The impact of a new emergency admission avoidance system for older people on length of stay and same-day discharges

AbstractIntroductionCOVID-19 deaths are commoner among care-home residents, but the mortality burden has not been quantified.MethodsCare-home residency was identified via a national primary care registration database linked to national mortality data. Life expectancy was estimated using Makeham-Gompertz models, to (i) describe yearly life expectancy from Nov 2015 to Oct 2020 (ii) compare life expectancy (during 2016-2018) between care-home residents and the wider Scottish population and (iii) apply care-home life expectancy estimates to COVID-19 death counts to estimate years of life lost (YLL).ResultsAmong care-home residents, life expectancy in 2015/16 to 2019/20 ranged from 2.7 to 2.3 years for women and 2.3 to 1.8 years for men. Life expectancy was lowest in 2019/20. Age-sex specific life expectancy in 2016-2018 in care-home residents was lower than in the Scottish population (10 and 2.5 years in those aged 70 and 90 respectively). Rather than using national life tables, applying care-home specific life expectancies to COVID-19 deaths yields, mean YLLs for care-home residents were 2.6 and 2.2 for women and men respectively, with total care-home resident YLLs of 3,560 years in women and 2,046 years in men. In people aged over-70, approximately half of deaths and a quarter of YLL attributed to COVID-19 were accounted for by the 5% of over-70s who were care-home residents.ConclusionPrioritising care-home residents for vaccination is justified not only in terms of total deaths, but also in terms of years of life lost.Research in contextEvidence before this studyWe searched PubMed to 1st December 2020, with the terms (“nursing home” OR “care-home” OR “long-term care” OR “residential care”) AND (“mortality” OR “life expectancy” OR “length of stay”). We also searched for studies specific to the impact of the COVID-19 pandemic on those living in care-homes. We restricted our search to publications in English. Usual care-home life expectancy, in a UK context, has not previously been defined. One systematic review of length of stay was identified, which found significant heterogeneity in factors and associations. The impact of COVID-19 on excess mortality among care-home residents was noted, but the impact on life expectancy was not reported. Studies evaluating life expectancy among older people in the COVID-19 pandemic have not taken account of residency in their estimates.Added value of this studyUsing Scottish national representative linked data we describe the usual life expectancy of older adults (aged ≥70 years) living in care-homes, compared to older people living elsewhere. Deaths among care-home residents account for a considerable proportion of all mortality in older adults, around 19% for men and 30% for women. Life expectancy in care-home residents during the pandemic fell by almost 6 months, from 2.7 to 2.3 years in men and 2.1 to 1.8 years in women. In total, over 5,600 Years of Life were Lost (YLL) by care-home residents in Scotland who died with COVID-19. Around half of COVID-19 deaths and a quarter of YLL in those aged 70 years and over occurred among care-home residents. During the COVID-19 pandemic a smaller proportion of deaths among care-home residents occurred in hospitals.Implications of all the available evidencePrioritising the 5% of older adults who are care-home residents for vaccination against COVID-19 is justified both in terms of total deaths and total years of life lost. Individual and societal planning for care needs in older age relies on understanding usual care-home life expectancy and patterns of mortality. Understanding life expectancy may help clinicians, residents and their families make decisions about their health care, facilitating more informed discussions around their priorities and wishes. Population-wide estimates of YLL and burden of disease should take account of residency status, given the significant differences between life expectancy of those living in care-homes from their peers in other settings.

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Redesigning care for frail older people: The impact of an elderly care pathway on admission avoidance, length of stay and readmission rates

Healthy Aging Research ◽

10.12715/har.2016.5.11 ◽

2016 ◽

Vol 05 (01) ◽

Author(s):

Zabien Nathaniel ◽

Kawa Amin

Keyword(s):

Length Of Stay ◽

Older People ◽

Care Pathway ◽

Elderly Care ◽

Frail Older People ◽

Readmission Rates ◽

The Impact

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The Institute for Healthcare Improvement–NeuroPoint Alliance collaboration to decrease length of stay and readmission after lumbar spine fusion: using national registries to design quality improvement protocols

Journal of Neurosurgery Spine ◽

10.3171/2020.5.spine20457 ◽

2020 ◽

Vol 33 (6) ◽

pp. 812-821

Author(s):

Scott L. Zuckerman ◽

Clinton J. Devin ◽

Vincent Rossi ◽

Silky Chotai ◽

E. Hunter Dyer ◽

...

