Geriatric-patient flow-rate modelling

We consider the application of a three-compartment mathematicalmodel using difference equations in discrete time to model theflow of patients through departments of geriatric medicine.It has been shown empirically that the time spent in hospitalsince admission may be described by a two-term mixed-exponentialdistribution. Previous work has explained this empirical findingin terms of a two-compartment model of geriatric in-patientbehaviour where the two compartments are acute/rehabilitativeand long-stay care. Our model extends this approach by consideringpatients released from geriatric departments and their subsequentlength of stay in the community. We have therefore, two statesof patient behaviour while in hospital: (i) patients can beadmitted to the acute-rehabilitative state, from which theymay die or be released back into the community; (ii) patientscan be admitted to the long-stay state, from which they eventuallydie. The community state currently has only one state, fromwhich patients may be readmitted back into the geriatric departmentor they may die. The model may then be used to estimate theaverage numbers and lengths of stay for short-term and long-termpatients and the average number and length of stay in the communityfor released patients, allowing for a significant improvementin the forecasting of future bed requirements to aid the planningof geriatric departments.     

Method for Assigning Priority Levels in Acute Care (MAPLe-AC) predicts outcomes of acute hospital care of older persons - a cross-national validation

Background

Although numerous risk factors for adverse outcomes for older persons after an acute hospital stay have been identified, a decision making tool combining all available information in a clinically meaningful way would be helpful for daily hospital practice. The purpose of this study was to evaluate the ability of the Method for Assigning Priority Levels for Acute Care (MAPLe-AC) to predict adverse outcomes in acute care for older people and to assess its usability as a decision making tool for discharge planning.

Methods

Data from a prospective multicenter study in five Nordic acute care hospitals with information from admission to a one year follow-up of older acute care patients were compared with a prospective study of acute care patients from admission to discharge in eight hospitals in Canada. The interRAI Acute Care assessment instrument (v1.1) was used for data collection. Data were collected during the first 24 hours in hospital, including pre-morbid and admission information, and at day 7 or at discharge, whichever came first. Based on this information a crosswalk was developed from the original MAPLe algorithm for home care settings to acute care (MAPLe-AC). The sample included persons 75 years or older who were admitted to acute internal medical services in one hospital in each of the five Nordic countries (n = 763) or to acute hospital care either internal medical or combined medical-surgical services in eight hospitals in Ontario, Canada (n = 393). The outcome measures considered were discharge to home, discharge to institution or death. Outcomes in a 1-year follow-up in the Nordic hospitals were: living at home, living in an institution or death, and survival. Logistic regression with ROC curves and Cox regression analyses were used in the analyses.

Results

Low and mild priority levels of MAPLe-AC predicted discharge home and high and very high priority levels predicted adverse outcome at discharge both in the Nordic and Canadian data sets, and one-year outcomes in the Nordic data set. The predictive accuracy (AUC's) of MAPLe-AC's was higher for discharge outcome than one year outcome, and for discharge home in Canadian hospitals but for adverse outcome in Nordic hospitals. High and very high priority levels in MAPLe-AC were also predictive of days to death adjusted for diagnoses in survival models.

Conclusion

MAPLe-AC is a valid algorithm based on risk factors that predict outcomes of acute hospital care. It could be a helpful tool for early discharge planning although further testing for active use in clinical practice is still needed.     

A randomized, controlled trial of a geriatric assessment unit in a community rehabilitation hospital

