookout Rd, New Lambton Heights, NSW, Australia.,College of Health, Medicine and Wellbeing, University of Newcastle, University Drive, Callaghan, NSW, Australia.,Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, NSW, Australia
| | - Jane Conway
- College of Health, Medicine and Wellbeing, University of Newcastle, University Drive, Callaghan, NSW, Australia
| | - Roslyn Barker
- Hunter New England Local Health District, Lookout Rd, New Lambton Heights, NSW, Australia
| | - Jacqueline Hewitt
- Hunter New England Central Coast Primary Health Network, Newcastle, NSW, Australia
| | - Leigh Darcy
- Hunter Primary Care Newcastle NSW 2300, Australia
| | - John Attia
- Hunter New England Local Health District, Lookout Rd, New Lambton Heights, NSW, Australia.,College of Health, Medicine and Wellbeing, University of Newcastle, University Drive, Callaghan, NSW, Australia.,Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, NSW, Australia
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14
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Curtis F, Jayawickrama WIU, Laparidou D, Weligamage D, Kumarawansha WKWS, Ortega M, Siriwardena AN. Perceptions and experiences of residents and relatives of emergencies in care homes: a systematic review and metasynthesis of qualitative research. Age Ageing 2021; 50:1925-1934. [PMID: 34591971 PMCID: PMC8581376 DOI: 10.1093/ageing/afab182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 07/05/2021] [Indexed: 11/30/2022] Open
Abstract
Background the perceptions and experiences of care home residents and their families are important for understanding and improving the quality of emergency care. Methods we conducted a systematic review and metasynthesis to understand the perceptions and experiences of care home residents and their family members who experienced medical emergencies in a care home setting. The review protocol was registered in PROSPERO (CRD42020167018). We searched five electronic databases, MEDLINE, CINAHL, PubMed, Cochrane Library and PsycINFO, supplemented with internet searches and forward and backward citation tracking from included studies and review articles. Data were synthesised thematically following the Thomas and Harden approach. The Critical Appraisal Skills Programme qualitative checklist was used to assess the quality of studies included in this review. Results of the 6,140 references retrieved, 10 studies from four countries (Australia, Canada, UK and USA) were included in the review and metasynthesis. All the included studies were assessed as being of good quality. Through an iterative approach, we developed six analytical themes: (i) infrastructure and process requirements in care homes to prevent and address emergencies; (ii) the decision to transfer to hospital; (iii) experiences of transfer and hospitalisation for older patients; (iv) good communication is vital for desirable outcomes; (v) legal, regulatory and ethical concerns and (vi) trusting relationships enabled residents to feel safe. Conclusions the emergency care experience for care home residents can be enhanced by ensuring resources, staff capacity and processes for high quality care and trusting relationships between staff, patients and relatives, underpinned by good communication and attention to ethical practice.
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Affiliation(s)
- Ffion Curtis
- Lincoln International Institute of Rural Health, University of Lincoln, Lincoln, Lincolnshire, UK
| | - Withanage Iresha Udayangani Jayawickrama
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, Lincolnshire, UK
- Postgraduate Institute of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Despina Laparidou
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, Lincolnshire, UK
| | - Dedunu Weligamage
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, Lincolnshire, UK
- Postgraduate Institute of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Weerapperuma Kankanamge Wijaya Sarathchandra Kumarawansha
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, Lincolnshire, UK
- Postgraduate Institute of Medicine, University of Colombo, Colombo, Sri Lanka
| | | | - Aloysius Niroshan Siriwardena
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, Lincolnshire, UK
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15
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Ho P, Lim Y, Tan LLC, Wang X, Magpantay G, Chia JWK, Loke JYC, Sim LK, Low JA. Does an Integrated Palliative Care Program Reduce Emergency Department Transfers for Nursing Home Palliative Residents? J Palliat Med 2021; 25:361-367. [PMID: 34495751 DOI: 10.1089/jpm.2021.0241] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Nursing homes (NHs) are faced with a myriad of challenges to provide quality palliative care to residents who are at their end of life. Objectives: To describe and examine the impact of the GeriCare Palliative Care Program, which comprises telemedicine, on-site clinical preceptorship, palliative care education program, and Advance Care Planning (ACP) advocacy in reducing emergency department (ED) transfers from NHs. Design: Retrospective cohort study. Setting/Subjects: A total of 217 telemedicine consults were conducted for 187 unique NH residents across 5 NHs in Singapore over a 27-month period from April 2018 to June 2020. Measurement: Records of all enrolled palliative care residents who were triaged by telemedicine consultations were examined. Results: Our findings revealed that 82% of our urgent telemedicine consultations have successfully averted ED transfers. Gender and completion of ACP were statistically significant between ED transfer group and non-ED transfer group. Among those who completed their ACP, 78.3% of the ED transfer group chose limited intervention as their main goals of care compared with 30% in the non-ED transfer group. Conclusions: The GeriCare Palliative Care Program is a novel program, which is developed to improve the quality of palliative care in NHs. The comprehensive GeriCare model comprises a systematic framework, an integration of clinical support, ACP advocacy, and education program. Our findings demonstrated that these interventions synergistically led to a reduction in ED transfers while optimizing the residents' quality of care. By carrying out the targeted initiatives to support NHs, the residents could age-in-place comfortably.
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Affiliation(s)
- Peiyan Ho
- Department of Geriatric Medicine, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Yujun Lim
- GeriCare, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Laurence Lean Chin Tan
- GeriCare, Khoo Teck Puat Hospital, Singapore, Singapore.,Department of Geriatric Medicine and Palliative Medicine, Khoo Teck Puat Hospital, Singapore, Singapore.,Geriatric Education and Research Institute (GERI), Singapore, Singapore
| | - Xingli Wang
- GeriCare, Khoo Teck Puat Hospital, Singapore, Singapore
| | | | | | | | - Lai Kiow Sim
- Palliative Care, Khoo Teck Puat Hospital, Singapore, Singapore
| | - James Alvin Low
- Department of Geriatric Medicine, Khoo Teck Puat Hospital, Singapore, Singapore.,GeriCare, Khoo Teck Puat Hospital, Singapore, Singapore.,Geriatric Education and Research Institute (GERI), Singapore, Singapore
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16
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Dai J, Liu F, Irwanto D, Kumar M, Tiwari N, Chen J, Xu Y, Smith M, Chan DKY. Impact of an acute geriatric outreach service to residential aged care facilities on hospital admissions. Aging Med (Milton) 2021; 4:169-174. [PMID: 34553113 PMCID: PMC8444962 DOI: 10.1002/agm2.12176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/22/2021] [Accepted: 08/23/2021] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Residential aged care facility (RACF) residents frequently present to the emergency department (ED) and are often admitted to hospital. Some presentations and admissions may be avoidable. In 2013, Bankstown-Lidcombe Hospital introduced a subacute geriatric outreach service (SGOS), which had little impact on reducing ED presentations. In 2015, Bankstown-Lidcombe Hospital introduced an acute geriatric outreach service (AGOS), a geriatrician-led team that assesses and treats acutely unwell patients in RACFs. We aim to determine whether the AGOS reduces the risk of hospital admission for RACF residents. METHODS Hospital admissions data from 2010 to 2019 were used to conduct an interrupted time series (ITS) analysis. AGOS activity data were also summarized. RESULTS The average number of admissions from RACF per month declined from 42.8 during the SGOS period to 27.1 during the AGOS period. The difference of 15.7 admissions from RACF per month was statistically significant (95% CI 12.1-19.2; P < .001). After the introduction of the AGOS, the risk of admission to our geriatric department from RACFs was reduced by 36.1% (incidence rate ratio =0.64; 95% CI: 0.58-0.71; P < .001) compared to the SGOS period, adjusting for seasonality. DISCUSSION The AGOS probably reduced the risk of hospital admission for RACF residents.
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Affiliation(s)
- Jun Dai
- Aged Care and Rehabilitation DepartmentBankstown‐Lidcombe HospitalBankstownNSWAustralia
| | - Frank Liu
- Aged Care and Rehabilitation DepartmentBankstown‐Lidcombe HospitalBankstownNSWAustralia
| | - Deni Irwanto
- Aged Care and Rehabilitation DepartmentBankstown‐Lidcombe HospitalBankstownNSWAustralia
| | - Manoj Kumar
- Aged Care and Rehabilitation DepartmentBankstown‐Lidcombe HospitalBankstownNSWAustralia
| | - Nabaraj Tiwari
- Aged Care and Rehabilitation DepartmentBankstown‐Lidcombe HospitalBankstownNSWAustralia
| | - Jack Chen
- Ingham Institute & Simpson Centre for Health Services ResearchSWS Clinical School/UNSWSydneyNSWAustralia
| | - Yinghua Xu
- Aged Care and Rehabilitation DepartmentBankstown‐Lidcombe HospitalBankstownNSWAustralia
- Ingham Institute & Simpson Centre for Health Services ResearchSWS Clinical School/UNSWSydneyNSWAustralia
| | - Matthew Smith
- Aged Care and Rehabilitation DepartmentBankstown‐Lidcombe HospitalBankstownNSWAustralia
| | - Daniel KY Chan
- Aged Care and Rehabilitation DepartmentBankstown‐Lidcombe HospitalBankstownNSWAustralia
- Ingham Institute & Simpson Centre for Health Services ResearchSWS Clinical School/UNSWSydneyNSWAustralia
- Faculty of MedicineUniversity of New South WalesKensingtonNSWAustralia
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17
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Venkatesh AK, Gettel CJ, Mei H, Chou SC, Rothenberg C, Liu SL, D'Onofrio G, Lin Z, Krumholz HM. Where Skilled Nursing Facility Residents Get Acute Care: Is the Emergency Department the Medical Home? J Appl Gerontol 2021; 40:828-836. [PMID: 32842827 PMCID: PMC7904961 DOI: 10.1177/0733464820950125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES This study aimed to characterize the distribution of acute care visits among Medicare beneficiaries receiving skilled nursing facility (SNF) services. METHODS We conducted a cross-sectional analysis of a 20% sample of continuously enrolled Medicare beneficiaries in the 2012 Chronic Condition Warehouse data set. Beneficiaries were grouped by the number of days of SNF services, and acute care visits were categorized as "before SNF," "during SNF," or "after SNF." RESULTS Among the 10,717,786 Medicare beneficiaries analyzed, 384,312 (3.6%) had at least one SNF stay. DISCUSSION Beneficiaries who received SNF services had a higher proportion of acute care visits made to emergency departments (EDs) than beneficiaries who did not receive SNF services. Also, a higher proportion of acute care visits were made to EDs by beneficiaries after a SNF stay in comparison to residents actively residing in a SNF. The acute care capabilities of SNFs and post-SNF transitions of care to the community setting are discussed.
