Inderpal Singh

Predictors of adverse outcomes on an acute geriatric rehabilitation ward

BACKGROUND multidisciplinary rehabilitation is of proven benefit in the management of older inpatients. However, the identification of patients who will do well with rehabilitation currently lacks a strong evidence base. OBJECTIVES the aims of this study were to compare the importance of chronological age, gender, co-morbidities and frailty in the prediction of adverse outcomes for patients admitted to an acute geriatric rehabilitation ward. DESIGN prospective observational cohort study. SUBJECTS AND SETTING two hundred and sixty-five patients admitted consecutively to an acute geriatric rehabilitation ward at a tertiary care teaching hospital. METHODS frailty status was measured by an index of accumulated deficits, giving a potential score from 0 (no deficits) to 1.0 (all 40 deficits present). Patients were stratified into three outcomes: good (discharged to original residence within 28 days), intermediate (discharged to original residence but longer hospital stay) and poor (newly institutionalised or died). RESULTS patients were old (82.6 ± 8.6 years) and frail (mean frailty index (FI) 0.34 ± 0.09). Frailty status correlated significantly with length of stay and was a predictor of poor functional gain. The odds ratio of intermediate and poor outcome relative to a good outcome was 4.95 (95% CI = 3.21, 7.59; P < 0.001) per unit increase in FI. Chronological age, gender and co-morbidity showed no significant association with outcomes. CONCLUSION frailty is associated with adverse rehabilitation outcomes. The FI may have clinical utility, augmenting clinical judgement in the management of older inpatients.

Risk of inpatient falls is increased with single rooms.

We recently compared a newly built Welsh hospital that has 100% single rooms with the old hospital, which has both single rooms and multi-bedded wards. In agreement with Pennington, we found that single rooms reduce the incidence of hospital acquired infections.1 Rates of acquisition of Clostridium difficile were also lower in the new hospital.2 As …

Outcome of in-patient falls in hospitals with 100% single rooms and multi-bedded wards

BACKGROUND Falls in hospital account for almost two-fifths of the patient safety incidents reported to the National Reporting and Learning System in U.K. Studies have suggested an increased incidence of falls in single-bedded hospitals. OBJECTIVE To compare the outcome of in-patient falls occurring in units with 100% single rooms (SRs) and multi-bedded wards (M-BWs). SAMPLING DESIGN AND METHODS: An observational study. Retrospective standard incident reporting data (DATIX) on in-patient falls and associated injury were obtained from both sites over 18 months each. There was no change in demographics, size and characteristics of population except change in the geography of new hospitals. RESULTS The total number of in-patient fall incidents reported over the 3 years was 1,749. The mean age of patients on M-BW and SR sites was 81.0 ± 2.4 (51.3% females) and 80.3 ± 10.3 (50.7% females), respectively. The mean incidence of falls/1,000 patient-bed days on M-BW and SR sites was 5.44 ± 4.76 and 15.82 ± 19.56, respectively (P < 0.01). Overall fracture incidence/1,000 patient-bed days on M-BW and SR sites was 0.07 ± 0.48 and 0.36 ± 1.52 (P < 0.01), respectively. The hip fracture incidence/1,000 patient-bed days on M-BW and SR sites was 0.04 ± 0.38 and 0.15 ± 1.00 (P < 0.01), respectively. One-year mortality from the date of first incident fall was lower in M-BWs (41.1%) compared with SRs (47.1%), but this is not significant (P = 0.12). CONCLUSION This observational study shows a significantly increased incidence of falls and fracture in a hospital design with SRs compared with a multi-bedded facility. Consideration should be given to increased incidence of falls and falls-related injury in SRs when deciding on the percentage of single-room provision in new hospitals to admit frail older adults.

Assessment and management of dementia in the general hospital setting

Populations are ageing worldwide. The prevalence of dementia will rise exponentially with the oldest old the most rapidly growing segment of society. Caring for this ageing population with dementia, many of whom will have multiple chronic and disabling diseases, will be a challenge to healthcare systems, particularly general hospitals. At any one time, a quarter of acute hospital beds in the UK are in use by people with dementia. Delivery of high-quality care to this growing and vulnerable population must be high on any health service agenda. Current medical training not only generates relatively low numbers of geriatricians and specialists with interest in dementia, but also there is a lack of appropriate training in assessment and management of dementia. There remains huge need for better staff training and support to provide safe, holistic and dignified dementia care. Here we explore various key features for non-specialist assessment and management of older people with dementia in the general hospital setting.

