A prospective study of consecutive emergency medical admissions to compare a novel automated computer-aided mortality risk score and clinical judgement of patient mortality risk.

OBJECTIVES: To compare the performance of a validated automatic computer-aided risk of mortality (CARM) score versus medical judgement in predicting the risk of in-hospital mortality for patients following emergency medical admission. DESIGN: A prospective study. SETTING: Consecutive emergency medical admissions in York hospital. PARTICIPANTS: Elderly medical admissions in one ward were assigned a risk of death at the first post-take ward round by consultant staff over a 2-week period. The consultant medical staff used the same variables to assign a risk of death to the patient as the CARM (age, sex, National Early Warning Score and blood test results) but also had access to the clinical history, examination findings and any immediately available investigations such as ECGs. The performance of the CARM versus consultant medical judgement was compared using the c-statistic and the positive predictive value (PPV). RESULTS: The in-hospital mortality was 31.8% (130/409). For patients with complete blood test results, the c-statistic for CARM was 0.75 (95% CI: 0.69 to 0.81) versus 0.72 (95% CI: 0.66 to 0.78) for medical judgements (p=0.28). For patients with at least one missing blood test result, the c-statistics were similar (medical judgements 0.70 (95% CI: 0.60 to 0.81) vs CARM 0.70 (95% CI: 0.59 to 0.80)). At a 10% mortality risk, the PPV for CARM was higher than medical judgements in patients with complete blood test results, 62.0% (95% CI: 51.2 to 71.9) versus 49.2% (95% CI: 39.8 to 58.5) but not when blood test results were missing, 50.0% (95% CI: 24.7 to 75.3) versus 53.3% (95% CI: 34.3 to 71.7). CONCLUSIONS: CARM is comparable with medical judgements in discriminating in-hospital mortality following emergency admission to an elderly care ward. CARM may have a promising role in supporting medical judgements in determining the patient's risk of death in hospital. Further evaluation of CARM in routine practice is required.

Effectiveness of a multi-component intervention to reduce delirium incidence in elderly care wards.

OBJECTIVE: to examine the effect of a multi-component, delirium prevention intervention on rates of incident delirium for patients admitted to specialist elderly care wards. DESIGN: 'before' and 'after' study. SETTING: three specialist elderly care wards in a general hospital. SUBJECTS: older people admitted as emergencies. METHODS: a multi-component delirium prevention intervention that targeted delirium risk factors was implemented by clinical staff. Demographic information and assessments for delirium risk factors were recorded by research staff within 24 h of admission to the ward. New onset (incident) delirium was diagnosed by daily research staff assessments using the Confusion Assessment Method and Delirium Rating Scale-Revised-98. RESULTS: a total of 436 patients were recruited (249 in the 'before' and 187 in the 'after' group). Incident delirium was significantly reduced ('before' = 13.3%; 'after' = 4.6%; P = 0.006). Delirium severity and duration were significantly reduced in the 'after' group. Mortality, length of stay, activities of daily living score at discharge and new discharge to residential or nursing home rates were similar for both groups. CONCLUSIONS: a multi-component, delirium prevention intervention directed at delirium risk factors and implemented by local clinical staff can reduce incident delirium on specialist elderly care wards.

Postacute care for older people in community hospitals: a multicenter randomized, controlled trial.

OBJECTIVES: To compare the effects of community hospital care on independence for older people needing rehabilitation with that of general hospital care. DESIGN: Randomized, controlled trial. SETTING: Seven community hospitals and five general hospitals in the midlands and north of England. PARTICIPANTS: Four hundred ninety patients needing rehabilitation after hospital admission with an acute illness. INTERVENTION: Multidisciplinary team care for older people in community hospitals. MEASUREMENTS: The primary outcome was the Nottingham extended activities of daily living scale (NEADL); secondary outcomes were the Barthel Index, Nottingham Health Profile, Hospital Anxiety and Depression Scale, mortality, discharge destination, 6-month residence status, and satisfaction with services. RESULTS: Loss of independence at 6 months was significantly less likely in the community hospital group (mean adjusted NEADL change score group difference 3.27; 95% confidence interval 0.26-6.28; P=.03). The results for the secondary outcome measures were similar for the two groups. CONCLUSION: Postacute community hospital rehabilitation care for older people is associated with greater independence.

Using targeted risk factor reduction to prevent falls in older in-patients: a randomised controlled trial.

BACKGROUND: falls and related injuries are known to be a significant problem for older people. There is evidence that identifying and addressing individual risk factors can reduce the incidence of falls in the community but no evidence of the effectiveness of targeted risk factor reduction methods applied to hospital in-patients. OBJECTIVE: to test the efficacy of a targeted risk factor reduction core care plan in reducing risk of falling while in hospital. DESIGN: a group (ward) randomised trial. SETTING: elderly care wards and associated community units of a district general hospital in the North of England. SUBJECTS: all elderly patients who received care in eight wards and community units during a 12-month study period. METHODS: matched pairs of wards were randomly allocated to intervention or control groups. In the intervention wards, staff used a pre-printed care plan for patients identified as at risk of falling and introduced appropriate remedial measures. Numbers of falls in each group were then compared. RESULTS: after introduction of the care plan there was a significant reduction in the relative risk of recorded falls on intervention wards (relative risk 0.79, 95% CI 0.65-0.95) but not on control wards (RR 1.12, 95% CI 0.96-1.31). The difference in change between the intervention wards and control wards was highly significant (RR 0.71, 95% CI 0.55-0.90, P = 0.006). There was no significant reduction in the incidence of falls-related injuries. CONCLUSION: the use of a core care plan targeting risk factor reduction in older hospital in-patients was associated with a reduction in the relative risk of recorded falls.