Does the use of store-and-forward telehealth systems improve outcomes for clinicians managing diabetic foot ulcers? : A pilot study

Diabetic foot ulcers are one of the most hospitalised diabetes complications and contribute to many leg amputations. Trained diabetic foot teams and specialists managing diabetic foot ulcers have demonstrated reductions in amputations and hospitalisation by up to 90%. Few such teams exist in Australia. Thus, access is limited for all geographical populations and may somewhat explain the high rates of hospitalisation. Aim: This pilot study aims to analyse if local clinicians managing diabetic foot complications report improved access to diabetic foot specialists and outcomes with the introduction of a telehealth store-and-forward system. Method: A store-and-forward telehealth system was implemented in six different Queensland locations between August 2009 and February 2010. Sites were offered ad hoc and/or fortnightly telehealth access to a diabetic foot speciality service. A survey was sent six months following commencement of the trial to the 14 eligible clinicians involved in the trial to gauge clinical perception of the telehealth system. Results: Eight participants returned the surveys. The majority of responding clinicians reported that the telehealth system was easy to use (100%), improved their access to diabetic foot speciality services (75%), improved upskilling of local diabetes service staff (100%), and improved patient outcomes (100%). Conclusion: This pilot study suggests that clinicians found the use of a telehealth store-and-forward system very useful in improving access to speciality services, clinical skills and patient outcomes. This study supports the recommendation that telehealth systems should be made available for diabetic foot ulcer management.

Standardising practices improves ambulatory diabetic foot management and reduces amputations : the Queensland Diabetic Foot Innovation Project, 2006 – 2009

Background Diabetic foot complications are recognised as the most common reason for diabetic related hospitalisation and lower extremity amputations. Multi-faceted strategies to reduce diabetic foot hospitalisation and amputation rates have been successful. However, most diabetic foot ulcers are managed in ambulatory settings where data availability is poor and studies limited. The project aimed to develop and evaluate strategies to improve the management of diabetic foot complications in three diverse ambulatory settings and measure the subsequent impact on ospitalisation and amputation. Methods Multifaceted strategies were implemented in 2008, including: multi-disciplinary teams, clinical pathways and training, clinical indicators, telehealth support and surveys. A retrospective audit of consecutive patient records from July 2006 – June 2007 determined baseline clinical indicators (n = 101). A clinical pathway teleform was implemented as a clinical record and clinical indicator analyser in all sites in 2008 (n = 327) and followed up in 2009 (n = 406). Results Prior to the intervention, clinical pathways were not used and multi-disciplinary teams were limited. There was an absolute improvement in treating according to risk of 15% in 2009 and surveillance of the high risk population of 34% and 19% in 2008 and 2009 respectively (p < 0.001). Improvements of 13 – 66% (p < 0.001) were recorded in 2008 for individual clinical activities to a performance > 92% in perfusion, ulcer depth, infection assessment and management, offloading and education. Hospitalisation impacts recorded reductions of up to 64% in amputation rates / 100,000 population (p < 0.001) and 24% average length of stay (p < 0.001) Conclusion These findings support the use of multi-faceted strategies in diverse ambulatory services to standardise practice, improve diabetic foot complications management and positively impact on hospitalisation outcomes. As of October 2010, these strategies had been rolled out to over 25 ambulatory sites, representing 66% of Queensland Health districts, managing 1,820 patients and 13,380 occasions of service, including 543 healed ulcer patients. It is expected that this number will rise dramatically as an incentive payment for the use of the teleform is expanded.