We conducted a randomized trial in a community rehabilitation hospital to determine the effect of treatment in a geriatric assessment unit on the physical function, institutionalization rate, and mortality of elderly patients. Functionally impaired elderly patients (mean age, 78.8 years) who were recovering from acute medical or surgical illnesses and were considered at risk for nursing home placement were randomly assigned either to the geriatric assessment unit (n = 78) or to a control group that received usual care (n = 77). The two groups were similar at entry and were stratified according to the perceived risk of an immediate nursing home placement. After six months, the patients treated in the geriatric assessment unit had significantly more functional improvement in three of eight basic self-care activities (P less than 0.05). Those in the lower-risk stratum had significantly more improvement in seven of eight self-care activities. Both six weeks and six months after randomization, significantly more patients treated in the geriatric assessment unit than controls (79 vs. 61 percent after six months) were residing in the community. During the year of follow-up, the control patients had more nursing home stays of six months or longer (10 vs. 3; P less than 0.05). However, there was no difference between the groups in the mean number of days spent in health care facilities (acute care hospital, nursing home, or rehabilitation hospital). Survival analysis showed a trend toward fewer deaths among the patients treated in the geriatric assessment unit, and mortality was significantly reduced in the patients considered to be at lower risk of immediate nursing home placement (P less than 0.05). We conclude that the treatment of selected elderly patients in a specialized geriatric rehabilitation unit improves function, decreases the risk of nursing home placement, and may reduce mortality. The beneficial effects on mortality and function appear greatest for patients at a moderate rather than high risk of nursing home placement.     

Nosocomial infection with Clostridium difficile investigated by pyrolysis mass spectrometry.

Fifty-eight isolates of Clostridium difficile from two distinct outbreaks were examined for inter-strain similarity by pyrolysis mass spectrometry (PMS). The first outbreak began on a geriatric acute unit and spread to a long stay geriatric facility. PMS analysis showed that most isolates from both sites were indistinguishable. Isolates obtained in the preceding year from the long stay facility were found to be closely similar to these outbreak isolates. In the second, smaller outbreak on a female medical ward in another general hospital, PMS again showed that a single strain was probably responsible. Representative isolates from these two different outbreaks were shown to be distinct. The ability to compare rapidly large numbers of isolates of C. difficile makes PMS attractive for initial screening in suspected outbreaks, providing important information for outbreak management and allowing conventional typing methods to be concentrated on relevant isolates.     

The challenge of teaching rehabilitative care in medical school.

Rehabilitative care has gained importance because the population is aging, and improved acute and chronic medical care saves and prolongs lives but leaves some patients with temporary or permanent physical impairments. However, despite its importance, the teaching and learning of rehabilitative care in medical school lag behind medical education relating to acute and chronic care. The authors analyze the broad scope of rehabilitative care and the need to include it in the medical school curriculum. They also discuss advantages for students and their patients of learning rehabilitative care in the undergraduate curriculum and suggest methods to improve teaching it.     

Correlates of rehabilitation hospital length of stay among older African-American patients

This study addresses a gap in the current literature on the correlates of rehabilitation hospital length of stay for older African Americans. Using data from 616 consecutively admitted rehabilitation patients who ranged in age from 50 to 103 years old, we tested the effect of patient's primary medical impairment; structural factors such as admit and discharge setting; level of depression (Geriatric Depression Scale); functional ability upon hospital admission (FIM score); and other control variables. Hierarchical linear regression models show that medical impairment alone was not a robust predictor of LOS. However, when controlling for structural and psychosocial factors, and medical condition, then circulation/amputation impairment was directly associated with longer LOS. Being unmarried or at risk for depression were also directly related to longer LOS. Consequently, rehabilitation administrators and hospital staff should note these findings to determine whether and how these factors affect discharge outcomes in their particular rehabilitative environments.     

Perinatal care of low-risk mothers and infants. Early discharge with home care.

A family-centered perinatal-care program featuring collaboration by nurse practitioners, obstetricians, pediatricians, and paramedical personnel was developed to enhance family participation and achieve a shorter but safe hospital stay. Discharge from the hospital was permitted as early as 12 hours after delivery. A perinatal nurse practitioner made daily home visits. The program's safety, feasibility, and acceptability to patients was studied by comparison of 44 patients so treated (study group) with 44 receiving traditional care (controls). Twenty-one study families, but no controls, went home within 24 hours. The study and control groups had no significant differences or trends in numbers of types of morbidity during hospitalization or the six-week post-partum period. The expense of the program is approximately equaled by hospital costs saved through early discharge. The results indicate that early discharge with home-care follow-up observation as described is safe, economically feasible, and well accepted by patients.     

Balance of care for the dying between hospitals and the community: perceptions of general practitioners, hospital consultants, community nurses and relatives.

