Psychosocial profile of elderly patients discharged from a community hospital

Social workers have historically been an advocate for vulnerable groups. One such vulnerable group is elderly patients who have been shown to have multiple, chronic health problems. The current fiscal environment favors shortened lengths of stay, potentially leaving these vulnerable patients at risk for adverse outcomes upon discharge, especially for those discharged home as opposed to institutional settings. The purpose of the study was to characterize the biopsychosocial risks for adverse outcomes in the elderly patients discharged home from Guelph General Hospital (Ontario, Canada). The objectives were to (1) estimate the number of elderly people who indicate biopsychosocial risk for adverse outcomes, (2) determine the specific risks and their severity, and (3) estimate the number of readmissions to hospital within three months after discharge. Standardized, self-reported scales were used to measure risks in elderly patients at discharge from acute care medical and surgical units. The sample included 62 patients with a mean age of 79 years. At discharge almost 40% of the patients were considered at risk for adverse outcomes, 11% indicated depression, 45% indicated psychological distress, 13% showed cognitive impairment, and 62.5% (35/56) had at least one nutritional concern. Over the three-month follow-up period, there were 23 readmissions, 8 ED visits (not mutually exclusive), and 7 outpatient visits. The mortality rate over the three-month period was 5% (3/62). Many elderly patients who were discharged from hospital to home experienced several challenges medically, psychologically and some also experienced social adversities. The implication is that these patients may benefit from a more comprehensive discharge plan than is currently practiced that addresses their challenges.     

Enteral tube feeding in a cohort of chronic hemodialysis patients.

Malnutrition affects up to half of all chronic dialysis patients and is an important predictor of mortality, but the efficacy of interventions designed to improve the nutritional status of dialysis patients has been poorly studied. Specifically, although enteral tube feeding is often cited as an important option in the treatment of malnourished dialysis patients, there are few studies examining the effectiveness and complications of enteral tube feedings in adults on dialysis. We performed a retrospective analysis of a small cohort (n = 10) of chronic hemodialysis patients who received enteral tube feeding as all or part of their nutrition between January 1 and May 1, 1999, with follow-up through May 1, 2000, to assess the efficacy and complications of enteral tube feeding. Six patients received feeding via a peritoneoscopically placed (PEG) tube, 3 via nasogastric (NG) tube, and 1 patient was switched from PEG to NG feeding after an exit site infection developed at her PEG site. Seven patients received enteral feeding because of swallowing difficulties occurring after a cerebrovascular accident. Four patients were fed via enteral tube temporarily (相似文献   

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

Background

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

Methods

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

Results

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

Conclusion

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

Methicillin-resistant Staphylococcus aureus: a ten-year survey in a Dublin hospital

We undertook a retrospective, longitudinal survey to monitor the changing incidence, phage types and patterns of antibiotic resistance of methicillin-resistant Staphylococcus aureus (MRSA) in St Laurence's Hospital (SLH), Dublin over the last 10 years. Following a peak in 1979, the incidence of MRSA has gradually decreased to around 17% of S. aureus isolates in 1986, almost identical to its incidence 10 years before. However, the spectrum of antibiotic resistance among these organisms remains broad and this seems to be at least partially related to antibiotic usage. Many strains could not be phage typed and others were typable only by the additional phage 90. This has severely limited the usefulness of phage typing in the tracing of sources of outbreaks. Thus, there is a need for a more specific method of typing as well as a rational antibiotic policy, to successfully monitor and curtail the hospital spread of MRSA.     

Quality of life in adult enteral tube feeding patients

BACKGROUND: Enteral tube feeding may impact significantly on patients' quality of life (QoL). The aim of this paper is to review studies that have measured QoL in adult patients receiving enteral tube feeding to determine the factors that are associated with feeding that impact on the patients' QoL. METHODS: An electronic search of CINAHL, MEDLINE and EMBASE was undertaken to identify articles that had measured QoL in adults receiving enteral tube feeding. RESULTS: Ten studies were included in the review. Quality of life in patients receiving enteral tube feeding generally appeared poor compared with control groups. Factors that were found to impact on patients' quality of life included symptoms such as nausea, vomiting, diarrhoea and fatigue. Issues around body image, inability to go out and discomfort while carrying out activities of daily living also impacted on QoL. CONCLUSIONS: Although the presence of underlying disease and the use of different QoL measures made comparison of the results difficult, issues requiring further consideration in clinical practice include effective symptom management, assessment of psychological and emotional issues and support for patients to enable them to cope with the resulting social isolation.     

Pneumococcal vaccine uptake in medical patients discharged from a district hospital

A survey of 400 patients discharged from medical wards found that 161 (40%) had risk factors for severe pneumococcal infection, but that only half of these had received pneumococcal vaccine. Improved vaccine uptake in high risk patients could be achieved by universal vaccination of people aged over 65 years.     

