A prospective cohort study of geriatric syndromes among older medical patients admitted to acute care hospitals

OBJECTIVES: To identify the prevalence of geriatric syndromes in the premorbid for all syndromes except falls (preadmission), admission, and discharge assessment periods and the incidence of new and significant worsening of existing syndromes at admission and discharge. DESIGN: Prospective cohort study. SETTING: Three acute care hospitals in Brisbane, Australia. PARTICIPANTS: Five hundred seventy-seven general medical patients aged 70 and older admitted to the hospital. MEASUREMENTS: Prevalence of syndromes in the premorbid (or preadmission for falls), admission, and discharge periods; incidence of new syndromes at admission and discharge; and significant worsening of existing syndromes at admission and discharge. RESULTS: The most frequently reported premorbid syndromes were bladder incontinence (44%), impairment in any activity of daily living (ADL) (42%). A high proportion (42%) experienced at least one fall in the 90 days before admission. Two-thirds of the participants experienced between one and five syndromes (cognitive impairment, dependence in any ADL item, bladder and bowel incontinence, pressure ulcer) before, at admission, and at discharge. A majority experienced one or two syndromes during the premorbid (49.4%), admission (57.0%), or discharge (49.0%) assessment period.The syndromes with a higher incidence of significant worsening at discharge (out of the proportion with the syndrome present premorbidly) were ADL limitation (33%), cognitive impairment (9%), and bladder incontinence (8%). Of the syndromes examined at discharge, a higher proportion of patients experienced the following new syndromes at discharge (absent premorbidly): ADL limitation (22%); and bladder incontinence (13%). CONCLUSION: Geriatric syndromes were highly prevalent. Many patients did not return to their premorbid function and acquired new syndromes.

'Online' geriatric assessment procedure for older adults referred for geriatric assessment during an acute care episode for consideration of reliability of triage decisions

Background Comprehensive geriatric assessment has been shown to improve patient outcomes, but the geriatricians who deliver it are in short-supply. A web-based method of comprehensive geriatric assessment has been developed with the potential to improve access to specialist geriatric expertise. The current study aims to test the reliability and safety of comprehensive geriatric assessment performed “online” in making geriatric triage decisions. It will also explore the accuracy of the procedure in identifying common geriatric syndromes, and its cost relative to conventional “live” consultations. Methods/Design The study population will consist of 270 acutely hospitalized patients referred for geriatric consultation at three sites. Paired assessments (live and online) will be conducted by independent, blinded geriatricians and the level of agreement examined. This will be compared with the level of agreement between two independent, blinded geriatricians each consulting with the patient in person (i.e. “live”). Agreement between the triage decision from live-live assessments and between the triage decision from live-online assessments will be calculated using kappa statistics. Agreement between the online and live detection of common geriatric syndromes will also be assessed using kappa statistics. Resource use data will be collected for online and live-live assessments to allow comparison between the two procedures. Discussion If the online approach is found to be less precise than live assessment, further analysis will seek to identify patient subgroups where disagreement is more likely. This may enable a protocol to be developed that avoids unsafe clinical decisions at a distance. Trial registration Trial registration number: ACTRN12611000936921

Patients’ satisfaction with acute care hospital foodservice: does age matter?

In an aging population, healthcare providers should understand the foodservice preferences of the elderly to reduce the risk of malnutrition through adequate nutrition. Conflicting reports exist for elderly patient satisfaction regarding foodservice.1 This study aimed to investigate the relationship between age and foodservice satisfaction within the acute care hospital setting. Patient satisfaction was assessed using the Acute Care Hospital Foodservice Patient Satisfaction Questionnaire with data collected over three years (2008–2010, n = 785) at The Wesley Hospital, Brisbane. Age was grouped into three categories; <50, 51–70 and >70 years. ANOVA was used to measure age related differences in patients’ overall foodservice satisfaction, four foodservice dimensions and two independent statements (meal size and hot food temperature). Results showed that older patients were more satisfied than younger patients and indicated increasing satisfaction with increasing age regarding food quality (F2,767 = 15.787, p < 0.001), staff/service issues (F2,768 = 12.243, p < 0.001), physical environment (F2,765 = 5.454, p = 0.004), meal size (F2,730 = 10.646, p < 0.001) and hot food temperature (F2,730 = 10.646, p < 0.001). While patients aged >70 years also reported greater satisfaction with meal service quality, those aged 51–70 years indicated the lowest (F2,762 = 9.988, p < 0.001). Overall patient satisfaction across all age groups was high (4.26–4.43/5) and a trend of increasing satisfaction with increasing age was evident (F2,752 = 2.900, p = 0.056). These findings suggest patients’ satisfaction with hospital foodservice increases with age and can assist foodservices to meet the varying generational expectations of their clients.

