Search

Intermediate care units (IMCUs) have become increasingly important in the care of critical and semi-critical patients, particularly during the COVID-19 pandemic. However, there is still no clear definition of their structural characteristics, specialties, types of patients, and the benefits they provide. The aim of this work is to describe the current state of implementation and operation of IMCUs in hospitals and patient care. To achieve this goal, a systematic review was conducted in the Web of Science, Scopus and CINAHL databases, along with a hand search. The research yielded 419 documents, of which 26 were included in this review after applying inclusion and exclusion criteria. The results were highly diverse and were categorized based on the following topics: material resources, human resources, continuity of care, and patient benefits. Despite the different objectives outlined in the studies, all of them demonstrate the numerous benefits provided by an IMCU, along with the increased relevance of this type of unit in recent years. Therefore, this systematic review highlights the benefits of IMCUs in the care of critical patients, as well as the role of health workers in these units. [ABSTRACT FROM AUTHOR]

The aging of the population is raising the need to make structural changes in the National Health System. First, the need to increase geriatric services in all hospitals. Second, implement and integrate intermediate care (IC), and Third and last, guarantee medical care in long-term care. IC is characterized by a wide range of resources located between acute hospital care and primary care, which include hospitalization devices, both with and without admission or confinement, home and outpatient care, which help to provide continuity and time-limited transition of care. The main objective of IC is an integral (multidimensional) and integrated (interdisciplinary and coordinated between different care levels) care of the older adults, based on the specialized geriatric care. The integration of the IC in the current health system is based on the establishment of two coordinated work dynamics with primary care and acute hospital care, AI becoming key, inside several devices, to prevent hospital admissions (prevent entry -Step Up- focus to give access to primary care to avoid unnecessary hospital admissions) and to facilitate early discharge in acute hospitals (Step Down- focus to promote the best autonomy and functional recovery after a complex acute care). With these objectives in mind, as members of the Intermediate Care Group of the Spanish Society of Geriatrics and Gerontology, the authors propose the following work aiming to revise the current status of available IC resources in Spain, to analyze the context, historical background and its conceptual framework. All these will allow to highlight the undeniable value of IC to healthcare professionals and managers., Competing Interests: Conflicto de intereses Los autores declaran no tener ningún conflicto de intereses., (Copyright © 2024. Publicado por Elsevier España, S.L.U.)

Abstract Background Clinical uncertainty is inherent for people with frailty and multimorbidity. Depleted physiological reserves increase vulnerability to a decline in health and adverse outcomes from a stressor event. Evidence-based tools can improve care processes and outcomes, but little is known about priorities to deliver care for older people with frailty and multimorbidity. This study aimed to explore the preferences and priorities for patients, family carers and healthcare practitioners to enhance care processes of comprehensive assessment, communication and continuity of care in managing clinical uncertainty using evidence-based tools. Methods A parallel mixed method observational study in four inpatient intermediate care units (community hospitals) for patients in transition between hospital and home. We used a discrete choice experiment (DCE) to examine patient and family preferences and priorities on the attributes of enhanced services; and stakeholder consultations with practitioners to discuss and generate recommendations on using tools to augment care processes. Data analysis used logit modelling in the DCE, and framework analysis for consultation data. Results Thirty-three patients participated in the DCE (mean age 84 years, SD 7.76). Patients preferred a service where family were contacted on admission and discharge (β 0.36, 95% CI 0.10 to 0.61), care received closer to home (β − 0.04, 95% CI − 0.06 to − 0.02) and the GP is fully informed about care (β 0.29, 95% CI 0.05–0.52). Four stakeholder consultations (n = 48 participants) generated 20 recommendations centred around three main themes: tailoring care processes to manage multiple care needs for an ageing population with frailty and multimorbidity; the importance of ongoing communication with patient and family; and clear and concise evidence-based tools to enhance communication between clinical teams and continuity of care on discharge. Conclusion Family engagement is vital to manage clinical uncertainty. Both patients and practitioners prioritise engaging the family to support person-centred care and continuity of care within and across care settings. Patients wished to maximise family involvement by enabling their support with a preference for care close to home. Evidence-based tools used across disciplines and services can provide a shared succinct language to facilitate communication and continuity of care at points of transition in care settings.

Abstract Background Despite increasing use of telemedicine in the field of palliative care, studies about the best circumstances and processes where it could replace face-to-face interaction are lacking. This study aimed to: (1) identify situations that are most amenable to the use of telemedicine for the provision of palliative care to patients in nursing homes; and (2) understand how telemedicine could best be integrated into the routine practice of mobile palliative care teams. Methods A qualitative study based on semi-structured focus groups (n = 7) with professionals (n = 33) working in mobile palliative care teams in France. Results Between June and July 2019, 7 mobile palliative care teams participated in one focus group each. Using thematic analysis, we found that telemedicine use in palliative care is about navigating between usual and new practices. Several influencing factors also emerged, which influence the use of telemedicine for palliative care, depending on the situation. Finally, we built a use-case model of palliative care to help mobile palliative care teams identify circumstances where telemedicine could be useful, or not. Conclusions The potential utility of telemedicine for delivering palliative care in nursing homes largely depends on the motive for calling on the mobile palliative care team. Requests regarding symptoms may be particularly amenable to telemedicine, whereas psycho-social distress may not. Further studies are warranted to assess the impact of influencing factors on real-life palliative care practices. Telemedicine could nonetheless be a useful addition to the mobile palliative care teams’ armamentarium.