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Affiliation(s)
| | | | - Hao Mei
- Yale School of Medicine, New Haven, CT, USA
| | - Shih-Chuan Chou
- Yale School of Medicine, New Haven, CT, USA
- Brigham and Women's Hospital, Boston, MA, USA
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18
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Martínez-Casal X, Rodriguez-Sánchez JL, Otero-Espinar FJ. Budget impact analysis of two pharmaceutical management models in relation to the administration of intravenous anti-infective therapy in a Spanish nursing home. Eur J Hosp Pharm 2021; 28:212-216. [PMID: 34162672 DOI: 10.1136/ejhpharm-2019-001989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 06/27/2019] [Accepted: 08/13/2019] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To perform a cost-effectiveness and budget impact analysis from the perspective of the Spanish public healthcare system (SHS) to compare the number of overnight hospital stays avoided under a community and a hospital pharmacy model due to the administration of intravenous anti-infective therapy (IVAT) at a nursing home with 145 beds. METHODS Analytical, observational, retrospective cohort study of a nursing home in Galicia (north-west Spain) that switched from a community to a hospital pharmaceutical management model. We compared the number of IVAT administrations, the number of hospital transfers and stays avoided, and mean annual costs avoided by the SHS before and after the switch. Costs were calculated using official SHS rates. RESULTS The switch from the community to the hospital pharmacy model resulted in 2.8 more IVAT administrations (95% CI, 2.71 to 2.88) and 20.79 fewer overnight hospital stays (95% CI, 20.07 to 21.51) per 100 nursing home beds a month (p<0.001). The net monthly avoided cost for the SHS was 9971.52 €2019. The budget impact analysis showed that implementation of this model throughout Galicia and Spain would respectively avoid costs of 13.78 and 221.21 million €2019 a year. CONCLUSIONS Hospital pharmacy models can contribute to a better optimisation of public healthcare resources and help improve the sustainability of the SHS.
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Affiliation(s)
| | | | - Francisco Javier Otero-Espinar
- Department of Pharmacy and Pharmaceutical Technology, University of Santiago de Compostela, Santiago de Compostela, Spain
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19
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Carter HE, Lee XJ, Farrington A, Shield C, Graves N, Cyarto EV, Parkinson L, Oprescu FI, Meyer C, Rowland J, Dwyer T, Harvey G. A stepped-wedge randomised controlled trial assessing the implementation, effectiveness and cost-consequences of the EDDIE+ hospital avoidance program in 12 residential aged care homes: study protocol. BMC Geriatr 2021; 21:347. [PMID: 34090368 PMCID: PMC8179705 DOI: 10.1186/s12877-021-02294-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/20/2021] [Indexed: 12/05/2022] Open
Abstract
Background Older people living in residential aged care homes experience frequent emergency transfers to hospital. These events are associated with risks of hospital acquired complications and invasive treatments or interventions. Evidence suggests that some hospital transfers may be unnecessary or avoidable. The Early Detection of Deterioration in Elderly residents (EDDIE) program is a multi-component intervention aimed at reducing unnecessary hospital admissions from residential aged care homes by empowering nursing and care staff to detect and manage early signs of resident deterioration. This study aims to implement and evaluate the program in a multi-site randomised study in Queensland, Australia. Methods A stepped-wedge randomised controlled trial will be conducted at 12 residential aged care homes over 58 weeks. The program has four components: education and training, decision support tools, diagnostic equipment, and implementation facilitation with clinical systems support. The integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework will be used to guide the program implementation and process evaluation. The primary outcome measure will be the number of hospital bed days used by residents, with secondary outcomes assessing emergency department transfer rates, admission rates, length of stay, family awareness and experience, staff self-efficacy and costs of both implementation and health service use. A process evaluation will assess the extent and fidelity of program implementation, mechanisms of impact and the contextual barriers and enablers. Discussion The intervention is expected to improve outcomes by reducing unnecessary hospital transfers. Fewer hospital transfers and admissions will release resources for other patients with potentially greater needs. Residential aged care home staff might benefit from feelings of empowerment in their ability to proactively manage early signs of resident deterioration. The process evaluation will be useful for supporting wider implementation of this intervention and other similar initiatives. Trial registration The trial is prospectively registered with the Australia New Zealand Clinical Trial Registry (ACTRN12620000507987, registered 23/04/2020). Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02294-8.
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Affiliation(s)
- Hannah E Carter
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, 4059, Queensland, Australia.
| | - Xing J Lee
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, 4059, Queensland, Australia
| | - Alison Farrington
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, 4059, Queensland, Australia
| | - Carla Shield
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, 4059, Queensland, Australia
| | - Nicholas Graves
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, 4059, Queensland, Australia.,Duke-NUS Postgraduate Medical School, National University of Singapore, 8 College Rd, Singapore, 169857, Singapore
| | - Elizabeth V Cyarto
- Bolton Clarke Research Institute, 347 Burwood Hwy, Forest Hill, Victoria, 3131, Australia.,Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, 4072, Australia.,Department of Psychiatry, University of Melbourne, Parkville, VIC, 3010, Australia
| | - Lynne Parkinson
- School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW, 2308, Australia
| | - Florin I Oprescu
- School of Health and Behavioural Sciences, University of the Sunshine Coast, Sippy Downs, QLD, 4556, Australia
| | - Claudia Meyer
- Bolton Clarke Research Institute, 347 Burwood Hwy, Forest Hill, Victoria, 3131, Australia.,Rehabilitation, Ageing and Independent Living Research Centre, Monash University, Frankston, Victoria, 3199, Australia.,Centre for Health Communication and Participation, La Trobe University, Bundoora, Victoria, 3083, Australia
| | - Jeffrey Rowland
- Faculty of Medicine, University of Queensland, 20 Weightman St, Herston, QLD, 4006, Australia.,Faculty of Health, School of Nursing, Kelvin Grove Campus, Queensland University of Technology, Brisbane, Australia.,Metro North Health, Royal Brisbane and Women's Hospital, 7 Butterfield St, Herston, QLD, 4029, Australia
| | - Trudy Dwyer
- School of Nursing, Midwifery and Social Sciences, Central Queensland University, Rockhampton, QLD, 4702, Australia
| | - Gillian Harvey
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, 4059, Queensland, Australia.,College of Nursing and Health Sciences, Flinders University, Bedford Park, Australia, 5042
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20
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Martin RS, Hayes BJ, Hutchinson A, Yates P, Lim WK. Healthcare-providers experiences with Advance Care Planning and Goals of Patient Care medical treatment orders in Residential Aged Care Facilities; an explanatory descriptive study. Intern Med J 2021; 52:776-784. [PMID: 34008332 DOI: 10.1111/imj.15374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 05/10/2021] [Accepted: 05/10/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Advance Care Planning (ACP) is a process by which people communicate their healthcare preferences and values, planning for a time when they are unable to voice them. Within Residential Aged Care Facilities (RACF) both the completion and the clarity of ACP documents is variable and, internationally, medical treatment orders have been used to address these issues. In this study, Goals of Patient Care (GOPC) medical treatment orders were introduced alongside usual ACP in three RACF to improve healthcare decision-making for residents. This study explored the experiences of RACF healthcare-providers with ACP and GOPC medical treatment orders. METHODS The study was of Explanatory Descriptive design. Within three RACF where the GOPC medical treatment orders had been introduced, focus groups and interviews with healthcare-providers were performed. The transcribed interviews were analysed thematically. RESULTS Healthcare-providers reported support for ACP and GOPC but also discussed many problematic issues. Analysis of the data identified four main themes: Enablers, Barriers, Resident autonomy and Advance documentation (ACP and GOPC). CONCLUSION Healthcare-providers identified ACP and GOPC as positive tools for assisting with medical decision-making for residents. Although barriers exist in completion and activation of plans, healthcare-providers described them as progressing resident-centred care. Willingness to follow ACP instructions was reported to be reduced by lack of trust by clinicians. Families were also reported to change their views from those documented in family-completed ACP, attributed to poor understanding of their purpose. Participants reported that GOPC led to clearer documentation of residents' medical treatment-plans than relying on ACP documents alone. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ruth S Martin
- Northern Health, 185 Cooper Street, Epping, Victoria, 3076, Australia.,University of Melbourne, 1-100 Grattan Street, Melbourne, Victoria, 3010, Australia
| | - Barbara J Hayes
- Northern Health, 185 Cooper Street, Epping, Victoria, 3076, Australia
| | - Anastasia Hutchinson
- Northern Health, 185 Cooper Street, Epping, Victoria, 3076, Australia.,Deakin University, 75 Pigdons Road, Waurn Ponds, Geelong, Victoria, 3216, Australia
| | - Paul Yates
- University of Melbourne, 1-100 Grattan Street, Melbourne, Victoria, 3010, Australia.,Austin Health, 145 Studley Road, Heidelberg, Victoria, 3084, Australia
| | - Wen Kwang Lim
- University of Melbourne, 1-100 Grattan Street, Melbourne, Victoria, 3010, Australia.,Melbourne Health, 300 Grattan Street, Melbourne, Victoria, 3052, Australia
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Putrik P, Jessup R, Buchbinder R, Glasziou P, Karnon J, O Connor DA. Prioritising models of healthcare service delivery for a more sustainable health system: a Delphi study of Australian health policy, clinical practice and management, academic and consumer stakeholders. AUST HEALTH REV 2021; 45:425-432. [PMID: 33731250 DOI: 10.1071/ah20160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 12/09/2020] [Indexed: 11/23/2022]
Abstract
Objectives Healthcare expenditure is growing at an unsustainable rate in developed countries. A recent scoping review identified several alternative healthcare delivery models with the potential to improve health system sustainability. Our objective was to obtain input and consensus from an expert Delphi panel about which alternative models they considered most promising for increasing value in healthcare delivery in Australia and to contribute to shaping a research agenda in the field. Methods The panel first reviewed a list of 84 models obtained through the preceding scoping review and contributed additional ideas in an open round. In a subsequent scoring round, the panel rated the priority of each model in terms of its potential to improve health care sustainability in Australia. Consensus was assumed when ≥50% of the panel rated a model as (very) high priority (consensus on high priority) or as not a priority or low priority (consensus on low priority). Results Eighty-two of 149 invited participants (55%) representing all Australian states/territories and wide expertise completed round one; 71 completed round two. Consensus on high priority was achieved for 59 alternative models; 14 were rated as (very) high priority by ≥70% of the panel. Top priorities included improving medical service provision in aged care facilities, providing single-point-access multidisciplinary care for people with chronic conditions and providing tailored early discharge and hospital at home instead of in-patient care. No consensus was reached on 47 models, but no model was deemed low priority. Conclusions Input from an expert stakeholder panel identified healthcare delivery models not previously synthesised in systematic reviews that are a priority to investigate. Strong consensus exists among stakeholders regarding which models require the most urgent attention in terms of (cost-)effectiveness research. These findings contribute to shaping a research agenda on healthcare delivery models and where stakeholder engagement in Australia is likely to be high. What is known about the topic? Healthcare expenditure is growing at an unsustainable rate in high-income countries worldwide. A recent scoping review of systematic reviews identified a substantial body of evidence about the effects of a wide range of models of healthcare service delivery that can inform health system improvements. Given the large number of systematic reviews available on numerous models of care, a method for gaining consensus on the models of highest priority for implementation (where evidence demonstrates this will lead to beneficial effects and resource savings) or for further research (where evidence about effects is uncertain) in the Australian context is warranted. What does this paper add? This paper describes a method for reaching consensus on high-priority alternative models of service delivery in Australia. Stakeholders with leadership roles in health policy and government organisations, hospital and primary care networks, academic institutions and consumer advocacy organisations were asked to identify and rate alternative models based on their knowledge of the healthcare system. We reached consensus among ≥70% of stakeholders that improving medical care in residential aged care facilities, providing single-point-access multidisciplinary care for patients with a range of chronic conditions and providing early discharge and hospital at home instead of in-patient stay for people with a range of conditions are of highest priority for further investigation. What are the implications for practitioners? Decision makers seeking to optimise the efficiency and sustainability of healthcare service delivery in Australia could consider the alternative models rated as high priority by the expert stakeholder panel in this Delphi study. These models reflect the most promising alternatives for increasing value in the delivery of health care in Australia based on stakeholders' knowledge of the health system. Although they indicate areas where stakeholder engagement is likely to be high, further research is needed to demonstrate the effectiveness and cost-effectiveness of some of these models.