Improved surgical safety after laparoscopic compared to open surgery for apparent early stage endometrial cancer : results from a randomised controlled trial

AIM: To compare Total Laparoscopic Hysterectomy (TLH) and Total Abdominal Hysterectomy (TAH) with regard to surgical safety. METHODS: Between October 2005 and June 2010, 760 patients with apparent early stage endometrial cancer were enroled in a multicentre, randomised clinical trial (LACE) comparing outcomes following TLH or TAH. The main study end points for this analysis were surgical adverse events (AE), hospital length of stay, conversion from laparoscopy to laparotomy, including 753 patients who completed at least 6 weeks of follow-up. Postoperative AEs were graded according to Common Toxicity Criteria (V3), and those immediately life-threatening, requiring inpatient hospitalisation or prolonged hospitalisation, or resulting in persistent or significant disability/incapacity were regarded as serious AEs. RESULTS: The incidence of intra-operative AEs was comparable in either group. The incidence of post-operative AE CTC grade 3+ (18.6% in TAH, 12.9% in TLH, p 0.03) and serious AE (14.3% in TAH, 8.2% in TLH, p 0.007) was significantly higher in the TAH group compared to the TLH group. Mean operating time was 132 and 107 min, and median length of hospital stay was 2 and 5 days in the TLH and TAH group, respectively (p<0.0001). The decline of haemoglobin from baseline to day 1 postoperatively was 2g/L less in the TLH group (p 0.006). CONCLUSIONS: Compared to TAH, TLH is associated with a significantly decreased risk of major surgical AEs. A laparoscopic surgical approach to early stage endometrial cancer is safe.

Encouraging, assisting and time to EAT : improved nutritional intake for older medical patients receiving Protected Mealtimes and/or additional nursing feeding assistance

Background & Aims: Inadequate feeding assistance and mealtime interruptions during hospitalisation may contribute to malnutrition and poor nutritional intake in older people. This study aimed to implement and compare three interventions designed to specifically address mealtime barriers and improve energy intakes of medical inpatients aged ≥65 years. Methods: Pre-post study compared three mealtime assistance interventions: PM: Protected Mealtimes with multidisciplinary education; AIN: additional assistant-in-nursing (AIN) with dedicated meal role; PM+AIN: combined intervention. Dietary intake of 254 patients (pre: n=115, post: n=141; mean age 80±8) was visually estimated on a single day in the first week of hospitalisation and compared with estimated energy requirements. Assistance activities were observed and recorded. Results: Mealtime assistance levels significantly increased in all interventions (p<0.01). Post-intervention participants were more likely to achieve adequate energy intake (OR=3.4, p=0.01), with no difference noted between interventions (p=0.29). Patients with cognitive impairment or feeding dependency appeared to gain substantial benefit from mealtime assistance interventions. Conclusions: Protected Mealtimes and additional AIN assistance (implemented alone or in combination) may produce modest improvements in nutritional intake. Targeted feeding assistance for certain patient groups holds promise; however, alternative strategies are required to address the complex problem of malnutrition in this population.

A six-year descriptive analysis of hospitalisations for ambulatory care sensitive conditions among people born in refugee-source countries

Background: Hospitalisation for ambulatory care sensitive conditions (ACSHs) has become a recognised tool to measure access to primary care. Timely and effective outpatient care is highly relevant to refugee populations given the past exposure to torture and trauma, and poor access to adequate health care in their countries of origin and during flight. Little is known about ACSHs among resettled refugee populations. With the aim of examining the hypothesis that people from refugee backgrounds have higher ACSHs than people born in the country of hospitalisation, this study analysed a six-year state-wide hospital discharge dataset to estimate ACSH rates for residents born in refugee-source countries and compared them with the Australia-born population. Methods: Hospital discharge data between 1 July 1998 and 30 June 2004 from the Victorian Admitted Episodes Dataset were used to assess ACSH rates among residents born in eight refugee-source countries, and compare them with the Australia-born average. Rate ratios and 95% confidence levels were used to illustrate these comparisons. Four categories of ambulatory care sensitive conditions were measured: total, acute, chronic and vaccine-preventable. Country of birth was used as a proxy indicator of refugee status. Results: When compared with the Australia-born population, hospitalisations for total and acute ambulatory care sensitive conditions were lower among refugee-born persons over the six-year period. Chronic and vaccine-preventable ACSHs were largely similar between the two population groups. Conclusion: Contrary to our hypothesis, preventable hospitalisation rates among people born in refugee-source countries were no higher than Australia-born population averages. More research is needed to elucidate whether low rates of preventable hospitalisation indicate better health status, appropriate health habits, timely and effective care-seeking behaviour and outpatient care, or overall low levels of health care-seeking due to other more pressing needs during the initial period of resettlement. It is important to unpack dimensions of health status and health care access in refugee populations through ad-hoc surveys as the refugee population is not a homogenous group despite sharing a common experience of forced displacement and violence-related trauma.

