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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.

COVID-19 has been associated with an increased risk of thrombotic events; however, the reported incidence of deep vein thrombosis varies depending, at least in part, on the severity of the disease. Aim of this prospective, multicenter, observational study was to investigate the incidence of lower limb deep vein thrombosis as assessed by compression ultrasound in consecutive patients admitted to three pulmonary medicine wards designated to care for patients with COVID-19 related pneumonia, with or without respiratory failure but not requiring admission to an intensive care unit. Consecutive patients admitted between March 27 and May 6, 2020 were enrolled. Patients were excluded if they were less than 18-year-old or if compression ultrasound could not be performed for any reason. Patients were assessed at admission (t0) and after 7 days (t1). Major and non-major clinically relevant bleedings were recorded. Sixty-eight patients were enrolled. Two were excluded due to anatomical abnormalities that prevented compression ultrasound; sixty patients were retested at (t1). All patients were started on antithrombotic prophylaxis, unless therapeutic anticoagulation was required. Deep vein thrombosis as assessed by compression ultrasound was observed in 2 patients (3%); one of them was later deemed to represent a previous episode. No new episodes were detected at t1. One major and 2 non-major clinically relevant bleedings were observed. In the setting of patients with COVID-related pneumonia not requiring admission to an intensive care unit, the incidence of deep vein thrombosis is low and our data support not screening asymptomatic patients., Highlights • COVID-19 is characterized by increased risk of thrombotic events. • Compression ultrasound is an easy and reliable method to detect deep vein thrombosis. • The incidence of deep vein thrombosis in our COVID-19 patients not in ICU is very low. • Screening for deep vein thrombosis in these patients is not warranted.

Inappropriate prescribing for older people is a global healthcare problem. This study aimed to determine the prevalence of older patients receiving potentially inappropriate medications (PIMs) at admission and discharge at the intermediate care facility of ASP Pio Albergo Trivulzio. We consecutively enrolled 100 patients aged ≥ 65 from December 2017 to May 2018 and evaluated PIMs with the 2015 version of the Beers criteria. We found a significant reduction in the prescription of drugs to avoid and proton pump inhibitors (PPIs), while patients with at least one psychotropic drug to avoid or to use with caution significantly increased. The inappropriate prescription of PPIs was mainly associated with the use of heparin. Optimizing PPI and psychotropic drug prescriptions should be considered for deprescribing inappropriate polypharmacy in intermediate care facilities.

Aim The aim of this study was to compare the clinical impact of two intermediate care pathways. Methods A prospective, uncontrolled before-after study was carried out to compare two non-synchronic intermediate care frameworks in Spain. Participants in the control group were transferred to the intermediate care center by hospital request, whereas those in the intervention group (Badalona Integrated Care Model [BICM]) were transferred based on a territory approach considering the assessment of an intermediate care team. The clinical characteristics of study participants were assessed at admission and discharge. Results Compared with participants in the control group, those in the BICM group were significantly older (mean age 81.6 years [SD 10.3] vs 78.3 years [10.1], P < 0.001) and had a lower Barthel score (mean score 32.8 [SD 25.9] vs 39.9 [28.4]; P < 0.001), and a higher proportion of participants with total dependence (38.4% vs 32.2%; P = 0.001). The length of stay in intermediate care was similar in both groups; however, stay in acute care was significantly shorter in the BICM group than in the control group (mean 21 days [SD 19.5] vs 25 days [SD 23]; P < 0.001). No significant differences were found regarding the Barthel Index at discharge, although participants in the BICM group had significantly higher functional gain. Conclusions The implementation of a territory-based integrated care pathway in an intermediate care center shifted the profile of admitted patients toward higher complexity. Despite this, patients managed under the integrated care model reduced their dependency and the referral rate to an acute unit during their stay in the intermediate care center. Geriatr Gerontol Int 2020; center dot center dot: center dot center dot-center dot center dot.

Objective Intermediate care units provide a high level of care to complex patients and are becoming increasingly popular in North America. Despite the growing popularity of Intermediate care units, very little is known about them. This study explored a typical Intermediate care unit, identifying patient characteristics including demographics, comorbidities, length of stay, as well as primary and secondary diagnosis and mortality. Results A total of 200 patients chart were reviewed, of which, 102 were male, and 89 patients were younger than 65 years old. Diabetes, hypertension, and chronic obstructive pulmonary disease were common among patients with a prevalence of 33.5%, 56%, and 32.5%, respectively. Alcohol use disorder, asthma, liver disease and IV drug abuse were much more common in patients younger than 65 years. The average length of stay was 5.31 days regardless of age. Almost two-thirds of the patients in the Intermediate care unit were admitted directly from the emergency room. The mortality rate among the patients studied was 9.5%. The most common admitting diagnosis was respiratory diseases such as chronic obstructive pulmonary disease or Pneumonia (38.0%), followed by cardiac disorders which were predominantly arrhythmias and congestive heart failure (27.0%).

BackgroundHigh incidence of delirium in hospitalized patients has been reported in the United States and is significantly associated with increased morbidity and mortality. The lack of knowledge and confidence in performing delirium assessment (KCDA) has led to significant underrecognition of delirium by nurses regardless of evidence-based education intervention.ObjectiveThe purpose of this study was to determine the effectiveness of a multimodal educational program (MEP) to enhance nurses' KCDA.MethodsA MEP including an online didactic with a video-simulation and 1:1 bedside coaching with delirium screening (DS) was conducted in the surgical intermediate-care unit of an academic medical center. A quasi-experimental pre- and post-test design was used.ResultsOf 23 nurses, the majority were p < .001). A positive correlation was noted between the changes of the KCDA scores (p = .009).ConclusionsThe MEP demonstrated improvement in nurses' KCDA. The MEP should focus on an individualized learning approach with a targeted patient population, using current delirium screening tools.Implications for NursingEducational programs are recommended in either an orientation or continuing education program on nursing units. This is also recommended for use in other academic centers that encompass similar clinical settings and could possibly be considered for use in other disease processes.

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.

