What Older Patients and their Relatives Say is Important During Acute Hospitalisation: A Qualitative Study

Background: Due to the growing elderly population across the world, providing safe and effective care to older people is an increasing concern. Hospitals need to adapt to ensure high-quality care for older patients. Several age-friendly frameworks and models aiming at reducing risks and complications have been promoted. However, care for the elderly must be based on the patients’ reported needs, and relatives are often an important part of the patients’ resources. The primary aim of this study was to explore elderly patients’ and their relatives’ experiences of acute hospitalisation and determine what is important for them to experience a good hospital stay. Methods: This study has a qualitative research design in which patients aged 75 years or older and their relatives were interviewed during their acute hospitalisation. The study was conducted at two medical bed wards at a large university hospital in Norway. All interviews were thematically analysed.Results: Four major themes were identified in patients’ and relatives’ descriptions of how they experienced the hospital stay and what was important for them during the hospital stay: being seen and valued as a person, individualised care, patient-adapted communication and information, and collaboration with relatives. The themes span both positive and negative experiences, reflecting great variability in the experiences described.Conclusions: The results underscore how small things matter in relation to how we meet and communicate with older patients and their relatives. How health personnel get to know the patient’s individual values, need for care, information and involvement of relatives affects their experiences of the hospital stay.

Home-based Extended Rehabilitation for Older people (HERO): study protocol for an individually randomised controlled multi-centre trial to determine the clinical and cost-effectiveness of a home-based exercise intervention for older people with frailty as extended rehabilitation following acute illness or injury, including embedded process evaluation

Background The majority of older people (> 65 years) in hospital have frailty and are at increased risk of readmission or death following discharge home. In the UK, following acute hospitalisation, around one third of older people with frailty are referred on for rehabilitation, termed ‘intermediate care’ services. Although this rehabilitation can reduce early readmission to hospital (< 30 days), recipients often do not feel ready to leave the service on discharge, suggesting possible incomplete recovery. Limited evidence suggests extended rehabilitation is of benefit in several conditions and there is preliminary evidence that progressive physical exercise can improve mobility and function for older people with frailty, and slow progression to disability. Our aim is to evaluate the effectiveness of the Home-based Older People’s Exercise (HOPE) programme as extended rehabilitation for older people with frailty discharged home from hospital or intermediate care services after acute illness or injury. Methods A multi-centre individually randomised controlled trial, to evaluate the clinical and cost-effectiveness of the HOPE programme. This individualised, graded and progressive 24-week exercise programme is delivered by NHS physiotherapy teams to people aged 65 and older with frailty, identified using the Clinical Frailty Scale, following discharge from acute hospitalisation and linked intermediate care rehabilitation pathways. The primary outcome is physical health-related quality of life, measured using the physical component summary score of the modified Short Form 36- item health questionnaire (SF36) at 12 months. Secondary outcomes include self-reported physical and mental health, functional independence, death, hospitalisations, care home admissions. Plans include health economic analyses and an embedded process evaluation. Discussion This trial seeks to determine if extended rehabilitation, via the HOPE programme, can improve physical health-related quality of life for older people with frailty following acute hospitalisation. Results will improve awareness of the rehabilitation needs of older people with frailty, and provide evidence on the clinical and cost-effectiveness of the targeted exercise intervention. There is potential for considerable benefit for health and social care services through widespread implementation of trial findings if clinical and cost-effectiveness is demonstrated. Trial registration ISRCTN 13927531. Registered on April 19, 2017.

Associations between degree-of-worry, self-rated health and acute hospitalisation after contacting a medical helpline: a Danish prospective cohort study