Keyword(s):

Quality Improvement ◽

Length Of Stay ◽

Discharge Planning ◽

Lumbar Fusion ◽

Nonparametric Tests ◽

Learning System ◽

Design Quality ◽

Implementation Phase ◽

Healthcare Improvement ◽

The Impact

OBJECTIVENational databases collect large amounts of clinical information, yet application of these data can be challenging. The authors present the NeuroPoint Alliance and Institute for Healthcare Improvement (NPA-IHI) program as a novel attempt to create a quality improvement (QI) tool informed through registry data to improve the quality of care delivered. Reducing the length of stay (LOS) and readmission after elective lumbar fusion was chosen as the pilot module.METHODSThe NPA-IHI program prospectively enrolled patients undergoing elective 1- to 3-level lumbar fusions across 8 institutions. A three-pronged approach was taken that included the following phases: 1) Research Phase, 2) Development Phase, and 3) Implementation Phase. Primary outcomes were LOS and readmission. From January to June 2017, a learning system was created utilizing monthly conference calls, weekly data submission, and continuous refinement of the proposed QI tool. Nonparametric tests were used to assess the impact of the QI intervention.RESULTSThe novel QI tool included the following three areas of intervention: 1) preoperative discharge assessment (location, date, and instructions), 2) inpatient changes (LOS rounding checklist, daily huddle, and pain assessments), and 3) postdischarge calls (pain, primary care follow-up, and satisfaction). A total of 209 patients were enrolled, and the most common procedure was a posterior laminectomy/fusion (60.2%). Seven patients (3.3%) were readmitted during the study period. Preoperative discharge planning was completed for 129 patients (61.7%). A shorter median LOS was seen in those with a known preoperative discharge date (67 vs 80 hours, p = 0.018) and clear discharge instructions (71 vs 81 hours, p = 0.030). Patients with a known preoperative discharge plan also reported significantly increased satisfaction (8.0 vs 7.0, p = 0.028), and patients with increased discharge readiness (scale 0–10) also reported higher satisfaction (r = 0.474, p < 0.001). Those receiving postdischarge calls (76%) had a significantly shorter LOS than those without postdischarge calls (75 vs 99 hours, p = 0.020), although no significant relationship was seen between postdischarge calls and readmission (p = 0.342).CONCLUSIONSThe NPA-IHI program showed that preoperative discharge planning and postdischarge calls have the potential to reduce LOS and improve satisfaction after elective lumbar fusion. It is our hope that neurosurgical providers can recognize how registries can be used to both develop and implement a QI tool and appreciate the importance of QI implementation as a separate process from data collection/analysis.

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Does admission prevalence change after reconfiguration of inpatient services? An interrupted time series analysis of the impact of reconfiguration in five centres

BMC Health Services Research ◽

10.1186/s12913-021-06070-7 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Joanne Martin ◽

Edwin Amalraj Raja ◽

Steve Turner

Keyword(s):

Time Series ◽

Time Series Analysis ◽

Emergency Admission ◽

Interrupted Time Series ◽

Interrupted Time Series Analysis ◽

Emergency Admissions ◽

Series Analysis ◽

Inpatient Services ◽

The Impact ◽

Admission Prevalence

Abstract Background Service reconfiguration of inpatient services in a hospital includes complete and partial closure of all emergency inpatient facilities. The “natural experiment” of service reconfiguration may give insight into drivers for emergency admissions to hospital. This study addressed the question does the prevalence of emergency admission to hospital for children change after reconfiguration of inpatient services? Methods There were five service reconfigurations in Scottish hospitals between 2004 and 2018 where emergency admissions to one “reconfigured” hospital were halted (permanently or temporarily) and directed to a second “adjacent” hospital. The number of emergency admissions (standardised to /1000 children in the regional population) per month to the “reconfigured” and “adjacent” hospitals was obtained for five years prior to reconfiguration and up to five years afterwards. An interrupted time series analysis considered the association between reconfiguration and admissions across pairs comprised of “reconfigured” and “adjacent” hospitals, with adjustment for seasonality and an overall rising trend in admissions. Results Of the five episodes of reconfiguration, two were immediate closure, two involved closure only to overnight admissions and one with overnight closure for a period and then closure. In “reconfigured” hospitals there was an average fall of 117 admissions/month [95% CI 78, 156] in the year after reconfiguration compared to the year before, and in “adjacent” hospitals admissions rose by 82/month [32, 131]. Across paired reconfigured and adjacent hospitals, in the months post reconfiguration, the overall number of admissions to one hospital pair slowed, in another pair admissions accelerated, and admission prevalence was unchanged in three pairs. After reconfiguration in one hospital, there was a rise in admissions to a third hospital which was closer than the named “adjacent” hospital. Conclusions There are diverse outcomes for the number of emergency admissions post reconfiguration of inpatient facilities. Factors including resources placed in the community after local reconfiguration, distance to the “adjacent” hospital and local deprivation may be important drivers for admission pathways after reconfiguration. Policy makers considering reconfiguration might consider a number of factors which may be important determinants of admissions post reconfiguration.