A survey was made of the general practitioners, hospital consultants and community nurses who had cared for a random sample of people dying in 1987. Their views and experiences of the balance of care between hospital and the community are reported. All three groups wanted more people to be looked after in their homes rather than in hospital if adequate care could be arranged at home. But they perceived inadequacies in home help and district nursing services and many wanted other community services expanded or introduced. The main shortcomings of the hospital service were seen as inadequate numbers of hospice beds, difficulty obtaining admission for people needing long term care, discharge too early and some over-treatment of people who were dying. There was some evidence from relatives that pain control was better in hospital than at home, and the district nurses also reported that pain was not controlled satisfactorily for patients dying at home as often as it could be. It is concluded that inadequacies in community services may discourage some people from taking on the care of their relatives at home.     

Geriatric autopsy findings in the last 10 years: an Urban Teaching Hospital experience

In this study, we reviewed autopsy records for clinical data and autopsy findings from patients aged 70 or more, over a 10-year period (1993 to 2002) in an urban university hospital. For that period, there were a total of 772 autopsy cases of which 180 (23%) patients were aged 70 years or older. We found that despite a marked decrease in total autopsy rates, there has been a perceptible rise in geriatric cases. Cardiovascular and infectious diseases in this age group are the leading causes of death as reported nationally. We found that women died more of acute myocardial infarctions than men, even though hypertensive and atherosclerotic cardiovascular diseases not otherwise specified were more prevalent in men. It is our conclusion that at our institution: 1) despite a marked decrease in the total autopsy rate, the geriatric autopsy rate is rising; 2) infectious and cardiovascular diseases are the leading causes of death in elderly patients; 3) Myocardial infarcts as a cause of death are more often seen in women for this age group. It is also our impression that better autopsy reporting is needed for maximal utilization of autopsy findings in medical auditing and teaching and for improvements in the quality of patient care in general and the geriatric patient in particular.     

New York University Medical Center's Cooperative Care Unit: patient education and family participation during hospitalization--the first ten years

The New York University Medical Center Cooperative Care (CC) program is a model of a delivery system of acute inpatient hospital care characterized by a live-in family member or friend acting as a "care partner". It has an emphasis on education in order to encourage full patient and family involvement in care during the acute hospitalization, thereby preparing both parties for management at home after discharge. The education-intensive experience of CC provides an alternative to traditional inpatient hospital care with the expected outcome of CC being to increase patient and family knowledge and satisfaction, adherence to the medical regimen, and appropriate self-management. The functioning ability of the patient-care partner team should be improved on discharge, which may result in decreased subsequent utilization of high cost healthcare resources such as rehospitalization. This paper describes the structure of the CC form of inpatient care, the types of patients appropriate for such care, and the experience of its first ten years of operation, with its implications as a replicable model for other institutions.     

Do relatives of elderly patients block the discharge process?

There is a perception that relatives of older patients "block" their discharge from acute hospitals, thereby compounding the capacity crises of Ireland's A+E departments. This study prospectively analyses 1,240 consecutive referrals to the discharge co-ordinator of an acute general hospital over a two-year period. The number of bed-days consumed by all patients whose discharge was delayed was calculated, in addition to reasons for delay and whether or not patients' relatives were opposing discharge. There were 90 cases of delayed discharge resulting in 2,436 bed-days consumed over the study period. Reasons for delays principally centred on access to long-term care facilities and organisation of community supports. Patients' relatives opposed discharge in 9 of the 90 delayed cases. Concerns expressed by patients' relatives reflected the paucity of community supports available for older people and their carers. Older people's relatives are patient advocates and seek appropriate facilities for those whom they represent.     