AIM To identify facility-level characteristics associated with hospitalization within 30 days after admission to a geriatric intermediate care facility (GICF) (30-day hospitalization) in Japan. METHODS This retrospective cohort study used nationwide long-term care insurance claims data and a national survey of long-term geriatric care facilities. The study population was residents admitted to GICFs between October 2016 and February 2018. The outcome variable was 30-day hospitalization. The independent variables were facility-level characteristics such as level of healthcare professionals. RESULTS The final sample for analysis comprised 282 991 residents of mean age ± SD, 85.8 ± 7.2 years, of whom 12 814 (4.5%) experienced 30-day hospitalization. In a multivariable logistic generalized estimating equation model adjusted for facility- and resident-level characteristics, and clustering GICFs, the odds of 30-day hospitalization were 0.906 times lower (95% confidence interval [CI] 0.857-0.958) among residents in a GICF with dental hygienist than in those in a facility without. Furthermore, the risk of 30-day hospitalization was lower among residents who had been admitted to a GICF with higher staffing levels of pharmacists (adjusted odds ratio [aOR] 0.941, 95% CI 0.899-0.985), registered nurses (aOR 0.931, 95% CI 0.880-0.986), care workers (aOR 0.920, 95% CI 0.879-0.964) and speech-language pathologists (aOR 0.926, 95% CI 0.874-0.982) than in those who had been admitted to a GICF with fewer of these healthcare professionals. CONCLUSIONS Transitional care including dental hygienist or higher staffing levels of pharmacists, registered nurses, care workers and speech-language pathologists may be a more effective way to prevent 30-day hospitalization. Geriatr Gerontol Int 2021; 21: 1010-1017.

Rationale The SARS-CoV2 pandemic increased exponentially the need for both Intensive (ICU) and Intermediate Care Units (RICU). The latter are of particular importance because they can play a dual role in critical and post-critical care of COVID-19 patients. Here, we describe the setup of 2 new RICUs in our institution to face the SARS-CoV-2 pandemic and discuss the clinical characteristics and outcomes of the patients attended. Methods Retrospective analysis of the characteristics and outcomes of COVID-19 patients admitted to 2 new RICUs built specifically in our institution to face the first wave of the SARS-CoV-2 pandemic, from April 1 until May 30, 2020. Results During this period, 106 COVID-19 patients were admitted to these 2 RICUs, 65 of them (61%) transferred from an ICU (step-down) and 41 (39%) from the ward or emergency room (step-up). Most of them (72%) were male and mean age was 66 ± 12 years. 31% of them required support with oxygen therapy via high-flow nasal cannula (HFNC) and 14% non-invasive ventilation (NIV). 42 of the 65 patients stepping down (65%) had a previous tracheostomy performed and most of them (74%) were successfully decannulated during their stay in the RICU. Length of stay was 7 [4–11] days. 90-day mortality was 19% being significantly higher in stepping up patients than in those transferred from the ICU (25 vs. 10% respectively; p Conclusions RICUs are a valuable hospital resource to respond to the challenges of the SARS-CoV-2 pandemic both to treat deteriorating and recovering COVID-19 patients.

BACKGROUND: Noninvasive ventilation (NIV) is increasingly used to manage acute respiratory failure in children, decreasing the need for mechanical ventilation. Safely managing these patients outside of the ICU improves ICU resource use. We measured the impact of a guideline permitting initiation of NIV in an intermediate care unit (IMCU) on ICU bed use. METHODS: A guideline for an NIV trial for acute respiratory failure was implemented in a 10-bed IMCU. The guideline stipulated criteria for initiation and maintenance of NIV. There were 4.5 years of intervention data collected. Baseline data were gathered for patients with acute respiratory failure who were transferred from the IMCU to the ICU for NIV initiation in the 3.25 years before guideline implementation. RESULTS: Three hundred eight patients were included: 101 in the baseline group and 207 in the intervention group. In the intervention group, 143 patients (69%) remained in the IMCU after NIV initiation, and 64 (31%) transferred to the ICU. A total of 656.4 ICU bed-days were saved in the intervention period (3.3 days per patient initiated on NIV in the IMCU). There was a significant decrease in the rate of intubation in the IMCU for patients awaiting ICU transfer (3 patients in the baseline group versus 0 patients in the intervention group; P = .035). CONCLUSIONS: The initiation of NIV in the IMCU for pediatric patients with acute respiratory failure saved ICU bed-days without increasing intubation in the IMCU for patients awaiting transfer. Close monitoring of these critically ill patients is a key component of their safe care.

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.

ObjectivesTo evaluate the prescription and discontinuation of psychotropic drugs (PD) and drugs with anticholinergic properties (DAP) in residents with dementia admitted to Roken, a major type of long-term care facility in Japan.DesignCohort study.SettingA nationwide questionnaire survey across 3598 Roken in Japan in 2015 (up to five randomly selected residents per facility).ParticipantsThis study included 1201 residents from 343 Roken (response rate: 10%). We determined the presence and severity of dementia using a nationally standardised measure.Primary and secondary outcome measuresPrescriptions of PD and DAP at admission and 2 months after admission were evaluated. Multivariable logistic regression was used to evaluate the associations of residents’ baseline characteristics with prescriptions or discontinuation.ResultsPrescription rates decreased for antidementia drugs (19.4% to 13.0%), hypnotics (25.1% to 22.6%) and anxiolytics (12.3% to 10.7%), whereas those for other PD, such as antipsychotics (13.2% to 13.6%), antidepressants (7.4% to 6.7%), antiepileptic drugs (7.1% to 7.8%) and DAP (35.2% to 36.6%) did not statistically significantly decrease. Some factors were associated with the prescriptions, for example, for antipsychotics, older age (≥85 years) (adjusted OR (aOR), 0.60; 95% CI 0.43 to 0.85) and being bedridden (aOR 0.67; 95% CI 0.47 to 0.97) were associated with a lower use of antipsychotics, whereas severe dementia was associated with a higher use of antipsychotics (aOR 3.26; 95% CI 2.26 to 4.70). At an individual level, a quarter of residents prescribed PD or DAP at admission had discontinued at least one PD or DAP, respectively, 2 months after admission. Antidementia drug use in severe dementia (aOR 1.86; 95% CI 1.04 to 3.31) and PD use in older age (aOR 1.61; 95% CI 1.00 to 2.60; in residents with disabling dementia) were associated with discontinuation.ConclusionsThere is possible scope for deprescribing PD and DAP in Roken residents with dementia to mitigate the risks of adverse events.

The imbalance between the prevalence of patients with acute respiratory failure (ARF) and acute-on-chronic respiratory failure and the number of intensive care unit (ICU) beds requires new solutions. The increasing use of non-invasive respiratory tools to support patients at earlier stages of ARF and the increased expertise of non-ICU clinicians in other types of supportive care have led to the development of adult pulmonary intensive care units (PICUs) and pulmonary intermediate care units (PIMCUs). As in other European countries, Italian PICUs and PIMCUs provide an intermediate level of care as the setting designed for managing ARF patients without severe non-pulmonary dysfunction. The PICUs and PIMCUs may also act as step-down units for weaning patients from prolonged mechanical ventilation and for discharging patients still requiring ventilatory support at home. These units may play an important role in the on-going coronavirus disease 2019 pandemic. This position paper promoted by the Italian Thoracic Society (ITS-AIPO) describes the models, facilities, staff, equipment, and operating methods of PICUs and PIMCUs.