ObjectivesSelf-rated health (SRH) is a strong predictor for healthcare utilisation among chronically ill patients. However, its association with acute hospitalisation is unclear. Individuals’ perception of urgency in acute illness expressed as degree-of-worry (DOW) is however associated with acute hospitalisation. This study examines DOW and SRH, respectively, and their association with acute hospitalisation within 48 hours after calling a medical helpline.DesignA prospective cohort study.SettingThe Medical Helpline 1813 (MH1813) in the Capital Region of Denmark, Copenhagen.ParticipantsAdult (≥18 years of age) patients and relatives/close friends calling the MH1813 between 24 January and 9 February 2017. A total of 6812 callers were included.Outcome measuresThe primary outcome measure was acute hospitalisation. Callers rated their DOW (1=minimum worry, 5=maximum worry) and SRH (1=excellent, 5=poor). Covariates included age, sex, Charlson Comorbidity Score and reason for calling. Logistic regression was conducted to measure the associations in three models: (1) crude; (2) age-and-sex-adjusted; (3) full fitted model (age, sex, comorbidity, reason for calling, DOW/SRH).ResultsOf 6812 callers, 492 (7.2%) were acutely hospitalised. Most callers rated their health as being excellent to good (65.3%) and 61% rated their worry to be low (DOW 1–3). Both the association between DOW and acute hospitalisation and SRH and acute hospitalisation indicated a dose–response relationship: DOW 1=ref, 3=1.8 (1.1;3.1), 5=3.5 (2.0;5.9) and SRH 1=ref, 3=0.8 (0.6;1.4), 5=1.6 (1.1;2.4). The association between DOW and acute hospitalisation decreased slightly, when further adjusting for SRH, whereas the estimates for SRH weakened markedly when including DOW.ConclusionsDOW and poor SRH were associated with acute hospitalisation. However, DOW had a stronger association with hospitalisation than SRH. This suggests that DOW may capture acutely ill patients’ perception of urgency better than SRH in relation to acute hospitalisation after calling a medical helpline.Trial registration numberNCT02979457.

Associations between loneliness and acute hospitalisation outcomes among patients receiving mental healthcare in South London: a retrospective cohort study

Purpose It is well known that loneliness can worsen physical and mental health outcomes, but there is a dearth of research on the impact of loneliness in populations receiving mental healthcare. This study aimed to investigate cross-sectional correlates of loneliness among such patients and longitudinal risk for acute general hospitalisations. Method A retrospective observational study was conducted on the data from patients aged 18 + receiving assessment/care at a large mental healthcare provider in South London. Recorded loneliness status was ascertained among active patients on the index date, 30th Jun 2012. Acute general hospitalisation (emergency/elective) outcomes were obtained until 31st Mar 2018. Length of stay was modelled using Poisson regression models and time-to hospitalisation and time-to mortality were modelled using Cox proportional hazards regression models. Results The data from 26,745 patients were analysed. The prevalence of patients with recorded loneliness was 16.4% at the index date. In the fully adjusted model, patients with recorded loneliness had higher hazards of emergency (HR 1.15, 95% CI 1.09–1.22) and elective (1.05, 1.01–1.12) hospitalisation than patients who were not recorded as lonely, and a longer duration of both emergency (IRR 1.06, 95% CI 1.05–1.07) and elective (1.02, 1.01–1.03) general hospitalisations. There was no association between loneliness and mortality. Correlates of loneliness included having an eating disorder (OR 1.67, 95% CI 1.29–2.25) and serious mental illnesses (OR 1.44, 1.29–1.62). Conclusion Loneliness in patients receiving mental healthcare is associated with higher use of general hospital services. Increased attention to the physical healthcare of this patient group is therefore warranted.

Advance care planning in older hospitalised patients following an emergency admission: A mixed methods study

Introduction Although advance care planning may be beneficial for older adults in the last year of life, its relevance following an emergency hospitalisation requires further investigation. This study quantifies the one-year mortality outcomes of all emergency admissions for patients aged 70+ years and explores patient views on the value of advance care planning following acute hospitalisation. Method This mixed methods study used a two-stage approach: firstly, a quantitative longitudinal cohort study exploring the one-year mortality of patients aged 70+ admitted as an emergency to a large multi-centre hospital cohort; secondly, a qualitative semi-structured interview study gathering information on patient views of advance care planning. Results There were 14,260 emergency admissions for 70+-year olds over a 12-month period. One-year mortality for admissions across all conditions was 22.6%. The majority of these deaths (59.3%) were within 3 months of admission. Binary logistic regression analysis indicated higher one-year mortality with increasing age and male sex. Interviews with 20 patients resulted in one superordinate theme, “Planning for health and wellbeing in the spectrum of illness”. Sub-themes entitled (1) Advance care planning benefitting healthcare for physical and psycho-social health, (2) Contemplation of physical deterioration death and dying and 3) Collaborating with healthcare professionals to undertake advance care planning, suggest that views of advance care planning are shaped by experiences of acute hospitalisation. Conclusion Since approximately 1 in 5 patients aged 70+ admitted to hospital as an emergency are in the last year of life, acute hospitalisation can act as a trigger for tailored ACP. Older hospitalised patients believe that advance care planning can benefit physical and psychosocial health and that discussions should consider a spectrum of possibilities, from future health to the potential of chronic illness, disability and death. In this context, patients may look for expertise from healthcare professionals for planning their future care.