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Effect of the Information Support Robot on the Daily Activity of Older People Living Alone in Actual Living Environment

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18052498 ◽

2021 ◽

Vol 18 (5) ◽

pp. 2498

Author(s):

Jumpei Mizuno ◽

Daisuke Saito ◽

Ken Sadohara ◽

Misato Nihei ◽

Shinichi Ohnaka ◽

...

Keyword(s):

Cognitive Function ◽

Older People ◽

Daily Activity ◽

Living Environment ◽

Living Alone ◽

Information Support ◽

Sleep Patterns ◽

High Cognitive Function ◽

Environment Study ◽

The Impact

Information support robots (ISRs) have the potential to assist older people living alone to have an independent life. However, the effects of ISRs on the daily activity, especially the sleep patterns, of older people have not been clarified; moreover, it is unclear whether the effects of ISRs depend on the levels of cognitive function. To investigate these effects, we introduced an ISR into the actual living environment and then quantified induced changes according to the levels of cognitive function. Older people who maintained their cognitive function demonstrated the following behavioral changes after using the ISR: faster wake-up times, reduced sleep duration, and increased amount of activity in the daytime (p < 0.05, r = 0.77; p < 0.05, r = 0.89, and p < 0.1, r = 0.70, respectively). The results suggest that the ISR is beneficial in supporting the independence of older people living alone since living alone is associated with disturbed sleep patterns and low physical activity. The impact of the ISR on daily activity was more remarkable in the subjects with high cognitive function than in those with low cognitive function. These findings suggest that cognitive function is useful information in the ISR adaptation process. The present study has more solid external validity than that of a controlled environment study since it was done in a personal residential space.

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11 Vitamin D Deficiency on Admission and the Association with Length of Stay in Patients with Thermal Injury: A Multi-center Analysis

Journal of Burn Care & Research ◽

10.1093/jbcr/irab032.016 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

pp. S13-S14

Author(s):

Sarah Zavala ◽

Kate Pape ◽

Todd A Walroth ◽

Melissa A Reger ◽

Katelyn Garner ◽

...

Keyword(s):

Vitamin D ◽

Length Of Stay ◽

Vitamin D Deficiency ◽

Burn Injury ◽

Total Body Surface Area ◽

Inhalation Injury ◽

Hospital Length Of Stay ◽

Burn Patients ◽

Comfort Care ◽

The Impact

Abstract Introduction In burn patients, vitamin D deficiency has been associated with increased incidence of sepsis. The objective of this study was to assess the impact of vitamin D deficiency in adult burn patients on hospital length of stay (LOS). Methods This was a multi-center retrospective study of adult patients at 7 burn centers admitted between January 1, 2016 and July 25, 2019 who had a 25-hydroxyvitamin D (25OHD) concentration drawn within the first 7 days of injury. Patients were excluded if admitted for a non-burn injury, total body surface area (TBSA) burn less than 5%, pregnant, incarcerated, or made comfort care or expired within 48 hours of admission. The primary endpoint was to compare hospital LOS between burn patients with vitamin D deficiency (defined as 25OHD < 20 ng/mL) and sufficiency (25OHD ≥ 20 ng/mL). Secondary endpoints include in-hospital mortality, ventilator-free days of the first 28, renal replacement therapy (RRT), length of ICU stay, and days requiring vasopressors. Additional data collected included demographics, Charlson Comorbidity Index, injury characteristics, form of vitamin D received (ergocalciferol or cholecalciferol) and dosing during admission, timing of vitamin D initiation, and form of nutrition provided. Dichotomous variables were compared via Chi-square test. Continuous data were compared via student t-test or Mann-Whitney U test. Univariable linear regression was utilized to identify variables associated with LOS (p < 0.05) to analyze further. Cox Proportional Hazard Model was utilized to analyze association with LOS, while censoring for death, and controlling for TBSA, age, presence of inhalation injury, and potential for a center effect. Results Of 1,147 patients screened, 412 were included. Fifty-seven percent were vitamin D deficient. Patients with vitamin D deficiency had longer LOS (18.0 vs 12.0 days, p < 0.001), acute kidney injury (AKI) requiring RRT (7.3 vs 1.7%, p = 0.009), more days requiring vasopressors (mean 1.24 vs 0.58 days, p = 0.008), and fewer ventilator free days of the first 28 days (mean 22.9 vs 25.1, p < 0.001). Univariable analysis identified burn center, AKI, TBSA, inhalation injury, admission concentration, days until concentration drawn, days until initiating supplementation, and dose as significantly associated with LOS. After controlling for center, TBSA, age, and inhalation injury, the best fit model included only deficiency and days until vitamin D initiation. Conclusions Patients with thermal injuries and vitamin D deficiency on admission have increased length of stay and worsened clinical outcomes as compared to patients with sufficient vitamin D concentrations.