Impact of Hospital Design on Acutely Unwell Patients with Dementia

Increasing emphasis on patient privacy and satisfaction has seen more 100% single-room hospitals opened across the UK. Few studies have addressed the impact of these new hospital designs (single rooms) on clinical outcomes specifically for acutely unwell frail patients with dementia. The objective of this study was to profile and compare the clinical outcomes of acutely unwell patients with dementia admitted to two different hospital environments. This prospective observation study was conducted for 100 dementia patients admitted at Ysbyty Ystrad Fawr (hospital with 100% single rooms) and Royal Gwent Hospital (traditional multi-bed wards) under the same University Health Board. The length of stay (LoS) was significantly longer for patients admitted to single rooms. The clinical profile of the patients was similar in both hospitals and has no association with LoS. There was no significant difference in terms of incidence of inpatient falls, fall-related injury, discharge to a new care home, 30-day readmission, or mortality. The single room environment appears to influence LoS, as previously reported; however, following the introduction of quality improvement initiatives to prevent inpatient falls, single rooms do not appear to be associated with higher inpatient fall incidence. We propose more research to understand the relationship between single rooms and LoS.

Fragility Fractures and Parkinsonism: Relationship of Fractures with Demography, Severity and Predictors of Adverse Outcomes

Background: The risk of falls is higher in patients with Parkinsonism (PwP) as compared to other older adults, leading to adverse outcomes including fragility fractures. Osteoporosis is under-recognised and the current prevalence of fragility fractures is not well-studied. The objectives of this study are to determine the prevalence of fragility fractures in PwP, to measure the relationship of fractures with demography, severity and to measure predictors of adverse outcomes in this population. Method/Description: This was a retrospective observational cohort study based on the analysis of existing data for all the patients attending Caerphilly Movement Disorder Clinic. Information on demographics, the severity of Parkinsonism and fragility fractures was extracted electronically from the clinical workstation, clinic letters and coding from January 2015 to October 2016. Results: 397 people (mean age = 77.1 ± 9.4, 46% females) were studied. Of these, 77% (306/397) had Parkinsonism and 80% (244/306) had idiopathic Parkinson’s disease (PD). The mean Hoehn & Yahr Score at the time assessment was 3.09 ± 1.16. Additionally, 23.5% (72/306) were deemed to have osteoporosis based on the radiological evidence of fragility fractures. The PwP who sustained fractures were comparatively older (80.4 ± 12.1) and 70% (50/72) were females. The most common site for fractures was vertebral (47.2%; 34/72). Also, 22.2% of the sample (16/72) had suffered a fragility fracture before the diagnosis of PD. However, a majority (77.8%; 56/72) had sustained a fracture during the course of PD with a mean lapse of 6 years (range = 0–13 years) from initial diagnosis. Only 40% (29/72) of patients were prescribed osteoporosis drugs as per guidelines. There is a significant correlation of advancing age, severity and duration of PD with fragility fractures. The single best predictor of mortality is severity of PD, followed by age and fractures. Conclusions: There is a high prevalence of fragility fractures in patients attending movement disorder clinics, although 60% do not receive evidence-based medical treatment for the underlying osteoporosis. The prevalence of fragility fractures is positively correlated with the duration and severity of PD. We acknowledge the relatively small sample size as the study’s limitation.

Clinical outcome and predictors of adverse events of an enhanced older adult psychiatric liaison service: Rapid Assessment Interface and Discharge (Newport)

