A mixed methods study investigating the quality of urinary and faecal continence assessment and management in residential aged care: Challenges, implications and solutions.

OBJECTIVE: Incontinence is one of the main reasons for institutionalisation into residential aged care. It is linked with increased falls, skin breakdown, depression, social isolation and impaired quality of life. Studies over the past decade have demonstrated poor-quality incontinence care, which has led to ongoing development of best practice guidelines and educational resources. This study investigated current practices, and staff and resident experiences with continence assessment and management, in comparison with best practice guidelines. METHODS: This concurrent mixed methods study was conducted in a 120-bed residential aged care home. Secondary analysis of data from clinical records provided a snapshot of how continence was assessed and managed. Semistructured interviews with four staff and five residents explored their experiences to understand the impact of current practice on resident emotional well-being. Mixing methods allowed for comparison between quantitative and qualitative findings, enabling a deeper understanding. RESULTS: Findings from the two data sets were highly congruent and identified: (1) lack of communication with residents and family members about continence needs; (2) heavy reliance on product usage and limited other conservative strategies; (3) staff frustration at inability to respond to calls in a timely manner; and (4) positive staff-resident relationships protect resident emotional well-being. CONCLUSIONS: Current practices are not consistent with best practice guidelines, which raises the question as to why nothing has changed. We argue that a stronger focus on implementation underpinned by a relationship-centred approach is required to improve continence care practices among residential care staff, and the quality of life for adults living with incontinence.

Social isolation, social support and loneliness as independent concepts, and their relationship with health-related quality of life among older women.

Objectives: To assess whether social isolation, social support, and loneliness are independently associated with health-related quality of life (HRQoL).Method: Retrospective analysis including 10,517 women aged 70-75 years from the Australian Longitudinal Study on Women's Health (ALSWH). Social isolation, social support (Duke Social Support Index), and loneliness (single item) were investigated for their association with standardised HRQoL (physical [PCS] and mental [MCS] components of the SF-36® questionnaire). Analyses were adjusted for sociodemographic variables and number of medical conditions.Results: Only 3% reported being socially isolated, having low social support and being lonely, and 34% reported being not socially isolated, high social support and not being lonely. Each construct was independently associated with HRQoL, with loneliness having the strongest inverse association (PCS: isolation -0.98, low support -2.01, loneliness -2.03; MCS: isolation -1.97, low support -4.79, loneliness -10.20; p-value < 0.001 for each). Women who were not isolated or lonely and with high social support had the greatest HRQoL (compared to isolated, low social support and lonely; MCS: 17 to 18 points higher, PCS: 5 to 8 points higher). Other combinations of social isolation, social support and loneliness varied in their associations with HRQoL.Conclusion: Ageing populations face the challenge of supporting older people to maintain longer, healthy, meaningful and community-dwelling lives. Among older women, social isolation, low social support and loneliness are distinct, partially overlapping yet interconnected concepts that coexist and are each adversely associated with HRQoL. Findings should be replicated in other cohorts to ensure generalisability across other age groups and men.

Predicting functional decline in older emergency patients-the Safe Elderly Emergency Discharge (SEED) project.

Objective: to profile the trajectory of, and risk factors for, functional decline in older patients in the 30 days following Emergency Department (ED) discharge. Methods: prospective cohort study of community-dwelling patients aged ≥65 years, discharged home from a metropolitan Melbourne ED, 31 July 2012 to 30 November 2013. The primary outcome was functional decline, comprising either increased dependency in personal activities of daily living (ADL) or in skills required for living independently instrumental ADL (IADL), deterioration in cognitive function, nursing home admission or death. Univariate analyses were used to select risk factors and logistic regression models constructed to predict functional decline. Results: at 30 days, 34.4% experienced functional decline; with 16.7% becoming more dependent in personal ADL, 17.5% more dependant in IADL and 18.4% suffering deterioration in cognitive function. Factors independently associated with decline were functional impairment prior to the visit in personal ADL (Odds Ratio [OR] 3.21, 95% confidence interval [CI] 2.26-4.53) or in IADL (OR 6.69, 95% CI 4.31-10.38). The relative odds were less for patients with moderately impaired cognition relative to those with normal cognition (OR 0.38, 95% CI 0.19-0.75). There was a 68% decline in the relative odds of functional decline for those with any impairment in IADL who used an aid for mobility (OR 0.32, 95% CI 0.14-0.7). Conclusion: older people with pre-existing ADL impairment were at high risk of functional decline in the 30 days following ED presentation. This effect was largely mitigated for those who used a mobility aid. Early intervention with functional assessments and appropriate implementation of support services and mobility aids could reduce functional decline after discharge.

