The burden of alcohol misuse on emergency in-patient hospital admissions among residents from a health board region in Ireland

AIMS: To identify in-patient emergency admissions to acute hospitals of residents from a health board region in the Republic of Ireland with an acute alcohol intoxication diagnosis; to profile the admissions and to assess whether the increase in alcohol consumption in Ireland has been mirrored by an increase in alcohol related emergency admissions over the same time period. DESIGN: A retrospective review of hospital admissions using Hospital In-Patient Enquiry (HIPE) data and alcohol consumption trends using data from the Central Statistics Office (CSO). SETTING: Acute hospitals in the Republic of Ireland. PARTICIPANTS: All residents from a health board region admitted with a recorded alcohol intoxication emergency admission to non-private acute hospitals in Ireland. MEASUREMENTS: All in-patient emergency admissions for which an acute alcohol intoxication diagnosis (ICD Codes 303.0 and 305.0) was recorded of residents from one health board region were extracted from the HIPE system for years 1997-2001 inclusive. Pearson's chi2 test was used to compare proportions in groups of categorical data and chi2 test for trend was used to identify linear trends. Age standardized rates were calculated for each year and trend analysis carried out. Demographic data on the patients were also extracted from the database. FINDINGS: There were 3289 acute alcohol intoxication admissions to acute hospitals of residents from the study region recorded for years 1997-2001 inclusive. There were 777 acute alcohol intoxication admissions in 2001 compared to 432 admissions in 1997, an increase of 80%. Age standardized rates showed a significant increasing linear trend (P < 0.001). Over half the admissions occurred on weekends. The average length of stay was 2.7 days (95% CI 2.5-2.8) with just under a quarter (24.3%) of these admissions being discharged on the same day. The majority of these patients were male (71.5%), 40.9% were under 30 years old and over half (59.4%) were single. CONCLUSIONS: This study shows that alcohol intoxication accounted for a substantial number of emergency in-patient admissions to acute hospitals in one health board region in Ireland and that the age standardized recorded acute alcohol related emergency admission rate increased significantly over the 5-year period, 1997-2001. This increase mirrored the national increase in alcohol consumption over the same time period.     

Advance care planning and hospital in the nursing home

BACKGROUND: the number of nursing home residents (NHRs) in hospital is increasing although hospital admission may be deleterious to their health. OBJECTIVE: to evaluate a system of educating residents, their families, staff and general practitioners about outcomes of dementia, advance care planning (ACP) and hospital in the home. METHODS: we employed one clinical nurse consultant, who utilised the 'Let Me Decide' Advance Care Directive. The intervention area consisted of two hospitals and the 21 nursing homes (NHs) around them compared with another, geographically separate, hospital and the 13 homes around it. We conducted a controlled evaluation monitoring emergency admissions to hospital. RESULTS: emergency calls to the ambulance service from intervention NHs decreased (intervention versus control; -1 versus +21%; P = 0.0019). The risk of a resident being in an intervention hospital bed for a day compared with in a control hospital bed, per NH bed, fell by a quarter from being initially similar [Relative Risk (RR) = 1.01; 95% confidence interval (CI) 0.98-1.04; P = 0.442] to being lower (RR = 0.74; 95% CI 0.72-0.77; P<0.0001). There was no significant change in mortality in the intervention homes, but in the control homes mortality rose in the third year to be 11.2 per 100 beds higher than in the intervention area (P<0.05). CONCLUSION: ACP and hospital in the home can result in decreased hospital admission and mortality of NHRs.     