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Affiliation(s)
- Polina Putrik
- Monash Department of Clinical Epidemiology, Cabrini Institute, 4 Drysdale Street, Malvern, Vic. 3144, Australia. , , ; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne Vic. 3004, Australia; and Corresponding author.
| | - Rebecca Jessup
- Monash Department of Clinical Epidemiology, Cabrini Institute, 4 Drysdale Street, Malvern, Vic. 3144, Australia. , , ; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne Vic. 3004, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, 4 Drysdale Street, Malvern, Vic. 3144, Australia. , , ; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne Vic. 3004, Australia
| | - Paul Glasziou
- Bond University, 14 University Drive, Robina, Qld 4226, Australia.
| | | | - Denise A O Connor
- Monash Department of Clinical Epidemiology, Cabrini Institute, 4 Drysdale Street, Malvern, Vic. 3144, Australia. , , ; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne Vic. 3004, Australia
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22
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Çağlar A, Sert ET, Mutlu H. Impact of chronic medical conditions on mortality in geriatric trauma, 10-year analysis of a single centre in Turkey. Acta Chir Belg 2021; 122:253-259. [PMID: 33719848 DOI: 10.1080/00015458.2021.1900523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The healthy and active lifestyle adopted by the elderly as a result of improvements in the standards of living may lead to an increase in the risk of injury. Comorbidities increase the risk of posttraumatic complications and mortality. The aim of this study was to investigate the impact of chronic medical conditions (CMCs) on the risk of mortality in geriatric trauma patients. METHODS All geriatric trauma patients admitted to emergency department over a 10-year period were retrospectively analysed. Patients were stratified by baseline characteristics, injury severity score (ISS), presence of CMCs, and in-hospital mortality. Multivariate logistic regression was used to determine variables significantly associated with in-hospital mortality. RESULTS 9455 patients included in the study. The median age was 74 (10) years and 57% of them were female. The presence of ≥1 CMC and ≥2 CMCs increased the risk of mortality 5.64 and 2.38 times respectively in mild traumas and 2.67 and 2.59 times respectively in moderate traumas. Age, ISS and penetrating traumas had a significant impact on the risk of mortality in all ISS groups. In severe traumas, only renal disease had an impact on the risk of mortality (OR = 2.58, 95%CI = 1.03-6.43, p = 0.042). All other CMCs, ≥1 CMC, and ≥2 CMCs had no impact on the risk of mortality. CONCLUSION The presence of CMCs in elderly patients with mild and moderate injuries increases the risk of mortality. Such patients should be diagnosed and treated more quickly and aggressively during the prehospital process and in the hospital.
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Affiliation(s)
- Ahmet Çağlar
- Department of Emergency Medicine, Aksaray University Training and Research Hospital, Aksaray, Turkey
| | - Ekrem Taha Sert
- Department of Emergency Medicine, Aksaray University Training and Research Hospital, Aksaray, Turkey
| | - Hüseyin Mutlu
- Department of Emergency Medicine, Aksaray University Training and Research Hospital, Aksaray, Turkey
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23
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Laging BL, Nay R, Bauer M, Laging R, Walker K, Kenny A. Advance care planning practices in the nursing home setting: A secondary analysis. THE GERONTOLOGIST 2021; 61:1307-1316. [PMID: 33624074 DOI: 10.1093/geront/gnab028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Advance care planning is intended to support resident's preferences regarding health decisions, even when they can no longer participate. Little is known about the power discourses influencing how residents, family-members, and healthcare workers engage in advance care planning and how advance care directives are used if conflict arises. A large critical ethnographic study was conducted exploring decision making when a resident's health deteriorates in the nursing home setting. Advance care planning practices were not the focus of the original study, but the richness of the data warranted further exploration. A new research question was developed to inform a secondary analysis: How does advance care planning influence the relationship between resident values and clinical expertise when determining a direction of care at the time of a resident deterioration? RESEARCH DESIGN AND METHODS A secondary analysis of data from an ethnographic study involving 184 hours of participatory observation, 40 semi-structured interviews and advance care planning policies and document review undertaken in in two nursing homes in Melbourne, Australia. RESULTS Advance care planning may result in inaccurate documentation of residents' preferences and devalue clinical decision-making and communication with residents and family-members at the time of deterioration. DISCUSSION AND IMPLICATIONS Advance care planning may contribute towards a reductionist approach to decision-making. There is an urgent need for the development of evidence-based policy and legislation to support residents, families, and healthcare workers to make appropriate decisions, including withholding invasive treatment when a resident deteriorates.
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Affiliation(s)
- Bridget L Laging
- Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia
| | - Rhonda Nay
- School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria, Australia
| | - Michael Bauer
- Australian Centre for Evidence Based Aged Care, La Trobe University, Melbourne, Victoria Australia
| | - Rohan Laging
- Alfred Emergency and Trauma Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Katie Walker
- School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Amanda Kenny
- La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
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24
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Testa L, Hardy JE, Jepson T, Braithwaite J, Mitchell RJ. Health service utilisation and health outcomes of residential aged care residents referred to a hospital avoidance program: A multi-site retrospective quasi-experimental study. Australas J Ageing 2021; 40:e244-e253. [PMID: 33547756 DOI: 10.1111/ajag.12906] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 12/03/2020] [Accepted: 12/09/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare the health system utilisation patterns and health outcomes of residential aged care facility (RACF) residents reviewed by a hospital avoidance program to those of RACF residents who received usual care. METHODS A retrospective evaluation of a hospital avoidance program provided by a hospital-based medical and nursing outreach team. Residents reviewed by the program were randomly matched 1:1 to comparison group residents based on age group, sex and number of co-morbidities. Number of hospital admissions, excess hospital length of stay and excess hospital treatment costs were compared. RESULTS Residents reviewed by the program spent an average 9-10 days fewer in hospital with AUD$2,091 to $8,014 lower hospital treatment costs compared to comparison group residents. CONCLUSION Rapid provision of outreach services for the management of acute care of RACF residents may reduce the number of days residents spend in hospital, as well as reducing the associated hospital treatment costs.
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Affiliation(s)
- Luke Testa
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - James E Hardy
- Royal North Shore Hospital, Sydney, New South Wales, Australia.,The University of Sydney, Sydney, New South Wales, Australia
| | - Therese Jepson
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Rebecca J Mitchell
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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25
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Carter HE, Lee XJ, Dwyer T, O'Neill B, Jeffrey D, Doran CM, Parkinson L, Osborne SR, Reid-Searl K, Graves N. The effectiveness and cost effectiveness of a hospital avoidance program in a residential aged care facility: a prospective cohort study and modelled decision analysis. BMC Geriatr 2020; 20:527. [PMID: 33287716 PMCID: PMC7720399 DOI: 10.1186/s12877-020-01904-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 11/17/2020] [Indexed: 11/29/2022] Open
Abstract
Background Residential aged care facility residents experience high rates of hospital admissions which are stressful, costly and often preventable. The EDDIE program is a hospital avoidance initiative designed to enable nursing and care staff to detect, refer and quickly respond to early signals of a deteriorating resident. The program was implemented in a 96-bed residential aged care facility in regional Australia. Methods A prospective pre-post cohort study design was used to collect data on costs of program delivery, hospital admission rates and length of stay for the 12 months prior to, and following, the intervention. A Markov decision model was developed to synthesize study data with published literature in order to estimate the cost-effectiveness of the program. Quality adjusted life years (QALYs) were adopted as the measure of effectiveness. Results The EDDIE program was associated with a 19% reduction in annual hospital admissions and a 31% reduction in the average length of stay. The cost-effectiveness analysis found the program to be both more effective and less costly than usual care, with 0.06 QALYs gained and $249,000 health system costs saved in a modelled cohort of 96 residents. A probabilistic sensitivity analysis estimated that there was an 86% probability that the program was cost-effective after taking the uncertainty of the model inputs into account. Conclusions This study provides promising evidence for the effectiveness and cost-effectiveness of a nurse led, early intervention program in preventing unnecessary hospital admissions within a residential aged care facility. Further research in multi-site randomised studies is needed to confirm the generalisability of these results. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-020-01904-1.