PurposeTo examine how intermediate care units (IMCUs) are used in relation to pediatric intensive care units (PICUs), characterize PICU patients that utilize IMCUs, and estimate the impact of IMCUs on PICU metrics.Materials & methodsRetrospective study of PICU patients discharged from 108 hospitals from 2009 to 2011. Patients admitted from or discharged to IMCUs were characterized. We explored the relationships between having an IMCU and several PICU metrics: physical length-of-stay (LOS), medical LOS, discharge wait time, admission severity of illness, unplanned PICU admissions from wards, and early PICU readmissions.ResultsThirty-three percent of sites had an IMCU. After adjusting for known confounders, there was no association between having an IMCU and PICU LOS, mean severity of illness of PICU patients admitted from general wards, or proportion of PICU readmissions or unplanned ward admissions. At sites with an IMCU, patients waited 3.1h longer for transfer from the PICU once medically cleared (p

Because many large, state-owned Intermediate Care Facilities for Individuals With Intellectual Disabilities (ICF/IIDs) have closed or downsized, their average size has fallen markedly, as has the number that are publicly owned. We probe the relationship between ownership type and four measures of care quality in ICF/IIDs. Data on deficiency citations suggest that for-profits underperform other ownership types, although data on complaints show no clear pattern. Meanwhile, data on staffing ratios and restrictive behavior management practices, based mostly on facility self-reports, generally tell the opposite story. Our results lend some credence to concerns regarding inadequate care in for-profit ICF/IIDs, while underscoring the importance of requiring ICF/IID operators to report more comprehensive, longitudinal data that are less prone to error and reporting bias. [ABSTRACT FROM AUTHOR]

Abstract Background Adults increasingly live and die with chronic progressive conditions into advanced age. Many live with multimorbidity and an uncertain illness trajectory with points of marked decline, loss of function and increased risk of end of life. Intermediate care units support mainly older adults in transition between hospital and home to regain function and anticipate and plan for end of life. This study examined the patient characteristics and the factors associated with mortality over 1 year post-admission to an intermediate care unit to inform priorities for care. Methods A national cohort study of adults admitted to intermediate care units in England using linked individual-level Hospital Episode Statistics and death registration data. The main outcome was mortality within 1 year from admission. The cohort was examined as two groups with significant differences in mortality between main diagnosis of a non-cancer condition and cancer. Data analysis used Kaplan-Meier curves to explore mortality differences between the groups and a time-dependant Cox proportional hazards model to determine mortality risk factors. Results The cohort comprised 76,704 adults with median age 81 years (IQR 70–88) admitted to 220 intermediate care units over 1 year in 2016. Overall, 28.0% died within 1 year post-admission. Mortality varied by the main diagnosis of cancer (total n = 3680, 70.8% died) and non-cancer condition (total n = 73,024, 25.8% died). Illness-related factors had the highest adjusted hazard ratios [aHRs]. At 0–28 days post-admission, risks were highest for non-cancer respiratory conditions (pneumonia (aHR 6.17 [95%CI 4.90–7.76]), chronic obstructive pulmonary disease (aHR 5.01 [95% CI 3.78–6.62]), dementia (aHR 5.07 [95% CI 3.80–6.77]) and liver disease (aHR 9.75 [95% CI 6.50–14.6]) compared with musculoskeletal disorders. In cancer, lung cancer showed largest risk (aHR 1.20 [95%CI 1.04–1.39]) compared with cancer ‘other’. Risks increased with high multimorbidity for non-cancer (aHR 2.57 [95% CI 2.36–2.79]) and cancer (aHR 2.59 [95% CI 2.13–3.15]) (reference: lowest). Conclusions One in four patients died within 1 year. Indicators for palliative care assessment are respiratory conditions, dementia, liver disease, cancer and rising multimorbidity. The traditional emphasis on rehabilitation and recovery in intermediate care units has changed with an ageing population and the need for greater integration of palliative care.

Abstract Background As an alternative to acute hospitalisations, all communities in Norway are required to provide inpatient care in municipal acute bed units (MAUs) for patients who can be treated at the primary care level. Patient selection is challenging, and some patients need transfer from MAUs to hospitals. The aim of this study was to examine associations between characteristics of the patient at admission to MAU and further transfer to hospital. Methods In a prospective observational study on all admissions to a large MAU, March 2016–August 2017, information was obtained on patient age, gender, comorbidities, drug use, reason for stay and Triage Early Warning Score (TEWS) on admission and at discharge, and length of stay. Comparison between admissions resulting in discharge to hospital, nursing home or own home were performed with chi-square and ANOVA tests. Estimated relative risks (RR) with 95% confidence interval for transfer to hospital versus being retained at primary care level was estimated for age, gender, comorbidity and TEWS in generalized linear models, crude and adjusted. Results Two thousand seven hundred forty-four admissions were included. Mean age of the patients was 69.5 years (SD 21.9), 65.2% were women. In 646 admissions (23.6%), the patients were transferred to hospital. Male gender and TEWS > 2 were associated with transfer to hospital. Most transfers to hospital occurred within 24 h, and these patients had unchanged or increasing TEWS during their stay at MAU. When transferred to hospital 41.5% of the patients had the same reason for stay as on MAU admission, 14.9% had another reason for stay, 25.2% had a medical condition outside the treatment scope of MAU, and 18.4% needed further diagnostic clarification in hospital. Conclusions Likelihood of transfer to hospital increased with male gender and higher TEWS on admission. Main reasons for transfer to hospital were lack of improvement and identification of clinical conditions that needed hospital care. TEWS > 2 at admission should make physicians alert to the need of close monitoring for lack of improvement.