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.

Quality problem or issue The on-going COVID-19 pandemic may cause the collapse of healthcare systems because of unprecedented hospitalization rates. Initial assessment A total of 8.2 individuals per 1000 inhabitants have been diagnosed with COVID-19 in our province. The hospital predisposed 110 beds for COVID-19 patients: on the day of the local peak, 90% of them were occupied and intensive care unit (ICU) faced unprecedented admission rates, fearing system collapse. Choice of solution Instead of increasing the number of ICU beds, the creation of a step-down unit (SDU) close to the ICU was preferred: the aim was to safely improve the transfer of patients and to relieve ICU from the risk of overload. Implementation A nine-bed SDU was created next to the ICU, led by intensivists and ICU nurses, with adequate personal protective equipment, monitoring systems and ventilators for respiratory support when needed. A second six-bed SDU was also created. Evaluation Patients were clinically comparable to those of most reports from Western Countries now available in the literature. ICU never needed supernumerary beds, no patient died in the SDU, and there was no waiting time for ICU admission of critical patients. SDU has been affordable from human resources, safety and economic points of view. Lessons learned COVID-19 is like an enduring mass casualty incident. Solutions tailored on local epidemiology and available resources should be implemented to preserve the efficiency and adaptability of our institutions and provide the adequate sanitary response.

Background As the global coronavirus pandemic (COVID-19) spreads across the world, new clinical challenges emerge in the hospital landscape. Among these challenges, the increased risk of coinfections is a major threat to the patients. Although still in a low number, due to the short time of the pandemic, studies that identified a significant number of hospitalised patients with COVID-19 who developed secondary fungal infections that led to serious complications and even death have been published. Objectives In this scenario, we aim to determine the prevalence of invasive fungal infections (IFIs) and describe possible associated risk factors in patients admitted due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Patients/methods We designed an open prospective observational study at the Rey Juan Carlos University Hospital (Mostoles, Spain), during the period from February 1 to April 30, 2020. Results In this article, we reported seven patients with COVID-19-associated pulmonary aspergillosis (CAPA) who had a poor prognosis. Severely ill patients represent a high-risk group; therefore, we must actively investigate the possibility of aspergillosis in all of these patients. Larger cohort studies are needed to unravel the role of COVID-19 immunosuppressive therapy as a risk factor for aspergillosis. Conclusions As the pandemic continues to spread across the world, further reports are needed to assess the frequency of emergent and highly resistant reemergent fungal infections during severe COVID-19. These coinfections are leading a significant number of patients with COVID-19 to death due to complications following the primary viral disease.

Importance Thirty-day home time, defined as time spent alive and out of a hospital or facility, is a novel, patient-centered performance metric that incorporates readmission and mortality. Objectives To characterize risk-adjusted 30-day home time in patients discharged with heart failure (HF) as a hospital-level quality metric and evaluate its association with the 30-day risk-standardized readmission rate (RSRR), 30-day risk-standardized mortality rate (RSMR), and 1-year RSMR. Design, Setting, and Participants This hospital-level cohort study retrospectively analyzed 100% of Medicare claims data from 2 968 341 patients from 3134 facilities from January 1, 2012, to November 30, 2017. Exposures Home time, defined as time spent alive and out of a short-term hospital, skilled nursing facility, or intermediate/long-term facility 30 days after discharge. Main Outcomes and Measures For each hospital, a risk-adjusted 30-day home time for HF was calculated similar to the Centers for Medicare & Medicaid Services risk-adjustment models for 30-day RSRR and RSMR. Hospitals were categorized into quartiles (lowest to highest risk-adjusted home time). The correlations between hospital rates of risk-adjusted 30-day home time and 30-day RSRR, 30-day RSMR, and 1-year RSMR were estimated using the Pearson correlation coefficient. Distribution of days lost from a perfect 30-day home time were calculated. Reclassification of hospital performance using 30-day home time vs 30-day RSRR was also evaluated. Results Overall, 2 968 341 patients (mean [SD] age, 81.0 [8.3] years; 53.6% female) from 3134 hospitals were included in this study. The median hospital risk-adjusted 30-day home time for patients with HF was 21.77 days (range, 8.22-28.41 days). Hospitals in the highest quartile of risk-adjusted 30-day home time (best-performing hospitals) were larger (mean [SD] number of beds, 285 [275]), with a higher volume of patients with HF (median, 797 patients; interquartile range, 395-1484) and were more likely academic hospitals (59.9%) with availability of cardiac surgery (51.1%) and cardiac rehabilitation (68.8%). A total of 72% of home time lost was attributable to stays in an intermediate- or long-term care facility (mean [SD], 2.65 [6.44] days) or skilled nursing facility (mean [SD], 3.96 [9.04] days), 13% was attributable to short-term readmissions (mean [SD], 1.25 [3.25] days), and 15% was attributable to death (mean [SD], 1.37 [6.04] days). Among 30-day outcomes, the 30-day RSRR and 30-day RSMR decreased in a graded fashion across increasing 30-day home time categories (correlation coefficients: 30-day RSRR and 30-day home time, -0.23, P

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.

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. Methods & Materials: 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.

To identify factors that may predict discharge to intermediate-care facilities following total laryngectomy and may promote earlier discharge planning and optimize resource utilization.Retrospective review of large national data set.Academic and nonacademic health care facilities in United States, contributing deidentified, risk-adjusted clinical data to the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP).Retrospective evaluation of the NSQIP database (2011-2014) identified 487 patients who underwent total laryngectomy without free tissue transfer. Risk of discharge to intermediate-care facilities was evaluated. Role of preoperative and postoperative factors and their association with discharge disposition were assessed using multivariable regression analysis.Compared to reference groups, advanced age (61-70 years: odds ratio [OR], 3.16; 95% confidence interval [CI], 1.12-8.89;70 years: OR, 3.77; 95% CI, 1.33-10.65), baseline functional dependence (OR, 5.61; 95% CI, 2.62-12.02), cardiac failure (OR, 3.80; 95% CI, 1.08-13.42), and steroid dependence (OR, 3.30; 95% CI, 1.36-8.0) independently predicted discharge to intermediate-care facilities.Patients with advanced age, functional dependence, cardiac failure, and steroid dependence may benefit from preemptive counseling and discharge planning in anticipation of postlaryngectomy discharge to intermediate-care facilities.

