Quality care outcomes following transitional care interventions for older people from hospital to home: a systematic review

 Background
Provision of high quality transitional care is a challenge for health care providers in many western countries. This systematic review was conducted to (1) identify and synthesise research, using randomised control trial designs, on the quality of transitional care interventions compared with standard hospital discharge for older people with chronic illnesses, and (2) make recommendations for research and practice.

Methods
Eight databases were searched; CINAHL, Psychinfo, Medline, Proquest, Academic Search Complete, Masterfile Premier, SocIndex, Humanities and Social Sciences Collection, in addition to the Cochrane Collaboration, Joanna Briggs Institute and Google Scholar. Results were screened to identify peer reviewed journal articles reporting analysis of quality indicator outcomes in relation to a transitional care intervention involving discharge care in hospital and follow-up support in the home. Studies were limited to those published between January 1990 and May 2013. Study participants included people 60 years of age or older living in their own homes who were undergoing care transitions from hospital to home. Data relating to study characteristics and research findings were extracted from the included articles. Two reviewers independently assessed studies for risk of bias.

Results
Twelve articles met the inclusion criteria. Transitional care interventions reported in most studies reduced re-hospitalizations, with the exception of general practitioner and primary care nurse models. All 12 studies included outcome measures of re-hospitalization and length of stay indicating a quality focus on effectiveness, efficiency, and safety/risk. Patient satisfaction was assessed in six of the 12 studies and was mostly found to be high. Other outcomes reflecting person and family centred care were limited including those pertaining to the patient and carer experience, carer burden and support, and emotional support for older people and their carers. Limited outcome measures were reported reflecting timeliness, equity, efficiencies for community providers, and symptom management.

Conclusions
Gaps in the evidence base were apparent in the quality domains of timeliness, equity, efficiencies for community providers, effectiveness/symptom management, and domains of person and family centred care. Further research that involves the person and their family/caregiver in transitional care interventions is needed.

Consensus guidelines for implementation of quality processes to prevent invasive fungal disease and enhanced surveillance measures during hospital building works, 2014

Healthcare-associated fungal outbreaks impose a substantial economic burden on the health system and typically result in high patient morbidity and mortality, particularly in the immunocompromised host. As the population at risk of invasive fungal infection continues to grow due to the increased burden of cancer and related factors, the need for hospitals to employ preventative measures has become increasingly important. These guidelines outline the standard quality processes hospitals need to accommodate into everyday practice and at times of healthcare-associated outbreak, including the role of antifungal stewardship programmes and best practice environmental sampling. Specific recommendations are also provided to help guide the planning and implementation of quality processes and enhanced surveillance before, during and after high-risk activities, such as hospital building works. Areas in which information is still lacking and further research is required are also highlighted.

The epidemiology of sepsis during rapid response team reviews in a teaching hospital

In a three-month retrospective study, we assessed the proportion of rapid response team (RRT) calls associated with systemic inflammatory response syndrome (SIRS) and sepsis. We also documented the site of infection (whether it was community- or hospital-acquired), antibiotic modifications after the call and in-hospital outcomes. Amongst 358 RRT calls, two or more SIRS criteria were present in 277 (77.4%). Amongst the 277 RRT calls with SIRS criteria, 159 (57.4%) fulfilled sepsis criteria in the 24 hours before and 12 hours after the call. There were 118 of 277 (42.6%) calls with SIRS criteria but no evidence of sepsis and 62 of 277 (22.3%) calls associated with both criteria for sepsis as well as an alternative cause for SIRS. Hence, 159 (44.4%) of all 358 RRT calls over the three-month study period fulfilled criteria for sepsis and in 97 (159-62) (27.1%) of the 358 calls, there were criteria for sepsis without other causes for SIRS criteria. The most common sites of infection were respiratory tract (86), abdominal cavity (38), urinary tract (26) and bloodstream (26). Infection was hospital-acquired in 91 (57.2%) and community-acquired in 67 (42.1%) cases, respectively. Patients were on antibiotics in 127 of 159 (79.9%) cases before the RRT call and antibiotics were added or modified in 76 of 159 (47.8%) cases after RRT review. The hospital length-of-stay of patients who received an RRT call associated with sepsis was longer than those who did not (16.0 [8.0 to 28.5] versus 10 days [6.0 to 18.0]; P=0.002).