Telephone support to rural and remote patients with heart failure : the Chronic Heart failure Assessment by Telephone (CHAT) study

Background Heart failure (HF) remains a condition with high morbidity and mortality. We tested a telephone support strategy to reduce major events in rural and remote Australians with HF, who have limited healthcare access. Telephone support comprised an interactive telecommunication software tool (TeleWatch) with follow-up by trained cardiac nurses. Methods Patients with a general practice (GP) diagnosis of HF were randomised to usual care (UC) or UC and telephone support intervention (UC+I) using a cluster design involving 143 GPs throughout Australia. Patients were followed for 12 months. The primary end-point was the Packer clinical composite score. Secondary end-points included hospitalisation for any cause, death or hospitalisation, as well as HF hospitalisation. Results Four hundred and five patients were randomised into CHAT. Patients were well matched at baseline for key demographic variables. The primary end-point of the Packer Score was not different between the two groups (P=0.98), although more patients improved with UC+I. There were fewer patients hospitalised for any cause (74 versus 114, adjusted HR 0.67 [95% CI 0.50-0.89], p=0.006) and who died or were hospitalised (89 versus 124, adjusted HR 0.70 [95% CI 0.53 – 0.92], p=0.011), in the UC+I vs UC group. HF hospitalisations were reduced with UC+I (23 versus 35, adjusted HR 0.81 [95% CI 0.44 – 1.38]), although this was not significant (p=0.43). There were 16 deaths in the UC group and 17 in the UC+I group (p=0.43). Conclusions Although no difference was observed in the primary end-point of CHAT (Packer composite score), UC+I significantly reduced the number of HF patients hospitalised amongst a rural and remote cohort. These data suggest that telephone support may be an efficacious approach to improve clinical outcomes in rural and remote HF patients.

The impact of malnutrition and decreased food intake on length of stay, readmission, and mortality in acute care patients

Rationale: The Australasian Nutrition Care Day Survey (ANCDS) evaluated if malnutrition and decreased food intake are independent risk factors for negative outcomes in hospitalised patients. Methods: A multicentre (56 hospitals) cross-sectional survey was conducted in two phases. Phase 1 evaluated nutritional status (defined by Subjective Global Assessment) and 24-hour food intake recorded as 0, 25, 50, 75, and 100% intake. Phase 2 data, which included length of stay (LOS), readmissions and mortality, were collected 90 days post-Phase 1. Logistic regression was used to control for confounders: age, gender, disease type and severity (using Patient Clinical Complexity Level scores). Results: Of 3122 participants (53% males, mean age: 65±18 years) 32% were malnourished and 23% consumed�25% of the offered food. Median LOS for malnourished (MN) patients was higher than well-nourished (WN) patients (15 vs. 10 days, p<0.0001). Median LOS for patients consuming �25% of the food was higher than those consuming �50% (13 vs. 11 days, p<0.0001). MN patients had higher readmission rates (36% vs. 30%, p = 0.001). The odds ratios of 90-day in-hospital mortality were 1.8 times greater for MN patients (CI: 1.03 3.22, p = 0.04) and 2.7 times greater for those consuming �25% of the offered food (CI: 1.54 4.68, p = 0.001). Conclusion: The ANCDS demonstrates that malnutrition and/or decreased food intake are associated with longer LOS and readmissions. The survey also establishes that malnutrition and decreased food intake are independent risk factors for in-hospital mortality in acute care patients; and highlights the need for appropriate nutritional screening and support during hospitalisation. Disclosure of Interest: None Declared.