Patterns of utilization for the Minnesota senior health options program

OBJECTIVES: To compare the use of medical services provided under the Minnesota Senior Health Options (MSHO) (a special program designed to serve dually eligible older persons) with that provided to controls who received fee-for-service Medicare and Medicaid managed care. DESIGN: Quasi-experimental design using two control groups; separate matched cohort and rolling cross-sectional analyses; regression models used to adjust for case-mix differences. SETTING: Urban Minnesota community and nursing home long-term care. PARTICIPANTS: Dually eligible elderly MSHO enrollees in the community and in nursing homes were compared with two sets of controls; one was drawn from nonenrollees living in the same area (control-in) and another from comparable persons living in another urban area where the program was not available (control-out). Cohorts living in the community and in nursing homes were included. MEASUREMENTS: Use of hospitals and emergency rooms, physician visits. RESULTS: In the community cohort, there were no significant differences in hospital admission rates or in hospital days. MSHO enrollees had significantly fewer preventable hospital admissions and significantly fewer preventable emergency services than the control-in group. MSHO nursing home enrollees had significantly fewer hospital admissions than either control group with or without adjustment at 12 and 18 months. MSHO enrollees had significantly fewer hospital days and preventable hospitalizations than the control-in group. MSHO enrollees had significantly fewer emergency room visits and preventable emergency room visits than either control group. CONCLUSION: In general, the results of this evaluation are mixed but favor MSHO. The effect of MSHO was stronger for nursing home enrollees than community enrollees. The lower rate of preventable hospitalizations and emergency room visits of MSHO enrollees suggests that MSHO affected the process of care by providing more of some types of preventive and community-care services for community residents.     

Appropriateness of the decision to transfer nursing facility residents to the hospital

OBJECTIVES: To develop and test a standardized instrument, the purpose of which is to assess (1) whether skilled nursing facilities (SNFs) transfer residents to emergency departments (ED) inappropriately, (2) whether residents are admitted to hospitals inappropriately, (3) and factors associated with inappropriate transfers. DESIGN: A structured implicit review (SIR) of medical records. SETTING AND PARTICIPANTS: Using nested random sampling in eight community SNFs, we identified SNF and hospital records of 100 unscheduled transfers to one of 10 hospitals. MEASUREMENTS: Seven trained physician reviewers assessed appropriateness using a SIR form designed for this study (2 independent reviews per record, 200 total reviews). We measured interrater reliability with kappa statistics and used bivariate analysis to identify factors associated with assessment that transfer was inappropriate. RESULTS: In 36% of ED transfers and 40% of hospital admissions, both reviewers agreed that transfer/admit was inappropriate, meaning the resident could have been cared for safely at a lower level of care. Agreement was high for both ED (percent agreement 84%, kappa .678) and hospital (percent agreement 89%, kappa .779). When advance directives were considered, both reviewers rated 44% of ED transfers and 45% of admissions inappropriate. Factors associated with inappropriateness included the perceptions that: (1) poor quality of care contributed to transfer need, (2) needed services would typically be available in outpatient settings, and (3) the chief complaint did not warrant hospitalization. CONCLUSIONS: Inappropriate transfers are a potentially large problem. Some inappropriate transfers may be associated with poor quality of care in SNFs. This study demonstrates that structured implicit review meets criteria for reliable assessment of inappropriate transfer rates. Structured implicit review may be a valuable tool for identifying inappropriate transfers from SNFs to EDs and hospitals.     

The quality of care under a managed-care program for dual eligibles

PURPOSE: Our objective in this study was to compare the quality of care provided under the Minnesota Senior Health Options (MSHO), a special program designed to serve dually eligible older persons, to care provided to controls who received fee-for-service Medicare and Medicaid managed care. DESIGN AND METHODS: Two control groups were used; one was drawn from nonenrollees living in the same area (Control-In) and another from comparable individuals living in another urban area where the program was not available (Control-Out). Cohorts living in the community and in nursing homes were included. Quality measures for both groups included mortality rates, preventable hospital admissions, and preventable emergency room (ER) visits. For the community group, nursing home admission rates were also tracked. For nursing home residents, quality measures included quality indicators derived from the Minimum Data Set. RESULTS: There were no differences in mortality rates for either cohort. MSHO had fewer short-stay nursing home admissions but no difference for stays 90 days or longer. MSHO community and nursing home residents had fewer preventable hospital and ER visits compared to Control-In. There were no major differences in nursing home quality indicator rates. IMPLICATIONS: The cost of changing the model of care for dual eligibles from a mixture of fee-for-service and managed care to a merged managed-care approach cannot be readily justified by the improvements in quality observed.     