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Affiliation(s)
- Hannah E Carter
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Australia.
| | - Xing J Lee
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Australia
| | - Trudy Dwyer
- Central Queensland University, Rockhampton, Australia
| | - Barbara O'Neill
- Central Queensland University, Rockhampton, Australia.,University of Connecticut, Storrs, USA
| | | | - Christopher M Doran
- Cluster for Resilience and Wellbeing, Central Queensland University, Brisbane, Australia
| | - Lynne Parkinson
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Sonya R Osborne
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Australia.,School of Nursing and Midwifery, Centre for Health Research, Institute for Resilient Regions, University of Southern Queensland, Ipswich, Australia
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26
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Patterns of benzodiazepine administration and prescribing to older adults in U.S. emergency departments. Aging Clin Exp Res 2020; 32:2621-2628. [PMID: 32056152 DOI: 10.1007/s40520-020-01496-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/23/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Benzodiazepine use in older adults is associated with adverse effects including delirium, mechanical falls, fractures, and memory disturbances. In this study we examine the overall utilization of benzodiazepines in the older adult population in U.S. EDs. METHODS Data were compiled from the National Hospital Ambulatory Medical Care Survey 2005-2015. Variables were created to identify all patients over 60 years of age who had and had not been administered benzodiazepines. Bivariate statistical tests were utilized to examine patient demographics, hospital course events and ED/hospital resource allocation and compare older adults administered (in the ED) and prescribed (from the ED) benzodiazepines to those not receiving these agents. RESULTS Between 2005 and 2015 approximately 280 million adults over 60 years of age were seen in EDs throughout the U.S. Overall, benzodiazepines were administered in the ED (only) during 8.5 million visits, and prescribed as a prescription (only) during over 1.3 million visits, with the rate increasing from 2.7% in 2005 to 3.5% in 2015 for benzodiazepines were administered in the ED (only). Overall 42.1% (95% CI 38.8-45.2, p < 0.001) of older adults administered benzodiazepines in the ED were subsequently admitted to the hospital. Rates of co-administration and co-prescription of opioid analgesics were high at 19.0% (95% CI 7.3-19.7) and 17.0% (95% CI 7.9-17.4) for those administered benzodiazepines in the ED, and 21.8% (95% CI 16.3-28.5) and 34.5% (95% CI 27.7-42.0) amongst those prescribed benzodiazepines at discharge. In both cases, these groups were no less likely to be administered opioids in the ED than those not receiving benzodiazepines. A total of 1.1% (95% CI 0.69-1.7, p < 0.001) of older adults administered (in the ED) benzodiazepines were diagnosed with delirium in the ED, compared to 0.0004% who were not (95% CI 0.0038-0.0052). CONCLUSION Despite the documented risks associated with the utilization of benzodiazepines in older adults, the rate of use in EDs continues to increase. Older adults administered benzodiazepines in the ED were more likely to be admitted to the hospital than those not receiving these agents. Despite the risks associated with co-prescription of benzodiazepines with opioids, those receiving these agents were no less likely to be administered opioids than those who did not. Older adults administered benzodiazepines in the ED were substantially more likely to be diagnosed with delirium in the ED.
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27
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Burkett E, Carpenter CR, Hullick C, Arendts G, Ouslander JG. It's time: Delivering optimal emergency care of residents of aged care facilities in the era of COVID-19. Emerg Med Australas 2020; 33:131-137. [PMID: 33131219 DOI: 10.1111/1742-6723.13683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Ellen Burkett
- Department of Emergency Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Healthcare Improvement Unit, Clinical Excellence Queensland, Brisbane, Queensland, Australia
| | | | - Carolyn Hullick
- Belmont Hospital, Belmont, New South Wales, Australia.,School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Glenn Arendts
- Emergency Department, Fiona Stanley Hospital, Perth, Western Australia, Australia.,School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Joseph G Ouslander
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
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Hullick CJ, Hall AE, Conway JF, Hewitt JM, Darcy LF, Barker RT, Oldmeadow C, Attia JR. Reducing Hospital Transfers from Aged Care Facilities: A Large-Scale Stepped Wedge Evaluation. J Am Geriatr Soc 2020; 69:201-209. [PMID: 33124692 DOI: 10.1111/jgs.16890] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/18/2020] [Accepted: 09/28/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Older people living in residential aged care facilities (RACFs) experience acute deterioration requiring assessment and decision making. We evaluated the impact of a large-scale regional Aged Care Emergency (ACE) program in reducing hospital admissions and emergency department (ED) transfers. DESIGN A stepped wedge nonrandomized cluster trial with 11 steps, implemented from May 2013 to August 2016. SETTING A large regional and rural area of northern and western New South Wales, Australia. PARTICIPANTS Nine hospital EDs and 81 RACFs participated in the evaluation. INTERVENTION The ACE program is an integrated nurse-led intervention underpinned by a community of practice designed to improve the capability of RACFs managing acutely unwell residents. It includes telephone support, evidence-based algorithms, defining goals of care for ED transfer, case management in the ED, and an education program. MEASUREMENTS ED transfers and subsequent hospital admissions were collected from administrative data including 13 months baseline and 9 months follow-up. RESULTS A total of 18,837 eligible ED visits were analyzed. After accounting for clustering by RACFs and adjusting for time of the year as well as RACF characteristics, a statistically significant reduction in hospital admissions (adjusted incident rate ratio = .79; 95% confidence interval [CI] = .68-.92); P = .0025) was seen (i.e., residents were 21% less likely to be admitted to the hospital). This was also observed in ED visit rates (adjusted incidence rate ratio = .80; 95% CI = .69-.92; P = .0023) (i.e., residents were 20% less likely to be transferred to the ED). Seven-day ED re-presentation fell from 5.7% to 4.9%, and 30-day hospital readmissions fell from 12% to 10%. CONCLUSION The stepped wedge design allowed rigorous evaluation of a real-world large-scale intervention. These results confirm that the ACE program can be scaled up to a large geographic area and can reduce ED visits and hospitalization of older people with complex healthcare needs living in RACFs.
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Affiliation(s)
- Carolyn J Hullick
- Belmont District Hospital, Belmont, New South Wales, Australia.,Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, New South Wales, Australia
| | - Alix E Hall
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, New South Wales, Australia
| | - Jane F Conway
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, Australia.,Faculty of Medicine and Health, University of New England, Armidale, New South Wales, Australia
| | - Jacqueline M Hewitt
- Hunter New England Central Coast Primary Health Network, Newcastle, New South Wales, Australia
| | - Leigh F Darcy
- Hunter Primary Care, Warabrook, New South Wales, Australia
| | - Roslyn T Barker
- Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia
| | - Christopher Oldmeadow
- Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, New South Wales, Australia
| | - John R Attia
- Belmont District Hospital, Belmont, New South Wales, Australia.,Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, New South Wales, Australia
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29
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Rainsford S, Liu WM, Johnston N, Glasgow N. The impact of introducing Palliative Care Needs Rounds into rural residential aged care: A quasi-experimental study. Aust J Rural Health 2020; 28:480-489. [PMID: 32985041 DOI: 10.1111/ajr.12654] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 05/26/2020] [Accepted: 06/24/2020] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE This study examined the impact of introducing Palliative Care Needs Rounds (hereafter Needs Rounds) into residential aged care on hospitalisations (emergency department presentations, admissions and length of stay) and documentation of advance care plans. DESIGN A quasi-experimental study. SETTING Two residential aged care facilities in one rural town in the Snowy Monaro region of New South Wales, Australia. PARTICIPANTS The intervention group consisted of all residents who died during the study period (April 2018-March 2019), and included a subgroup of decedents who were discussed in a Needs Round. The control cohort included all residents who died in the three-year period prior to introducing Needs Rounds (2015-2017). INTERVENTION Needs Rounds are monthly onsite triage/risk stratification meetings where case-based education and staff support help to identify residents most at risk of dying without an adequate plan in place. Needs Rounds were attended by residential aged care staff and led by a palliative medicine physician. MAIN OUTCOME MEASURES Decedents' hospitalisations (emergency department presentations, admissions and length of stay) in the last three months of life, place of death and documentation of advance care plans. RESULTS Eleven Needs Rounds were conducted between April and September 2018. The number of documented advance care plans increased (P < .01). There were no statistically significant changes in hospitalisations or in-hospital deaths. CONCLUSION Needs Rounds are an effective approach to increase the documentation of advance care plans within rural residential aged care. Further studies are required to explore the rural influence on outcomes including hospital transfers and preferred place of death.
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Affiliation(s)
- Suzanne Rainsford
- Medical School, Australian National University, Canberra, ACT, Australia.,Clare Holland House, Calvary Health Care Bruce, Canberra, ACT, Australia
| | - Wai-Man Liu
- Research School of Finance, Actuarial Studies and Statistics, College of Business and Economics, Australian National University, Canberra, ACT, Australia
| | - Nikki Johnston
- Clare Holland House, Calvary Health Care Bruce, Canberra, ACT, Australia
| | - Nicholas Glasgow
- Medical School, Australian National University, Canberra, ACT, Australia.,Clare Holland House, Calvary Health Care Bruce, Canberra, ACT, Australia
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30
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Kwa JM, Storer M, Ma R, Yates P. Integration of Inpatient and Residential Care In-Reach Service Model and Hospital Resource Utilization: A Retrospective Audit. J Am Med Dir Assoc 2020; 22:670-675. [PMID: 32928658 PMCID: PMC7486062 DOI: 10.1016/j.jamda.2020.07.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 10/28/2022]
Abstract
OBJECTIVE In parts of Australia, Residential In-Reach (RIR) services have been implemented to treat residential aged care (RAC) residents for acute conditions in their place of residence to avoid preventable hospital presentation. Our service was initiated in 2009 and restructured in 2014. We compared acute healthcare resource utilization (RIR activity and emergency hospital presentations) by RAC residents under 2 RIR models of care. DESIGN Acute RAC RIR service model of care was changed from existing nurse/emergency physician-led service to nurse/geriatrician-led service and incorporate inpatient liaison nurse consultant into the team. SETTING RAC episodes and hospital presentations from a single tertiary referral hospital and its associated RAC RIR service. METHODS Retrospective audit comparing RIR activity, hospital presentations, and associated costs from 2 12-month periods, prior to and postimplementation. Data were expressed as a proportion of the total number of RAC beds in the hospital RIR catchment. RESULTS After implementation of the new model of care, RIR episodes of care increased from 589 to 985 (15.3 vs 24.7 episodes/100 RAC beds, P < .001). Emergency department (ED) presentations fell from 1616 to 1478 (41.9 vs 37.2 presentations/100 RAC beds, P < .001). There were fewer unplanned ED presentations by RIR patients (2.4% vs 0.8%, = 0.03) and fewer 28-day ED re-presentations (16.8% vs 13.7%, P = .01) under the new model of care. ED cost [$AUD 30,830 vs $28,030/100 RAC beds ($USD 21,344 vs $19,407), P < .001] and inpatient admission costs [$145,607 vs $117,531/100 RAC beds ($USD 100,814 vs $81,380), P < .001] were each lower in the second period. CONCLUSIONS AND IMPLICATIONS In the 12 months following implementation of the new model of care, an increase in RIR activity, and a decrease in ED presentations was observed. Further research is necessary to validate these retrospective findings and better evaluate clinical outcomes and consumer satisfaction of the service.