Background Hospitals are currently admitting an increasing number of older people, and more than one-third could have an underlying mental health problem. The existing Older Adult Mental Health (OAMH) liaison service was increasingly unable to meet the escalating needs of older and frail patients. Therefore, the service was modernized and enhanced on an “invest-to-save” principle to provide a prompt holistic assessment for older adults with mental health problems. The objective of this study was a service evaluation to appraise clinical outcome, minimize the length of stay, and measure the predictors of adverse outcomes to streamline this enhanced service. Materials and methods Patient demographics, social care needs, comorbidity burden (Charlson comorbidity index, CCI), and functional status (Barthel index, BI) were recorded from November 2014 to February 2015. Frailty status (frailty index, FI) was measured by an index (Rockwood index) of accumulated deficits. The outcomes were compared with the previous OAMH liaison service data over the same period a year earlier. Results The new Rapid Assessment Interface and Discharge service assessed 339 patients compared to 179 by the previous liaison team over the 4-month period. Mean age was 82.18±8.04 years, with 60% women; preadmission BI was 14.96±4.35, and admission BI was 11.38±5.73 (P<0.001, paired t-test); mean CCI was 1.66±1.53, and mean FI was 0.34±0.99, and 80% were on polypharmacy. The direct discharges from front door were increased by 7%. The mean hospital stay reduced from 35 to 20 days in acute site and from 108 to 47 days in long-stay wards. The cost benefits were based on the mean reduction in hospital stay (41.8 days) and admission reduction (2.2 days), leading to a total annualized bed savings of 44 days. FI was the most highly significant factor between patient groups with a good and poor outcome (P=0.00003, independent groups t-test, t=−4.38, df 98). Conclusion Prompt mental health assessments for acutely unwell frail older people are not only cost effective but also improve clinical outcomes.

Selecting best-suited “patient-related outcomes” in older people admitted to an acute geriatric or emergency frailty unit and applying quality improvement research to improve patient care

The population is aging worldwide, and hospitals are admitting a higher proportion of acutely unwell older people. Population-specific factors such as multimorbidity and frailty in older people compounded by deficient expertise contribute to longer lengths of stay, higher readmission rates, and increased rates of institutionalization. A wide range of acute geriatric care models are currently providing acute care to frail older people and these have been shown to provide a cost-effective high-quality service. In this review, population-specific factors, service models, and a wide range of patient-related outcomes of “at risk” older people admitted to an acute geriatric care unit are explored. In addition, we also discuss data measurements and a quality improvement methodology to improve the delivery of care based on the patient outcome data. We hope, in addition to ensuring effectiveness and sustainability of our current services, this may also enhance academic research. Regular monitoring and evaluation of patient-related clinical outcomes not only improve the patient care and reduce the caregiver burden but also help in implementing quality initiatives to develop existing services.

One-Year Mortality Rates Before and After Implementing Quality-Improvement Initiatives to Prevent Inpatient Falls (2012–2016)

Single-room ward design has previously been associated with increased risk of inpatient falls and adverse outcomes. However, following quality initiatives, the incidence of inpatient falls has shown a sustained reduction. Benefits have also been observed in the reduction of hip fractures. However, one-year mortality trends have not been reported. The aim of this observational study is to report the trends in one-year mortality rates before and after implementing quality-improvement initiatives to prevent inpatient falls over the last 5 years (2012–2016). This retrospective observational study was conducted for all patients who had sustained an inpatient fall between January 2012 and December 2016. All the incident reports in DATIX patient-safety software which were completed for each inpatient fall were studied, and the clinical information was extracted from Clinical Work Station software. Mortality data were collected on all patients for a minimum of one year following the discharge from the hospital. The results show that 95% patients were admitted from their own homes; 1704 patients had experienced 3408 incidents of an inpatient fall over 5 years. The mean age of females (82.61 ± 10.34 years) was significantly higher than males (79.36 ± 10.14 years). Mean falls/patient = 2.0 ± 2.16, range 1–33). Mean hospital stay was 45.43 ± 41.42 days. Mean hospital stay to the first fall was 14.5 ± 20.79 days, and mean days to first fall prior to discharge was 30.8 ± 34.33 days. The results showed a significant and sustained reduction in the incidence of inpatient falls. There was a downward trend in the incidence of hip fractures over the last two years. There was no significant difference in the inpatient and 30-day mortality rate over the last five years. However, mortality trends appear to show a significant downward trend in both six-month and one-year mortality rates over the last two years following the implementation of quality initiatives to prevent inpatient falls. A significant reduction in the incidence of inpatient falls following quality initiatives initially has been observed, followed by a downward trend in the incidence of hip fractures. We have just started to observe a significant reduction in the 6-month and one-year mortality. We propose prompt completion of multifactorial falls risk assessments, and every possible quality initiative should be taken to prevent a ‘first inpatient fall’, which should result in the sustained improvement of clinical outcomes.