Precipitants of emergency room visits and acute hospitalization in short-stay medicare nursing home residents

OBJECTIVES: To determine what precipitates rehospitalization for residents who become acutely ill in the first 90 days of a nursing home (NH) admission. DESIGN: NH medical record review comparing acutely ill Medicare admissions transferred back to hospital with those not transferred. SETTING: Sixty skilled nursing facilities in five states during 1994. PARTICIPANTS: Six hundred thirty-six residents who became acutely ill with urinary tract infection (UTI), pneumonia, or congestive heart failure (CHF) during the first 90 days of their nursing home admission were identified from 2,414 random NH Medicare admissions, excluding those with orders not to be hospitalized. MEASUREMENTS: Diagnosis, age, gender, advance care directives, nursing shift during which problem occurred, comorbidity, symptoms, and signs of acutely ill NH residents transferred to the hospital or emergency department were compared with those not transferred. RESULTS: Rates of hospitalization varied markedly by acute illness: 11 of residents with UTI, 46 with pneumonia, and 58 with an exacerbation of CHF (P< .001). In stratified multivariate analysis, older age decreased the odds of rehospitalization only for CHF. Male gender increased odds of hospitalization for pneumonia (odds ratio (OR) = 2.94) and decreased odds of hospitalization for CHF (OR = 0.28). Do not resuscitate orders were negatively associated with hospitalization only for pneumonia (OR = 0.23), whereas weekend and evening/night shifts increased odds of hospitalization for UTI. Each illness had its own set of symptoms, signs, and comorbidities associated with hospitalization.CONCLUSIONS: Whether an acutely ill NH Medicare patient was rehospitalized depended primarily on the particular illness. The relative importance of age, gender, shift, advance care directives, symptom severity, signs, and comorbid illnesses varied by diagnosis.     

Nursing home patients transferred by ambulance to a VA emergency department

Nursing home residents are frequently transferred to hospital emergency departments. Delayed transfer may lead to poor outcomes. However, inappropriate transfer of the frail elderly may cause social and financial problems. We prospectively evaluated 221 consecutive ambulance transfers from community nursing homes to a VA emergency department. The objectives of the study were to describe the process and outcomes of transferred patients and to determine if alternative interventions were feasible. The results indicate that the problems of nearly half the study group could have been treated at the nursing home by a visiting physician with minimal medical equipment. Those admitted to the hospital (52%) were seriously ill, had prolonged lengths of stay (23.6 days), and had a high mortality rate (11%). Complex issues of physician reimbursement, proprietary nursing home budgeting, and day-to-day expediency appear to be involved in decisions to transport patients by ambulance to VA emergency departments.     

Emergency Department Use by Nursing Home Residents

Study objective: To describe a community's experience with the use of emergency department services by nursing home residents. Methods: We performed a retrospective chart review of a population-based cohort of nursing home residents in an urban county in central Georgia with 10 nursing homes (1,300 beds) and 4 hospital-based EDs. All ED visits by nursing home residents during 1995 were analyzed. Demographic data, timing of the visit, chief complaint, tests and treatments, disposition, and financial charges were recorded. Further, we calculated the number of ED visits per 100 nursing home patient-years. Results: A total of 873 nursing home residents made 1,488 ED visits. Mean age was 76.0 years; 66.4% were female, and 55.2% were white. Of the transfers, 42.9% occurred during regular working hours. The most common chief complaints were respiratory symptoms (14.4%), altered mental status (10.1%), gastrointestinal symptoms (9.9%), and falls (8.2%); 101 patients (6.8%) were transferred for malfunction of a gastrostomy tube. The most common laboratory tests were complete blood cell count (69.5%), chest radiograph (52.0%), electrocardiogram (45.0%), urinalysis (42.7%), and determination of electrolytes (42.7%). A total of 42.4% of the ED visits led to admission to the hospital. From the 10 nursing homes, there were 110 ED visits per 100 patient-years. A 3.5-fold difference in ED use among these nursing homes could not be explained by age, gender, or other factors. The average charge per ED visit was $1,239. Conclusion: Elders living in nursing homes are frequently transferred to EDs for costly medical evaluations, and more than 40% of such visits lead to admission to the hospital. [Ackermann RJ, Kemle KA, Vogel RL, Griffin RC Jr: Emergency department use by nursing home residents. Ann Emerg Med June 1998;31:749-757.]     

