The association between ward staffing levels, mortality and hospital readmission in older hospitalised adults, according to presence of cognitive impairment: a retrospective cohort study.

BACKGROUND: Lower nurse staffing levels are associated with increased hospital mortality. Older patients with cognitive impairments (CI) have higher mortality rates than similar patients without CI and may be additionally vulnerable to low staffing. OBJECTIVES: To explore associations between registered nurse (RN) and nursing assistant (NA) staffing levels, mortality and readmission in older patients admitted to general medical/surgical wards. RESEARCH DESIGN: Retrospective cohort. PARTICIPANTS: All unscheduled admissions to an English hospital of people aged ≥75 with cognitive screening over 14 months. MEASURES: The exposure was defined as deviation in staffing hours from the ward daily mean, averaged across the patient stay. Outcomes were mortality in hospital/within 30 days of discharge and 30-day re-admission. Analyses were stratified by CI. RESULTS: 12,544 admissions were included. Patients with CI (33.2%) were exposed to similar levels of staffing as those without. An additional 0.5 RN hours per day was associated with 10% reduction in the odds of death overall (odds ratio 0.90 [95% CI 0.84-0.97]): 15% in patients with CI (OR 0.85 [0.74-0.98]) and 7% in patients without (OR 0.93 [0.85-1.02]). An additional 0.5 NA hours per day was associated with a 15% increase in mortality in patients with no impairment. Readmissions decreased by 6% for an additional 0.5 RN hours in patients with CI. CONCLUSIONS: Although exposure to low staffing was similar, the impact on mortality and readmission for patients with CI was greater. Increased mortality with higher NA staffing in patients without CI needs exploration.

Wessex Acute Frailty Audit: applying quality improvement methodology to design and implement a regional frailty audit using a collaborative, multiprofessional approach.

INTRODUCTION: An acute hospital stay increases the risk of negative outcomes for those living with frailty. This paper describes the application of quality improvement methodology to design and implement a regional audit to gain an understanding of care provision. METHODS: Small scale tests of change (Plan-Do-Study-Act cycles) were used to design the audit structure and questions. Data collectors met face to face with 2-3 multiprofessional clinicians on 58 wards in 10 hospitals across the region, using an electronic tool to gather data. Outcomes were analysed manually in Excel by extracting from the electronic audit tool. RESULTS: 58 wards across 10 hospitals participated in the audit, which identified three key themes: lack of awareness and frailty training outside medicine for older people specialties, and significant variability of both frailty identification and comprehensive geriatric assessment. CONCLUSION: Combining quality improvement methodology with a collaborative, regional approach to design and implementation of a frailty audit creates a reliable tool ensuring all stakeholders are considering improvement from the outset. The results have facilitated an agreed regional approach on how best to use local resources to improve and standardise frailty care provision. By highlighting areas of good practice and significant gaps in frailty identification, personalised care planning and hospital wide provision of frailty training, this region of the UK will now be able to drive up standards of care.

Cognitive impairment is independently associated with mortality, extended hospital stays and early readmission of older people with emergency hospital admissions: A retrospective cohort study.

BACKGROUND: Older adults admitted to hospital are often cognitively impaired. It is not clear whether the presence of cognitive impairment conveys an additional risk for poor hospital outcomes in this patient population. OBJECTIVES: To determine whether cognitive impairment in hospitalised older adults is independently associated with poor outcomes. DESIGN: Retrospective cohort study using electronic, routinely collected data from linked clinical and administrative databases. SETTING: Large, acute district general hospital in England. PARTICIPANTS: 21,399 incident emergency admissions of people aged ≥75, screened for cognitive impairment, categorised to 3 groups: (i) cognitive impairment with a diagnosis of dementia, (ii) cognitive impairment with no dementia diagnosis, (iii) no cognitive impairment. METHODS: Multivariable logistic regression and Fine and Gray competing risks survival models were employed to explore associations between cognitive impairment and mortality (in-hospital alone, and in-hospital plus up to 30 days after discharge), time to hospital discharge, and hospital readmission within 30 days of discharge. Covariates included age, severity of illness, main diagnosis, comorbidities and nutritional risk. RESULTS: Twenty-seven percent of patients had cognitive impairment; of these, 61.5% had a diagnosis of dementia and 38.5% did not. Patients with cognitive impairment and no diagnosis of dementia were most likely to die in hospital or be readmitted, they also had the longest hospital stays. Cognitive impairment was independently associated with mortality in hospital (Odds Ratio 1.34 [1.17-1.55] with dementia; Odds Ratio 1.78 [1.52-2.07] without), mortality in hospital or within 30 days of discharge (Odds Ratio 1.66 [1.48-1.86]; Odds Ratio 1.67 [1.46-1.90]); readmission (Odds Ratio 1.21 [1.04-1.40]; Odds Ratio 1.47 [1.25-1.73]), and increased time until discharge (sub-hazard ratio 0.80 [0.76-0.83]; sub-hazard ratio 0.66 [0.63-0.69]). CONCLUSIONS: Cognitive impairment is associated with an increased risk of adverse outcomes in hospitalised older people with an unscheduled admission, by increasing hospital mortality, extending hospital stays and increasing frequency of readmissions. Future research should focus on understanding the mechanisms contributing to poorer outcomes in this population.

Development of stroke care in Ghana.

The burden of stroke in the developing world is huge and growing. In Ghana, located in West Africa, stroke is in the top five causes of death. Disability resulting from stroke creates many challenges to healthcare staff, patients, their families and the wider society. Health professionals from the South West of England, Ridge Hospital Accra and Korle Bu Teaching Hospital Accra formed an international health partnership to share knowledge of stroke management and service development to support the improvement of stroke care in Ghana.

The Winchester falls project: a randomised controlled trial of secondary prevention of falls in older people.

BACKGROUND: the mortality and morbidity of falls in older people is significant, with recurrent fallers being at an increased risk. The most effective way to reduce falls in this group is not clear. OBJECTIVE: to determine the effectiveness of two interventions, one based in primary care and the other in secondary care, at preventing further falls in recurrent fallers. DESIGN: cluster randomised controlled trial. PARTICIPANTS: sixty-five years or over, living in the community, two or more falls in the previous year and not presenting to an emergency department with index fall. SETTING: Mid Hampshire, UK. INTERVENTION: eighteen general practices were randomly allocated to one of three groups. The primary care group was assessed by nurses in the community, using a risk factor review and subsequent targeted referral to other professionals. The secondary care group received a multi-disciplinary assessment in a day hospital followed by identified appropriate interventions. The control group received usual care. Follow-up was for 1 year. RESULTS: five hundred and five participants were recruited. Follow-up was completed in 83% (421/505). The proportion of participants who fell again was significantly lower in the secondary care group (75%, 158/210) compared to the control group [84%, 133/159, adjusted odds ratio (OR) 0.52 (95% CI 0.35-0.79) P = 0.002]. The primary care group showed similar results to the control group [87%, 118/136, adjusted OR 1.17 (95% CI 0.57-2.37) P = 0.673]. CONCLUSION: a structured multi-disciplinary assessment of recurrent fallers significantly reduced the number experiencing further falls, but a community-based nurse-led assessment with targeted referral to other professionals did not.

Where now with Do Not Attempt Resuscitation decisions?

Geriatricians are often asked to make decisions about withholding cardiopulmonary resuscitation. This seems to be becoming more difficult and more controversial. There has been increased public concern about this subject recently and a recognition within the profession of the need for more openness and transparency in decision making. The implementation of The Human Rights Act led to updated guidelines from professional bodies, but these are likely to need careful interpretation in light of local circumstances before they can become a practical tool for decision making.