Social representations associated with tube feeding among adult hospitalized patients

This study aimed to identify and understand adult patients' representations on tube feeding. Data were collected through interviews with sixteen patients who were using feeding tubes, which were analyzed through discourse analysis and Social Representation Theory. We identified a sequence in which representations are reorganized and redefined through experience, in order to turn this treatment tolerable. This sequence begins when patients face the need of a feeding tube, followed by the experience of its use and finally, when deciding about continuing its use or not, when going home. Some representations contribute to treatment adherence and others to its rejection. Getting to know positive and negative ideas about this treatment makes it possible to approach these patients in a more direct way, with a view to better adherence and satisfaction.     

Enteral feeding tube guidewire—another factor in the retrograde contamination of enteral feeding systems?

Background: In vitro enteral feeding systems were used to investigate the effect that withdrawal of the guidewire from the feeding tube has on bacteria ascending from a patients’ stomach or intestine via the feeding tube to the giving set and nutrient container of the feeding system. Methods: Enteral feeding systems were assembled with the feeding tube running into nutrient broth contaminated with Klebsiella aerogenes. The enteral feeding tubes were held in different orientations (horizontal and vertical) to examine the effect in both prostrate and ambulant patients. The guidewire was removed either prior to or after the enteral feeding tube had been inserted into the K. aerogenes broth. Feed was then run through the systems for 24 h, with feed samples being collected from the distal (patient) end of the giving set at 0 and 24 h. Results: After 24 h, 10^3–108 c.f.u. (colony forming units) K. aerogenes/ml were detected in feed samples taken from the distal end of the giving set in systems where the guidewire had been removed after the enteral feeding tube had been inserted into the contaminated broth (both orientations), but K. aerogenes was not detected in samples from systems in which the guidewire had been removed before the end of the tube was inserted into the broth (both orientations). However, when the latter feed samples were enriched (i.e. incubated at 37 °C for a further 24 h to detect if very low levels of bacteria were present in the original sample), 40% of samples from systems with horizontally orientated tubes, and 20% from systems with vertically orientated tubes were positive for the test organism. K. aerogenes was not detected in any samples of feed taken from the nutrient container or just below the drip chamber. Conclusion: The results demonstrate: (i) that bacteria ascend the feeding tube over a 24-h period (retrograde contamination) and (ii) removal of the guidewire can contribute to the colonization of the lumen of the feeding tube and distal end of the giving set with bacteria from a patients’ own flora.     

Microbial contamination of enteral feeding solutions in a community hospital

Seven related studies were done to estimate the type and amount of contamination that occurred in nutrient feeding solution when administered according to procedure in a community hospital. The initial study was done in a simulated nonclinical setting with select technicians monitoring for gavage systems delivering a commercially prepared nutrient feeding solution. The solution remained sterile over 48 hr. In the second study, various nurses maintained the enteral feeding simulations unaware of the objective of study. Significant contamination was found, but a decrease occurred when the study was duplicated and the nurses were made aware that contamination was the issue being studied. The subsequent study had all gavage equipment in clinical use in the hospital on a given day cultured for microbial contamination. Significant contamination was present and did not decrease when the study was duplicated following inservice training. Suggestions for standards of care are made.     

Virus-specific RNA and antibody from convalescent-phase SARS patients discharged from hospital

Severe acute respiratory syndrome (SARS) is caused by a novel coronavirus (SARS-CoV). In a longitudinal cross-sectional study, we determined the prevalence of virus in bodily excretions and time of seroconversion in discharged patients with SARS. Conjunctival, throat, stool, and urine specimens were collected weekly from 64 patients and tested for SARS-CoV RNA by real-time polymerase chain reaction; serum samples were collected weekly and tested for SARS-CoV antibody with indirect enzyme immunoassay and immunofluorescence assay. In total, 126 conjunctival, 124 throat swab, 116 stool, and 124 urine specimens were analyzed. Five patients had positive stool samples, collected in weeks 5-9. Two patients seroconverted in weeks 7 and 8; the others were seropositive at the first serum sample collection. In this study, 5 (7.8%) of 64 patients continued to shed viral RNA in stool samples only, for up to week 8 of illness. Most seroconversions occurred by week 6 of illness.     

A 3-month survey of enteral tube feeding and parenteral feeding: a baseline for improvement

This paper presents the results of a 3-month survey of tube feeding and parenteral nutrition in hospital in-patients, undertaken to provide information for the development of guidelines by the Hospitals Nutritional Advisory Group and a baseline for future monitoring. This represents the first steps in the audit cycle. The results highlighted the following problems.

• 1. 

  Total parenteral nutrition is often continued after bowel sounds have returned.
• 2. 