Objective: To understand the impact of adding a medical step-down unit (SDU) on patient outcomes and throughput in a medical intensive care unit (ICU). Design: Retrospective cohort study. Setting: Two academic tertiary care hospitals within the same health-care system. Patients: Adults admitted to the medical ICU at either the control or intervention hospital from October 2013 to March 2014 (preintervention) and October 2014 to March 2015 (postintervention). Interventions: Opening a 4-bed medical SDU at the intervention hospital on April 1, 2014. Measurements and Main Results: Using standard summary statistics, we compared patients across hospitals. Using a difference-in-differences approach, we quantified the association of opening an SDU and outcomes (hospital mortality, hospital and ICU length of stay [LOS], and time to transfer to the ICU) after adjustment for secular trends in patient case-mix and patient-level covariates which might impact outcome. We analyzed 500 (245 pre- and 255 postintervention) patients in the intervention hospital and 678 (323 pre- and 355 postintervention) in the control hospital. Patients at the control hospital were younger (60.5-60.6 vs 64.0-65.4 years, P < .001) with a higher severity of acute illness at the time of evaluation for ICU admission (Sequential Organ Failure Assessment score: 4.9-4.0 vs 3.9-3.9, P < .001). Using the difference-in-differences methodology, we identified no association of hospital mortality (odds ratio [95% confidence interval]: 0.81 [0.42 to 1.55], P = .52) or hospital LOS (% change [95% confidence interval]: −8.7% [−28.6% to 11.2%], P = .39) with admission to the intervention hospital after SDU opening. The ICU LOS overall was not associated with admission to the intervention hospital in the postintervention period (−23.7% [−47.9% to 0.5%], P = .06); ICU LOS among survivors was significantly reduced (−27.5% [−50.5% to −4.6%], P = .019). Time to transfer to ICU was also significantly reduced (−26.7% [−44.7% to −8.8%], P = .004). Conclusions: Opening our medical SDU improved medical ICU throughput but did not affect more patient-centered outcomes of hospital mortality and LOS.

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

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.

Background Many surgeons prefer to discharge patients home due to patient preferences, improved outcomes, and decreased costs. Despite an institutional protocol to send total hip arthroplasty (THA) patients home, some patients still required postacute care (PAC) facilities. This study aimed to create two predictive models based on preoperative and postoperative risk factors to identify which patients require PAC facilities. Methods A retrospective review of 2,372 patients undergoing primary unilateral THA at a single institution from 2012 to 2017 was done. An electronic query followed by manual review identified discharge disposition, demographic factors, comorbidities, and other patient factors. Of the 2,372 patients, 6.2% were discharged to skilled nursing facilities or inpatient rehabilitation facilities and 93.8% discharged home. Univariate and multivariate analysis were conducted to create two predictive models for patient discharge: preoperative visit and postoperative hospital course. Results Of 45 variables evaluated, 7 were found to be notable predictors for PAC facility discharge. In descending order, these included age 65 years or greater, non-Caucasian race, history of depression, female sex, and greater comorbidities. In addition to preoperative factors, in-hospital complications and surgical duration of 90 minutes or greater led to a higher likelihood of PAC facility discharge. Both models had excellent predictive assessments with area under curve values of 0.77 and 0.80 for the preoperative visit and postoperative models, respectively. Discussion This study identifies both preoperative and postoperative risk factors that predispose patients to nonroutine discharges after THA. Orthopaedic surgeons may use these models to better predict which patients are predisposed to discharge to PAC facilities.

Background The number of chronic critical illness (CCI) patients requiring prolonged mechanical ventilation (PMV) is increasing worldwide, mandating health professionals to discuss interventions while considering disease trajectory. The aim of this study was to analyze the survival of CCI patients who underwent percutaneous dilatational tracheostomy (PDT) within intermediate care units. Methods We carried out a retrospective study of all patients who underwent PDT in our intermediate care units from 2009 to 2015. Based on their survival statuses at different time points, patients were categorized into groups of survival at one week, one month, and one year following the procedure. Results This study included 254 patients. The mean age was 77.7 (±11.8) years. Out of the 254 patients included, 213 patients (84.2%) were defined as nursing care dependent. In-hospital mortality was 38.2% (97 patients). Seven patients (2.7%) were discharged to their homes. Overall survival rates at one week, one month, and one year following PDT were 88.6%, 66.1%, and 29.5%, respectively. Upon multivariate analyses, higher creatinine levels and resuscitation prior to the procedure were associated with increased mortality rates at one week and one month following tracheostomy. Higher creatinine and low albumin levels were associated with increased mortality at one year following tracheostomy. Conclusion The prognosis of CCI patients in intermediate care units is generally poor. Identified risk factors for complications and survival should be presented to patients and their surrogates when discussing courses of action and future treatments.

Patients express strong opinion regarding discharge destination, preferring discharge home vs elsewhere. As focus on patient satisfaction increases, we sought to understand differences in postoperative discharge destination after minimally invasive vs open anatomic lung resection for lung cancer to guide patient education and management and better understand the postoperative patient experience.Procedures were identified by Current Procedural Terminology and International Classification of Diseases codes using the 2012-2017 American College of Surgeons National Surgical Quality Improvement Program dataset. Propensity score analysis was used to assess the relationship between the surgical approach and nonhome discharge destination (primary outcome) and postoperative complications; related, unplanned readmission; and mortality (secondary outcomes).A total of 17,303 patients underwent anatomic lung resection for lung cancer, including 10,121 (58.5%) minimally invasive and 7182 (41.5%) open resections. Patients undergoing open resection had 60% greater odds of nonhome discharge (P.001), 58% greater odds of postoperative mortality (P = .003), 36% greater odds of postoperative complication (P.001), and 17% greater odds of readmission (P = .04) compared with patients undergoing minimally invasive resection.The minimally invasive approach to lung resection for lung cancer offers patients a more desirable patient-centered postoperative experience, as well as more favorable clinical outcomes, and should be favored when feasible.