After-hours medical deputising services: patterns of use by older people.

OBJECTIVES: To examine how older people use an after-hours medical deputising service that arranges home visits by locum general practitioners; to identify differences in how people who live in the community and those who live in residential aged care facilities (RACFs) use this service. DESIGN, SETTING AND PARTICIPANTS: Retrospective analysis of routinely collected administrative data from the Melbourne Medical Deputising Service (MMDS) for the 5-year period, 1 January 2008 - 31 December 2012. Data for older people (≥ 70 years old) residing in greater Melbourne and surrounding areas were analysed. MAIN OUTCOME MEASURES: Numbers and rates of MMDS bookings for acute after-hours care, stratified according to living arrangements (RACF v community-dwelling residents). RESULTS: Of the 357 112 bookings logged for older patients during 2008-2012, 81% were for RACF patients, a disproportionate use of the service compared with that by older people dwelling in the community. Most MMDS bookings resulted in a locum GP visiting the patient. During 2008-2012, the booking rate for RACFs increased from 121 to 168 per 1000 people aged 70 years or more, a 39% increase; the booking rate for people not living in RACFs increased from 33 to 40 per 1000 people aged 70 years or more, a 21% increase. CONCLUSIONS: After-hours locum GPs booked through the MMDS mainly attended patients living in RACFs during 2008-2012. Further research is required to determine the reasons for differences in the use of locum services by older people living in RACFs and in the community.

Demand at the emergency department front door: 10-year trends in presentations.

OBJECTIVES: To measure the increase in volume and age-specific rates of presentations to public hospital emergency departments (EDs), as well as any changes in ED length of stay (LOS); and to describe trends in ED utilisation. DESIGN, PATIENTS AND SETTING: Population-based retrospective analysis of Department of Health public hospital ED data for metropolitan Melbourne for 1999-00 to 2008-09. MAIN OUTCOME MEASURES: Presentation numbers; presentation rates per 1000 person-years; ED LOS. RESULTS: ED presentations increased from 550,662 in 1999-00 to 853,940 in 2008-09. This corresponded to a 32% rise in rate of presentation (95% CI, 29%-35%), an average annual increase of 3.6% (95% CI, 3.4%-3.8%) after adjustment for population changes. Almost 40% of all patients remained in the ED for ≥4 hours in 2008-09, with LOS increasing over time for patients who were more acutely unwell. The likelihood of presentation rose with increasing age, with people aged≥85 years being 3.9 times as likely to present as those aged 35-59 years (95% CI, 3.8-4.0). The volume of older people presenting more than doubled over the decade. They were more likely to arrive by emergency ambulance and were more acutely unwell than 35-59 year olds, with 75% having an LOS≥4 hours and 61% requiring admission in 2008-09. CONCLUSION: The rise in presentation numbers and presentation rates per 1000 person-years over 10 years was beyond that expected from demographic changes. Current models of emergency and primary care are failing to meet community needs at times of acute illness. Given these trends, the proposed 4-hour targets in 2012 may be unachievable unless there is significant redesign of the whole system.

The challenges of population ageing: accelerating demand for emergency ambulance services by older patients, 1995-2015.