The decline in activities of daily living at discharge (DADLD) index : stratifying patients at lower and higher risk

Background: Decreased ability to perform Activities of Daily Living (ADLs) during hospitalisation has negative consequences for patients and health service delivery. Objective: To develop an Index to stratify patients at lower and higher risk of a significant decline in ability to perform ADLs at discharge. Design: Prospective two cohort study comprising a derivation (n=389; mean age 82.3 years; SD� 7.1) and a validation cohort (n=153; mean age 81.5 years; SD� 6.1). Patients and setting: General medical patients aged = 70 years admitted to three university-affiliated acute care hospitals in Brisbane, Australia. Measurement and main results: The short ADL Scale was used to identify a significant decline in ability to perform ADLs from premorbid to discharge. In the derivation cohort, 77 patients (19.8%) experienced a significant decline. Four significant factors were identified for patients independent at baseline: 'requiring moderate assistance to being totally dependent on others with bathing'; 'difficulty understanding others (frequently or all the time)'; 'requiring moderate assistance to being totally dependent on others with performing housework'; a 'history of experiencing at least one fall in the previous 90 days prior to hospital admission' in addition to 'independent at baseline', which was protective against decline at discharge. 'Difficulty understanding others (frequently or all the time)' and 'requiring moderate assistance to being totally dependent on others with performing housework' were also predictors for patients dependent in ADLs at baseline. Sensitivity, specificity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV) of the DADLD dichotomised risk scores were: 83.1% (95% CI 72.8; 90.7); 60.5% (95% CI 54.8; 65.9); 34.2% (95% CI 27.5; 41.5); 93.5% (95% CI 89.2; 96.5). In the validation cohort, 47 patients (30.7%) experienced a significant decline. Sensitivity, specificity, PPV and NPV of the DADLD were: 78.7% (95% CI 64.3; 89.3); 69.8% (95% CI 60.1, 78.3); 53.6% (95% CI 41.2; 65.7); 88.1% (95% CI 79.2; 94.1). Conclusions: The DADLD Index is a useful tool for identifying patients at higher risk of decline in ability to perform ADLs at discharge.

Older drivers' crashes in Queensland, Australia

Background: The growing proportion of older adults in Australia is predicted to comprise 23% of the population by 2030. Accordingly, an increasing number of older drivers and fatal crashes of these drivers could also be expected. While the cognitive and physiological limitations of ageing and their road safety implications have been widely documented, research has generally considered older drivers as a homogeneous group. Knowledge of age-related crash trends within the older driver group itself is currently limited. Objective: The aim of this research was to identify age-related differences in serious road crashes of older drivers. This was achieved by comparing crash characteristics between older and younger drivers and between sub-groups of older drivers. Particular attention was paid to serious crashes (crashes resulting in hospitalisation and fatalities) as they place the greatest burden on the Australian health system. Method: Using Queensland Crash data, a total of 191,709 crashes of all-aged drivers (17–80+) over a 9-year period were analysed. Crash patterns of drivers’ aged 17–24, 25–39, 40–49, 50–59, 60–69, 70–79 and 80+ were compared in terms of crash severity (e.g., fatal), at fault levels, traffic control measures (e.g., stop signs) and road features (e.g., intersections). Crashes of older driver sub-groups (60–69, 70–79, 80+) were also compared to those of middle-aged drivers (40–49 and 50–59 combined, who were identified as the safest driving cohort) with respect to crash-related traffic control features and other factors (e.g., speed). Confounding factors including speed and crash nature (e.g., sideswipe) were controlled for. Results and discussion: Results indicated that patterns of serious crashes, as a function of crash severity, at-fault levels, road conditions and traffic control measures, differed significantly between age groups. As a group, older drivers (60+) represented the greatest proportion of crashes resulting in fatalities and hospitalisation, as well as those involving uncontrolled intersections and failure to give way. The opposite was found for middle-aged drivers, although they had the highest proportion of alcohol and speed-related crashes when compared to older drivers. Among all older drivers, those aged 60–69 were least likely to be involved in or the cause of crashes, but most likely to crash at interchanges and as a result of driving while fatigued or after consuming alcohol. Drivers aged 70–79 represented a mid-range level of crash involvement and culpability, and were most likely to crash at stop and give way signs. Drivers aged 80 years and beyond were most likely to be seriously injured or killed in, and at-fault for, crashes, and had the greatest number of crashes at both conventional and circular intersections. Overall, our findings highlight the heterogeneity of older drivers’ crash patterns and suggest that age-related differences must be considered in measures designed to improve older driver safety.