Objectives: this prospective, cluster randomised, controlled trial investigated the effect of oral neuromuscular training among older people in intermediate care with impaired swallowing. Methods: older people (≥65 years) with swallowing dysfunction were cluster randomised according to care units for 5 weeks of neuromuscular training of the orofacial and pharyngeal muscles or usual care. The primary endpoint was the change in swallowing rate (assessed with a timed water swallow test) from baseline to the end-of-treatment and 6 months post-treatment. The secondary endpoints were changes in signs of aspiration during the water swallow test, and swallowing-related quality of life (QOL). An intention-to-treat principle was followed, and mixed-effects models were used for data analysis with the clustered study design as a random factor. Results: in total, 385 participants from 36 intermediate care units were screened, and 116 participants were randomly assigned to oral neuromuscular training (intervention; n = 49) or usual care (controls; n = 67). At the end of treatment, the geometric mean of the swallowing rate in the intervention group had significantly improved 60% more than that of controls (P = 0.007). At 6 months post-treatment, the swallowing rate of the intervention group remained significantly better (P = 0.031). Signs of aspiration also significantly reduced in the intervention group compared with controls (P = 0.01). No significant between-group differences were found for swallowing-related QOL. Conclusions: oral neuromuscular training is a new promising swallowing rehabilitation method among older people in intermediate care with impaired swallowing. Trial registration: ClinicalTrials.gov: NCT02825927. Originally included in thesis in manuscript form.

ObjectivesAlmost all healthcare today is team-based in collaboration over professional borders, and numerous students have work-based learning in such contexts. However, interprofessional learning (IPL) in clinical settings has mostly been systematically explored in specially designed contexts dedicated to interprofessional education (IPE). This study aimed to explore the possibilities for IPL activities, and if or how they occur, in an acute ward context not dedicated to IPE.Design and settingBetween 2011 and 2013 ethnographic observations were performed of medical and nursing students’ interactions and IPL during early clerkship at an acute internal medicine ward in Sweden. Field notes were taken and analysed based on the framework of IPE:learning with, from and about.Participants21 medical, 4 nursing students and 30 supervisors participated.ResultsLearning with—there were no organised IPE activities. Instead, medical and nursing students learnt in parallel. However, students interacted with staff members from other professions.Learning from—interprofessional supervision was frequent. Interprofessional supervision of nursing students by doctors focused on theoretical questions and answers, while interprofessional supervision of medical students by nurses focused on the performance of technical skills.Learning about—students were observed to actively observe interactions between staff and learnt how staff conducted different tasks.ConclusionThis study shows that there were plenty of possibilities for IPL activities, but the potential was not fully utilised or facilitated. Serendipitous IPL activities differed between observed medical and nursing students. Although interprofessional supervision was fairly frequent, students were not learning with, from or about each other over professional borders.

PurposeThere have been few studies on the limitation of Life Supporting Care (LSC) and Withdrawal of LSC in Intermediate Care Units (IMCUs). We report the prevalence of LSC limited patients in a medico-surgical IMCU over a six-month period, examining the description, outcomes, and patterns of LSC Limitations and Withdrawal of LSC.MethodsSingle center, retrospective observational study in an IMCU of a 500-bed general hospital.ResultsOur study of 404 patients, reported 79 (19.5%, 95%CI: [16.0-23.7]%) being admitted with LSC limitations in the IMCU. This group of LSC limited patients presented with higher chronic and acute severity scores. The most common admission diagnosis of LSC limited patients was acute respiratory failure (51%). Non-invasive ventilation (NIV) was frequently used within this population (39%). Hospital mortality for LSC limited patients was high (53%) and associated with age (OR = 1.07, 95%CI: [1.01-1.13)]), SOFA score (OR 1.29, 95%CI: [1.01-1.64]), and hypoxemic respiratory failure (OR 7.2, 95%CI: [1.27-40.9]). Withdrawal of LSC occurred in 19.5% of cases, often accompanied with terminal sedation with or without NIV removal (43.8%).ConclusionsPatients with limitation of LSC are frequently admitted into IMCU. Hospital mortality rate was high and associated with age, acute organ failures, and hypoxemic respiratory failure. Life support withdrawal includes palliative sedation with or without NIV discontinuation.

Introduction Care for patients with chronic obstructive pulmonary disease (COPD) can be provided in primary, secondary or tertiary care. Whether and to what extent patients with COPD treated in various healthcare settings differ in disease burden and healthcare utilization remains unknown. Therefore, daily symptoms, functional mobility, mood status, health status and healthcare utilization were compared between COPD patients in various care settings, to explore possibilities for healthcare-optimization. Methods Current data are part of the Chance study. Demographics, functional mobility (Care Dependency Scale (CDS); Timed-Up-and-Go (TUG) test), mood status (Hospital Anxiety and Depression scale (HADS)), health status (COPD Assessment test (CAT); Clinical COPD questionnaire (CCQ); COPD specific St. George Respiratory questionnaire (SGRQ-C)), received treatments and severity of physical and psychological symptoms were assessed in subjects with and without COPD. Results 836 subjects (100 primary care patients, 100 secondary care patients, 518 tertiary care patients and 118 non-COPD subjects) were included. The burden of disease significantly increased from primary care to tertiary care. However, in all three healthcare settings a high percentage of patients with an impaired health status was observed (i.e. CAT ≥10 points, 68.0% vs. 91.0% vs. 94.5%, respectively). Furthermore, many patients treated in secondary care remain highly symptomatic despite treatment, while others with low burden of disease would allow for de-intensification of care. Conclusion This study revealed important shortcomings and challenges for the care of COPD patients in the Netherlands. It emphasizes the need for detailed patient characterization and more individualized treatment, independent of the healthcare setting.

Optimal care for children and adolescents with type 1 diabetes is well described in guidelines, such as those of the International Society for Pediatric and Adolescent Diabetes. High-income countries can usually provide this, but the cost of this care is generally prohibitive for lower-income countries. Indeed, in most of these countries, very little care is provided by government health systems, resulting in high mortality, and high complications rates in those who do survive. As lower-income countries work toward establishing guidelines-based care, it is helpful to describe the levels of care that are potentially affordable, cost-effective, and result in substantially improved clinical outcomes. We have developed a levels of care concept with three tiers: "minimal care," "intermediate care," and "comprehensive (guidelines-based) care." Each tier contains levels, which describe insulin and blood glucose monitoring regimens, requirements for hemoglobin A1c (HbA1c) testing, complications screening, diabetes education, and multidisciplinary care. The literature provides various examples at each tier, including from countries where the life for a child and the changing diabetes in children programs have assisted local diabetes centres to introduce intermediate care. Intra-clinic mean HbA1c levels range from 12.0% to 14.0% (108-130 mmol/mol) for the most basic level of minimal care, 8.0% to 9.5% (64-80 mmol/mol) for intermediate care, and 6.9% to 8.5% (52-69 mmol/mol) for comprehensive care. Countries with sufficient resources should provide comprehensive care, working to ensure that it is accessible by all in need, and that resulting HbA1c levels correspond with international recommendations. All other countries should provide Intermediate care, while working toward the provision of comprehensive care.