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Affiliation(s)
- Jie-Min Kwa
- Department of Geriatric Medicine, Austin Health, Studley Road, Heidelberg, VIC, Australia
| | - Meg Storer
- Department of Geriatric Medicine, Austin Health, Studley Road, Heidelberg, VIC, Australia
| | - Ronald Ma
- Department of Finance, Austin Health, Studley Road, Heidelberg, VIC, Australia
| | - Paul Yates
- Department of Geriatric Medicine, Austin Health, Studley Road, Heidelberg, VIC, Australia; Department of Medicine, University of Melbourne, Austin Health, Heidelberg, VIC, Australia.
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31
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Marsden EJ, Taylor A, Wallis M, Craswell A, Broadbent M, Johnston-Devin C, Crilly J. A structure and process evaluation of the Geriatric Emergency Department Intervention model. Australas Emerg Care 2020; 24:28-33. [PMID: 32631775 DOI: 10.1016/j.auec.2020.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/23/2020] [Accepted: 05/25/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The positive effect of the Geriatric Emergency Department Intervention (GEDI) model, on the outcomes of frail older adults, is established. This study aimed to describe and evaluate the structures and processes required for the effective delivery of the GEDI model to assist in its potential translation into emergency departments in Australia and overseas. METHODS This was a descriptive qualitative study. Twenty-four semi-structured interviews were conducted with emergency department staff and GEDI doctors and nurses from a regional hospital in Queensland, Australia. An a priori framework guided interview questions and analysis. RESULTS Structures required for successful model deployment included having an emergency department physician champion and nurses with gerontology experience, adequate funding, and geriatric specific resources. Processes identified as fundamental to the GEDI model included having a targeted approach to assessment, a patient-centred approach to care, and staff with inter-facility, intra-facility and inter-personal communication skills. CONCLUSIONS The GEDI model addresses the specific care needs of our aging population. For optimal performance of the model, key structures and processes require identification and acknowledgement. Research involving qualitative methodology is vital for successful translation and integration of emergency department models of care.
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Affiliation(s)
- Elizabeth J Marsden
- Nambour Emergency Department, Sunshine Coast and Hospital Health Service, Hospital Rd, Nambour, QLD 4560, Australia; School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD 4556, Australia.
| | - Andrea Taylor
- Nambour Emergency Department, Sunshine Coast and Hospital Health Service, Hospital Rd, Nambour, QLD 4560, Australia; School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD 4556, Australia
| | - Marianne Wallis
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD 4556, Australia; Menzies Health Institute Queensland, Griffith University, Parklands Drive, Parkwood, QLD 4215, Australia
| | - Alison Craswell
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD 4556, Australia
| | - Marc Broadbent
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD 4556, Australia
| | - Colleen Johnston-Devin
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD 4556, Australia; School of Nursing, Midwifery and Social Sciences, CQUniversity, 90 Goodchap St, Noosaville 4566, Australia
| | - Julia Crilly
- Department of Emergency Medicine, Gold Coast Health, 1 Hospital Blvd, Southport, QLD 4215, Australia; Menzies Health Institute Queensland, Griffith University, Parklands Drive, Parkwood, QLD 4215, Australia
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Venkatesh AK, Mei H, Shuling L, D’Onofrio G, Rothenberg C, Lin Z, Krumholz HM. Cross-sectional Analysis of Emergency Department and Acute Care Utilization Among Medicare Beneficiaries. Acad Emerg Med 2020; 27:570-579. [PMID: 32302034 DOI: 10.1111/acem.13971] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND We sought to develop a claims-based definition of unscheduled care to describe the use and role of the emergency department (ED) in providing unscheduled care to vulnerable older adult populations. METHODS This study was a cross-sectional analysis of national 20% sample of Medicare beneficiaries included in the 2012 Chronic Condition Warehouse data set. We measured three outcomes: the number of ED visits per 1,000 Medicare beneficiaries, the proportion of all unscheduled ED and office-based visits occurring in the ED and the number of ED and non-ED unscheduled visits adjusting for risk factors. Each outcome was estimated for vulnerable subpopulations of Medicare beneficiaries with multiple chronic conditions (MCCs), dual eligibility, hospice enrollment, and skilled nursing facility use. RESULTS A total of 10,717,786 Medicare beneficiaries were included with 33,696,461 potentially unscheduled care visits of which 5,192,235 (15%) occurred in the ED, 364,334 (1.1%) in facility-based urgent care, and 31,570,113 (84%) in ambulatory office settings. In regression analyses each subpopulation was more likely to visit the ED for unscheduled care services than the reference population of Medicare beneficiaries ages 65 to 80. Dual-eligible beneficiaries demonstrated higher ED visit rates and lower non-ED visit rates for unscheduled care. The subpopulation with MCCs uses both the ED and the non-ED setting for unscheduled care more so than any other group. CONCLUSIONS Medicare beneficiaries, particularly vulnerable subpopulations, disproportionately visit the ED in comparison to physician offices for unscheduled care. Efforts to improve care coordination, measure quality, or reform payment to influence ED visitation should acknowledge these patterns and the unique availability of acute care services in the ED.
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Affiliation(s)
- Arjun K. Venkatesh
- Department of Emergency Medicine Yale University School of Medicine New Haven CT
- Yale‐New Haven Hospital Center for Outcomes Research and Evaluation New Haven CT
| | - Hao Mei
- Yale‐New Haven Hospital Center for Outcomes Research and Evaluation New Haven CT
- Yale School of Public Health New Haven CT
| | - Liu Shuling
- Yale‐New Haven Hospital Center for Outcomes Research and Evaluation New Haven CT
| | - Gail D’Onofrio
- Department of Emergency Medicine Yale University School of Medicine New Haven CT
| | - Craig Rothenberg
- Department of Emergency Medicine Yale University School of Medicine New Haven CT
| | - Zhenqiu Lin
- Yale‐New Haven Hospital Center for Outcomes Research and Evaluation New Haven CT
| | - Harlan M. Krumholz
- Yale‐New Haven Hospital Center for Outcomes Research and Evaluation New Haven CT
- Yale School of Public Health New Haven CT
- Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
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Gnanamanickam ES, Dyer SM, Harrison SL, Liu E, Whitehead C, Crotty M. Associations between Cognitive Function, Hospitalizations and Costs in Nursing Homes: A Cross-sectional Study. J Aging Soc Policy 2020; 34:552-567. [PMID: 32600162 DOI: 10.1080/08959420.2020.1777824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In an Australian nursing home population, associations between cognitive function and 12-month hospitalizations and costs were examined. Participants with dementia had 57% fewer hospitalizations compared to those without dementia, with 41% lower mean hospitalization costs; poorer cognition scores were also associated with fewer hospitalizations. The cost per admission for those with dementia was 33% greater due to longer hospital stays (5.5 days versus 3.1 days for no dementia, p = .05). People with dementia were most frequently hospitalized for fractures. These findings have policy implications for increasing investment in accurate and timely diagnosis of dementia and fall and fracture prevention strategies to further reduce associated hospitalization costs.
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Affiliation(s)
- Emmanuel Sumithran Gnanamanickam
- Rehabilitation, Aged and Extended Care, College of Medicine and Public Health, Flinders University, Adelaide, Australia.,NHMRC Cognitive Decline Partnership Centre, The University of Sydney, Sydney, Australia.,Health Economics and Social Policy, Australian Centre for Precision Health, University of South Australia, Adelaide, Australia.,Health Data Science and Clinical Trials, Flinders University, Adelaide, Australia
| | - Suzanne Marie Dyer
- Rehabilitation, Aged and Extended Care, College of Medicine and Public Health, Flinders University, Adelaide, Australia.,NHMRC Cognitive Decline Partnership Centre, The University of Sydney, Sydney, Australia
| | - Stephanie Lucy Harrison
- Rehabilitation, Aged and Extended Care, College of Medicine and Public Health, Flinders University, Adelaide, Australia.,NHMRC Cognitive Decline Partnership Centre, The University of Sydney, Sydney, Australia.,Registry of Older South Australians, Health Ageing Research Consortium, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Enwu Liu
- Rehabilitation, Aged and Extended Care, College of Medicine and Public Health, Flinders University, Adelaide, Australia.,NHMRC Cognitive Decline Partnership Centre, The University of Sydney, Sydney, Australia.,Bone Health and Fractures Research Program, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Craig Whitehead
- Rehabilitation, Aged and Extended Care, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Maria Crotty
- Rehabilitation, Aged and Extended Care, College of Medicine and Public Health, Flinders University, Adelaide, Australia.,NHMRC Cognitive Decline Partnership Centre, The University of Sydney, Sydney, Australia
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Craswell A, Wallis M, Coates K, Marsden E, Taylor A, Broadbent M, Nguyen KH, Johnston-Devin C, Glenwright A, Crilly J. Enhanced primary care provided by a nurse practitioner candidate to aged care facility residents: A mixed methods study. Collegian 2020. [DOI: 10.1016/j.colegn.2019.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Nursing home patients and Emergency Department attendance in a single urban Irish catchment area: an observational study surrounding the introduction of a community medicine for older person service. Ir J Med Sci 2020; 190:379-385. [PMID: 32472242 DOI: 10.1007/s11845-020-02267-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Nursing home (NH) patients are at a high risk of Emergency Department (ED) attendance, and adverse events in the ED. With an increasing NH population, monitoring trends in ED utilization is important to aid service planning, and attention to potentially preventable attendances should be paid, to identify areas that may benefit from specialist support. AIMS This 12-year (2008-2019) study aimed to observe trends in ED utilization of NH patients in a single urban Irish catchment area, surrounding the introduction of a Community Medicine for the Older Person (CMOP) outreach program. METHOD A retrospective review of all NH attendances within the catchment area was performed based upon NH address. Attendance, admission, discharge, and died in department (DID) were adjusted per annual NH bed numbers (PBC). Trends were observed and compared pre and post the CMOP activation. Comparisons of continuous variables were performed using an unpaired parametric Student's t test. RESULTS There were 6877 attendances, with 58% (n = 3989) admitted, 40% (n = 2785) discharged, and 2% (n = 123) DID. There was a statistically significant difference in mean discharge rate PBC pre and post the CMOP introduction (0.22 vs 0.16, P = 0.04). There was no statistically significant difference in attendance, admission, or DID. CONCLUSION This is the first Irish study of NH ED utilization over an extended period. ED attendances PBC have not decreased since the introduction of the CMOP. Discharges PBC, however, have decreased and may represent a decrease in potentially preventable attendance/improvement in appropriateness of ED transfers, following the introduction of this intervention.