Using participatory action research for heart self care amongst indigenous patients

This paper describes the initial phases of the Fluid Watchers Pacific Rim project: a participatory action research project that involves developing and trialling an iPad app to provide monitoring and self-care for Indigenous Australians with heart failure. The development phase involved working with health experts, an IT team and Indigenous heart-failure patients through three cycles of development and critical reflection. This was followed by a small pilot study to examine the app’s effectiveness. In this paper, the researchers explain why IT-supported health education can be successful in decreasing re-hospitalisation and improving self-management skills. They describe the steps they took to ensure community participation and ownership of the project and present the findings of their pilot study. This pilot project suggests that an iPad app may be a practical and successful way to provide health-care support for Indigenous Australian heart-failure patients.

Predictors of physical and mental health-related quality of life outcomes among myocardial infarction patients

Background Health-related quality of life (HRQoL) is an important outcome for patients diagnosed with coronary heart disease. This report describes predictors of physical and mental HRQoL at six months post-hospitalisation for myocardial infarction. Methods Participants were myocardial infarction patients (n=430) admitted to two tertiary referral centres in Brisbane, Australia who completed a six month coronary heart disease secondary prevention trial (ProActive Heart). Outcome variables were HRQoL (Short Form-36) at six months, including a physical and mental summary score. Baseline predictors included demographics and clinical variables, health behaviours, and psychosocial variables. Stepwise forward multiple linear regression analyses were used to identify significant independent predictors of six month HRQoL. Results Physical HRQoL was lower in participants who: were older (p<0.001); were unemployed (p=0.03); had lower baseline physical and mental HRQoL scores (p<0.001); had lower confidence levels in meeting sufficient physical activity recommendations (p<0.001); had no intention to be physically active in the next six months (p<0.001); and were more sedentary (p=0.001). Mental HRQoL was lower in participants who: were younger (p=0.01); had lower baseline mental HRQoL (p<0.001); were more sedentary (p=0.01) were depressed (p<0.001); and had lower social support (p=0.001). Conclusions This study has clinical implications as identification of indicators of lower physical and mental HRQoL outcomes for myocardial infarction patients allows for targeted counselling or coronary heart disease secondary prevention efforts. Trial registration Australian Clinical Trials Registry, Australian New Zealand Clinical Trials Registry, CTRN12607000595415. Keywords: Myocardial infarction; Secondary prevention; Cardiac rehabilitation; Telephone-delivered; Health-related quality of life; Health coaching; Tele-health

A single dose of azithromycin does not improve clinical outcomes of children hospitalised with bronchiolitis : a randomised, placebo-controlled trial

Objective Bronchiolitis, one of the most common reasons for hospitalisation in young children, is particularly problematic in Indigenous children. Macrolides may be beneficial in settings where children have high rates of nasopharyngeal bacterial carriage and frequent prolonged illness. The aim of our double-blind placebo-controlled randomised trial was to determine if a large single dose of azithromycin (compared to placebo) reduced length of stay (LOS), duration of oxygen (O2) and respiratory readmissions within 6 months of children hospitalised with bronchiolitis. We also determined the effect of azithromycin on nasopharyngeal microbiology. Methods Children aged ≤18 months were randomised to receive a single large dose (30 mg/kg) of either azithromycin or placebo within 24 hrs of hospitalisation. Nasopharyngeal swabs were collected at baseline and 48hrs later. Primary endpoints (LOS, O2) were monitored every 12 hrs. Hospitalised respiratory readmissions 6-months post discharge was collected. Results 97 children were randomised (n = 50 azithromycin, n = 47 placebo). Median LOS was similar in both groups; azithromycin = 54 hours, placebo = 58 hours (difference between groups of 4 hours 95%CI -8, 13, p = 0.6). O2 requirement was not significantly different between groups; Azithromycin = 35 hrs; placebo = 42 hrs (difference 7 hours, 95%CI -9, 13, p = 0.7). Number of children re-hospitalised was similar 10 per group (OR = 0.9, 95%CI 0.3, 2, p = 0.8). At least one virus was detected in 74% of children. The azithromycin group had reduced nasopharyngeal bacterial carriage (p = 0.01) but no difference in viral detection at 48 hours. Conclusion Although a single dose of azithromycin reduces carriage of bacteria, it is unlikely to be beneficial in reducing LOS, duration of O2 requirement or readmissions in children hospitalised with bronchiolitis. It remains uncertain if an earlier and/or longer duration of azithromycin improves clinical and microbiological outcomes for children.