(Mis)Using Pulse Oximetry : A Review of Pulse Oximetry use in Acute Care Medical Wards

Background: Nurses routinely use pulse oximetry (SpO2) monitoring equipment in acute care. Interpretation of the reading involves physical assessment and awareness of parameters including temperature, haemoglobin, and peripheral perfusion. However, there is little information on whether these clinical signs are routinely measured or used in pulse oximetry interpretation by nurses. Aim: The aim of this study was to review current practice of SpO2 measurement and the associated documentation of the physiological data that is required for accurate interpretation of the readings. The study reviewed the documentation practices relevant to SpO2 in five medical wards of a tertiary level metropolitan hospital. Method: A prospective casenote audit was conducted on random days over a three-month period. The audit tool had been validated in a previous study. Results: One hundred and seventy seven episodes of oxygen saturation monitoring were reviewed. Our study revealed a lack of parameters to validate the SpO2 readings. Only 10% of the casenotes reviewed had sufficient physiological data to meaningfully interpret the SpO2 reading and only 38% had an arterial blood gas as a comparator. Nursing notes rarely documented clinical interpretation of the results. Conclusion: The audits suggest that medical and nursing staff are not interpreting the pulse oximetry results in context and that the majority of the results were normal with no clinical indication for performing this observation. This reduces the usefulness of such readings and questions the appropriateness of performing “routine” SpO2 in this context.

Nutritional status and dietary intake of acute care patients : results from the Nutrition Care Day Survey 2010

Background & aims: One aim of the Australasian Nutrition Care Day Survey was to determine the nutritional status and dietary intake of acute care hospital patients. Methods: Dietitians from 56 hospitals in Australia and New Zealand completed a 24-h survey of nutritional status and dietary intake of adult hospitalised patients. Nutritional risk was evaluated using the Malnutrition Screening Tool. Participants ‘at risk’ underwent nutritional assessment using Subjective Global Assessment. Based on the International Classification of Diseases (Australian modification), participants were also deemed malnourished if their body mass index was <18.5 kg/m2. Dietitians recorded participants’ dietary intake at each main meal and snacks as 0%, 25%, 50%, 75%, or 100% of that offered. Results: 3122 patients (mean age: 64.6 ± 18 years) participated in the study. Forty-one percent of the participants were “at risk” of malnutrition. Overall malnutrition prevalence was 32%. Fifty-five percent of malnourished participants and 35% of well-nourished participants consumed ≤50% of the food during the 24-h audit. “Not hungry” was the most common reason for not consuming everything offered during the audit. Conclusion: Malnutrition and sub-optimal food intake is prevalent in acute care patients across hospitals in Australia and New Zealand and warrants appropriate interventions.

How do Australasian hospitals identify and manage malnutrition in their acute care wards?