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Paramedics' Perspectives on the Hospital Transfers of Nursing Home Residents-A Qualitative Focus Group Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17113778. [PMID: 32466568 PMCID: PMC7312002 DOI: 10.3390/ijerph17113778] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 01/09/2023]
Abstract
Emergency department (ED) visits and hospital admissions are common among nursing home residents (NHRs). Little is known about the perspectives of emergency medical services (EMS) which are responsible for hospital transports. The aim of this study was to explore paramedics’ experiences with transfers from nursing homes (NHs) and their ideas for possible interventions that can reduce transfers. We conducted three focus groups following a semi-structured question guide. The data were analyzed by content analysis using the software MAXQDA. In total, 18 paramedics (mean age: 33 years, male n = 14) participated in the study. Paramedics are faced with complex issues when transporting NHRs to hospital. They mainly reported on structural reasons (e.g., understaffing or lacking availability of physicians), which led to the initiation of an emergency call. Handovers were perceived as poorly organized because required transfer information (e.g., medication lists, advance directives (ADs)) were incomplete or nursing staff was insufficiently prepared. Hospital transfers were considered as (potentially) avoidable in case of urinary catheter complications, exsiccosis/infections and falls. Legal uncertainties among all involved professional groups (nurses, physicians, dispatchers, and paramedics) seemed to be a relevant trigger for hospital transfers. In paramedics’ point of view, emergency standards in NHs, trainings for nursing staff, the improvement of working conditions and legal conditions can reduce potentially avoidable hospital transfers from NHs.
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Forbat L, Liu WM, Koerner J, Lam L, Samara J, Chapman M, Johnston N. Reducing time in acute hospitals: A stepped-wedge randomised control trial of a specialist palliative care intervention in residential care homes. Palliat Med 2020; 34:571-579. [PMID: 31894731 DOI: 10.1177/0269216319891077] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Care home residents are frequently transferred to hospital, rather than provided with appropriate and timely specialist care in the care home. AIM To determine whether a model of care providing specialist palliative care in care homes, called Specialist Palliative Care Needs Rounds, could reduce length of stay in hospital. DESIGN Stepped-wedge randomised control trial. The primary outcome was length of stay in acute care (over 24-h duration), with secondary outcomes being the number and cost of hospitalisations. Care homes were randomly assigned to cross over from control to intervention using a random number generator; masking was not possible due to the nature of the intervention. Analyses were by intention to treat. The trial was registered with ANZCTR: ACTRN12617000080325. Data were collected between 1 February 2017 and 30 June 2018. SETTING/PARTICIPANTS 1700 residents in 12 Australian care homes for older people. RESULTS Specialist Palliative Care Needs Rounds led to reduced length of stay in hospital (unadjusted difference: 0.5 days; adjusted difference: 0.22 days with 95% confidence interval: -0.44, -0.01 and p = 0.038). The intervention also provided a clinically significant reduction in the number of hospitalisations by 23%, from 5.6 to 4.3 per facility-month. A conservative estimate of annual net cost-saving from reduced admissions was A$1,759,011 (US$1.3 m; UK£0.98 m). CONCLUSION The model of care significantly reduces hospitalisations through provision of outreach by specialist palliative care clinicians. The data offer substantial evidence for Specialist Palliative Care Needs Rounds to reduce hospitalisations in older people approaching end of life, living in care homes.
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Affiliation(s)
- Liz Forbat
- Faculty of Social Sciences, University of Stirling, Stirling, UK.,Australian Catholic University, Canberra, ACT, Australia
| | - Wai-Man Liu
- Australian National University, Canberra, ACT, Australia
| | - Jane Koerner
- Australian Catholic University, Canberra, ACT, Australia
| | - Lawrence Lam
- University of Technology Sydney, Ultimo, NSW, Australia
| | | | - Michael Chapman
- Australian National University, Canberra, ACT, Australia.,ACT Health, Canberra Hospital, Canberra, ACT, Australia
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Nouvenne A, Caminiti C, Diodati F, Iezzi E, Prati B, Lucertini S, Schianchi P, Pascale F, Starcich B, Manotti P, Brianti E, Fabi M, Ticinesi A, Meschi T. Implementation of a strategy involving a multidisciplinary mobile unit team to prevent hospital admission in nursing home residents: protocol of a quasi-experimental study (MMU-1 study). BMJ Open 2020; 10:e034742. [PMID: 32071189 PMCID: PMC7045229 DOI: 10.1136/bmjopen-2019-034742] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Nursing home residents represent a particularly vulnerable population experiencing high risk of unplanned hospital admissions, but few interventions have proved effective in reducing this risk. The aim of this research will be to verify the effects of a hospital-based multidisciplinary mobile unit (MMU) team intervention delivering urgent care to nursing home residents directly at their bedside. METHODS AND ANALYSIS Four nursing homes based in the Parma province, in Northern Italy, will be involved in this prospective, pragmatic, multicentre, 18-month quasiexperimental study (sequential design with two cohorts). The residents of two nursing homes will receive the MMU team care intervention. In case of urgent care needs, the nursing home physician will contact the hospital physician responsible for the MMU team by phone. The case will be triaged as (a) manageable by phone advice, (b) requiring urgent assessment by the MMU team or (c) requiring immediate emergency department (ED) referral. MMU team is composed of one senior physician and one emergency-medicine resident chosen within the staff of Internal Medicine and Critical Subacute Care Unit of Parma University-Hospital, usually with different specialty background, and equipped with portable ultrasound, set of drugs and devices useful in urgency. The MMU visits patients in nursing homes, with the mission to stabilise clinical conditions and avoid hospital admission. Residents of the other two nursing homes will receive usual care, that is, ED referral in every case of urgency. Study endpoints include unplanned hospital admissions (primary), crude all-cause mortality, hospital mortality, length of stay and healthcare-related costs (secondary). ETHICS AND DISSEMINATION The study protocol was approved by the Ethics Committee of Area Vasta Emilia Nord (Emilia-Romagna region). Informed consent will be collected from patients or legal representatives. The results will be actively disseminated through peer-reviewed journals and conference presentations, in compliance with the Italian law. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT04085679); Pre-results.
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Affiliation(s)
- Antonio Nouvenne
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Caterina Caminiti
- Research and Innovation Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Francesca Diodati
- Research and Innovation Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Elisa Iezzi
- Research and Innovation Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Beatrice Prati
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Stefano Lucertini
- Primary Care Department, Azienda Unità Sanitaria Locale di Parma, Parma, Emilia-Romagna, Italy
| | - Paolo Schianchi
- Primary Care Department, Azienda Unità Sanitaria Locale di Parma, Parma, Emilia-Romagna, Italy
| | - Federica Pascale
- Primary Care Department, Azienda Unità Sanitaria Locale di Parma, Parma, Emilia-Romagna, Italy
| | - Bruno Starcich
- Primary Care Department, Azienda Unità Sanitaria Locale di Parma, Parma, Emilia-Romagna, Italy
| | - Pietro Manotti
- Medical Direction, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Ettore Brianti
- Medical Direction, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Massimo Fabi
- General Management, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Andrea Ticinesi
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Tiziana Meschi
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
- Department of Medicine and Surgery, Università degli studi di Parma, Parma, Italy
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Pulst A, Fassmer AM, Schmiemann G. Experiences and involvement of family members in transfer decisions from nursing home to hospital: a systematic review of qualitative research. BMC Geriatr 2019; 19:155. [PMID: 31164101 PMCID: PMC6549333 DOI: 10.1186/s12877-019-1170-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 05/23/2019] [Indexed: 11/23/2022] Open
Abstract
Background Nursing home residents (NHR) are characterized by increasing frailty, multimorbidity and care dependency. These conditions result in frequent hospital transfers which can lead to negative effects on residents’ health status and are often avoidable. Reasons for emergency department (ED) visits or hospital admissions are complex. Prior research indicated factors influencing transfer decisions in view of nursing staff and general practitioners. The aim of this systematic review is to explore how family members experience and influence transfers from nursing home (NH) to hospital and how they are involved in the transfer decision. Methods A systematic literature search was performed in Medline via PubMed, Ebsco Scopus and CINAHL in May 2018. Studies were eligible if they contained information a) about the decision to transfer NHR to hospital and b) the experiences or influence of family members. The review followed Joanna Briggs Institute's (JBI) approach for qualitative systematic reviews. Screening, selection and quality appraisal of studies were performed independently by two reviewers. Synthesis of qualitative data was conducted through meta-aggregation. Results After screening of n = 2863 articles, in total n = 10 qualitative studies were included in the review. Results indicate that family members of NHR experience decision-making before hospitalization differently. They mainly reported NH-related, hospital-related, and family/resident-related factors influencing the transfer decision. The involvement of family members in the decision-making process varies - from no involvement to insistence on a decision in favor of their personal preferences. However, hospital transfer decisions and other treatment decisions (e.g. advance care planning (ACP) discussions) were commonly discussed with physicians and nurses. Conflicts between family members and healthcare providers mostly arose around the interpretation of resident’s best interest. In general, family members perceive discussions as challenging thus leading to emotional stress and discomfort. Conclusion The influence of NHR family members concerning hospital transfer decisions varies. Family members are an important link for communication between resident and medical staff and for communication between NH and hospital. Interventions aiming to reduce hospitalization rates have to take these findings into account. Electronic supplementary material The online version of this article (10.1186/s12877-019-1170-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexandra Pulst
- Department of Health Services Research, Institute for Public Health and Nursing Research, University of Bremen, Grazer Str. 4, 28359, Bremen, Germany. .,Health Sciences Bremen, University of Bremen, 28359, Bremen, Germany.