Virtual geriatric clinics and the COVID-19 catalyst: a rapid review

Background During the current COVID-19 health crisis virtual geriatric clinics have become increasingly utilised to complete outpatient consultations, although concerns exist about feasibility of such virtual consultations for older people. The aim of this rapid review is to describe the satisfaction, clinic productivity, clinical benefit, and costs associated with the virtual geriatric clinic model of care. Methods A rapid review of PubMed, MEDLINE and CINAHL databases was conducted up to April 2020. Two independent reviewers extracted the information. Four subdomains were focused on: satisfaction with the virtual geriatric clinic, clinic productivity, clinical benefit to patients, costs and any challenges associated with the virtual clinic process. Results Nine studies with 975 patients met our inclusion criteria. All were observational studies. Seven studies reported patients were satisfied with the virtual geriatric clinic model of care. Productivity outcomes included reports of cost-effectiveness, savings on transport, and improved waiting list metrics. Clinical benefits included successful polypharmacy reviews, and reductions in acute hospitalisation rates. Varying challenges were reported for both clinicians and patients in eight of the nine studies. Hearing impairments and difficulty with technology added to anxieties experienced by patients. Physicians missed the added value of a thorough physical examination and had concerns about confidentiality. Conclusion Virtual geriatric clinics demonstrate evidence of productivity, benefit to patients, cost effectiveness and patient satisfaction with the treatment provided. In the current suboptimal pandemic climate, virtual geriatric clinics may allow Geriatricians to continue to provide an outpatient service, despite the encountered inherent challenges.

Serum Endothelin-1 Correlates with Myocardial Injury and Independently Predicts Adverse Cardiac Events in Non-ST-Elevation Acute Myocardial Infarction

Introduction. Serum endothelin-1 is increasingly released in acute myocardial infarction, by necrotic cardiomyocytes. In non-ST-elevation acute myocardial infarction (Non-STEMI), increased serum endothelin-1 on-admission may have clinical significance during acute hospitalisation events. Objective. The purpose of this study is to investigate whether increased serum endothelin-1 level predict adverse cardiac events in patients hospitalized with Non-STEMI. Methods. The design of this research was a prospective cohort study. Consecutive subjects with Non-STEMI undergoing symptom onset ≤24 hour were enrolled and observed during intensive hospitalization. Serum endothelin-1, troponin-I, and hs-C reactive protein were measured from peripheral blood taken on-admission. In-hospital adverse cardiac events were a composite of death, acute heart failure, cardiogenic shock, reinfarction, and resuscitated VT/VF. Results. We enrolled 66 subjects. The incidence of in-hospital adverse cardiac events is 13.6% (10 out of 66 subjects). Serum endothelin-1 level was significantly higher in subjects with in-hospital adverse cardiac events. Subjects with endothelin-1 level >2.59 pg/mL independently predicted adverse cardiac events in hospitalised Non-STEMI patients (adjusted odds ratio 44.43, 95% confidence interval: 1.44-1372.99, p value 0.03). The serum endothelin-1 level was correlated with serum troponin I level (correlation coefficient of 0.413, p value 0.012). Conclusion. Increased serum endothelin-1 on-admission correlated with increased troponin-I and independently predicted in-hospital adverse cardiac events in patients with Non-STEMI.