Simple clinical score is associated with mortality and length of stay of acute general medical admissions to an Australian hospital

Background: In a rural Irish hospital, a simple clinical score (SCS) determined at the time of admission enabled stratification of acute general medical admissions into five categories that were associated incrementally with patients' immediate and 30‐day mortality. The aim of this study was to examine the representative performance of this SCS in predicting the outcomes of general medical admissions to an Australian teaching hospital. Methods: A retrospective chart review was undertaken of a representative sample from 480 admissions in 2007 to an urban university teaching hospital in Australia. The SCS was calculated and related to that patient's outcome in terms of mortality, length of stay, nursing home placement on discharge, the occurrence of medical emergency team call and intensive care unit transfer. These data were compared, where possible, with the outcomes reported in the Irish hospital. Results: Four hundred and seventeen complete sets of data allowed calculation of the SCS. There were significant linear correlations of the SCS (divided into quintiles) and patients' in‐hospital and 30‐day mortality, their length of stay and their discharge to a nursing home. There was no association of the SCS and the patients' readmission rate, intensive care unit transfer rate or likelihood of a medical emergency team call. The significant trends replicated those from the Irish hospital. Conclusion: The SCS can predict significant outcomes for general medical admissions in an Australian hospital despite obvious differences to the hospital of its derivation. A wider study of Australasian hospitals and the performance of the SCS as a predictor of general medical admission outcomes is underway.     

Discretionary hospitalization of nursing home residents with and without Alzheimer's disease: a multilevel analysis

This study analyzes facility variations in hospital admission rates of nursing home (NH) residents with and without Alzheimer's disease (AD) or related dementia with the aim of better understanding how facility-level contextual factors differentially affect hospitalization risks. METHOD: The sample population consists of 19,217 and 18,399 Medicaid residents with and without AD, respectively, from 546 NHs in Massachusetts between 1991 and 1993. Hospital use is measured as annual nonpsychiatric discretionary hospital admissions to short-term general hospitals. Multilevel estimation methods are used to obtain facility and market area parameter estimates. RESULTS: There was greater interfacility variation in discretionary hospital admission rates of AD residents than residents without AD, particularly among more vulnerable subgroups of AD residents. DISCUSSION: The findings underscore the importance of licensed nursing personnel in reducing discretionary hospitalizations among NH residents with AD.     

Outcomes of infection in nursing home residents with and without early hospital transfer

Objectives: To compare outcomes of infection in nursing home residents with and without early hospital transfer.
Design: Observational cohort study.
Setting: Fifty-nine nursing homes in Maryland.
Participants: Two thousand one hundred fifty-three individuals admitted to nursing homes between 1992 and 1995.
Measurements: Incident infection was recorded when a new infectious diagnosis was documented in the medical record or nonprophylactic antibiotic therapy was prescribed. Early hospital transfer was defined as transfer to the emergency department or admission to the hospital within 3 days of infection onset. Infection, resident, and facility characteristics were entered into a multivariate model to create a propensity score for early hospital transfer. Association between early hospital transfer and outcomes of infection, namely pressure ulcers and death between Days 4 and 34 after infection onset, were examined, controlling for propensity score.
Results: Four thousand nine hundred ninety infections occurred in 1,301 residents. Genitourinary (28%), skin (19%), upper respiratory (13%), and lower respiratory (12%) were the most common types. Three hundred seventy-five episodes in which residents survived 3 days (7.6%) resulted in early hospital transfer. In multivariate regression, individuals with early hospital transfer had higher mortality (odds ratio (OR) 1.44, 95% confidence interval (CI)=1.04–1.99) and, in 1-month survivors, a greater occurrence of pressure ulcers (OR 1.61, 95% CI=1.17–2.20) than those without, after adjusting for propensity score.
Conclusion: Using observational data and propensity score methods, outcomes were worse in nursing home residents transferred to the hospital within 3 days of infection onset than in those who remained in the nursing home.     

High mortality of older patients admitted to hospital from care homes and insight into potential interventions to reduce hospital admissions from care homes: The Norfolk experience

There is a high mortality rate in patients admitted to hospitals acutely from care homes. In a retrospective case analysis study of 3772 older people admitted to the Department of Medicine for the Elderly between January and June 2005, 340 (9.0%) were from care homes, and 93 (27.3%) of the residents died during the index admission. Nearly 40% of these deaths occurred within 24 h of admission indicating a high level of less appropriate admissions. Investigating eight nursing homes which admitted the highest number of patients from one primary care trust revealed that the most cited reasons for admission were the lack of advance care plans, access to General Practitioners (GPs) out of hours, as well as general access to palliative care and specialist nurses, and poor communication between patient, relatives, GPs, hospitals and care home staff. Our findings provide some useful insight into the factors that need to be addressed to avoid unnecessary or inappropriate admissions from care homes for better end of life care in aging societies.     