| | - Alexander Maximilian Fassmer
- Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Ammerländer Heerstraße 114-118, 26129, Oldenburg, Germany
| | - Guido Schmiemann
- Department of Health Services Research, Institute for Public Health and Nursing Research, University of Bremen, Grazer Str. 4, 28359, Bremen, Germany.,Health Sciences Bremen, University of Bremen, 28359, Bremen, Germany
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Lo K, Karnon J. in-DEPtH framework: evidence- informed, co-creation framework for the Design, Evaluation and Procuremen t of Health services. BMJ Open 2019; 9:e026482. [PMID: 31061038 PMCID: PMC6501978 DOI: 10.1136/bmjopen-2018-026482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
With a multitude of variables, the combinations of care, health program activities and outcomes are infinite, and this renders improvement efforts to complex health service interventions particularly intricate. Here, we describe a framework that seeks to incorporate research evidence and the multi-faceted considerations of stakeholders, context and resources to co-create sustainable health solutions that improve the health outcomes of patients and communities. This evidence-informed, co-creation framework for the Design, Evaluation and Procurement of Health services (in-DEPtH) is a systematic approach to support health agencies to commission services that are evidence-informed, contextually relevant and stakeholder engaged. The framework consists of several steps from defining the research question, health outcomes and search inclusion criteria, to the synthesis of evidence, and to co-creation and Delphi consultations with stakeholders. In this paper, we describe the various steps of the framework and explain the theoretical methods underpinning the framework. The approach of the framework is context neutral and can be applied to healthcare systems of different countries.
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Affiliation(s)
- Kenneth Lo
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Jonathan Karnon
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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Testa L, Seah R, Ludlow K, Braithwaite J, Mitchell RJ. Models of care that avoid or improve transitions to hospital services for residential aged care facility residents: An integrative review. Geriatr Nurs 2019; 41:360-372. [PMID: 30876676 DOI: 10.1016/j.gerinurse.2019.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 02/18/2019] [Accepted: 02/22/2019] [Indexed: 11/26/2022]
Abstract
Care transitions for older people moving from residential aged care facilities (RACFs) to hospital services are associated with greater challenges and poorer outcomes. An integrative review was conducted to investigate models of care designed to avoid or improve transitions for older people residing in RACFs to hospital settings. Twenty-one studies were included in the final analysis. Models of care aimed to either improve or avoid transitions of residents through enhanced primary care in RACFs, promoting quality improvement in RACFs, instilling comprehensive hospital care, conducting outreach services, transferring information, or involved a combination of outreach services and comprehensive hospital care. As standalone interventions, standardised communication tools may improve information transfer between RACFs and hospital services. For more complex models, providing quality improvement and outreach to RACFs may prevent some types of hospital admissions.
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Affiliation(s)
- L Testa
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, Australia.
| | - R Seah
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, Australia
| | - K Ludlow
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, Australia
| | - J Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, Australia
| | - R J Mitchell
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, Australia
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Ling R, Searles A, Hewitt J, Considine R, Turner C, Thomas S, Thomas K, Drinkwater K, Higgins I, Best K, Conway J, Hullick C. Cost analysis of an integrated aged care program for residential aged care facilities. AUST HEALTH REV 2019; 43:261-267. [DOI: 10.1071/ah16297] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 12/01/2017] [Indexed: 11/23/2022]
Abstract
Objective
To compare annual costs of an intervention for acutely unwell older residents in residential age care facilities (RACFs) with usual care. The intervention, the Aged Care Emergency (ACE) program, includes telephone clinical support aimed to reduce avoidable emergency department (ED) presentations by RACF residents.
Methods
This costing of the ACE intervention examines the perspective of service providers: RACFs, Hunter Medicare Local, the Ambulance Service of New South Wales, and EDs in the Hunter New England Local Health District. ACE was implemented in 69 RACFs in the Hunter region of NSW, Australia. Analysis used 14 weeks of ACE and ED service data (June–September 2014). The main outcome measure was the net cost and saving from ACE compared with usual care. It is based on the opportunity cost of implementing ACE and the opportunity savings of ED presentations avoided.
Results
Our analysis estimated that 981 avoided ED presentations could be attributed to ACE annually. Compared with usual care, ACE saved an estimated A$921214.
Conclusions
The ACE service supported a reduction in avoidable ED presentations and ambulance transfers among RACF residents. It generated a cost saving to health service providers, allowing reallocation of healthcare resources.
What is known about the topic?
Residents from RACFs are at risk of further deterioration when admitted to hospital, with high rates of delirium, falls, and medication errors. For this cohort, some conditions can be managed in the RACF without hospital transfer. By addressing avoidable presentations to EDs there is an opportunity to improve ED efficiency as well as providing care that is consistent with the resident’s goals of care. RACFs generate some avoidable ED presentations for residents who may be more appropriately treated in situ.
What does this paper add?
Telephone triaging with nursing support and training is a means by which ED presentations from RACFs can be reduced. One of the consequences of this intervention is ‘cost avoided’, largely through savings on ambulance costs.
What are the implications for practitioners?
Unnecessary transfer from RACFs to ED can be avoided through a multicomponent program that includes telephone support with cost-saving implications for EDs and ambulance services.
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Burkett E, Martin-Khan MG, Gray LC. Comparative emergency department resource utilisation across age groups. AUST HEALTH REV 2019; 43:194-199. [DOI: 10.1071/ah17113] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 10/09/2017] [Indexed: 11/23/2022]
Abstract
Objectives The aim of the present study was to assess comparative emergency department (ED) resource utilisation across age groups. Methods A retrospective analysis of data collected in the National Non-admitted Patient Emergency Department Care Database was undertaken to assess comparative ED resource utilisation across six age groups (0–14, 15–35, 36–64, 65–74, 75–84 and ≥85 years) with previously used surrogate markers of ED resource utilisation. Results Older people had significantly higher resource utilisation for their individual ED episodes of care than younger people, with the effect increasing with advancing age. Conclusion With ED care of older people demonstrated to be more resource intensive than care for younger people, the projected increase in older person presentations anticipated with population aging will have a magnified effect on ED services. These predicted changes in demand for ED care will only be able to be optimally managed if Australian health policy, ED funding instruments and ED models of care are adjusted to take into account the specific care and resource needs of older people. What is known about the topic? Current Australian ED funding models do not adjust for patient age. Several regional studies have suggested higher resource utilisation of ED patients aged ≥65 years. Anticipated rapid population aging mandates that contribution of age to ED visit resource utilisation be further explored. What does this paper add? The present study of national Australian ED presentations compared ED resource utilisation across age groups using surrogate markers of ED cost. Older people were found to have significantly higher resource utilisation in the ED, with the effect increasing further with advancing age. What are the implications for practitioners? The higher resource utilisation of older people in the ED warrants a review of current ED funding models to ensure that they will continue to meet the needs of an aging population.
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Wallis M, Marsden E, Taylor A, Craswell A, Broadbent M, Barnett A, Nguyen KH, Johnston C, Glenwright A, Crilly J. The Geriatric Emergency Department Intervention model of care: a pragmatic trial. BMC Geriatr 2018; 18:297. [PMID: 30509204 PMCID: PMC6276263 DOI: 10.1186/s12877-018-0992-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 11/22/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate a Geriatric Emergency Department Intervention (GEDI) model of service delivery for adults aged 70 years and older. METHODS A pragmatic trial of the GEDI model using a pre-post design. GEDI is a nurse-led, physician-championed, Emergency Department (ED) intervention; developed to improve the care of frail older adults in the ED. The nurses had gerontology experience and education and provided targeted geriatric assessment and streamlining of care. The final format included 2.4 full time equivalent nurses working 7 days from 0700 h to 1730 h (1530 h at weekends). There were three implementations periods: pre-implementation (2012); a developmental phase from January 2013 to August 2015; and full implementation from September 2015 to August 2016. The outcomes measured were disposition (discharged home, admitted or died); ED length of stay; hospital length of stay; all cause in-hospital mortality within 28 days; time to ED re-presentation up to 28 days post-discharge; in-hospital costs. The setting was a tertiary hospital ED, with 385 beds, in Queensland, Australia. Approximately 53,000 patients presented to the ED annually with 20% aged 70 years and older. All patients over the age 70 who presented to the ED between January 2012 and August 2016 (n = 44,983) were included in the trial. RESULTS Older persons who presented to the ED when the GEDI team were working had increased likelihoods of discharge (Hazard ratio (HR) = 1.19; 95% CI: 1.13-1.24) and reduced ED length of stay (HR = 1.42; 95% CI: 1.33-1.52) compared with those who presented when GEDI were not working. There was no increase in the risk of mortality (HR = 1.01; 95% CI = 0.23-4.43) or risk of same cause re-presentation to 28 days (HR = 1.21; 95% CI: 0.99-1.49). The GEDI service resulted in average cost savings per ED presentation of $35 [95% CI, $21, $49] and savings of $1469 [95% CI, $1105, $1834] per hospital admission. CONCLUSIONS Implementation of a nurse-led physician-championed model of ED care, focused on frail older adults, reduced ED length of stay, hospital admission and if admitted, hospital length of stay and cost, without increasing mortality or same cause re-presentation. These increases were sustained over time and after the initial implementation team had changed roles. TRIAL REGISTRATION Australian Clinical Trials Registration Number ACTRN12615001157561 - retrospectively registered on 29/10/2015. Data were retrieved via retrospective access to clinical information systems. First data access was on 1/7/2015.