What are the perceived learning needs of Australian general practice registrars for quality prescribing?

BACKGROUND: Little is known about the perceived learning needs of Australian general practice (GP) registrars in relation to the quality use of medicines (QUM) or the difficulties experienced when learning to prescribe. This study aimed to address this gap. METHODS: GP registrars' perceived learning needs were investigated through an online national survey, interviews and focus groups. Medical educators' perceptions were canvassed in semi-structured interviews in order to gain a broader perspective of the registrars' needs. Qualitative data analysis was informed by a systematic framework method involving a number of stages. Survey data were analysed descriptively. RESULTS: The two most commonly attended QUM educational activities took place in the workplace and through regional training providers. Outside of these structured educational activities, registrars learned to prescribe mainly through social and situated means. Difficulties encountered by GP registrars included the transition from hospital prescribing to prescribing in the GP context, judging how well they were prescribing and identifying appropriate and efficient sources of information at the point of care. CONCLUSIONS: GP registrars learn to prescribe primarily and opportunistically in the workplace. Despite many resources being expended on the provision of guidelines, decision-support systems and training, GP registrars expressed difficulties related to QUM. Ways of easing the transition into GP and of managing the information 'overload' related to medicines (and prescribing) in an evidence-guided, efficient and timely manner are needed. GP registrars should be provided with explicit feedback about the process and outcomes of prescribing decisions, including the use of audits, in order to improve their ability to judge their own prescribing.

Incident delirium in the acute general medical setting

 Delirium is a serious neuro‐cognitive disorder that affects many people admitted to hospital. Results of this research have contributed valuable knowledge regarding the risk factors, health outcomes and management of medical patients with who developed incident delirium during hospitalisation.

Obesity impacts on general practice appointments

Objective: To quantify the impact of obesity on the number of visits to both primary and secondary care teams.

Research Methods and Procedures: The adult populations of 80 general practices throughout the United Kingdom were classified according to their BMI. We undertook a cross-sectional survey of computer-generated and handwritten records of 6150 obese people (BMI ≥ 30 kg/m2) and 1150 normal weight (BMI = 18.5 to 24.9 kg/m2) control subjects over an 18-month retrospective period.

Results: Obese patients made significantly more visits to the general practitioner (GP), practice nurse (PN), and hospital outpatient units than normal weight patients (all p < 0.001), and they were admitted to the hospital more often (p = 0.034). For both GP and PN visits, the relationship remained after adjusting for age, sex, social deprivation category, country, and number of comorbidities. Among obese patients, there was an increasing relationship between frequent GP visits (at least four appointments) and greater BMI, which remained significant after adjustment had been made for age, sex, deprivation, country, and number of comorbidities.

Discussion: The human resource burden to general practice is significantly higher in the obese population than in the normal weight population, even when adjusted for confounding factors. The increase in prevalence of obesity will continue to put pressure on GP and PN time unless appropriate action is taken.

A profile of four patterns of vulnerability to functional decline in older general medicine patients in Victoria, Australia: a cross sectional survey

BACKGROUND: There are limited published data reporting Australian hospitalized elders' vulnerability to functional decline to guide best practice interventions. The objectives of this study were to describe the prevalence of vulnerability to functional decline and explore profiles of vulnerability related to the performance of physical activity in a representative group of elders in a single centre in Victoria, Australia.

METHODS: A cross-sectional survey of patients aged ≥ 70 years (Mean age 82.4, SD 7 years) admitted to a general medical ward of an Australian tertiary-referral metropolitan public hospital from March 2010 to March 2011 (n = 526). Patients were screened using the Vulnerable Elders Survey (VES-13). Distinct typologies of physical difficulties were identified using latent class analysis.

RESULTS: Most elders scored ≥3/10 on the VES-13 and were rated vulnerable to functional decline (n = 480, 89.5 %). Four distinct classes of physical difficulty were identified: 1) Elders with higher physical functioning (n = 114, 21.7 %); 2) Ambulant elders with diminished strength (n = 24, 4.6 %); 3) Elders with impaired mobility, strength and ability to stoop (n = 267, 50.8 %) and 4) Elders with extensive physical impairment (n = 121, 23 %) Vulnerable elders were distributed through all classes.

