Alison M. Mudge

Recurrent readmissions in medical patients: A prospective study

BACKGROUND Hospital readmissions are common and costly. A recent previous hospitalization preceding the index admission is a marker of increased risk of future readmission. OBJECTIVES To identify factors associated with an increased risk of recurrent readmission in medical patients with 2 or more hospitalizations in the past 6 months. DESIGN Prospective cohort study. SETTING Australian teaching hospital acute medical wards, February 2006-February 2007. PARTICIPANTS 142 inpatients aged ≥ 50 years with a previous hospitalization ≤ 6 months preceding the index admission. Patients from residential care, with terminal illness, or with serious cognitive or language difficulties were excluded. VARIABLES OF INTEREST Demographics, previous hospitalizations, diagnosis, comorbidities and nutritional status were recorded in hospital. Participants were assessed at home within 2 weeks of hospital discharge using validated questionnaires for cognition, literacy, activities of daily living (ADL)/instrumental activities of daily living (IADL) function, depression, anxiety, alcohol use, medication adherence, social support, and financial status. MAIN OUTCOME MEASURE Unplanned readmission to the study hospital within 6 months. RESULTS A total of 55 participants (38.7%) had a further unplanned hospital admission within 6 months. In multivariate analysis, chronic disease (adjusted odds ratio [OR] 3.4; 95% confidence interval [CI], 1.3-9.3, P = 0.002), depressive symptoms (adjusted OR, 3.0; 95% CI, 1.3-6.8, P = 0.01), and underweight (adjusted OR, 12.7; 95% CI, 2.3-70.7, P = 0.004) were significant predictors of readmission after adjusting for age, length of stay and functional status. CONCLUSIONS In this high-risk patient group, multiple chronic conditions are common and predict increased risk of readmission. Post-hospital interventions should consider targeting nutritional and mood status in this population.

Helping understand nutritional gaps in the elderly (HUNGER): A prospective study of patient factors associated with inadequate nutritional intake in older medical inpatients

BACKGROUND & AIMS Malnutrition and poor intake during hospitalisation are common in older medical patients. Better understanding of patient-specific factors associated with poor intake may inform nutritional interventions. The aim of this study was to measure the proportion of older medical patients with inadequate nutritional intake, and identify patient-related factors associated with this outcome. METHODS Prospective cohort study enrolling consecutive consenting medical inpatients aged 65 years or older. Primary outcome was energy intake less than resting energy expenditure estimated using weight-based equations. Energy intake was calculated for a single day using direct observation of plate waste. Explanatory variables included age, gender, number of co-morbidities, number of medications, diagnosis, usual residence, nutritional status, functional and cognitive impairment, depressive symptoms, poor appetite, poor dentition, and dysphagia. RESULTS Of 134 participants (mean age 80 years, 51% female), only 41% met estimated resting energy requirements. Mean energy intake was 1220 kcal/day (SD 440), or 18.1 kcal/kg/day. Factors associated with inadequate energy intake in multivariate analysis were poor appetite, higher BMI, diagnosis of infection or cancer, delirium and need for assistance with feeding. CONCLUSIONS Inadequate nutritional intake is common, and patient factors contributing to poor intake should be considered in designing nutritional interventions.

Controlled trial of multidisciplinary care teams for acutely ill medical inpatients: enhanced multidisciplinary care

Background: Acute hospital general medicine services care for ageing complex patients, using the skills of a range of health‐care providers. Evidence suggests that comprehensive early assessment and discharge planning may improve efficiency and outcomes of care in older medical patients.

Encouraging, assisting and time to EAT: Improved nutritional intake for older medical patients receiving Protected Mealtimes and/or additional nursing feeding assistance