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Affiliation(s)
- Marianne Wallis
- School of Nursing, Midwifery and Paramedicine, University of Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD, 4556, Australia.
| | - Elizabeth Marsden
- School of Nursing, Midwifery and Paramedicine, University of Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD, 4556, Australia.,Sunshine Coast and Hospital Health Service, Emergency Services, Birtinya, QLD, Australia
| | - Andrea Taylor
- School of Nursing, Midwifery and Paramedicine, University of Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD, 4556, Australia.,Sunshine Coast and Hospital Health Service, Emergency Services, Birtinya, QLD, Australia
| | - Alison Craswell
- School of Nursing, Midwifery and Paramedicine, University of Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD, 4556, Australia
| | - Marc Broadbent
- School of Nursing, Midwifery and Paramedicine, University of Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD, 4556, Australia
| | - Adrian Barnett
- Institute of Health and Biomedical Innovation & School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, QLD, 4059, Australia
| | - Kim-Huong Nguyen
- Center for Health Service Research, Faculty of Medicine, University of Queensland, Herston, QLD, 4006, Australia
| | - Colleen Johnston
- School of Nursing, Midwifery and Paramedicine, University of Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD, 4556, Australia
| | - Amanda Glenwright
- Program Management Office, Central Queensland, Wide Bay, Sunshine Coast PHN, Ground Floor, Mayfield House, 29 The Esplanade, Maroochydore, QLD, 4558, Australia
| | - Julia Crilly
- Menzies Health Institute Queensland, Griffith University, Gold Coast Campus, Griffith, QLD, 4222, Australia.,Department of Emergency Medicine, Gold Coast Health, Southport, QLD, Australia
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Santosaputri E, Laver K, To T. Efficacy of interventions led by staff with geriatrics expertise in reducing hospitalisation in nursing home residents: A systematic review. Australas J Ageing 2018; 38:5-14. [DOI: 10.1111/ajag.12593] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Elita Santosaputri
- Department of Rehabilitation, Aged Care, and Palliative Care Flinders Medical Centre Adelaide South Australia Australia
| | - Kate Laver
- Department of Rehabilitation, Aged Care, and Palliative Care Flinders Medical Centre Adelaide South Australia Australia
- College of Medicine and Public Health Flinders University Adelaide South Australia Australia
| | - Timothy To
- Department of Rehabilitation, Aged Care, and Palliative Care Flinders Medical Centre Adelaide South Australia Australia
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Barker RO, Craig D, Spiers G, Kunonga P, Hanratty B. Who Should Deliver Primary Care in Long-term Care Facilities to Optimize Resident Outcomes? A Systematic Review. J Am Med Dir Assoc 2018; 19:1069-1079. [PMID: 30173957 DOI: 10.1016/j.jamda.2018.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 06/28/2018] [Accepted: 07/08/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Across the world, health care for residents in long-term care facilities (LTCFs) is provided by a range of different professionals, and there is no consensus on which professional group(s) deliver the best outcomes for residents. The objective of this review is to investigate how the health outcomes of older adults in LTCFs vary according to which professional group(s) provides first-line medical care. DESIGN A systematic review and narrative synthesis were performed. Medline, Embase, the Cochrane Central Register of Controlled Trials, and Scopus were searched for studies from high-income countries, of any design, published after 2000. Quality was assessed using the Cochrane Risk of Bias and ROBINS-I tools. The exposure of interest was the professional group(s) involved in the delivery of first-line primary care. SETTING AND PARTICIPANTS Older adults living in LTCFs. MEASURES The principal outcomes were unplanned transfer to hospital, prescribing quality, and mortality. RESULTS Searches identified 10,532 citations after removing duplicates. Twenty-six publications (across 24 studies) met the inclusion criteria. A narrative synthesis was conducted of the 20 experimental and 4 observational studies, involving approximately 98,000 residents. Seven studies were set in the USA, 6 in Australia, 3 in Canada, 2 in New Zealand, and 6 in European countries. Interventions were varied, complex and multi-faceted. Nineteen interventional studies, including 4 randomized trials, involved the addition of a specialist practitioner, either a doctor or nurse, to supplement usual primary care. The most commonly reported outcomes were unplanned hospital transfer and prescribing quality. Interventions based on specialist nurses were associated with reductions in unplanned hospital transfers in 10 out of 12 publications. There was no consistent evidence of a positive impact of specialist doctor interventions on unplanned hospital transfers. However, specialist doctors were associated with improvements in prescribing quality in all 7 relevant studies. There was a paucity of evidence on the impact of specialist nurse interventions on prescribing, and of specialist practitioners on mortality, and no improvements were reported. CONCLUSIONS Addition of specialist doctors or nurses to the first-line medical team has the potential to improve key health outcomes for residents in LTCFs.
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Affiliation(s)
- Robert Oliver Barker
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom.
| | - Dawn Craig
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Gemma Spiers
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Patience Kunonga
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Barbara Hanratty
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
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Brucksch A, Hoffmann F, Allers K. Age and sex differences in emergency department visits of nursing home residents: a systematic review. BMC Geriatr 2018; 18:151. [PMID: 29970027 PMCID: PMC6029412 DOI: 10.1186/s12877-018-0848-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 06/26/2018] [Indexed: 12/22/2022] Open
Abstract
Background Nursing home residents (NHRs) are often transferred to emergency departments (EDs). A great proportion of ED visits is considered inappropriate. There is evidence that male NHRs are more often hospitalised, but this is less clear for ED visits. It is unclear, which influence age has on ED visits. We aimed to study the epidemiology of ED visits in NHRs focusing on age- and sex-specific differences. Methods A systematic review was carried out based on articles found in MEDLINE (via PubMed), CINAHL and Scopus. Articles published on or before Aug 31, 2017 were eligible. Two reviewers independently identified articles for inclusion. The quality of studies was assessed by the Joanna Briggs Institute critical appraisal tool for prevalence studies. Results Out of 1192 references, we found seven studies meeting our inclusion criteria. Six studies were conducted in the USA or Canada. Overall, 29–62% of NHRs had at least one ED visit over the course of 1 year. Most studies assessing the influence of sex found that male residents visited EDs more frequently. All but one of the five studies with multivariable analyses reported a statistically significant positive association (with odds or rate ratios of 1.05–1.38). All studies assessed the influence of age. There was no clear pattern with some studies showing no association between ED visits and age and other studies reporting decreasing ED visits with increasing age or increasing proportions followed by a decrease in the highest age group. Studies used 85+ or 86+ years as the highest age category. Hospital admission rate ranged from 36.4 to 48.7%. There was no study reporting stratified analyses by age and sex. Only one study reported main diagnoses leading to ED visits stratified by sex. Conclusion Male NHRs visit EDs more often than females, but there is no evidence on reasons. The association with age is unclear. Any future study on acute care of NHRs should assess the influence of age and sex. These studies should include large sample sizes to provide a more differentiated age categorisation. Trial registration PROSPERO CRD42017074845. Electronic supplementary material The online version of this article (10.1186/s12877-018-0848-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annika Brucksch
- Department 11 Human and Health Sciences, University Bremen, Bremen, Germany
| | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Katharina Allers
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany.
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Rainsford S, Phillips CB, Glasgow NJ, MacLeod RD, Wiles RB. Dying at home in rural residential aged care: A mixed-methods study in the Snowy Monaro region, Australia. HEALTH & SOCIAL CARE IN THE COMMUNITY 2018; 26:705-713. [PMID: 29766598 DOI: 10.1111/hsc.12583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/03/2018] [Indexed: 06/08/2023]
Abstract
Residential aged care (RAC) is a significant provider of end-of-life care for people aged 65 years and older. Rural residents perceive themselves as different to their urban counterparts. Most studies describing place of death (PoD) in RAC are quantitative and reflect an urban voice. Using a mixed-methods design, this paper examines the PoD of 80 RAC residents (15 short-stay residents who died in RAC during respite or during an attempted step-down transition from hospital to home, and 65 permanent residents), within the rural Snowy Monaro region, Australia, who died between 1 February 2015 and 31 May 2016. Death data were collected from local funeral directors, RAC facilities, one multi-purpose heath service and obituary notices in the local media. The outcome variable was PoD: RAC, local hospital or out-of-region tertiary hospital. For the permanent RAC residents, the outcome of interest was dying in RAC or dying in hospital. Cross tabulations by PoD and key demographic data were performed. Pearson Chi squared tests and exact p-values were used to determine if any of the independent variables were associated with PoD. Using an ethnographic approach, data were collected from 12 face-to-face, open-ended interviews with four RAC residents, with a life expectancy of ≤6 months, and six family caregivers. Interviews were audio-recorded, transcribed and analysed thematically. Fifty-one (78.5%) of the permanent residents died in RAC; 21.5% died in hospital. Home was the initial preferred POD for most interviewed participants; most eventually accepted the transfer to RAC. Long-term residents considered RAC to be their "home"-a familiar place, and an important part of their rural community. The participants did not consider a transfer to hospital to be necessary for end-of-life care. Further work is required to explore further the perspectives of rural RAC residents and their families, and if transfers to hospital are avoidable.
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Affiliation(s)
- Suzanne Rainsford
- Medical School, Australian National University, Canberra, ACT, Australia
| | | | - Nicholas J Glasgow
- Medical School, Australian National University, Canberra, ACT, Australia
| | - Roderick D MacLeod
- HammondCare, Greenwich Hospital, Sydney, NSW, Australia
- Palliative Medicine, University of Sydney, Sydney, NSW, Australia
| | - Robert B Wiles
- Rural Clinical School, Australian National University, Cooma, NSW, Australia
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Marsden E, Craswell A, Taylor A, Coates K, Crilly J, Broadbent M, Glenwright A, Johnston C, Wallis M. Nurse-led multidisciplinary initiatives to improve outcomes and reduce hospital admissions for older adults: The Care coordination through Emergency Department, Residential Aged Care and Primary Health Collaboration project. Australas J Ageing 2018; 37:135-139. [PMID: 29614207 DOI: 10.1111/ajag.12526] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This article describes the Care coordination through Emergency Department, Residential Aged Care and Primary Health Collaboration (CEDRiC) project. METHODS CEDRiC is designed to improve the health outcomes for older people with an acute illness. It attempts this via enhanced primary care in residential aged care facilities, focused and streamlined care in the emergency department and enhanced intersectoral communication and referral. RESULTS Implementing this approach has the potential to decrease inappropriate hospital admissions while improving care for older people in residential aged care and community settings. CONCLUSION This article discusses an innovative way of caring for older adults in an ageing population utilising the existing evidence. A formal evaluation is currently underway.
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Affiliation(s)
- Elizabeth Marsden
- Sunshine Coast Hospital and Health Service, Sunshine Coast, Queensland, Australia
| | - Alison Craswell
- University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| | - Andrea Taylor
- Sunshine Coast Hospital and Health Service, Sunshine Coast, Queensland, Australia
| | - Kaye Coates
- Sundale Ltd., Sunshine Coast, Queensland, Australia
| | - Julia Crilly
- School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.,Gold Coast Health, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Marc Broadbent
- University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| | - Amanda Glenwright
- Central Queensland, Wide Bay and Sunshine Coast PHN, Sunshine Coast, Queensland, Australia
| | - Colleen Johnston
- University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| | - Marianne Wallis
- University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
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