Acceptability of early discharge, hospital at home schemes

Client-Centred Practice: Is it Compatible with Early Discharge Hospital-at-Home Policies?

Current Government initiatives promote the provision of health care in the community rather than in medical institutions. Over the last decade there has been a growth in the number of early discharge hospital-at-home initiatives which provide a level of nursing and rehabilitation care in the home that previously would have been provided in an acute hospital. Simultaneously, there has been a move away from medical to client-centred models of health care delivery. These new client-centred models of health care emphasise collaboration between client and professional and encourage users of health care services to take greater control over and responsibility for their health care. Some occupational therapists may question whether the principles of client-centred care are compatible with the policy of discharging patients early from hospital while they remain in need of health care.

This paper briefly reviews some of the principles of the Canadian Model of Occupational Performance; discusses some of the barriers to providing client-centred services in the early discharge hospital-at-home setting; and reflects upon whether the principles of client-centredness are consistent with early discharge from hospital policies.

Outpatient parenteral antibiotic therapy in Singapore

Outpatient parenteral antibiotic therapy (OPAT) remains in its infancy in Singapore, with the first patients enrolled 4 years ago. Singapore's three largest hospitals, with over 3000 inpatient beds, now have designated and approved OPAT services. This study reviews the demographic, clinical and cost data of all patients enrolled in 2005 to facilitate benchmarking between services in Singapore and abroad and also to identify common needs for further development. In 2005, 225 OPAT enrollments in 208 different patients resulted in 4050 days of OPAT care. Orthopaedic diagnoses constituted 40% of admissions. Vancomycin was the most frequently used antibiotic (34%). The re-admission rate was 8.9%, but complications of OPAT care were only occasionally implicated. An estimated $207,200 was saved by patients despite there being significant financial disincentives to subsidised patients. OPAT is a safe, cost-efficient system that is becoming increasingly accepted in Singapore by patients, clinicians and management. Our three services have evolved independently into very similar practices. There is potential for further innovation, including outreach and carer-delivered dosing. However, major financial disincentives require review.

A chronic disease management programme can reduce days in hospital for patients with chronic obstructive pulmonary disease

BACKGROUND

A steady increase in chronic obstructive pulmonary disease (COPD) admissions was addressed by enhancing primary care to provide intensive chronic disease management.

AIM

To compare the effect of a disease management programme, including a COPD management guideline, a patient-specific care plan and collaboration between patients, general practitioners, practice nurses, hospital physicians and nurse specialists with conventional care, on hospital admissions and quality of life.

METHODS

One hundred and thirty-five patients with a clinical diagnosis of moderate to severe COPD were identified from hospital admission data and general practice records. General practices were randomized to either conventional care (CON), or the intervention (INT). Pre- and post-study assessment included spirometry, Shuttle Walk Test, Short Form-36, and the Chronic Respiratory Questionnaire (CRQ). Admission data were compared for 12 months prior to and during the trial.

RESULTS

For respiratory conditions, mean hospital bed days per patient per year for the INT group were reduced from 2.8 to 1.1, whereas those for the CON group increased from 3.5 to 4.0 (group difference, P = 0.030) The INT group also showed an improvement for two dimensions of the CRQ, fatigue (P = 0.010) and mastery (P = 0.007).

CONCLUSIONS

A chronic disease management programme for COPD patients that incorporated a variety of interventions, including pulmonary rehabilitation and implemented by primary care, reduced admissions and hospital bed days. Key elements were patient participation and information sharing among healthcare providers.

Identifying the palliative care role of the nurse working in community hospitals: an exploratory study

AIM

to ascertain registered nurses' and GPs' perceptions of and influences on the nurse's role in providing palliative care in community hospitals.

DESIGN

qualitative exploratory/descriptive study.

SETTING

two community hospital sites within Perth and Kinross, Scotland.

METHOD

taped semi-structured interviews with four registered nurses and two GPs. Participants' perceptions were sought on the roles of nursing and medical professionals and of factors facilitating and hindering the provision of palliative care within the community hospital setting.

FINDINGS

six key themes were identified through thematic analysis of the information: communication, teamwork and relationships, holistic care, resources, culture, professional role.

CONCLUSION

the themes were inter-related and gave valuable insight into the multidimensional nature and significance of the nurse's role in palliative care in the community hospital setting.

Hospital in the home: constructions of the nursing role - a literature review

Acute medical and nursing treatment in the home is increasingly seen as an alternative to hospitalization. Models such as hospital in the home (HITH) or acute home care are said to provide a safe, comfortable environment for patients that is conducive to healing. A review of the literature reveals the embryonic nature of the research and discussion related to this alternative care delivery model. In general, the benefits of hospital in the home programmes are presented in an uncritical manner. Medical practitioners have embraced the move to home care as a means of expanding the use of advanced technologies and improved drug regimes beyond the hospital walls. The nursing response has been mechanistic and recipe-like while advancing the HITH nursing role as an opportunity for specialty practice by virtue of the increased autonomy and independence required. This review demonstrates the influence of a professional mandate for specialization, and the ideological and scientific interests that have influenced the role of the nurse.

Parents and partners: lay carers' perceptions of their role in the treatment and care of adults with cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) is the most common autosomal recessive genetic disease in Caucasian people, traditionally conceptualized as a condition whereby sufferers died in childhood. However, the current median survival age of 30 and a predicted median survival age of 40 for those born with the disease over the last decade ensure that families members will assist hospital staff with treatment and care well into most patients' adulthood.

AIMS

This study explores the perceptions and experiences of lay care-giving amongst parents and partners of adults with CF who were being treated at a specialist CF centre in England.

METHODS

Thirty-one relatives of adults with CF were interviewed in their own homes using an interview topic guide. All interviews were audiotape recorded and transcribed verbatim. Analysis of data was assisted by ATLAS-ti, a software package for qualitative research.

FINDINGS

Two main themes surrounding lay carers' role in treatment and care were identified. Firstly, the notion of lay carers giving 'expert' care, both in hospital and at home was recognized. Parents' expertise was greater than that of partners until the patient required intensive hospital interventions, when partner expertise increased. Secondly, the degree of lay carers' felt inclusion in the hospital consultation appeared to depend on the nature of their relationship with the patient and the patients' health state.

CONCLUSION

Lay carers are routinely performing tasks for adults with CF that were once the remit of trained nurses. Families need higher levels of nursing and social support when certain treatments are used at home. Attention needs to be directed to how lay carers of adult patients can be included in hospital consultations.