Low-End Videoconferencing for Vascular Access Device Site Assessment in Homecare

Vascular access devices (VAD) represent high technology and are used frequently in infant, pediatric, adult, and geriatric populations for vascular infusion of chemotherapy, immunotherapy, blood products, biologic response modifiers, nutrition support, analgesics, ionotropics, antibiotics, and other medications, as well as for extraction of pleural fluid from patients with chronic effusions and for treatment with dialysis. Increasingly, these devices are migrating to the home setting as they are used in chronic care and as insurance requirements reduce access to prolonged hospital stays.Surveillance of infections in high risk patients such as those with cancer, cardiac conditions, or post-trauma convalescence is essential to avoid adverse events and to offer early treatment. VAD site and blood stream infections are common VAD complications, occurring in up to 50% of home care patients, usually during days 4–25 after hospital discharge. Our literature search for reports of remote home monitoring for support of VAD patients and their caregivers found none.The use of videoconferencing technology to assess VAD sites in the post-discharge environment would significantly enhance patient safety, facilitate continuity of care, and meet the Communicable Disease Center's stated need for the development of surveillance systems to monitor infections in home care settings. Low-cost Internet- or telephone-based videoconferencing technology that could be deployed easily and used during risk periods would be highly beneficial to patients and increase the cost-effective use of homecare nursing personnel.We report criteria-based protocols for remote assessment of VAD status, for monitoring VAD care procedures employed in the home, and for conducting VAD-care teaching of patients and their caregivers. In addition, we report an initial evaluation of the ability to assess VAD status using low-end videoconferencing technologies.     

EMR based telegeriatric system

INTRODUCTION: As medical services improve due to new technologies and breakthroughs, it has lead to an increasingly aging population. There has been much discussion and debate on how to solve various aspects such as psychological, socioeconomic and medical problems related to aging. Our effort is to implement a feasible telegeriatric medical service with the use of the state of the art technology to deliver medical services efficiently to remote sites where elderly homes are based. Telegeriatric system will lead to rapid decision-making in the presence of acute or subacute emergencies. This triage will also lead to a reduction of unnecessary admission. It will enable the doctors who visit these elderly homes on a once-a-week basis to improve their geriatric management skills by communication with geriatric specialist. Nursing skills in geriatric care will also benefit from this system. Integrated EMR service will be indispensable in the face of emergency admissions to hospitals. Evolution of EMR database would lead to future research in telegeriatrics and will help to identify the areas where telegeriatrics can be optimally used. METHODOLOGY: This system is based on current web browsing technology and broadband communication. EMR web based server is developed using Java Technology. EMR database was developed using Microsoft SQL server. Both are based at the Medical Informatics Programme, National University of Singapore. Two elderly homes situated in the periphery of Singapore and a leading government hospital in geriatric care has been chosen for the project. These three institutions and National University of Singapore are connected via ADSL protocol, which support high bandwidth, which is necessary for high quality videoconferencing. Each time a patient needs a teleconsultation, a nurse or doctor in the remote site sends the history to the EMR server. EMR server forwards the request to the Alexandra Hospital for consultation. Geriatrics specialists at Alexandra Hospital carry out teleward rounds twice weekly and on demand basis. SUMMARY OF RESULTS: Following the implementation of the system, a trial run has been done. This shows a high degree of coordination and cooperation between remote site and the Alexandra Hospital Also the patient compliance is very high and they prefer teleconsultation. CONCLUSION: Initial results show that telegeriatric system has definite advantages in managing geriatric patients at a remote site. As the system evolves, further research will show the areas where telegeriatrics can be used optimally.     

A questionnaire on treatment satisfaction and disease specific knowledge among patients with acute coronary syndrome. II: Insights for patient education and quality improvement

Objective

Secondary prevention for coronary heart disease is achieved by pharmaceutical control of risk factors and patients’ own self management behaviour. To comply with longterm treatment patients need sufficient knowledge of their condition and should be satisfied with acute care. Therefore a questionnaire measuring both issues was constructed.

Methods and results

Latent class analysis applied in a sample of over 2000 patients suffering from acute coronary syndrome revealed 4 configurative patterns of knowledge and 5 distinct patterns of (dis-)satisfaction. Nearly 50% of all patients displayed insufficient knowledge upon discharge. Deficits clustered around misinformation on necessary lifestyle changes versus dysfunctional strategies for future emergency situations. Satisfaction and disease specific knowledge were interrelated in complex patterns.

Conclusions

Disease specific knowledge and satisfaction with treatment proved to be psychometrically valid indicators of the quality of the treatment process that might also have an impact on outcome.

