RESUMO
Intermediate care services have developed internationally to expedite discharge from hospital and to provide an alternative to an emergency hospital admission. Inconsistencies in the evidence base and under-developed governance structures led to concerns about the care quality, outcomes and provision of intermediate care in the NHS. The National Audit of Intermediate Care was therefore established by an interdisciplinary group. The second national audit reported in 2013 and included crisis response teams, home-based and bed-based services in approximately a half of the NHS. The main findings were evidence of weak local strategic planning, considerable under-provision, delays in accessing the services and lack of mental health involvement in care. There was a very high level of positive patient experience reported across all types of intermediate care, though reported involvement with care decisions was less satisfactory.
Assuntos
Prestação Integrada de Cuidados de Saúde/normas , Serviços de Saúde para Idosos/normas , Instituições para Cuidados Intermediários/normas , Auditoria Médica , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Medicina Estatal/normas , Prestação Integrada de Cuidados de Saúde/organização & administração , Necessidades e Demandas de Serviços de Saúde/normas , Serviços de Saúde para Idosos/organização & administração , Humanos , Instituições para Cuidados Intermediários/organização & administração , Modelos Organizacionais , Avaliação das Necessidades , Avaliação de Processos e Resultados em Cuidados de Saúde/organização & administração , Satisfação do Paciente , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Medicina Estatal/organização & administração , Reino UnidoRESUMO
This article describes the differences in training and departmental function between the specialties of emergency medicine in China and acute medicine in the U.K., based on the experience of a visiting international medical graduate from Shanghai.
Assuntos
Educação de Pós-Graduação em Medicina/organização & administração , Medicina de Emergência/educação , China , Currículo , Avaliação Educacional , Inglaterra , HumanosRESUMO
BACKGROUND: Frailty, history of dementia (HoD), and acute confusional states (ACS) are common in older patients admitted to hospital. OBJECTIVE: To study the association of frailty (≥6 points in the Clinical Frailty Scale [CFS]), HoD, and ACS with hospital outcomes, controlling for age, gender, acute illness severity (measured by a Modified Early Warning Score in the emergency department), comorbidity (Charlson Comorbidity Index), and discharging specialty (general medicine, geriatric medicine, surgery). DESIGN: Retrospective observational study. SETTING: Large university hospital in England. PATIENTS: We analyzed 8202 first nonelective inpatient episodes of people aged 75 years and older between October 2014 and October 2015. MEASUREMENTS: The outcomes studied were prolonged length of stay (LOS ≥10 days), inpatient mortality, delayed discharge, institutionalization, and 30-day readmission. Statistical analyses were based on multivariate regression models. RESULTS: Independently of controlling variables, prolonged LOS was predicted by CFS ≥6: odds ratio (OR) =1.55; 95% confidence interval [CI], 1.36-1.77; P ⟨ 0.001; HoD: OR = 2.16; 95% CI, 1.79-2.61; P ⟨ 0.001; and ACS: OR = 3.31; 95% CI, 2.64-4.15; P ⟨ 0.001. Inpatient mortality was predicted by CFS ≥6: OR = 2.29; 95% CI, 1.79-2.94; P ⟨ 0.001. Delayed discharge was predicted by CFS ≥6: OR = 1.46; 95% CI, 1.27-1.67; P ⟨ 0.001; HoD: OR = 2.17; 95% CI, 1.80-2.62; P ⟨ 0.001; and ACS: OR = 2.29; 95% CI: 1.83-2.85; P ⟨ 0.001. Institutionalization was predicted by CFS ≥6: OR = 2.56; 95% CI, 2.09-3.14; P ⟨ 0.001; HoD: OR = 2.51; 95% CI, 2.00-3.14; P ⟨ 0.001; and ACS: OR 1.93; 95% CI, 1.46-2.56; P ⟨ 0.001. Readmission was predicted by ACS: OR = 1.36; 95% CI, 1.09-1.71; P = 0.006. CONCLUSIONS: Routine screening for frailty, HoD, and ACS in hospitals may aid the development of acute care pathways for older adults. Journal of Hospital Medicine 2017;12:83-89.
Assuntos
Idoso Fragilizado , Avaliação Geriátrica/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde/tendências , Readmissão do Paciente , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Confusão/psicologia , Demência/psicologia , Inglaterra , Feminino , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação , Masculino , Estudos Retrospectivos , Inquéritos e QuestionáriosRESUMO
Clonal hemopoiesis driven by leukemia-associated gene mutations can occur without evidence of a blood disorder. To investigate this phenomenon, we interrogated 15 mutation hot spots in blood DNA from 4,219 individuals using ultra-deep sequencing. Using only the hot spots studied, we identified clonal hemopoiesis in 0.8% of individuals under 60, rising to 19.5% of those ≥90 years, thus predicting that clonal hemopoiesis is much more prevalent than previously realized. DNMT3A-R882 mutations were most common and, although their prevalence increased with age, were found in individuals as young as 25 years. By contrast, mutations affecting spliceosome genes SF3B1 and SRSF2, closely associated with the myelodysplastic syndromes, were identified only in those aged >70 years, with several individuals harboring more than one such mutation. This indicates that spliceosome gene mutations drive clonal expansion under selection pressures particular to the aging hemopoietic system and explains the high incidence of clonal disorders associated with these mutations in advanced old age.
Assuntos
Envelhecimento , Hematopoese/genética , Leucemia/genética , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biologia Computacional , DNA (Citosina-5-)-Metiltransferases/genética , DNA Metiltransferase 3A , Sequenciamento de Nucleotídeos em Larga Escala , Humanos , Leucemia/patologia , Pessoa de Meia-Idade , Mutação , Síndromes Mielodisplásicas/genética , Síndromes Mielodisplásicas/patologia , Proteínas Nucleares/genética , Fosfoproteínas/genética , Fatores de Processamento de RNA , Ribonucleoproteína Nuclear Pequena U2/genética , Ribonucleoproteínas/genética , Análise de Sequência de DNA , Fatores de Processamento de Serina-Arginina , Adulto JovemAssuntos
Dor/diagnóstico , Idoso , Algoritmos , Analgésicos/farmacocinética , Analgésicos/uso terapêutico , Humanos , Dor/etiologia , Manejo da Dor , Medição da DorRESUMO
Management of electrolyte abnormalities is challenging in older people as the sensation of thirst, renal function and hormonal modulators of the milieu interior are often impaired. Furthermore, the complex effects of ageing upon these homeostatic mechanisms are often superimposed upon a background of chronic disease, malnutrition and co-existent medications. Hyponatraemia is one of the commonest electrolyte abnormalities, occurring in approximately 7% of healthy elderly persons. Hyponatraemia may only come to light when some other ailment prompts investigations or hospital admission. Drug-induced hyponatraemia is common in older people and is most commonly associated with diuretics and SSRI/SNRI antidepressants, but has also been reported with a wide range of other drugs. We believe this is the first case report of hyponatraemia due to tolterodine.