High mortality of older patients admitted to hospital from care homes and insight into potential interventions to reduce hospital admissions from care homes: the Norfolk experience

There is a high mortality rate in patients admitted to hospitals acutely from care homes. In a retrospective case analysis study of 3772 older people admitted to the Department of Medicine for the Elderly between January and June 2005, 340 (9.0%) were from care homes, and 93 (27.3%) of the residents died during the index admission. Nearly 40% of these deaths occurred within 24 h of admission indicating a high level of less appropriate admissions. Investigating eight nursing homes which admitted the highest number of patients from one primary care trust revealed that the most cited reasons for admission were the lack of advance care plans, access to General Practitioners (GPs) out of hours, as well as general access to palliative care and specialist nurses, and poor communication between patient, relatives, GPs, hospitals and care home staff. Our findings provide some useful insight into the factors that need to be addressed to avoid unnecessary or inappropriate admissions from care homes for better end of life care in aging societies.     

A Special Dementia Unit (Hostel): Review of the First Eleven Years Operation

The aim of this review was to study the outcome of residents in a Special Dementia Unit (SDU) in the form of a hostel for 36 people during the first eleven years of operation. The participants were one hundred and seventy one residents admitted for permanent care during that period. The median length of stay in the hostel was 2.3 years. By the end of the period 113 residents (83 percent of those who had completed their time in the hostel) had been transferred to nursing homes. The average survival time after admission to the hostel was 4.7 years. In order to accommodate those who had been transferred from the SDU about the same number of hostel places were needed in nursing homes. We concluded that admission to an SDU hostel for selected people with dementia is more appropriate and less costly than direct admission to a nursing home, notwithstanding the need for subsequent nursing care for the majority. Adequate subsidy should be provided by the Commonwealth Government so that voluntary associations are encouraged to set up SDU hostels for this purpose. Nursing homes should be run in association with these hostels.     

A community-wide effort to reduce hospital utilization by patients requiring nursing home placement

Described is an effort by health care providers to reduce hospital utilization by increasing admissions to skilled nursing facilities from hospitals. For a 6-month period, there were increased admissions from hospitals to nursing homes and a reduced number of hospital nonacute patients who required long-term care placement. Eventually, however, the nursing homes shifted their admission patterns to accept more persons from non-hospital settings. As a result, admissions from hospitals declined and the number of nonacute patients in hospitals increased.     

Geriatrician input into nursing homes reduces emergency hospital admissions

Nursing home residents are often very dependent, very frail and have complex care needs. Effective partnerships between primary and secondary care will be of benefit to these residents. We looked at 1954 admission episodes to our Trust from April 2006 to March 2009 inclusive. 3 nursing homes had the highest number of multiple admissions (≥ 4). Four strategies to reduce hospital admissions were used at these nursing homes for 3 months. An alert was also sent to the geriatrician if one of the residents was admitted so that their discharge from hospital could be expedited. The project was then extended for another 4 months with 6 nursing homes. The results showed that geriatrician input into nursing homes had a significant impact on admissions from nursing homes (χ(2)(2)=6.261, p < 0.05). The second part of the project also showed significant impact on admissions (χ(2)(2) = 12.552, p < 0.05). Furthermore, in both parts of the project the length of stay in hospital for the residents was reduced. Geriatricians working together with co-ordinated multidisciplinary teams are well placed to manage the care needs of frail, elderly care home residents.     

Improving disposition outcomes for patients in a geriatric skilled nursing facility