OBJECTIVE: To measure the growth in emergency ambulance use across metropolitan Melbourne since 1995, to measure the impact of population growth and ageing on these services, and to forecast demand for these services in 2015. DESIGN AND SETTING: A population-based retrospective analysis of Ambulance Victoria's metropolitan emergency ambulance transportation data for the period from financial year 1994-95 to 2007-08, and modelling of demand in the financial year 2014-15. MAIN OUTCOME MEASURES: Numbers and rates of emergency ambulance transportations. RESULTS: The crude annual rate of emergency transportations across all age groups increased from 32 per 1000 people in 1994-95 to 58 per 1000 people in 2007-08. The rate of transportation for all ages increased by 75% (95% CI, 62%-89%) over the 14-year study period, representing an average annual growth rate of 4.8% (95% CI, 4.3%-5.3%) beyond that explained by demographic changes. Patients aged ≥ 85 years were eight times (incident rate ratio, 7.9 [95% CI, 7.6-8.3]) as likely to be transported than those aged 45-69 years over this period. Forecast models suggest that the number of transportations will increase by 46%-69% between 2007-08 and 2014-15, disproportionately driven by increasing usage by patients aged ≥ 85 years. CONCLUSIONS: These findings confirm a dramatic rise in emergency transportations over the study period, beyond that expected from demographic changes. Rates increased across all age groups, but more so in older patients. In the future, such acceleration is likely to have major effects on ambulance services and acute hospital capacity. This calls for further investigation of underlying causes and alternative models of care.

Streamlining elective surgery care in a public hospital: the Alfred experience.

OBJECTIVE: To evaluate the effectiveness of redesigning and streamlining perioperative services. DESIGN: A before-and-after evaluation, with retrospective analysis of de-identified administrative data. SETTING: A major tertiary hospital, Melbourne, Australia. PARTICIPANTS: Patients undergoing elective surgery, February 2005 - February 2010. INTERVENTION: Implementing a process redesign to streamline clinical pathways for elective surgery, with a focus on the patient journey from referral to discharge, and establishing a separate, dedicated elective surgery facility. MAIN OUTCOME MEASURES: Numbers of patients waiting beyond national recommended waiting times for elective surgery; hospital-initiated postponement (HIP) rates for elective surgery; and lengths of stay (LOS), both combined and for specific diagnostic-related groups. RESULTS: The clinical process redesign resulted in a sustained downward trend in the number of elective surgery patients waiting longer than national recommended maximum waiting times. HIP rates were reduced to 1% in the dedicated elective surgery facility, and there was a significant reduction in the combined LOS, as well as the LOS for the most common surgical procedures (P < 0.001). CONCLUSIONS: Clinical process redesign of perioperative services and collocation of a separate elective surgery centre improved (i) timeliness of care for elective surgery patients and (ii) key indicators (LOS and HIP rates) for planned elective admissions.

Systematic review of trends in emergency department attendances: an Australian perspective.

Emergency departments (EDs) in many developed countries are experiencing increasing pressure due to rising numbers of patient presentations and emergency admissions. Reported increases range up to 7% annually. Together with limited inpatient bed capacity, this contributes to prolonged lengths of stay in the ED; disrupting timely access to urgent care, posing a threat to patient safety. The aim of this review is to summarise the findings of studies that have investigated the extent of and the reasons for increasing emergency presentations. To do this, a systematic review and synthesis of published and unpublished reports describing trends and underlying drivers associated with the increase in ED presentations in developed countries was conducted. Most published studies provided evidence of increasing ED attendances within developed countries. A series of inter-related factors have been proposed to explain the increase in emergency demand. These include changes in demography and in the organisation and delivery of healthcare services, as well as improved health awareness and community expectations arising from health promotion campaigns. The factors associated with increasing ED presentations are complex and inter-related and include rising community expectations regarding access to emergency care in acute hospitals. A systematic investigation of the demographic, socioeconomic and health-related factors highlighted by this review is recommended. This would facilitate untangling the dynamics of the increase in emergency demand.