  Enteral tube feeding is often instituted for only a very short period of time and may be of little nutritional benefit to the patient.
• 3. 

  Significantly lower amounts of energy and nitrogen are received by the patients in the enterally tube-fed group than is indicated by their estimated energy and nitrogen requirements.
• 4. 

  The medical staff noted the start of feeding in 60% of the case notes, however, the aims of feeding and the reason for commencing feeding were never documented. Nutritional aims were defined in the case notes by dietitians for all tube-fed and 18 of the 20 patients who were parenterally fed.

     

An audit of adult patients on home enteral tube feeding in a region of Northern Ireland

Background: Increasing numbers of patients on enteral tube feeding (ETF) are being cared for in the community. This study surveyed patients receiving home ETF (HETF) in order to provide a clinical profile of patients, compare energy requirements with actual intake and to assess the patients' and carers' perspective. Method: A structured interview conducted with patients and carers in their homes or nursing homes. Results: Thirty-nine patients were studied, 19 living at home and 20 living in nursing homes. Thirty-four patients (87%) were fed via a gastrostomy tube, with the enteral feed being the sole source of nutrition in 29 (74%). The mean length of time on HETF was 18 months (s.d. 14.5 months). It was felt that eight (20%) patients were on feeding regimens that were not suitable for their energy requirements, but there was no significant difference between the patients living at home and those living in a nursing home ( P < 0.05). Of those patients and carers at home, 15 (79%) were satisfied that the training they received had adequately prepared them for HETF, however, only 12 (63%) were satisfied with support since discharge, whereas 16 nursing home patients (80%) were satisfied with support. Conclusions: This study profiles adult patients on HETF, highlighting that patients may not be on the most appropriate feeding regimen and the wide range of concerns that patients and carers have relating to their support. The production of a HETF post-discharge protocol, as recommended by the British Association of Enteral and Parenteral Nutrition (Elia, 1994b), would help to address these issues.     

Regional survey of neurodisabled clients in the community on long‐term tube feeding as a main source of nutrition

Background: It is well recognised that some people with cerebral palsy and other conditions have low energy requirements because they lack mobility and have a low resting energy expenditure (Dickerson et al., 1999). When tube fed, it may be necessary to give a reduced amount of an age appropriate feed to ensure an appropriate energy intake and avoid excessive weight gain, although this may compromise the intake of other nutrients (Skelton et al., 2006). The aim of the survey was to compare prescribed nutrient intake of tube fed clients, who have enteral feeding as their major source of nutrition, with dietary reference values. Methods: Data on type and quantity of prescribed feeds was collected retrospectively from the case notes of 59 adults and 16 children aged >3 years with a learning disability who have tube feeds as their main source of nutrition. A nutritional analysis of the feed was completed using Microdiet dietary analysis programme, which was compared with the reference values for nutrient intake (Department of Health, 1991) for energy, protein potassium, vitamin D and chloride. Results: None of the prescribed feeds met the estimated average requirements (EAR) for energy. The level of compliance varied for the other nutrients as shown in Table 1.

Table 1. Percentage (n) of clients compliant with dietary reference values (EAR/lower reference nutrient intake)

某院1999-2006年出院病人院内转科病例因素分析

目的探讨我院转科病人的产生原因和变化情况,争取杜绝消极作用的转科。方法将1999—2006年间住院转科病例采用典型调查的抽样方法,并作统计学处理。结果转科病人住院天数、人均住院费用都大大高于同期住院病人,但两者的每床日费用差异无统计学意义。结论积极作用的转科能够适应不同人群医疗意向的特点和差异,能够满足患者的不同医疗需求。     

Enteral feeding misconnections: a consortium position statement

A consortium of organization identified solutions to the problem of enteral feeding misconnections in three areas: (1) education, awareness, and human factors; (2) purchasing strategies; and (3) design changes.     

A survey of survivors of acute stroke discharged from hospital to private nursing homes in Nottingham

Increasing numbers of disabled elderly stroke survivors are being discharged from hospital to Private Nursing Homes. However, there is little data available on which specific guidelines for the care of stroke patients in these homes can be based. A survey was undertaken therefore, to review patients on their discharge from hospital to Private Nursing Homes, and to assess the severity of their disability and handicap before and after entering the home. Nearly all patients were severely disabled on discharge from hospital, and the Barthel Activities of Daily Living scores of the survivors showed no significant change after four months. High levels of emotional distress and loneliness were identified by the Nottingham Health Profile, with little change after four months of nursing home care. The National Health Service has a continuing responsibility for the welfare of such vulnerable elderly people. The findings of this survey indicate that the emphasis of their care should be on the management of severe physical disability, exploitation of opportunities for further rehabilitation, alleviation of emotional distress and loneliness and, where appropriate, the provision of humane terminal care.