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The Impact of Intersectional Identities on Older People With HIV

Innovation in Aging ◽

10.1093/geroni/igaa057.2560 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 723-723

Author(s):

Mark Brennan-Ing ◽

Charles Emlet

Keyword(s):

Older People ◽

African American Women ◽

Well Being ◽

Hiv Stigma ◽

Neurocognitive Functioning ◽

Bisexual Men ◽

And Bisexual ◽

And Gender ◽

The Impact ◽

Racial Ethnic

Abstract Kimberlé Crenshaw introduced the term “intersectionality” in the late 1980s to highlight the experience discrimination and marginalization of Black and African-American women originating from the confluence of their racial/ethnic and gender identities. Since that time the focus on intersectionality has broadened to consider other communities and individuals who may have multiple stigmatized and discredited identities, including older people with HIV (PWH). For example, Porter and Brennan-Ing described the “Five Corners” model as the intersection of ageism, racism, classism, sexism, and HIV stigma for older transgender and gender non-conforming PWH. HIV disproportionately affects marginalized communities (e.g., racial/ethnic and sexual minorities). Thus, for older PWH it is important to consider how HIV stigma may intersect with other marginalized identities and impact physical and psychological well-being. The first paper in this session examines how the intersection of HIV serostatus, gay identity, and age complicates identity disclosure, leading to social isolation and interference with care planning. The second paper describes how intersectional identities among older PWH interfere with access to mental health services in a population that is disproportionately affected by depression and PTSD. Our third paper examines the role of race, education, and behavioral health in neurocognitive functioning among a diverse sample of older HIV+ gay and bisexual men. Our last paper examines neurocognitive functioning among older Latinx PWH, finding that sexual and gender minorities were at greater risk for impairment. Implications of these findings for research and programming that accounts for the effects of intersectionality among older PWH will be discussed.

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Association of Emergency Department Waiting Times With Patient Experience in Admitted and Discharged Patients

Journal of Patient Experience ◽

10.1177/23743735211011404 ◽

2021 ◽

Vol 8 ◽

pp. 237437352110114

Author(s):

Andrew Nyce ◽

Snehal Gandhi ◽

Brian Freeze ◽

Joshua Bosire ◽

Terry Ricca ◽

...

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Patient Experience ◽

Waiting Times ◽

Hospital Length ◽

Short Length ◽

Hospital Length Of Stay ◽

Patient’S Experience ◽

Discharged Patients ◽

The Impact

Prolonged waiting times are associated with worse patient experience in patients discharged from the emergency department (ED). However, it is unclear which component of the waiting times is most impactful to the patient experience and the impact on hospitalized patients. We performed a retrospective analysis of ED patients between July 2018 and March 30, 2020. In all, 3278 patients were included: 1477 patients were discharged from the ED, and 1680 were admitted. Discharged patients had a longer door-to-first provider and door-to-doctor time, but a shorter doctor-to-disposition, disposition-to-departure, and total ED time when compared to admitted patients. Some, but not all, components of waiting times were significantly higher in patients with suboptimal experience (<100th percentile). Prolonged door-to-doctor time was significantly associated with worse patient experience in discharged patients and in patients with hospital length of stay ≤4 days. Prolonged ED waiting times were significantly associated with worse patient experience in patients who were discharged from the ED and in inpatients with short length of stay. Door-to-doctor time seems to have the highest impact on the patient’s experience of these 2 groups.

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