Encouraging, assisting, and time to eat : comparison of mealtime assistance interventions in elderly medical inpatients

BACKGROUND: The prevalence of protein-energy malnutrition in older adults is reported to be as high as 60% and is associated with poor health outcomes. Inadequate feeding assistance and mealtime interruptions may contribute to malnutrition and poor nutritional intake during hospitalisation. Despite being widely implemented in practice in the United Kingdom and increasingly in Australia, there have been few studies examining the impact of strategies such as Protected Mealtimes and dedicated feeding assistant roles on nutritional outcomes of elderly inpatients. AIMS: The aim of this research was to implement and compare three system-level interventions designed to specifically address mealtime barriers and improve energy intakes of medical inpatients aged ≥65 years. This research also aimed to evaluate the sustainability of any changes to mealtime routines six months post-intervention and to gain an understanding of staff perceptions of the post-intervention mealtime experience. METHODS: Three mealtime assistance interventions were implemented in three medical wards at Royal Brisbane and Women's Hospital: AIN-only: Additional assistant-in-nursing (AIN) with dedicated nutrition role. PM-only: Multidisciplinary approach to meals, including Protected Mealtimes. PM+AIN: Combined intervention: AIN + multidisciplinary approach to meals. An action research approach was used to carefully design and implement the three interventions in partnership with ward staff and managers. Significant time was spent in consultation with staff throughout the implementation period to facilitate ownership of the interventions and increase likelihood of successful implementation. A pre-post design was used to compare the implementation and nutritional outcomes of each intervention to a pre-intervention group. Using the same wards, eligible participants (medical inpatients aged ≥65 years) were recruited to the preintervention group between November 2007 and March 2008 and to the intervention groups between January and June 2009. The primary nutritional outcome was daily energy and protein intake, which was determined by visually estimating plate waste at each meal and mid-meal on Day 4 of admission. Energy and protein intakes were compared between the pre and post intervention groups. Data were collected on a range of covariates (demographics, nutritional status and known risk factors for poor food intake), which allowed for multivariate analysis of the impact of the interventions on nutritional intake. The provision of mealtime assistance to participants and activities of ward staff (including mealtime interruptions) were observed in the pre-intervention and intervention groups, with staff observations repeated six months post-intervention. Focus groups were conducted with nursing and allied health staff in June 2009 to explore their attitudes and behaviours in response to the three mealtime interventions. These focus group discussions were analysed using thematic analysis. RESULTS: A total of 254 participants were recruited to the study (pre-intervention: n=115, AIN-only: n=58, PM-only: n=39, PM+AIN: n=42). Participants had a mean age of 80 years (SD 8), and 40% (n=101) were malnourished on hospital admission, 50% (n=108) had anorexia and 38% (n=97) required some assistance at mealtimes. Occasions of mealtime assistance significantly increased in all interventions (p<0.01). However, no change was seen in mealtime interruptions. No significant difference was seen in mean total energy and protein intake between the preintervention and intervention groups. However, when total kilojoule intake was compared with estimated requirements at the individual level, participants in the intervention groups were more likely to achieve adequate energy intake (OR=3.4, p=0.01), with no difference noted between interventions (p=0.29). Despite small improvements in nutritional adequacy, the majority of participants in the intervention groups (76%, n=103) had inadequate energy intakes to meet their estimated energy requirements. Patients with cognitive impairment or feeding dependency appeared to gain substantial benefit from mealtime assistance interventions. The increase in occasions of mealtime assistance by nursing staff during the intervention period was maintained six-months post-intervention. Staff focus groups highlighted the importance of clearly designating and defining mealtime responsibilities in order to provide adequate mealtime care. While the purpose of the dedicated feeding assistant was to increase levels of mealtime assistance, staff indicated that responsibility for mealtime duties may have merely shifted from nursing staff to the assistant. Implementing the multidisciplinary interventions empowered nursing staff to "protect" the mealtime from external interruptions, but further work is required to empower nurses to prioritise mealtime activities within their own work schedules. Staff reported an increase in the profile of nutritional care on all wards, with additional non-nutritional benefits noted including improved mobility and functional independence, and better identification of swallowing difficulties. IMPLICATIONS: The PhD research provides clinicians with practical strategies to immediately introduce change to deliver better mealtime care in the hospital setting, and, as such, has initiated local and state-wide roll-out of mealtime assistance programs. Improved nutritional intakes of elderly inpatients was observed; however given the modest effect size and reducing lengths of hospital stays, better nutritional outcomes may be achieved by targeting the hospital-to-home transition period. Findings from this study suggest that mealtime assistance interventions for elderly inpatients with cognitive impairment and/or functional dependency show promise.

Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality

Background & aims The confounding effect of disease on the outcomes of malnutrition using diagnosis-related groups (DRG) has never been studied in a multidisciplinary setting. This study aims to determine the impact of malnutrition on hospitalisation outcomes, controlling for DRG. Methods Subjective Global Assessment was used to assess the nutritional status of 818 patients within 48 hours of admission. Prospective data were collected on cost of hospitalisation, length of stay (LOS), readmission and mortality up to 3 years post-discharged using National Death Register data. Mixed model analysis and conditional logistic regression matching by DRG were carried out to evaluate the association between nutritional status and outcomes, with the results adjusted for gender, age and race. Results Malnourished patients (29%) had longer hospital stays (6.9±7.3 days vs. 4.6±5.6 days, p<0.001) and were more likely to be readmitted within 15 days (adjusted relative risk = 1.9, 95%CI 1.1–3.2, p=0.025). Within a DRG, the mean difference between actual cost of hospitalisation and the average cost for malnourished patients was greater than well-nourished patients (p=0.014). Mortality was higher in malnourished patients at 1 year (34% vs. 4.1 %), 2 years (42.6% vs. 6.7%) and 3 years (48.5% vs. 9.9%); p<0.001 for all. Overall, malnutrition was a significant predictor of mortality (adjusted hazard ratio = 4.4, 95%CI 3.3-6.0, p<0.001). Conclusions Malnutrition was evident in up to one third of inpatients and led to poor hospitalisation outcomes, even after matching for DRG. Strategies to prevent and treat malnutrition in the hospital and post-discharge are needed.

The interface of acute and aged care : the role of the nurse in a provincial area

Objective This study was to investigate issues that arose from pre-admission to post-discharge, for people in Toowoomba, Queensland over the age of 65 admitted to an acute facility. This paper concentrates on a significant concern that emerged from the large amount of data collected during this project, that is,the role of the nurse in the continuum of health care involving elderly people. Method The study involved a multi-site, multi-agency and multi-method (qualitative and quantitative) approach. Data was collected from regional service providers, the Department of Health and Aged Care (DHAC), the Australian Bureau of Statistics (ABS), Home and Community Care (HACC), the Aged Care Assessment Team (ACAT), elderly people who had been discharged from regional hospitals and their carers, residents of regional aged care facilities, area health professionals and elderly regional hospital inpatients. Results The data indicated that nurses in this provincial area currently play a limited role in preadmission planning, being mostly concerned with elective surgery, especially joint replacements. While nurses deliver the majority of care during hospitalisation, they do not appear to be cognizant of the needs of the elderly regarding post-acute discharge. Conclusion The recent introduction of the model of nurse case management in the acute sector appears to be a positive development that will streamline and optimise the health care of the elderly across the continuum in the Toowoomba area. The paper recommends some strategies, such as discharge liaison nurses based in Emergency Departments and the expansion of the nurse case management role, which would optimise care for the elderly person at the interface of care.