Practice implications

A validated questionnaire is ready for routine administration after discharge of patients with acute coronary syndrome from acute hospital care. Patient education efforts and quality improvement in treatment centres might be effectively monitored using this questionnaire.     

Teleconsultation in geriatrics: Impact on professional practice

Teleconsultations in medicine are encouraged by authorities and decision-makers to improve access to specialty services for isolated patients. For elderly patients in geriatric hospitals, they thus avoid trips to consult with specialists. However, teleconsultation can modify clinical practice and it may be abandoned for reasons not related to technical issues. Qualitative research on the impact of teleconsultation on medical practice and organisation are thus crucial for an understanding of the changes it can generate.MethodsWe used qualitative methods to analyse the impact on professional work practices and care organisation of an initially experimental and then permanent teleconsultation system using a video conference system set up between a geriatric hospital and a tertiary care hospital. Sixty-six teleconsultations (56 during the experimental phase and 10 when the system was in routine use) were observed and ten semi-structured interviews were carried out with the actors in the teleconsultations.ResultsOur study shows that the uses of teleconsultation affected work practices of both the consulted specialist and the geriatrician who participated in the consultation alongside the patient. The interactions of specialists with the patient were more difficult than in a face-to-face setting and delegation of the clinical examination of the patient depended on a specific form of cooperation and on trust in the person doing the examination. New kinds of relationships between health professionals contributed to sharing and transmission of knowledge between practitioners. While teleconsultations established alliances between geriatricians and specialists, they none-the-less called for a certain humility on the part of geriatricians. In order for these relationships to become routine and to facilitate interaction among participants, the project manager carried out important work during the experimental phase of the teleconsultations by organising these interactions. Finally, the teleconsultations went through several local reorganisations, especially within the geriatric hospital. These included changes in the geriatrician's schedule and the added presence of an assistant knowledgeable in telemedicine.ConclusionsSpecialists found the system used for teleconsultation between a geriatric hospital and a tertiary care hospital to be suitable for their consultations. The main advantage brought about by the teleconsultation system studied resulted from its collaborative nature, which created relationships between health professionals. This resulted in improved care for elderly patients. However, using the system required effort on the part of both the specialists and the geriatricians. Adapting to the system was facilitated by coordination work carried out by the project manager during the experimental phase that created a favourable context for cooperation between actors, allowing diagnoses to be made at a distance. Finally, teleconsultations do not appear suitable for all specialties, by reason of the limits imposed on the delegation of tasks, or to all situations. They require setting up new forms of organisation that must be encouraged by decision-makers.     

Use of general practitioner beds in Leicestershire community hospitals.

BACKGROUND. The shift in care from secondary to primary services is likely to place greater demands on community hospitals. Before changes in the provision of community hospitals can occur, baseline data are needed, outlining their current use. AIM. A study was undertaken to obtain baseline data describing the use of general practitioner beds in Leicestershire community hospitals. METHOD. A three-month prospective, observational study was carried out between February and May 1992 using data from a questionnaire completed by nurses and general practitioners and from patient hospital records. Study patients comprised all patients admitted to general practitioner beds in all eight Leicestershire community hospitals. RESULTS. A 100% questionnaire response rate was obtained giving data on 685 hospital admissions. Around 70% of admissions were of patients aged 75 years and over. Of admissions, 35% were for acute care, 31% for respite care, 22% for rehabilitation, 7% for terminal/palliative care and 5% for other reasons. Fifteen per cent of patients had been transferred from a consultant bed. Of those not transferred, 91% were admitted by their usual general practitioner or practice partner and for 96% of these patients this was the general practitioner's first choice for care. There was significant variation in both the age mix and care category mix of patients between individual hospitals. Medical deterioration in an underlying condition and family pressure on the general practitioner or carers' inability to cope each contributed to around half of all admissions. Of all admissions, 38% lived alone, and 18% of carers were disabled. Incontinence was reported for 35% of patients, and 26% of all patients were of a high nursing dependency. There was low utilization of community services before admission and 33% received none. There was variation between individual hospitals in use of local and district general hospital investigations, specialist referral and types of therapy. Of 685 admissions 11% died during their stay. Of those discharged, 76% went to their own or a relative's home, 10% to a residential or nursing home and 9% were transferred to an acute bed. Nine percent of discharges were postponed and 10% were brought forward. On discharge to non-residential care, 26% of patients received no community services. CONCLUSION. Shifting resources from secondary to primary care is a priority for purchasers. Both the introduction of the National Health Service and community care act 1990, and acute units having increasing incentives for earlier discharge, are likely to place greater demands on community hospital beds. Not all general practitioners have the option of community hospital beds. Before access to general practitioner beds can be broadened, existing beds should be used appropriately and shown to be cost-effective. Purchasers therefore require criteria for the appropriateness of admissions to general practitioner beds, and the results of a general practitioner bed cost-benefit analysis.     