BACKGROUND & AIMS Inadequate feeding assistance and mealtime interruptions during hospitalisation may contribute to malnutrition and poor nutritional intake in older people. This study aimed to implement and compare three interventions designed to specifically address mealtime barriers and improve energy intakes of medical inpatients aged ≥ 65 years. METHODS Pre-post study compared three mealtime assistance interventions: PM: Protected Mealtimes with multidisciplinary education; AIN: additional assistant-in-nursing (AIN) with dedicated meal role; PM + AIN: combined intervention. Dietary intake of 254 patients (pre: n = 115, post: n = 141; mean age 80 ± 8) was visually estimated on a single day in the first week of hospitalisation and compared with estimated energy requirements. Assistance activities were observed and recorded. RESULTS Mealtime assistance levels significantly increased in all interventions (p < 0.01). Post-intervention participants were more likely to achieve adequate energy intake (OR = 3.4, p = 0.01), with no difference noted between interventions (p = 0.29). Patients with cognitive impairment or feeding dependency appeared to gain substantial benefit from mealtime assistance interventions. CONCLUSIONS Protected Mealtimes and additional AIN assistance (implemented alone or in combination) may produce modest improvements in nutritional intake. Targeted feeding assistance for certain patient groups holds promise; however, alternative strategies are required to address the complex problem of malnutrition in this population. AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRY NUMBER: ACTRN12609000525280.

Exercising Body and Mind: An Integrated Approach to Functional Independence in Hospitalized Older People

OBJECTIVES: To evaluate the effect of a structured, multi‐component, early rehabilitation program on functional status, delirium, and discharge outcomes of older acute medical inpatients.

Improving quality of delirium care in a general medical service with established interdisciplinary care: a controlled trial.

Clinical practice guidelines have been developed to improve screening, prevention and management of delirium.

The paradox of readmission: effect of a quality improvement program in hospitalized patients with heart failure.

BACKGROUND Congestive heart failure (CHF) is an increasingly common condition associated with significant hospital resource utilization. Initiating better disease management at the time of initial hospital admission has the potential to reduce readmissions. OBJECTIVE To evaluate the impact of a multifaceted quality improvement program on 12-month hospital utilization in patients admitted to hospital with CHF. DESIGN Prospective longitudinal study comparing baseline and intervention cohorts. PARTICIPANTS All consecutive patients with CHF discharged alive from 3 metropolitan hospitals during the baseline (October 1, 2000 to April 17, 2001) and intervention (February 15, 2002 to August 31, 2002) study periods. Active prospective case-finding identified 220 baseline and 235 intervention participants; full data was available on 197 baseline and 219 intervention participants. INTERVENTIONS Education and performance feedback for hospital and primary care practitioners; clinical decision support tools; individualized, guideline-based treatment plans; patient education and self-management support; and improved hospital-community integration. MEASUREMENTS Twelve-month all-cause hospital readmission, 12-month mortality, readmission-free survival, heart failure-specific readmission, and total hospital days over 12 months. RESULTS Intervention patients had a higher rate of all-cause readmission (odds ratio [OR] = 1.65; 95% confidence interval [CI] = 1.10-2.46) but a trend to reduction in mortality (OR = 0.68; 95% CI = 0.44-1.07). There was no difference in frequency of hospitalizations per year, number of hospital days, or the composite outcome of death or readmission. CONCLUSIONS The intervention improved care processes and may have reduced mortality, but at the cost of higher readmission rates. Better understanding of intervention components, intensity, and targeting may optimize the effectiveness of disease management programs.

Exercise training in recently hospitalized heart failure patients enrolled in a disease management programme: design of the EJECTION-HF randomized controlled trial

The Exercise Joins Education: Combined Therapy to Improve Outcomes in Newly‐discharged Heart Failure (EJECTION‐HF) study will evaluate the impact of a supervised exercise training programme (ETP) on clinical outcomes in recently hospitalized heart failure patients attending a disease management programme (DMP).

Towards more effective use of decision support in clinical practice: what the guidelines for guidelines don't tell you.

The Brisbane Cardiac Consortium Clinical Support Systems Program used multiple strategies in optimising quality of care of patients with either of two cardiac conditions. One of these strategies was the development and active implementation of decision support systems centred on evidence‐based, locally agreed clinical practice guidelines. Our experience in undertaking this task highlighted numerous operational challenges for which solutions were difficult to extract from existing published literature. In the present article we provide a methodology grounded in both theory and real‐world experience that may assist others in developing and implementing systems of guideline‐based decision support. (Intern Med J 2004; 34: 492−500)

Quality of care of patients hospitalized with congestive heart failure

Background:  Congestive heart failure (CHF) is an increasingly prevalent poor‐prognosis condition for which effective interventions are available. It is therefore important to determine the extent to which patients with CHF receive appropriate care in Australian hospitals and identify ways for improving suboptimal care, if it exists.