CONCLUSIONS: Older general medicine patients in Victoria, Australia, are highly vulnerable to functional decline. We identified four distinct patterns of physical difficulties associated with vulnerability to functional decline that can inform health service planning, delivery and education.

Risk factors for incident delirium in an acute general medical setting: a retrospective case – control study

Aims and ObjectivesTo determine predisposing and precipitating risk factors for incident delirium in medical patients during an acute hospital admission.BackgroundIncident delirium is the most common complication of hospital admission for older patients. Up to 30% of hospitalised medical patients experience incident delirium. Determining risk factors for delirium is important for identifying patients that are most susceptible to incident delirium.DesignRetrospective case-control study with two controls per case.MethodsAn audit tool was used to review medical records of patients admitted to acute medical units for data regarding potential risk factors for delirium. Data was collected between August 2013 and March 2014 at three hospital sites of a healthcare organisation in Melbourne, Australia. Cases were 161 patients admitted to an acute medical ward and diagnosed with incident delirium between 1st January 2012 and 31st December 2013. Controls were 321 patients sampled from the acute medical population admitted within the same time range, stratified for admission location and who did not develop incident delirium during hospitalisation.ResultsIdentified using logistic regression modelling, predisposing risk factors for incident delirium were: dementia, cognitive impairment, functional impairment, previous delirium, and fracture on admission. Precipitating risk factors for incident delirium were: use of an indwelling catheter, adding more than three medications during admission and having an abnormal sodium level during admission.ConclusionsMultiple risk factors for incident delirium exist; patients with a history of delirium, dementia and cognitive impairment are at greatest risk of developing delirium during hospitalisation.Relevance to clinical practiceNurses and other health care professionals should be aware of patients that have one or more risk factors for incident delirium. Knowledge of risk factors for delirium has the potential to increase the recognition and understanding of patients who are vulnerable to delirium. Early recognition and prevention of delirium can contribute to improved patients safety and reduction in harm.

Creating opportunities for interdisciplinary collaboration and patient-centred care: how nurses, doctors, pharmacists and patients use communication strategies when managing medications in an acute hospital setting.

AIMS AND OBJECTIVES: This paper examines the communication strategies that nurses, doctors, pharmacists and patients use when managing medications. BACKGROUND: Patient-centred medication management is best accomplished through interdisciplinary practice. Effective communication about managing medications between clinicians and patients has a direct influence on patient outcomes. There is a lack of research that adopts a multidisciplinary approach and involves critical in-depth analysis of medication interactions among nurses, doctors, pharmacists and patients. DESIGN: A critical ethnographic approach with video reflexivity was adopted to capture communication strategies during medication activities in two general medical wards of an acute care hospital in Melbourne, Australia. METHODS: A mixed ethnographic approach combining participant observations, field interviews, video recordings and video reflexive focus groups and interviews was employed. Seventy-six nurses, 31 doctors, 1 pharmacist and 27 patients gave written consent to participate in the study. Data analysis was informed by Fairclough's critical discourse analytic framework. FINDINGS: Clinicians' use of communication strategies was demonstrated in their interpersonal, authoritative and instructive talk with patients. Doctors adopted the language discourse of normalisation to standardise patients' illness experiences. Nurses and pharmacists employed the language discourses of preparedness and scrutiny to ensure that patient safety was maintained. Patients took up the discourse of politeness to raise medication concerns and question treatment decisions made by doctors, in their attempts to challenge decision-making about their health care treatment. In addition, the video method revealed clinicians' extensive use of body language in communication processes for medication management. CONCLUSIONS: The use of communication strategies by nurses, doctors, pharmacists and patients created opportunities for improved interdisciplinary collaboration and patient-centred medication management in an acute hospital setting. Language discourses shaped and were shaped by complex power relations between patients and clinicians and among clinicians themselves. RELEVANCE TO CLINICAL PRACTICE: Clinicians need to be encouraged to have regular conversations to talk about and challenge each other's practices. More emphasis should be placed on ensuring that patients are given opportunities to voice their concerns about how their medications are managed.