OBJECTIVES: To evaluate an intervention to improve discharge disposition from a skilled nursing unit (SNU). DESIGN: Historical control comparison of discharge disposition before and after implementation. SETTING: Fifty‐bed SNU. PARTICIPANTS: All patients admitted from acute care hospitals to a SNU between June 2008 and May 2010. INTERVENTION: Physician admission procedures were standardized using a template, patients with three or more hospital admissions over the prior 6 months received palliative care consultations, and multidisciplinary root‐cause analysis conferences for patients transferred back to the hospital acutely were conducted bimonthly to identify problems and improve processes of care. MEASUREMENTS: Patients' discharge disposition (i.e., acute care, long‐term care, home, or death) before and after implementation were compared. RESULTS: Discharge dispositions were determined for all 1,725 patients admitted during the study; 862 patients before (June–May 2008) and 863 during (June 2009–May 2010) the intervention. Discharge dispositions were significantly differently distributed across the two periods (P=.03). Readmission to acute care declined (from 16.5% to 13.3%, a nearly 20% decline). Multivariable logistic regression, controlling for age, sex, and case‐mix index and adjusting for clustering due to repeated admissions of individual patients, suggests that, during the intervention period, patients were more likely than during the baseline period to die on the unit in accordance with their wishes than to be transferred out to the hospital (odds ratio=2.45, 95% confidence interval=1.09–5.5). CONCLUSION: Interventions such as the ones implemented can lead to fewer hospital transfers for SNUs.     

Burden of recurrent emergency hospital admissions in children and young people in England: a cohort study

BackgroundIn England, the number of emergency admissions in children and young people has increased by 28% since 1999. Evidence is lacking about the contribution of recurrent admissions to the high rate of emergency admissions among children and young people. We quantified the contribution of recurrent admissions to the total burden of admissions in England.MethodsWe analysed all hospital admissions to the National Health Service in England using Hospital Episode Statistics from 2009 to 2011 for children and young people aged 0–24 years. We followed up children and young people for 2 years from their first emergency admission (index admission) in 2009. We determined the number of subsequent admissions, time to next admission, length of stay, and the proportion of admissions for injury and of children affected by a chronic condition measured by diagnostic codes in all admissions during the 2 years.Findings869 895 children had an index admission in 2009, resulting in a further 939 710 admissions (of which 600 322 [64%] were emergency admissions) over the next 2 years. We excluded 4371 children (0·5%) with inconsistent records (eg, multiple birth admissions). After discharge from the index admission, 274 986 children (32%) had a recurrent emergency admission, accounting for 41% (n=1 470 107) of all emergency admissions in the 2-year cohort. A few children and young people (37 311, 4%) had four or more emergency admissions. The proportion of patients with recurrent admissions was similar across all age groups. 73 830 first recurrent admissions (26%) occurred within the first month after discharge from the index admission. 360 633 index admissions (41%), in contrast with 459 167 recurrent emergency admissions (76%), were in patients with a chronic condition.InterpretationThis snapshot of hospital flow during 2 years shows that recurrent emergency admissions account for a substantial minority of all emergency admissions and predominantly affect children and young people with chronic conditions. Since we only included inpatient hospital data, our analysis provides a limited overview of health-care use. Interventions to reduce re-admissions should consider discharge planning for support by community services for parents caring for children with chronic conditions.FundingLW was supported by funding from the Department of Health Policy Research Programme through funding to the Policy Research Unit in the Health of Children, Young People and Families. This is an independent report commissioned and funded by the Department of Health.     

The outcome of CPR initiated in nursing homes

To determine outcomes following attempted cardiopulmonary resuscitation initiated in nursing homes, we retrospectively reviewed ambulance and hospital records for all 705 people aged 65 or over who underwent attempted resuscitation by ambulance crews in 1987 in Baltimore City and Baltimore County. From medic unit encounter forms we noted whether or not the address of origin was a nursing home and to what hospital the person was taken. Hospital records were then examined to determine outcomes: death in the emergency room, death during consequent hospitalization, or live discharge. Complete information was obtained for all 117 nursing-home residents and for 580 of 588 nonresidents. When attempted resuscitation was begun in a nursing home, only two patients survived to hospital discharge, whereas 61 nonresidents (11%) survived after a mean stay of 14 days. Of the 115 nursing-home residents who did not survive to hospital discharge, 102 (89%) were pronounced dead in the emergency room, two (2%) more died within 24 hours of admission, and the remaining 11 (9%) died after an average stay of five days. Of the 519 nonresidents who died before discharge, 433 (83%) were pronounced dead in the emergency room, 16 (3%) died in the first 24 hours, and 70 (14%) lived an average of nine days. One of the two nursing-home residents who survived was an 87-year-old woman who spent 30 days in the hospital and died eight months after returning to the nursing home, demented, cachectic, with a large sacral pressure sore.(ABSTRACT TRUNCATED AT 250 WORDS)