One aim of the Australasian Nutrition Care Day Survey was to explore nutrition care practices in acute care hospital wards across Australia and New Zealand. Managers of Dietetic departments completed a questionnaire regarding ward nutrition care practices. Overall, 370 wards from 56 hospitals participated. The median ward size was 28 beds (range: 8–60 beds). Although there was a wide variation in full-time equivalent availability of dietitians (median: 0.3; range: 0–1.4), their involvement in providing nutrition care across ward specialities was signifi cantly higher than other staff members (χ2, p < 0.01). Feeding assistance, available in 89% of the wards, was provided mainly by nursing staff and family members (χ2, p < 0.01). Protected meal times were implemented in 5% (n = 18) of the wards. Fifty-three percent of the wards (n = 192) weighed patients on request and 40% (n = 148) on admission. Routine malnutrition screening was conducted in 63% (n = 232) of the wards and 79% (n = 184) of these wards used the Malnutrition Screening Tool, 16% (n = 37) the Malnutrition Universal Screening Tool, and 5% (n = 11) other tools. Nutrition rescreening was routinely conducted in 20% of the wards. Among wards that implemented nutrition screening, 41% (n = 100) routinely referred patients “at risk” of malnutrition to dietitians as part of their standard protocol for malnutrition management. Results of this study provide new knowledge regarding current nutrition care practice, highlight gaps in existing practice, and can be used to inform improved nutrition care in acute care wards across Australia and New Zealand.

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.

A leap into foodservice satisfaction in the private acute care setting

Monitoring foodservice satisfaction is a risk management strategy for malnutrition in the acute care sector, as low satisfaction may be associated with poor intake. This study aimed to investigate the relationship between age and foodservice satisfaction in the private acute care setting. Patient satisfaction was assessed using a validated tool, the Acute Care Hospital Foodservice Patient Satisfaction Questionnaire for data collected 2008–2010 (n = 779) at a private hospital, Brisbane. Age was grouped into three categories; <50 years, 51–70 years and >70 years. Fisher’s exact test assessed independence of categorical responses and age group; ANOVA or Kruskal–Wallis test was used for continuous variables. Dichotomised responses were analysed using logistic regression and odds ratios (95% confidence interval, p < 0.05). Overall foodservice satisfaction (5 point scale) was high (≥4 out of 5) and was independent of age group (p = 0.377). There was an increasing trend with age in mean satisfaction scores for individual dimensions of foodservice; food quality (p < 0.001), meal service quality (p < 0.001), staff service issues (p < 0.001) and physical environment (p < 0.001). A preference for being able to choose different sized meals (59.8% > 70 years vs 40.6% ≤50 years; p < 0.001) and response to ‘the foods are just the right temperature’ (55.3% >70 years vs 35.9% ≤50 years; p < 0.001) was dependent on age. For the food quality dimension, based on dichotomised responses (satisfied or not), the odds of satisfaction was higher for >70 years (OR = 5.0, 95% CI: 1.8–13.8; <50 years referent). These results suggest that dimensions of foodservice satisfaction are associated with age and can assist foodservices to meet varying generational expectations of clients.

Pain : the views of elderly people living in long term residential care settings

While an individual's beliefs and attitudes have long been considered important factors in how people respond to pain, few studies have attempted to provide in-depth descriptions of the nature of such pain beliefs and attitudes The aim of this research was to investigate the views of pain and pain management practices held by elderly people living in long-term residential care settings Ten 60–90 minute focus group interviews, each involving around five elderly people, were conducted in four large, long-term residential care settings in Brisbane, Australia Categories of beliefs and attitudes regarding pain were identified following analysis of the verbatim transcripts of these interviews Findings suggest that many elderly people living in long-term residential care settings may have become resigned to pain, that they are ambivalent about the benefit of any action for their pain and that they may be reluctant to express their pain Implications of these beliefs and attitudes are discussed

Development of the Rapid Assessment, Prioritisation and Referral Tool (RAPaRT) for multidisciplinary teams in emergency care settings

Objective This investigation utilised the expertise of allied members of multidisciplinary teams working in emergency care settings to develop and validate a Rapid Assessment Prioritisation and Referral Tool (RAPaRT). This instrument is intended for use among patients (with non-life threatening acuity) presenting to emergency care settings to indicate when referral to an allied member of the multidisciplinary team is warranted. Method This three stage instrument development and validation study included: a Delphi panel process to determine key criteria to guide instrument development and identify potential items to be carried forward for testing (stage 1); a prospective cohort of consecutive admissions (n=153) to investigate item sensitivity and specificity and retain only the most suitable items (stage 2); then final consultation with the Delphi panel to ensure the final instrument was clinically amenable (stage 3). Results 23 potential items were identified following stage 1. At the completion of item sensitivity and specificity analysis and in consultation with the Delphi panel, seven items were retained in the instrument. Area under the receiver operating characteristic curve was 0.803 for these seven items in predicting when a referral was warranted. Final consultation with the Delphi panel members also resulted in the addition of an open ended (eighth) item to allow description of any infrequent, but important, reason for referral. Conclusions The RAPaRT has demonstrated substantial promise as an efficient clinically amenable instrument to assist multidisciplinary teams in emergency care settings. Further research to investigate the wider implementation of the RAPaRT is warranted.