Purpose: To refine the admission criteria of the Acute Geriatric Community Hospital (AGCH) by defining its target group boundaries with (geriatric) hospital care and other bed-based intermediate care models in the Netherlands., Methods: A qualitative study consisting of a three-phase refinement procedure with case vignettes. Physicians, medical specialists, nurse practitioners, and physician assistants in hospitals (n = 10) or intermediate care facilities (n = 10) in the Netherlands participated. They collected case vignettes from clinical practice (phase one). The referral considerations and decisions for each case were then documented through surveys (phase two) and two focus groups (phase 3). For thematic data analysis, inductive and deductive approaches were used., Results: The combination of medical specialist care (MSC) and medical generalist care (MGC), is unique for the AGCH compared to other intermediate care models in the Netherlands. Compared to (geriatric) hospital care, the AGCH offers a more limited scope of MSC. Based on these findings, 13 refined admission criteria were developed such as 'The required diagnostic tests to monitor the effectiveness of treatment are available at the AGCH'. Besides admission criteria, additional clinical and organizational considerations played a role in referral decision-making; 10 themes were identified., Conclusion: This case vignette study defined the target group boundaries between the AGCH and other care models, allowing us to refine the AGCH admission criteria. Our findings may help to determine the required competencies of the interdisciplinary AGCH team and to develop triage instruments. The identified consideration themes can be used as conceptual framework in further research. The findings may also be of interests for healthcare systems outside the Netherlands who aspire to design integrated care for older people closer to home., (© 2024. The Author(s).)

Background: Despite increasing use of telemedicine in the field of palliative care, studies about the best circumstances and processes where it could replace face-to-face interaction are lacking. This study aimed to: (1) identify situations that are most amenable to the use of telemedicine for the provision of palliative care to patients in nursing homes; and (2) understand how telemedicine could best be integrated into the routine practice of mobile palliative care teams. Methods: A qualitative study based on semi-structured focus groups (n = 7) with professionals (n = 33) working in mobile palliative care teams in France. Results: Between June and July 2019, 7 mobile palliative care teams participated in one focus group each. Using thematic analysis, we found that telemedicine use in palliative care is about navigating between usual and new practices. Several influencing factors also emerged, which influence the use of telemedicine for palliative care, depending on the situation. Finally, we built a use-case model of palliative care to help mobile palliative care teams identify circumstances where telemedicine could be useful, or not. Conclusions: The potential utility of telemedicine for delivering palliative care in nursing homes largely depends on the motive for calling on the mobile palliative care team. Requests regarding symptoms may be particularly amenable to telemedicine, whereas psycho-social distress may not. Further studies are warranted to assess the impact of influencing factors on real-life palliative care practices. Telemedicine could nonetheless be a useful addition to the mobile palliative care teams' armamentarium. [ABSTRACT FROM AUTHOR]

Background: Clinical uncertainty is inherent for people with frailty and multimorbidity. Depleted physiological reserves increase vulnerability to a decline in health and adverse outcomes from a stressor event. Evidence-based tools can improve care processes and outcomes, but little is known about priorities to deliver care for older people with frailty and multimorbidity. This study aimed to explore the preferences and priorities for patients, family carers and healthcare practitioners to enhance care processes of comprehensive assessment, communication and continuity of care in managing clinical uncertainty using evidence-based tools.Methods: A parallel mixed method observational study in four inpatient intermediate care units (community hospitals) for patients in transition between hospital and home. We used a discrete choice experiment (DCE) to examine patient and family preferences and priorities on the attributes of enhanced services; and stakeholder consultations with practitioners to discuss and generate recommendations on using tools to augment care processes. Data analysis used logit modelling in the DCE, and framework analysis for consultation data.Results: Thirty-three patients participated in the DCE (mean age 84 years, SD 7.76). Patients preferred a service where family were contacted on admission and discharge (β 0.36, 95% CI 0.10 to 0.61), care received closer to home (β - 0.04, 95% CI - 0.06 to - 0.02) and the GP is fully informed about care (β 0.29, 95% CI 0.05-0.52). Four stakeholder consultations (n = 48 participants) generated 20 recommendations centred around three main themes: tailoring care processes to manage multiple care needs for an ageing population with frailty and multimorbidity; the importance of ongoing communication with patient and family; and clear and concise evidence-based tools to enhance communication between clinical teams and continuity of care on discharge.Conclusion: Family engagement is vital to manage clinical uncertainty. Both patients and practitioners prioritise engaging the family to support person-centred care and continuity of care within and across care settings. Patients wished to maximise family involvement by enabling their support with a preference for care close to home. Evidence-based tools used across disciplines and services can provide a shared succinct language to facilitate communication and continuity of care at points of transition in care settings. [ABSTRACT FROM AUTHOR]

Older adults often experience functional decline following acute medical care. This functional decline may lead to permanent disability, which will increase the burden on the medical and long-term care systems, families, and society as a whole. Post-acute care aims to promote the functional recovery of older adults, prevent unnecessary hospital readmission, and avoid premature admission to a long-term care facility. Research has shown that post-acute care is a cost-effective service model, with both the hospital-at-home and community hospital post-acute care models being highly effective. This paper describes the post-acute care models of the United States and the United Kingdom and uses the example of Taiwan’s highly effective post-acute care system to explain the benefits and importance of post-acute care. In the face of rapid demographic aging and smaller household size, a post-acute care system can lower medical costs and improve the health of older adults after hospitalization.