Objectives No established approaches exist for the pharmacological management of cardiovascular diseases (CVDs) in residents of long-term care facilities (LTCFs). This study aimed to evaluate the use of drugs for CVD prevention and treatment (CVD-related drugs) in a major type of LTCF in Japan. Methods This study included 1318 randomly selected residents at 349 intermediate care facilities for older adults (called Roken). Prescriptions were investigated at admission and two months after admission according to therapeutic categories. Logistic regression was used to identify residents’ characteristics that were associated with prescriptions of CVD-related drugs. Results Prescriptions of all types of drugs and CVD-related drugs decreased in 36 % and 16 % of residents, respectively. Half of the residents received antihypertensives, a quarter received antiplatelets and diuretics, whereas one-tenth received antidiabetics, oral anticoagulants, and lipid-modifying drugs. The prevalence of most of individual drug categories were similar among residents with different physical or cognitive function, except for fewer antihypertensive and lipid-modifying drugs in those with severe cognitive disability. Adjusted analyses for prescriptions at two months after admission revealed that bedridden residents were more likely to be prescribed diuretics but less likely to be prescribed antihypertensives, antiplatelets, or lipid-modifying drugs. Residents with severe cognitive disability were less likely to be prescribed antihypertensives or lipid-modifying drugs. A known history of cardiovascular events was associated with greater use of CVD-related drugs. Conclusion CVD-related drugs were commonly prescribed for Roken residents, including those with low physical and cognitive functions. Deprescribing may contribute to the optimization of pharmacotherapy in LTCF residents.

IntroductionHospital admission in older adults with multiple chronic conditions is associated with unwanted outcomes like readmission, institutionalisation, functional decline and mortality. Providing acute care in the community and integrating effective components of care models might lead to a reduction in negative outcomes. Recently, the first geriatrician-led Acute Geriatric Community Hospital (AGCH) was introduced in the Netherlands. Care at the AGCH is focused on the treatment of acute diseases, comprehensive geriatric assessment, setting patient-led goals, early rehabilitation and streamlined transitions of care.Methods and analysisThis prospective cohort study will investigate the effectiveness of care delivery at the AGCH on patient outcomes by comparing AGCH patients to two historic cohorts of hospitalised patients. Propensity score matching will correct for potential population differences. The primary outcome is the 3-month unplanned readmission rate. Secondary outcomes include functional decline, institutionalisation, healthcare utilisation, occurrence of delirium or falls, health-related quality of life, mortality and patient satisfaction. Measurements will be conducted at admission, discharge and 1, 3 and 6 months after discharge. Furthermore, an economic evaluation and qualitative process evaluation to assess facilitators and barriers to implementation are planned.Ethics and disseminationThe study will be conducted according to the Declaration of Helsinki. The Medical Ethics Research Committee confirmed that the Medical Research Involving Human Subjects Act did not apply to this research project and official approval was not required. The findings of this study will be disseminated through public lectures, scientific conferences and journal publications. Furthermore, the findings of this study will aid in the implementation and financing of this concept (inter)nationally.Trial registration numberNL7896; Pre-results.

ObjectiveTo examine changes in places of dementia-related death following implementation of the national dementia plan and other policy initiatives.DesignObservational study.SettingJapan between October 1996 and September 2016. Four major changes in health and social care systems were identified: (1) the public long-term care insurance programme (April 2000); (2) community centres as a first access point for older residents (April 2006); (3) medical care system for older people (April 2008) and (4) the national dementia plan (April 2013).Participants9 60 423 decedents aged 65 years or older whose primary cause of death was Alzheimer’s disease, vascular or other types of dementia or senility.Main outcome measuresPlace of death which was classified into ‘hospital’, ‘intermediate geriatric care facility’ (rehabilitation facility aimed at home discharge), ‘nursing home’ or ‘own home’.ResultsThe annual number of deaths at hospital was consistently increased over time from 1996 to 2016 (age-adjusted OR: 6.01; 95% CI 5.81 to 6.21 versus home deaths). Controlling for individual characteristics, regional supply of hospital and nursing home beds and other changes in health and social care systems, death from dementia following the national dementia plan was likely to occur in hospital (adjusted OR: 1.21; 95% CI 1.18 to 1.24), intermediate geriatric care facility (adjusted OR: 1.53; 95% CI 1.48 to 1.58) or nursing home (adjusted OR: 1.64; 95% CI 1.60 to 1.69) rather than at home.ConclusionsAs the number of deaths from dementia increased over the decades, in-hospital deaths increased regardless of the national dementia plan. Further strategies should be explored to improve the availability of palliative and end-of-life care at patients’ places of residence.

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 PointsEvaluation 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.

BackgroundIntermediate care (IC) acts as a bridging service between hospital and home, for those deemed medically fit for discharge but who are delayed in hospital. The aim of this study was to measure the effect of IC and a 72-hour discharge target on days delayed.MethodsRate of days delayed per 1000 population aged 75 years+ in Glasgow City was compared before and after onset of IC with a 6-month phase-in period, using segmented linear regression. Inverclyde and West Dunbartonshire (IWD) was a control. Autoregressive and moving average terms were included in the model, as well as a Fourier term to adjust for seasonality.ResultsPrior to IC, rate of days delayed increased in both Glasgow City and the rest of Scotland. There was a large reduction in rate of days delayed in Glasgow during the phase-in period, greater than the rest of Scotland but comparable with that observed in IWD, with subsequent increases thereafter. Adjusting for changes in IWD, the impact of IC and the discharge target in Glasgow City was a level change of −15.20 (95% CI −17.52 to –12.88) and a trend change of −0.29 (95% CI −0.55 to –0.02). This is equivalent to a predicted reduction due to IC of −16.04 days delayed per 1000 population per month, in June 2016, and a relative reduction of 35%.ConclusionIC and the 72-hour discharge target were associated with a reduction in days delayed. Rate of days delayed continued to increase over time, although at a slower rate than if IC had not been implemented.

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.