Delirium knowledge and recognition : a randomized controlled trial of a web-based educational intervention for acute care nurses

Delirium is a significant problem for older hospitalized people and is associated with poor outcomes. It is poorly recognized and evidence suggests that a major reason is lack of education. Nurses, who are educated about delirium, can play a significant role in improving delirium recognition. This study evaluated the impact of a delirium specific educational website. A cluster randomized controlled trial, with a pretest/post-test time series design, was conducted to measure delirium knowledge (DK) and delirium recognition (DR) over three time-points. Statistically significant differences were found between the intervention and non-intervention group. The intervention groups' DK scores were higher and the change over time results were statistically significant [T3 and T1 (t=3.78 p=<0.001) and T2 and T1 baseline (t=5.83 p=<0.001)]. Statistically significant improvements were also seen for DR when comparing T2 and T1 results (t=2.56 p=0.011) between both groups but not for changes in DR scores between T3 and T1 (t=1.80 p=0.074). Participants rated the website highly on the visual, functional and content elements. This study supports the concept that web-based delirium learning is an effective and satisfying method of information delivery for registered nurses. Future research is required to investigate clinical outcomes as a result of this web-based education.

A prospective cohort study examining the preferred learning styles of acute care registered nurses

Objectives This paper reports on the preferred learning styles of Registered Nurses practicing in acute care environments and relationships between gender, age, post-graduate experience and the identified preferred learning styles. Methods A prospective cohort study design was used. Participants completed a demographic questionnaire and the Felder-Silverman Index of Learning Styles (ILS) questionnaire to determine preferred learning styles. Results Most of the Registered Nurse participants were balanced across the Active-Reflective (n = 77, 54%), and Sequential-Global (n = 96, 68%) scales. Across the other scales, sensing (n = 97, 68%) and visual (n = 76, 53%) were the most common preferred learning style. There were only a small proportion who had a preferred learning style of reflective (n = 21, 15%), intuitive (n = 5, 4%), verbal (n = 11, 8%) or global learning (n = 15, 11%). Results indicated that gender, age and years since undergraduate education were not related to the identified preferred learning styles. Conclusions The identification of Registered Nurses’ learning style provides information that nurse educators and others can use to make informed choices about modification, development and strengthening of professional hospital-based educational programs. The use of the Index of Learning Styles questionnaire and its ability to identify ‘balanced’ learning style preferences may potentially yield additional preferred learning style information for other health-related disciplines.

The once-and-for-all withdrawal of the Liverpool Care Pathway in the UK : what are the implications for Australia?

This Perspective reflects on the withdrawal of the Liverpool Care Pathway in the UK, and its implications for Australia. Integrated care pathways are documents which outline the essential steps of multidisciplinary care in addressing a specific clinical problem. They can be used to introduce best clinical practice, to ensure that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. By providing clear instructions, decision support and a framework for clinician-patient interactions, care pathways guide the systematic provision of best evidence-based care. The Liverpool Care Pathway (LCP) is an example of an integrated care pathway, designed in the 1990s to guide care for people with cancer who are in their last days of life and are expected to die in hospital. This pathway evolved out of a recognised local need to better support non-specialist palliative care providers’ care for patients dying of cancer within their inpatient units. Historically, despite the large number of people in acute care settings whose treatment intent is palliative, dying patients receiving general hospital acute care tended to lack sufficient attention from senior medical staff and nursing staff. The quality of end-of-life care was considered inadequate, therefore much could be learned from the way patients were cared for by palliative care services. The LCP was a strategy developed to improve end-of-life care in cancer patients and was based on the care received by those dying in the palliative care setting.