Many factors affect the healthcare costs and outcomes in patients with hip fracture (HF). Through the construction of a Continuum-Care Episode (CCE), we investigated the costs of CCEs for HF and their determinants. We used data extracted from administrative databases of 5094 consecutive elderly patients hospitalized in 2017 in Emilia Romagna, Italy, to evaluate the overall costs of the CCE. We calculated the acute and post-acute costs from the date of the hospital admission to the end of the CCE. The determinants of costs by type of surgical intervention (total hip replacement, partial hip replacement, open reduction, and internal fixation) were investigated using generalized linear regression models. Regardless of the type of surgical intervention, hospital bed-based rehabilitation in public or private healthcare facilities either followed by rehabilitation in a community hospital/temporary nursing home beds or not were the strongest determinants of costs, while rehabilitation in intermediate care facilities alone was associated with lower costs. CCE's cost and its variability is mainly related to the rehabilitation setting. Cost-wise, intermediate care resulted to be an appropriate setting for providing post-acute rehabilitation for HF, representing the one associated with lower overall costs. Intermediate care organizational setting should be privileged when planning integrated care HF pathways. [ABSTRACT FROM AUTHOR]

Background: Adults increasingly live and die with chronic progressive conditions into advanced age. Many live with multimorbidity and an uncertain illness trajectory with points of marked decline, loss of function and increased risk of end of life. Intermediate care units support mainly older adults in transition between hospital and home to regain function and anticipate and plan for end of life. This study examined the patient characteristics and the factors associated with mortality over 1 year post-admission to an intermediate care unit to inform priorities for care.Methods: A national cohort study of adults admitted to intermediate care units in England using linked individual-level Hospital Episode Statistics and death registration data. The main outcome was mortality within 1 year from admission. The cohort was examined as two groups with significant differences in mortality between main diagnosis of a non-cancer condition and cancer. Data analysis used Kaplan-Meier curves to explore mortality differences between the groups and a time-dependant Cox proportional hazards model to determine mortality risk factors.Results: The cohort comprised 76,704 adults with median age 81 years (IQR 70-88) admitted to 220 intermediate care units over 1 year in 2016. Overall, 28.0% died within 1 year post-admission. Mortality varied by the main diagnosis of cancer (total n = 3680, 70.8% died) and non-cancer condition (total n = 73,024, 25.8% died). Illness-related factors had the highest adjusted hazard ratios [aHRs]. At 0-28 days post-admission, risks were highest for non-cancer respiratory conditions (pneumonia (aHR 6.17 [95%CI 4.90-7.76]), chronic obstructive pulmonary disease (aHR 5.01 [95% CI 3.78-6.62]), dementia (aHR 5.07 [95% CI 3.80-6.77]) and liver disease (aHR 9.75 [95% CI 6.50-14.6]) compared with musculoskeletal disorders. In cancer, lung cancer showed largest risk (aHR 1.20 [95%CI 1.04-1.39]) compared with cancer 'other'. Risks increased with high multimorbidity for non-cancer (aHR 2.57 [95% CI 2.36-2.79]) and cancer (aHR 2.59 [95% CI 2.13-3.15]) (reference: lowest).Conclusions: One in four patients died within 1 year. Indicators for palliative care assessment are respiratory conditions, dementia, liver disease, cancer and rising multimorbidity. The traditional emphasis on rehabilitation and recovery in intermediate care units has changed with an ageing population and the need for greater integration of palliative care. [ABSTRACT FROM AUTHOR]

Objective: During the COVID-19 pandemic, some centers converted intermediate care units (IMCUs) to COVID-19 ICUs (IMCU/ICUs). In this study, we compared adherence to lung protective ventilation (LPV) and outcomes for patients with COVID-19-related acute respiratory distress syndrome (ARDS) treated in an IMCU/ICU versus preexisting medical ICUs (MICUs)., Design: Retrospective observational study using electronic medical record data., Setting: Two academic medical centers from March 2020 to September 2020 (period 1) and October 2020 to May 2021 (period 2), which capture the first two COVID-19 surges in this health system., Patients: Adults with COVID-19 receiving invasive mechanical ventilation who met ARDS oxygenation criteria (Pao2/Fio2 ≤ 300 mm Hg or Spo2/Fio2 ≤ 315)., Interventions: None., Measurements and Main Results: We defined LPV adherence as the percent of the first 48 hours of mechanical ventilation that met a restrictive definition of LPV of, tidal volume/predicted body weight (Vt/PBW) less than or equal to 6.5 mL/kg and plateau pressure (Pplat) less than or equal to 30 cm H2o. In an expanded definition, we added that if Pplat is greater than 30 cm H2o, Vt/PBW had to be less than 6.0 mL/kg. Using the restricted definition, period 1 adherence was lower among 133 IMCU/ICU versus 199 MICU patients (92% [95% CI, 50-100] vs. 100% [86-100], p = 0.05). Period 2 adherence was similar between groups (100% [75-100] vs. 95% CI [65-100], p = 0.68). A similar pattern was observed using the expanded definition. For the full study period, the adjusted hazard of death at 90 days was lower in IMCU/ICU versus MICU patients (hazard ratio [HR] 0.73 [95% CI, 0.55-0.99]), whereas ventilator liberation by day 28 was similar between groups (adjusted subdistribution HR 1.09 [95% CI, 0.85-1.39])., Conclusions: In patients with COVID-19 ARDS treated in an IMCU/ICU, LPV adherence was similar to, and observed survival better than those treated in preexisting MICUs. With adequate resources, protocols, and staffing, IMCUs provide an effective source of additional ICU capacity for patients with acute respiratory failure., Competing Interests: Dr. Brodie reports receiving research support from and consults for LivaNova. He has been on the medical advisory boards for Xenios, Medtronic, Inspira, and Cellenkos. He is the President-elect of the Extracorporeal Life Support Organization and the Chair of the Board of the International ECMO Network, and he writes for UpToDate. Dr. Hochberg received funding from the National Institutes of Health-National Heart Blood and Lung Institute (K23HL169743). Dr. Case received funding from the NIH-NHBLI (T32HL007534). Dr. Sahetya received funding from the NIH-NHLBI (K23HL155507) and personal consulting fees from Getinge. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background & Aim: Non-invasive ventilation is a procedure that reduces respiratory stress and improves gas exchange, using a patient-ventilator interface; however, it presents consequences such as the development of facial pressure ulcers. We aim to identify the factors associated with facial pressure ulcers in Intermediate Care Facilities patients submitted to non-invasive ventilation. Materials & Methods: A cross-sectional descriptive and analytic study was performed in an intermediate care facilities, of a Portuguese hospital, from August to October of 2018, the study population consisted of patients hospitalized in this unit, who underwent to non-invasive ventilation. Data were collected through an observational form developed to obtain the information of the entire period of hospitalization of the patient. The software used to analyze the data was IBM SPSS Statistics for Windows, Version 23.0. For the descriptive analysis, absolute and relative frequencies also means and standard deviations were computed. Also, to describe the association between the variables, The point biserial correlation coefficient (rpb) were calculated. For data analysis, a significance level of .05 (α) was used. Results: 14.6% of the individuals developed PU, all in the nasal pyramid. NIV was used for 6.07±3.91 days, and PU developed between the 3rd and the 20th day. It was observed that the presence of PU had a significant positive correlation with the GCS score (rpb=0.390, p=0.012) and a significant negative correlation with the duration of NIV (rpb=-0.438, p=0.004). Dependency level, PU risk, and nutritional risk did not correlate with the development of PU. Conclusion: The pressure ulcers associated with non-invasive ventilation appear to be more frequently developed on the nasal pyramid and between the 3rd and the 20th day. Moreover, the level of consciousness and the time of administration of non-invasive ventilation are associated with the development of pressure ulcers.