Objective Surgical site infections (SSIs) carry significant patient morbidity and mortality and are a major source of readmissions after craniotomy. Because of their deleterious effects on health care outcomes and costs, identifying modifiable risk factors holds tremendous value. However, because SSIs after craniotomy are rare and most existing data comprise single-institution studies with small sample sizes, many are likely underpowered to discern for such factors. The objective of this study was to use a large hetereogenous patient sample to determine SSI incidence after nonemergent craniotomy and identify factors associated with readmission and subsequent need for wound washout. Methods We used the 2010–2014 Nationwide Readmissions Database cohorts to discern for factors predictive of SSI and washout. Results We identified 93,920 nonemergent craniotomies. There were 2079 cases of SSI (2.2%) and 835 reoperations for washout (0.89%) within 30 days of index admission and there were 2761 cases of SSI (3.6%) and 1220 reoperations for washout (1.58%) within 90 days. Several factors were predictive of SSI in multivariate analysis, including tumor operations, external ventricular drain (EVD), age, length of stay, diabetes, discharge to an intermediate-care facility, insurance type, and hospital bed size. Many of these factors were similarly implicated in reoperation for washout. Conclusions SSI incidence in neurosurgery is low and most readmissions occur within 30 days. Several factors predicted SSI after craniotomy, including operations for tumor, younger age, hospitalization length, diabetes, discharge to institutional care, larger hospital bed size, Medicaid insurance, and presence of an EVD. Diabetes and EVD placement may represent modifiable factors that could be explored in subsequent prospective studies for their associations with cranial SSIs.

Intermediate Care Units (IMCU) are established in many hospitals to better match the requirements of patient care with respect to their personnel, equipment and other resources. This should relieve Intensive Care Unit (ICU) capacities for more severely ill patients and reduce readmissions to ICU. This study was conducted to investigate the effects of IMCU use on ICU populations.This is a retrospective analysis of the German National Registry of Intensive Care from the years 2000 to 2010.We included 39 ICUs with high and 11 ICUs with low IMCU use. Patients in ICUs with high IMCU use were younger (mean age [high vs. low]: 60.5 vs. 64.5 years, P0.001), while the severity of illness was higher (percentage of ventilated patients during ICU stay [high vs. low ICMU use]: 67.2% vs. 40.2%, P0.001; patients ventilated24 hours: 22% vs. 18%, P0.001; mean therapeutic intervention scoring system-28 (TISS-28) score: 25.7 vs. 23.3, P0.001). Readmission rates to ICU did not differ between ICU groups ([high vs. low]: 4.5% vs. 4.4%, P=0.25). ICUs with high IMCU use discharged 90.3% of all patients who were discharged to the IMCU or general ward between the regular workday hours of 06:00 and 14:59, while ICUs with low IMCU use discharged 83.8% of all patients discharged to the general ward in the same time period.The use of IMCUs influences resource utilization of ICUs. Severity of illness and workload was higher in ICUs with high IMCU and more scheduled discharges occurred during the main working hours while readmission rates were similar.

Purpose: Intermediate care units (IMCUs) represent an alternative care setting with nurse staffing levels between those of the general ward and the intensive care unit (ICU). Despite rising prevalence, little is known about IMCU practices across US hospitals. The purpose of this study is to characterize utilization patterns and assess for variation. Materials and Methods: A 14-item survey was distributed to a random nationwide sample of pulmonary and critical care physicians between January and April 2017. Results: A total of 51 physicians from 24 different states completed the survey. Each response represented a unique institution, the majority of which were public (59%), academic (73%), and contained at least 1 IMCU (65%). Of the IMCUs surveyed, 58% operated as 1 mixed unit that admitted medical, cardiac, and surgical patients as opposed to having separate subspecialty units. Ninety-one percent of units admitted step-down patients from the ICU, but 39% of units accepted a mix of step-up patients, step-down patients, postoperative patients, and patients from the emergency department. Intensivists managed care in 21% of units whereas 36% had no intensivist involvement. Conclusion: Organization practices vary considerably between IMCUs across institutions. The impact of different organization practices on patient outcomes should be assessed.

BACKGROUND: The incidence of chronically ill subjects with prolonged mechanical ventilation (PMV) has significantly increased over the last decade because of improvements in acute critical care. The aim of this study was to describe the outcomes and care pathways of subjects receiving PMV through a tracheostomy tube in an intermediate-care facility. METHODS: Sixty-six subjects with chronic respiratory failure who experienced 109 hospitalizations between December 2010 and December 2012 in a 34-bed post-care unit were retrospectively included and followed for at least 1 y. RESULTS: The median (interquartile range [IQR]) length of stay (LOS) was 42 (26–77) d. Subjects were admitted from home (40.4%), our hospital ICU (40.4%; median [IQR] LOS = 17 [7–38] d), or another hospital (19.2%; median [IQR] LOS = 60 [8–71] d, P = .001 vs LOS in ICU). Thirty-five percent of subjects were readmitted at least once during the follow-up period. Sixteen subjects died in the intermediate-care facility. Discharge destinations of alive subjects were home ( n = 78), another hospital ( n = 6), a skilled-nursing facility ( n = 5), or an ICU ( n = 4). A complete or partial weaning was obtained in 30.3% of subjects. One year after the first day of hospitalization, 57% of subjects were alive. CONCLUSIONS: Despite the chance of survival at 1 y and/or weaning from ventilation, the resources needed by subjects with PMV are high, as shown by the number of readmissions and long LOS in our unit and in other hospital units before transfer.

Objectives Early transfer to intermediate-care hospitals, low-tech but with geriatric expertise, represents an alternative to conventional acute hospitalization for selected older adults visiting emergency departments (EDs). We evaluated if simple screening tools predict discharge destination in patients included in this pathway. Design, Setting, and Participants Cohort study, including patients transferred from ED to the intermediate-care hospital Parc Sanitari Pere Virgili, Barcelona, during 14 months (2012–2013) for exacerbated chronic diseases. Measurements At admission, we collected demographics, comprehensive geriatric assessment, and 3 screening tools (Identification of Seniors at Risk [ISAR], SilverCode, and Walter indicator). Outcome Discharge destination different from usual living situation (combined death and transfer to acute hospitals or long-term nursing care) versus return to previous situation (home or nursing home). Results Of 265 patients (mean age ± SD = 85.3 ± 7.5, 69% women, 58% with acute respiratory infections, 38% with dementia), 80.8% returned to previous living situation after 14.1 ± 6.5 days (mean ± SD). In multivariable Cox proportional hazard models, ISAR >3 points (hazard ratio [HR] 2.06, 95% confidence interval [95% CI] 1.16–3.66) and >1 pressure ulcers (HR 2.09, 95% CI 1.11–3.93), but also continuous ISAR, and, in subanalyses, Walter indicator, increased the risk of negative outcomes. Using ROC curves, ISAR showed the best prediction among other variables, although predictive value was poor (AUC = 0.62 (0.53–0.71) for ISAR >3 and AUC = 0.65 (0.57–0.74) for continuous ISAR). ISAR and SilverCode showed fair prediction of acute hospital readmissions. Conclusions Among geriatric screening tools, ISAR was independently associated with discharge destination in older adults transferred from ED to intermediate care. Predictive validity was poor. Further research on selection of candidates for alternatives to conventional hospitalization is needed.