A randomized clinical trial of early hospital discharge and home follow-up of very-low-birth-weight infants

To determine the safety, efficacy, and cost savings of early hospital discharge of very-low-birth-weight infants (less than or equal to 1500 g), we randomly assigned infants to one of two groups. Infants in the control group (n = 40) were discharged according to routine nursery criteria, which included a weight of about 2200 g. Those in the early-discharge group (n = 39) were discharged before they reached this weight if they met a standard set of conditions. For families of infants in the early-discharge group, instruction, counseling, home visits, and daily on-call availability of a hospital-based nurse specialist for 18 months were provided. Infants in the early-discharge group were discharged a mean of 11 days earlier, weighed 200 g less, and were two weeks younger at discharge than control infants. The mean hospital charge for the early-discharge group was 27 percent less than that for the control group ($47,520 vs. $64,940; P less than 0.01), and the mean physician's charge was 22 percent less ($5,933 vs. $7,649; P less than 0.01). The mean cost of the home follow-up care in the early-discharge group was $576, yielding a net saving of $18,560 for each infant. The two groups did not differ in the numbers of rehospitalizations and acute care visits, or in measures of physical and mental growth. We conclude that early discharge of very-low-birth-weight infants, with follow-up care in the home by a nurse specialist, is safe and cost effective.     

Wechsler Memory Scale performance in geropsychiatric patients

Patients (N = 36) on a geropsychiatric acute care unit were administered the Wechsler Memory Scale (WMS) at admission and discharge. The results indicated that there were significant increases in WMS scores from admission to discharge. Mean scores on the WMS were generally below those previously reported for normal geriatric groups, but above those reported for chronically ill or demented groups. As in previous studies, a significant positive relationship was found between education and WMS score, although no such relationship was found between age and WMS score. Overall, the results highlight the need for comprehensive norms for the elderly, which would increase greatly the practical utility of the WMS in clinical settings.     

A randomized controlled trial of hospital discharge three days after myocardial infarction in the era of reperfusion

To evaluate the feasibility and cost savings of hospital discharge three days after acute myocardial infarction, we screened 507 consecutive patients prospectively for clinical complications and exercise-test performance. Of 179 patients whose condition was classified as uncomplicated (no angina, heart failure, or arrhythmia 72 hours after admission), 126 underwent early exercise testing and 90 had no provocable myocardial ischemia. Eighty of these patients were randomly assigned to early (day 3) or conventional (days 7 to 10) hospital discharge. Seventy-six of them had received coronary reperfusion therapy (thrombolysis, angioplasty, or both). At six months of follow-up, there were no deaths or new ventricular aneurysms, and the early-discharge and conventional-discharge groups had similar numbers of hospital readmissions (6 and 10), reinfarctions (none and 5), and patients with angina (3 and 8). In the early-discharge group, 25 of 29 previously employed patients returned to work 40.7 +/- 21.9 days (mean +/- SD) after admission, as compared with 25 of 27 patients in the conventional-discharge group, who returned to work after a mean of 56.9 +/- 30.3 days (P = 0.054). The mean cumulative hospital and professional charges were $12,546 +/- 3,034 in the early-discharge group, as compared with $17,868 +/- 3,688 in the conventional-discharge group (P less than 0.0001). In carefully selected patients with uncomplicated myocardial infarction, hospital discharge after three days is feasible and leads to a substantial reduction in hospital charges. Before this strategy can be widely recommended, however, its safety must be confirmed in larger prospective clinical trials.