The objective of this study was to assess complexity of patients discharged from hospital to intermediate care facility in an Italian setting. Multiple anonymous health-related databases were linked at the individual patient level through a stochastic key to study patients discharged from the University Hospital of Udine, Italy, from 2010 to 2019. Patient complexity was measured through diagnosis related group (DRG) relative weight of each hospitalization, number of chronic conditions and annual use of health resources. 12,674 intermediate care facility admissions were recorded in the study period. Mean DRG weight was 1.54±1.05 with variations depending on the discharging hospital ward. Patients discharged to intermediate facilities had higher DRG weight, had more comorbidities and consumed more health resources than the others, particularly in case of patients discharged from surgical wards. Patients discharged to intermediate care facilities are particularly complex, have high use of health resources, and may be difficult to manage.

Objective: To evaluate the use of a small municipality acute bed unit (MAU) in rural Norway resulting from the Coordination reform regarding occupancy-rate, patient characteristics and healthcare provided during the first four years of operation. Further, to investigate whether implementation of the new municipal service avoided acute hospital admissions. Design: Observational study. Setting: A two-bed municipal acute bed unit. Subjects: All patients admitted to the unit between 2013 and 2016. Main outcome measures: Demographics, comorbidity, main diagnoses and level of municipal care on admission and discharge, diagnostic and therapeutic initiatives, MAU occupancy rate, and acute hospital admission rate. Results: Altogether, 389 admissions occurred, 215 first-time admissions and 174 readmissions. The mean MAU bed occupancy rate doubled from of 0.26 in 2013 to 0.50 in 2016, while acute hospital admission rates declined. The patients (median age 84.0 years, 48.9% women at first time admission) were most commonly admitted for infections (28.0%), observation (22.1%) or musculoskeletal symptoms (16.2%). Some 52.7% of the patients admitted from home were discharged to a higher care level; musculoskeletal problems as admission diagnosis predicted this (RR =1.43, 95% CI 1.20–1.71, adjusted for age and sex). Conclusion: Admission rates to MAU increased during the first years of operation. In the same period, there was a reduction in acute hospital admissions. Patient selection was largely in accordance with national and local criteria, including observational stays. Half the patients admitted from home were discharged to nursing home, suggesting that the unit was used as pathway to a higher municipal care level.Key Points Evaluation of the first four years of operation of a municipality acute bed unit (MAU) in rural Norway revealed: • Admission rates to MAU increased, timely coinciding with decreased acute admission rates to hospital medical wards. • Most patients were old and had complex health problems. • Only half the patients were discharged back home; musculoskeletal symptoms were associated with discharge to a higher care level.

Objective: To determine patients', healthcare providers', and insurance company employees' preferences for knee and hip osteoarthritis (KHOA) care.Design: In a discrete choice experiment, patients with KHOA or a joint replacement, healthcare providers, and insurance company employees were repetitively asked to choose between KHOA care alternatives that differed in six attributes: waiting times, out of pocket costs, travel distance, involved healthcare providers, duration of consultation, and access to specialist equipment. A (panel latent class) conditional logit model was used to determine preference heterogeneity and relative importance of the attributes.Results: Patients (n = 648) and healthcare providers (n = 76) valued low out of pocket costs most, while insurance company employees (n = 150) found a joint consultation by general practitioner (GP) and orthopaedist most important. Patients found the duration of consultation less important than healthcare providers and insurance company employees did. Patients without a joint replacement were likely to prefer healthcare with low out of pocket costs. Patients with a joint replacement and/or low disease-specific quality of life were likely to prefer healthcare from an orthopaedist. Patients who already received healthcare for knee/hip problems were likely to prefer a joint consultation by GP and orthopaedist, and direct access to specialist equipment.Conclusions: Patients, healthcare providers, and insurance company employees highly prefer a joint consultation by GP and orthopaedist with low out of pocket costs. Within patients, there is substantial preference heterogeneity. These results can be used by policy makers and healthcare providers to choose the most optimal combination of KHOA care aligned to patients' preferences. [ABSTRACT FROM AUTHOR]