Little is known about the utility of provision of high-dependency care (HDC) that is in a geographically separate location from a primary intensive care unit (ICU).To determine whether the availability of HDC in a geographically separate unit affects patient flow or mortality for critically ill patients.Admissions to ICUs in the United Kingdom, from 2009 to 2011, who received Level 3 intensive care in the first 24 hours after admission and subsequently Level 2 HDC. We compared differences in patient flow and outcomes for patients treated in hospitals providing some HDC in a geographically separate unit (dual HDC) with patients treated in hospitals providing all HDC in the same unit as intensive care (integrated HDC) using multilevel mixed effects models.In 192 adult general ICUs, 21.4% provided dual HDC. Acute hospital mortality was no different for patients cared for in ICUs with dual HDC versus those with integrated HDC (adjusted odds ratio, 0.94 [0.86-1.03]; P = 0.16). Dual HDC was associated with a decreased likelihood of a delayed discharge from the primary unit. However, total duration of critical care and the likelihood of discharge from the primary unit at night were increased with dual HDC.Availability of HDC in a geographically separate unit does not impact acute hospital mortality. The potential benefit of decreasing delays in discharge should be weighed against the increased total duration of critical care and greater likelihood of a transfer out of the primary unit at night.

Prior studies report safety and effectiveness of laparoscopic colectomy in older patients. The study aimed to examine the impact of laparoscopic colectomy on 30-day readmissions, discharge destination, hospital length of stay, and cost in younger (19-65 years) and older adults (65 years).We used the nationwide readmission database from 2013 to study adults undergoing elective colectomy. The outcomes were 30-day readmissions, discharge destination for the index hospitalization (routine, skilled nursing facility [SNF]/intermediate care facility [ICF], home healthcare), length of stay, and cost. Multivariable analyses were conducted to determine the association of laparoscopic colectomy on outcome; logistic regression for 30-day readmission, multinomial logistic regression for discharge destination, and linear regression for length of stay and cost. An interaction between age and colectomy approach was included, and all models controlled gender, income, insurance status, All Patients Refined Diagnosis Related Groups (APR-DRG), Elixhauser comorbidities, hospital bed size, ownership, and teaching status.Of 79,581 colectomies, 40.2% were laparoscopic. Laparoscopic colectomy was more frequent in younger patients (41.9% versus 38.5%, p .0001). Regardless of age, patients undergoing laparoscopic colectomy were 20% less likely to be readmitted within 30 days (odds ratio [OR] 0.80, confidence interval [95% CI] 0.75-0.85). For postdischarge destination, laparoscopic colectomy offered higher benefits to younger patients (SNF/ICF: OR 0.42, 95% CI 0.36-0.49; home health: OR 0.32, 95% CI 0.30-0.35) than older patients (SNF/ICF: OR 0.50, 95% CI 0.47-0.54; home health: OR 0.59, 95% CI 0.55-0.62). Regardless of age, laparoscopic colectomy resulted in 1.46 days (p .0001) shorter hospital stays compared to open colectomy. Laparoscopic colectomy had significantly lower cost compared to open approach, particularly in younger ($1,466) versus older ($632) patients.Laparoscopic colectomy is superior to an open approach, with fewer 30-day readmissions, fewer discharges to SNF/ICF or home health, shorter hospital stays, and less overall cost; younger patients benefit more than older patients.

A growing number of patients with increasingly complex or specialized diseases are being treated in hospitals worldwide. The treatment requirements of some of these patients are exceeding the capacity of standard nursing units. However, the severity of these diseases or the treatment requirements for these specific clinical pictures do not always justify admission to an intensive care unit. For this reason, an increasing number of special units (intermediate care units) are being set up to offer highly specialized treatment and close monitoring, in order to fulfil an intermediate role between the standard care unit and the intensive care unit. The recommendations of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) on the personnel, capacity, equipment and structure of these units are intended to provide the framework for the setting up and operation of intermediate care units in collaboration with experts on both an evidence-based and an expert-based basis (where scientific evidence is not available). Where only minimal or indirect evidence is available, patient safety is paramount in the formulation of the recommendation.

BackgroundIn South Africa, 600-700 new cases of paediatric cancers have been reported every year for the past 25 years, and in the year 2000, HIV/AIDS was responsible for 42,479 deaths in children under five. These children need intermediate care but research in the field is lacking, with the few costing studies conducted in South Africa reporting a range of inpatient day costs.MethodsA retrospective cost analysis for the period April 2014-March 2015 was undertaken from the provider perspective in the public sector, using a step down costing approach. Costs of paediatric intermediate care were estimated for an intermediate care facility (ICF) and a tertiary hospital in Cape Town. Costs were inflated to 2016 prices and reported in US dollars.ResultsCost per inpatient day was $713.09 at the hospital and $695.17 at the ICF for any child requiring care at these institutions. The cost for a paediatric patient who is HIV/TB co-infected was $7 130.94 and $6 951.67 at the hospital and ICF respectively, assuming an average length of stay of 10 days. For a patient with terminal brain carcinoma the cost was $19 966.63 and $19 464.69 at the hospital and ICF respectively, assuming an average length of stay of 28 days. Personnel costs accounted for 60% and 17% of the total cost at the hospital and ICF respectively. Overhead costs accounted for 12.33% at the ICF and 4.48% at the hospital.ConclusionsThe drivers of cost are not uniform across settings. Providing intermediate care at an ICF could be less costly than providing this care at a hospital, however more in-depth analysis is needed. The costs presented in this study were considerably higher than those found in other studies, however, the paucity of cost data available in this area makes comparisons difficult.

Objective Although the concept of patient participation has been discussed for a number of years, there is still no clear definition of what constitutes the multidimensional concept, and the application of the concept in an intermediate care (IC) context lacks clarity. Therefore this paper seeks to identify and explore the attributes of the concept, to elaborate ways of understanding the concept of patient participation for geriatric patients in the context of IC. Methods Walker and Avant’s model of Concept analysis [ 1 ] based on a literature review. Results Patient participation in the context of IC can be defined as a dynamic process emphasizing the person as a whole, focusing on the establishment of multiple alliances that facilitate individualized information and knowledge exchange, and ensuring a reciprocal engagement in activities within flexible and interactive/dynamic organizational structures. Conclusion Patient participation in IC means involving patients and their relatives in holistic interdisciplinary collaborative decision-making. The results highlight the complexity of patient participation and contribute to a greater understanding of the influence of organizational structure and management. Practical implications The present study may provide a practical framework for researchers, policy makers and health professionals to facilitate patient participation in IC services.