Care needs, social support and meaning in life in patients after acute heart failure hospitalisation: a longitudinal study

Background: Meaning in life serves as a protective mechanism for coping with persistent, often distressful symptoms in patients with heart failure. However, meaning in life and its associated factors are not adequately explored in patients after acute hospitalisation for heart failure. Aims: To explore the associated factors of meaning in life in patients with heart failure from acute hospitalisation to 3 months post-discharge. Methods: A total of 103 hospitalised patients with heart failure in Northern Taiwan were recruited using a longitudinal study design and interviewed with structured questionnaires including meaning in life, symptom distress, care needs, and social support at hospitalisation, 1 month and 3 months post-discharge. Results: A total of 83 patients completed the 3 months follow-up. The presence of meaning in life significantly increased from hospitalisation to 3 months post-discharge. Decreases in care needs ( B=−0.10, P=0.020) and social support ( B=−0.18, P=0.016) from hospitalisation to 3 months post-discharge were significantly associated with an increase in the presence of meaning in life, while a decrease in social support was associated with an increase in the search for meaning in life ( B=−0.17, P=0.034). Conclusion: Care needs and social support were pivotal factors for developing meaning in life for patients with heart failure. Assessments of care needs and social support might help strengthen their meaning in life.

Attitudes of multimorbid patients to surviving future acute illness and subsequent functional disability: A systematic review

BACKGROUND: Multimorbid patients have worse outcomes following acute hospitalisation. These include increased mortality as an in-patient and after hospital discharge, and increased morbidity and dependence requiring greater use of care facilities. The literature is unclear on the views and wishes of multimorbid patients regarding the outcomes of acute hospitalisation, specifically regarding survival with additional functional disability following acute illness. This is increasingly relevant, with the recent National Institute for Health and Care Excellence (NICE) guidance on admission to hospital and critical care being based on the presence of comorbidities and function as opposed to numerical age. Objectives: We performed a systematic review to assess the current qualitative literature exploring attitudes, wishes and perspectives of adult patients with multimorbidity on surviving future acute illness and subsequent acquired functional disability. METHODS: Eligibility criteria: Eligible studies addressed the attitudes, wishes and perspectives of multimorbid adults to illness and treatment-acquired disability using qualitative methods. Information sources: A search of PubMed, Embase, and CINAHL databases was conducted from database inception through April 2020. References lists from selected papers and NICE Guidelines on Multimorbidity (NG56) were searched iteratively for additional relevant articles. Review methods: Two researchers reviewed candidate full texts independently. Relevant data was extracted to an evidence table. The risk of bias was avoided by adhering to the previously published extensive search strategy and use of qualitative methodology. RESULTS: From 35606 records of which 6370 were duplicates, 20 full texts were reviewed for inclusion, but none met the eligibility criteria. Coverage of domains of importance to multimorbid adults and those highlighted in the NICE guidelines on multimorbidity (NG56) by the 20 short-listed papers was determined; no publications were found to address all domains. DISCUSSION: No studies were identified which have applied appropriate qualitative methodology to understand the wishes, attitudes, and preferences of multimorbid adults regarding treatment and outcomes of acute illness. Such enquiries need to be urgently undertaken to inform and progress policy and clinical practice relating to decisions around admission to hospital and critical care. OTHER: Funding: National Institute of Health Research (NIHR) Research for Patient Benefit grant; NIHR Programme grant; NIHR Doctoral Research Fellowship. Registration: PROSPERO International Prospective Register of systematic reviews (CRD: 42019155028) https://www.crd.york.ac.uk/PROSPERO/

Extended-hours palliative care service with a hospital-avoidance and enhanced-care approach: report of a quality improvement project

Background: A community palliative care service (CPCS) identified its after-hours support as sub-optimal in avoiding acute hospitalisation and supporting patients to remain at home. It created and conducted a pilot of an extended hours palliative care service (EHPCS) using current resources. Aims: To evaluate the efficacy of an extended hours palliative care service pilot. Methods: Retrospective chart review of after-hours calls taken before the trial, usual care, was undertaken. During the trial, quantitative data was gathered of the outcome of each after-hours call, including outcomes of occasion of service, reason for and length and times of calls. Findings: The extended hours palliative care service, compared with usual care, showed an almost 50% decrease in acute hospitalisation, nearly doubled after-hours palliative care unit admission and a 17% increase in patients staying in their home. EHPCS was positively received by CPCS staff, despite cost and workforce impact. Conclusions: EHPCS can positively impact on reducing avoidable hospitalisations and facilitate palliative care patients to be in their preferred place of care.