The objective of this study was to assess complexity of patients discharged from hospital to intermediate care facility in an Italian setting. Multiple anonymous health-related databases were linked through a stochastic key at individual patient level, in order to study patients discharged from the University Hospital of Udine, Italy, between 2010 and 2019. Patient complexity was measured through diagnosis-related group (DRG) relative weight of each hospitalization, number of chronic conditions and annual use of health resources. 12,674 intermediate care facility admissions were recorded in the study period. Mean DRG weight was 1.54±1.05 with variations depending on the discharging hospital ward. Patients discharged to intermediate facilities had higher DRG weight, had more comorbidities and consumed more health resources than the others, particularly in case of patients discharged from surgical wards. Patients discharged to intermediate care facilities are particularly complex, make extensive use of health resources, and may be difficult to manage. [ABSTRACT FROM AUTHOR]

Objective: The Coordination reform was implemented in Norway from 2012, aiming at seamless patient trajectories. All municipalities are required to establish emergency care beds (MEBs) to avoid unnecessary hospital admissions. We aimed to examine occupancy rate, patient characteristics, diagnoses and discharge level of municipal care in a small MEB unit. Design: Cross-sectional, observational study. Setting: A two-bed emergency care unit. Subjects: All patients admitted to the unit during one year. Main outcome measures: Patients’ age and gender, comorbidity, main diagnoses and municipal care level on admission and discharge, diagnostic and therapeutic initiatives, occupancy rate. Results: Sixty admissions were registered, with total bed occupancy 194 days, and an occupancy rate of 0.27. The patients (median age 83 years, 57% women) had mostly infections, musculoskeletal symptoms or undefined conditions. Some 48% of the stays exceeded three days and 43% of the patients were subsequently transferred to nursing homes or hospitals. Conclusion: Occupancy rate was low. Patient selection was not according to national standards, and stays were longer. Many patients were transferred to nursing homes, indicating that the unit was an intermediate pathway or a short cut to institutional care. It is unclear whether the unit avoided hospital admissions.

Objective: Mild cognitive impairment (MCI) and dementia (DEM) are prevalent in skilled nursing facilities (SNFs), confounding delirium detection. We report characteristics of delirium in an SNF to ascertain distinguishing features for delirium diagnosis, despite challenges of comorbidity with MCI and DEM.Methods: Cross-sectional study of 200 consecutive patients from an SNF in Catalunya, Spain, assessed within the first 24 to 48 admission hours by independent experts with Spanish-Informant Questionnaire on Cognitive Decline in the Elderly (for MCI-DEM), Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) delirium criteria, and Delirium Rating Scale Revised-98 (DRS-R98) for delirium phenomenology. Delirium characteristics were modeled in successive steps, according to the presence of delirium and MCI-DEM, with analysis of variance (ANOVA), receiver operator characteristic analyses, and conditional logistic regression.Results: The final model produced symptoms that represented each of the three delirium core domains (ie, cognitive, higher order thinking, and circadian). The DRS-R98 items rated these symptoms as moderate-severe attention/vigilance, mild-severe language, and moderate-severe sleep-wake cycle alterations. The delirium discriminant accuracy of the three symptoms together was high: 84.6% in the MCI-DEM group to 92.8% in the No MCI-DEM group.Conclusions: Impairments of attention, language, and sleep-wake cycle indicate delirium in SNF patients regardless of the underlying MCI-DEM status. Because delirium is underdetected in SNFs, where nursing staff/patient ratios are low, brief simple tools that measure these symptoms could potentially enhance delirium detection. [ABSTRACT FROM AUTHOR]

Aim: Limited information is available on the prevalence of drug–drug interactions (DDI) in residents of long‐term care facilities who often receive multiple drugs. This study aimed to evaluate the prevalence of clinically relevant cytochrome P450‐mediated potential DDI in residents of intermediate care facilities for older adults (called Roken) in Japan. Methods: A nationwide drug utilization study was carried out for Roken residents in 2015 (up to five residents per facility). Potential DDI were identified with an explicit list of drugs that can be involved in clinically relevant cytochrome P450‐mediated DDI in Japan. Logistic regression was used to evaluate the association of the number of drugs prescribed with the presence of potential DDI, adjusted for age, sex and long‐term care needs level. Results: The study included 1222 residents of 348 Roken who were prescribed two or more active drug substances. The participants who received ≥6 and ≥10 drugs represented 49% and 10% of total participants, respectively. In total, 42 two‐drug combinations involving potential DDI were identified in 33 participants (2.7%) – benzodiazepines, proton pump inhibitors, calcium channel blockers and anti‐epileptic drugs were frequently involved. The adjusted odds ratios for potential DDI were 2.84 (95% confidence interval 1.15–7.02) or 7.82 (95% confidence interval 2.96–20.70) in residents receiving six to nine drugs or ≥10 drugs, compared with those receiving two to five drugs. Conclusions: Approximately 3% of Roken residents were at risk for clinically relevant DDI. Reducing the number of drugs prescribed through medication reviews would mitigate the potential risk. Geriatr Gerontol Int 2019; 19: 513–517. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the use of a small municipality acute bed unit (MAU) in rural Norway resulting from the Coordination reform regarding occupancy-rate, patient characteristics and healthcare provided during the first four years of operation. Further, to investigate whether implementation of the new municipal service avoided acute hospital admissions. Design: Observational study. Setting: A two-bed municipal acute bed unit. Subjects: All patients admitted to the unit between 2013 and 2016. Main outcome measures: Demographics, comorbidity, main diagnoses and level of municipal care on admission and discharge, diagnostic and therapeutic initiatives, MAU occupancy rate, and acute hospital admission rate. Results: Altogether, 389 admissions occurred, 215 first-time admissions and 174 readmissions. The mean MAU bed occupancy rate doubled from of 0.26 in 2013 to 0.50 in 2016, while acute hospital admission rates declined. The patients (median age 84.0 years, 48.9% women at first time admission) were most commonly admitted for infections (28.0%), observation (22.1%) or musculoskeletal symptoms (16.2%). Some 52.7% of the patients admitted from home were discharged to a higher care level; musculoskeletal problems as admission diagnosis predicted this (RR =1.43, 95% CI 1.20-1.71, adjusted for age and sex). Conclusion: Admission rates to MAU increased during the first years of operation. In the same period, there was a reduction in acute hospital admissions. Patient selection was largely in accordance with national and local criteria, including observational stays. Half the patients admitted from home were discharged to nursing home, suggesting that the unit was used as pathway to a higher municipal care level. Key Points: Evaluation of the first four years of operation of a municipality acute bed unit (MAU) in rural Norway revealed: • Admission rates to MAU increased, timely coinciding with decreased acute admission rates to hospital medical wards. • Most patients were old and had complex health problems. • Only half the patients were discharged back home; musculoskeletal symptoms were associated with discharge to a higher care level. [ABSTRACT FROM AUTHOR]

Objectives: The aim of the study was to investigate whether nutritional status as measured by the Mini Nutritional Assessment Short-Form (MNA-SF) predicts level of care of the discharge destination after post-acute care in a nursing home.Design: Cohort study.Setting: Post-acute intermediate care nursing home, 19-bed unit with increased multidisciplinary staff.Participants: Patients ≥70 years in post-acute care (N=900) following an acute admission to the hospital.Measurements: The predictive value of nutritional status, as measured by the MNA-SF, on discharge destination was analysed by means of a multinomial logistic regression model with the MNA-SF as the independent variable, discharge destination as the dependent variable and age and living situation as co-variates. The participants were grouped into three categories according to their discharge destination: home, other institution or readmitted to the hospital.Results: A higher score on the MNA-SF significantly predicted a reduced risk of discharge to institution (adjusted OR=0.90 (95% CI=0.84;0.97), p=0.003).Conclusion: Nutritional status, as measured by the MNA-SF, predicted discharge destination from an intermediate care nursing home following acute hospitalisation. The findings underscore the value of nutritional assessment as part of overall clinical assessment and care planning prior to discharge. The findings may also imply that interventions to improve nutritional status could increase patients’ ability to return home, as opposed to further institutionalisation, after hospitalisation. [ABSTRACT FROM AUTHOR]

Objective:The Coordination reformwas implemented in Norway from 2012, aiming at seamless patient trajectories. All municipalities are required to establish emergency care beds (MEBs) to avoid unnecessary hospital admissions. We aimed to examine occupancy rate, patient characteristics, diagnoses and discharge level of municipal care in a small MEB unit. Design:Cross-sectional, observational study. Setting:A two-bed emergency care unit. Subjects:All patients admitted to the unit during one year. Main outcome measures:Patients’ age and gender, comorbidity, main diagnoses and municipal care level on admission and discharge, diagnostic and therapeutic initiatives, occupancy rate. Results:Sixty admissions were registered, with total bed occupancy 194 days, and an occupancy rate of 0.27. The patients (median age 83 years, 57% women) had mostly infections, musculoskeletal symptoms or undefined conditions. Some 48% of the stays exceeded three days and 43% of the patients were subsequently transferred to nursing homes or hospitals. Conclusion:Occupancy rate was low. Patient selection was not according to national standards, and stays were longer. Many patients were transferred to nursing homes, indicating that the unit was an intermediate pathway or a short cut to institutional care. It is unclear whether the unit avoided hospital admissions. [ABSTRACT FROM PUBLISHER]

Background Potentially inappropriate prescribing (PIP) [encompassing potentially inappropriate medicines (PIMs) and potential prescribing omissions (PPOs)], is prevalent amongst older adults in primary and secondary care. However, PIP prevalence in intermediate care (IC) is unknown. Objective To determine the prevalence of PIMs/PPOs and associated patient factors. Setting Three IC facilities in Northern Ireland. Method The Screening Tool of Older People's Prescriptions and the Screening Tool to Alert doctors to Right Treatment were used to identify PIP over 8 weeks. Wilcoxon signed-rank tests were performed to compare the prevalence of PIMs/PPOs at admission and discharge. Spearman's correlation coefficients were calculated to determine factors associated with PIMs/PPOs (p < 0.05 considered significant). Main outcome measure Prevalence of PIMs/PPOs. Results 74 patients [mean age 83.5(±7.4) years] were included. Discharge medication data were available for 30 (40.5%) patients. 53 (71.6%) and 22 (73.3%) patients had ≥1 PIM at admission and discharge, respectively. 45 (60.8%) and 15 (50.0%) patients had ≥1 PPO at admission and discharge, respectively. No significant difference was found in PIM/PPO prevalence at admission compared to discharge (Z = -0.36, p = 0.72; Z = -1.63, p = 0.10). Increasing comorbidity and medication regimen complexity were associated with PIMs at admission (r = 0.265, p = 0.023; r = 0.338 p = 0.003). The number of medicines was correlated with PIMs at admission (r = 0.391, p = 0.001) and discharge (r = 0.515, p = 0.004). Conclusion Whilst IC represents an ideal setting in which to review prescribing, this study found PIP to be highly prevalent in older adults in IC, with no detectably significant change in prevalence between admission to and discharge from this setting. [ABSTRACT FROM AUTHOR]

Introduction: COVID-19 pandemic has led to an increased rate of intensive care unit (ICU) stays. Intermediate care units (IMCUs) are a useful resource for the management of patients with severe COVID-19 that do not require ICU admission. In this research, we aimed to determine survival outcomes and parameters predicting mortality in patients who have been admitted to IMCU., Materials and Methods: Patients who were admitted to IMCU between April 2019 and January 2021 were analyzed retrospectively. Sociodemographics, clinical characteristics, and blood parameters on admission were compared between the patients who died in IMCU and the others. Blood parameters at discharge were compared between survived and deceased individuals. Survival analysis was performed via Kaplan-Meier analysis. Blood parameters predicting mortality were determined by univariate and multivariate Cox regression analysis., Results: A total of 140 patients were included within the scope of this study. The median age was 72.5 years, and 77 (55%) of them were male and 63 (45%) of them were female. A total of 37 (26.4%) patients deceased in IMCU, and 40 patients (28.5%) were transferred to ICU. Higher platelet count (HR 3.454; 95% CI 1.383-8.625; p =0.008), procalcitonin levels (HR 3.083; 95% CI 1.158-8.206; p =0.024), and lower oxygen saturation (HR 4.121; 95% CI 2.018-8.414; p < 0.001) were associated with an increased risk of mortality in IMCU. At discharge from IMCU, higher procalcitonin levels (HR 2.809; 95% CI 1.216-6.487; p =0.016), lower platelet count (HR 2.269; 95% CI 1.012-5.085; p =0.047), and noninvasive mechanic ventilation requirement (HR 2.363; 95% CI 1.201-4.651; p =0.013) were associated with an increased risk of mortality. Median OS was found as 41 days. The overall survival rate was found 40% while the IMCU survival rate was 73.6%., Conclusions: IMCU seems to have a positive effect on survival in patients with severe COVID-19 infection. Close monitoring of these parameters and early intervention may improve survival rates and outcomes., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2023 Hale Bülbül et al.)

Aim: The risk of developing infectious diarrhea among elderly residents at Japanese geriatric intermediate care facilities is unclear. We investigated the incidence rate and risk factors of norovirus-related diarrhea at such facilities., Methods: This prospective cohort study followed 1727 residents from November 2018 to April 2020 at 10 geriatric intermediate care facilities in Osaka, Japan regarding the occurrence of diarrhea. Resident data were collected from their medical records using structured forms at two to three of the following three time points: at recruitment, if they developed diarrhea, and when they left the facility. Residents who developed diarrhea were tested using rapid diagnostic tests for norovirus. Cox proportional hazard model was employed to hazard ratios (HRs) with 95% confidence intervals (CIs) to estimate the risk factors for norovirus-related diarrhea., Results: During the study period, 74 residents developed diarrhea, 13 of whom were norovirus positive. The incidence rate of norovirus-related diarrhea was 10.11 per 1000 person-years (95% CI: 4.61-15.61). In terms of risk factors, people with care-needs level 3 were at a higher risk for developing norovirus-related diarrhea (adjusted HR [aHR] = 7.35, 95% CI: 1.45-37.30). Residents with hypertension (aHR = 3.41, 95% CI: 1.05-11.04) or stroke (aHR = 8.84, 95% CI: 2.46-31.83), and those who walked with canes (aHR = 16.68, 95% CI: 1.35-206.52) also had a significantly higher risk for norovirus-related diarrhea., Conclusions: Throughout the study period, the incidence of development of diarrhea was low. Care-needs level 3, stroke, hypertension and use of a cane were identified as risk factors for norovirus-related diarrhea in Japanese geriatric intermediate care facilities. Geriatr Gerontol Int 2023; 23: 179-187., (© 2023 The Authors. Geriatrics & Gerontology International published by John Wiley & Sons Australia, Ltd on behalf of Japan Geriatrics Society.)

Rationale: Intermediate care (i.e., step-down or progressive care) is an alternative to the intensive care unit (ICU) for patients with moderate severity of illness. The adoption and current use of intermediate care is unknown.Objectives: To characterize trends in intermediate care use among U.S. hospitals.Methods: We examined 135 million acute care hospitalizations among elderly individuals (≥65 yr) enrolled in fee-for-service Medicare (U.S. federal health insurance program) from 1996 to 2010. We identified patients receiving intermediate care as those with intensive care or coronary care room and board charges labeled intermediate ICU.Measurements and Main Results: In 1996, a total of 960 of the 3,425 hospitals providing critical care billed for intermediate care (28%), and this increased to 1,643 of 2,783 hospitals (59%) in 2010 (P < 0.01). Only 8.2% of Medicare hospitalizations in 1996 were billed for intermediate care, but billing steadily increased to 22.8% by 2010 (P < 0.01), whereas the percentage billed for ICU care and ward-only care declined. Patients billed for intermediate care had more acute organ failures diagnoses codes compared with general ward patients (22.4% vs. 15.8%). When compared with patients billed for ICU care, those billed for intermediate care had fewer organ failures (22.4% vs. 43.4%), less mechanical ventilation (0.9% vs. 16.7%), lower mean Medicare spending ($8,514 vs. $18,150), and lower 30-day mortality (5.6% vs. 16.5%) (P < 0.01 for all comparisons).Conclusions: Intermediate care billing increased markedly between 1996 and 2010. These findings highlight the need to better define the value, specific practices, and effective use of intermediate care for patients and hospitals. [ABSTRACT FROM AUTHOR]

Older people may face many challenges and experience insecurity after discharge from hospital to home. To bridge the potential gap between general hospital and home, the concept of intermediate care (IC) was developed in the year 2000. IC aims to safeguard older people from being discharged to their home before they have sufficiently recovered. However, knowledge within this area is sparse, and the experience of older people in particular is yet to be explored. The aim of this study was to explore older people's experiences of being back home after a stay in an IC unit. Data were drawn from 12 interviews. Transcripts were analysed using a phenomenological approach. The essential meaning of being back home after a stay in an IC unit was characterised by uncertainty. Four constituents emerged: experiencing a state of shock about coming home, dependence on informal helpers, feeling a sense of isolation, and fearing loss of functional ability permanently. [ABSTRACT FROM AUTHOR]