Health-care professionals' experiences of patient participation among older patients in intermediate care-At the intersection between profession, market and bureaucracy.

BACKGROUND: Patient participation is a key concern in health care. Nevertheless, older patients often do not feel involved in their rehabilitation process. Research states that when organizational conditions exert pressure on the work situation, care as a mere technical activity seems to be prioritized by the health-care staff, at the expense of patient involvement. OBJECTIVE: The aim of this article is to explore how health-care professionals experience patient participation in IC services, and explain how they perform their clinical work balancing between the patient's needs, available resources and regulatory constraints. DESIGN: Using a framework of professional work and institutional logics, underpinned by critical realism, we conducted semi-structured interviews with 18 health-care professionals from three IC institutions. RESULTS: IC appears as an important service in the patient pathway for older people with a great potential for patient participation. However, health care staff may experience constraints that prohibit them from using professional discretion, which is perceived as a threat to patient participation. Further, they may adopt routines that simplify their interactions with patients. Our results call for more emphasis on an individualized rehabilitation process and a recognition that psychological and social aspects are critical for patient participation in IC. CONCLUSION: Patients interact in the face of conflicting institutional priorities or protocols. The study adds important knowledge about the practice of patient participation in IC from a front-line provider perspective. Underlying mechanisms are identified to understand and recommend how to facilitate patient participation at different levels in narrowing the gap between policy and clinical work in IC.

A cross-sectional evaluation of community pharmacists' perceptions of intermediate care and medicines management across the healthcare interface.

Background Despite the importance placed on the concept of the multidisciplinary team in relation to intermediate care (IC), little is known about community pharmacists' (CPs) involvement. Objective To determine CPs' awareness of and involvement with IC services, perceptions of the transfer of patients' medication information between healthcare settings and views of the development of a CP-IC service. Setting Community pharmacies in Northern Ireland. Methods A postal questionnaire, informed by previous qualitative work was developed and piloted. Main outcome measure CPs' awareness of and involvement with IC. Results The response rate was 35.3 % (190/539). Under half (47.4 %) of CPs 'agreed/strongly agreed' that they understood the term 'intermediate care'. Three quarters of respondents were either not involved or unsure if they were involved with providing services to IC. A small minority (1.2 %) of CPs reported that they received communication regarding medication changes made in hospital or IC settings 'all of the time'. Only 9.5 and 0.5 % of respondents 'strongly agreed' that communication from hospital and IC, respectively, was sufficiently detailed. In total, 155 (81.6 %) CPs indicated that they would like to have greater involvement with IC services. 'Current workload' was ranked as the most important barrier to service development. Conclusion It was revealed that CPs had little awareness of, or involvement with, IC. Communication of information relating to patients' medicines between settings was perceived as insufficient, especially between IC and community pharmacy settings. CPs demonstrated willingness to be involved with IC and services aimed at bridging the communication gap between healthcare settings.

How Well Do Inexpensive, Portable Pulse Oximeter Values Agree with Arterial Oxygenation Saturation in Acutely Ill Patients?

The purpose of this study was to examine the level of agreement between a portable SpO2 device and the clinical gold standard SaO2 in intermediate care patients.

Características de pacientes asmáticos ingresados en una unidad de cuidados respiratorios intermedios / Characteristics of Asthma Patients Admitted to an Intermediate Respiratory Care Unit

Introducción: Las unidades de cuidados respiratorios intermedios (UCRI) permiten la monitorización continua y la ventilación mecánica no invasiva (VMNI) en los pacientes con insuficiencia respiratoria grave que habitualmente ingresan en unidades de cuidados intensivos (UCI). La utilidad de las UCRI en el manejo de las agudizaciones graves del asma nunca ha sido evaluada. Métodos: Se recogieron de forma prospectiva y sistemática los datos clínicos de pacientes ingresados en la UCRI con el diagnóstico principal de asma bronquial agudizada, se evaluó el fracaso terapéutico (intubación o fallecimiento) y su evolución hasta 6meses tras el alta, comparada con un grupo de pacientes ingresados en planta de hospitalización convencional pareados por edad y sexo, con el mismo diagnóstico principal. Resultados: Se incluyeron un total de 74 pacientes asmáticos (37 ingresan en la UCRI y 37 en planta) con una edad media (±DE) de 58±20 años, predominantemente mujeres (67%), con diagnóstico previo y tratamiento de asma persistente. La causa principal de ingreso en la UCRI fue insuficiencia respiratoria grave. Los pacientes que ingresaron en la UCRI presentaron más afectación radiológica (infiltrados alveolares) y tenían una pCO2 significativamente mayor. Diez pacientes ingresados en la UCRI precisaron VMNI. No hubo diferencias entre ambos grupos en fracasos terapéuticos, ni en seguimiento a los 6meses del alta. Conclusiones: Los pacientes con agudizaciones graves del asma pueden ser atendidos en una UCRI, evitando ingresos en la UCI y con un pronóstico similar a las agudizaciones más leves que son ingresadas en una planta de hospitalización convencional(AU)

Introduction: Intermediate respiratory care units (IRCU) provide continuous monitoring and non-invasive mechanical ventilation (NIMV) in patients with severe respiratory failure who are usually admitted to intensive care units (ICUs). The usefulness of IRCU in managing severe asthma exacerbations has never been evaluated. Methods: Clinical data were prospectively and systematically compiled from patients admitted to the IRCU with a principal diagnosis of bronchial asthma exacerbation. We assessed therapeutic failure (intubation or exitus) and patient evolution up until 6 months after discharge compared with a group of patients admitted to a conventional hospital ward, paired for age and sex, and with the same principal diagnosis. Results: A total of 74 asthma patients were included (37 admitted to IRCU and 37 to the hospital ward) with a mean age (±SD) of 58±20, who were predominantly women (67%), with previous diagnosis of asthma and persistent asthma treatment. The main cause of admittance to the IRCU was severe respiratory failure. The patients who were admitted to the IRCU presented more radiological affectation (alveolar infiltrates) and had significantly higher pCO2. Ten patients admitted to the IRCU required non-invasive mechanical ventilation (NIMV). There were no differences between the two groups regarding either therapeutic failure or the 6-month follow-up after discharge. Conclusions: Patients with severe asthma exacerbations can be managed in an IRCU while avoiding hospitalization in an ICU and demonstrating a prognosis similar to milder exacerbations treated in conventional hospital wards(AU)

Results of a retrospective observational study of intermediate care staffed by hospitalists: impact on mortality, co-management, and teaching.

BACKGROUND: Hospitalized patients are complex and institutions have to face the high cost of critical care and the limited resources of the ward. Intermediate care appears as an attractive strategy to provide rational care according to patient needs. It is an interesting scenario to expand co-management and teaching. STUDY DESIGN: Retrospective observational study. SETTING: Intermediate care unit (ImCU) of a single academic hospital. PATIENTS AND METHODS: 456 patients admitted from April 2006 to April 2010 were included in the study. Demographics, admission physiologic parameters and in-hospital mortality were recorded. We used the Simplified Acute Physiology Score II (SAPS II) as prognostic score system. Co-management with medical and surgical teams, and the number of training residents were evaluated. RESULTS: In-hospital mortality was 20.6%, whereas the expected mortality was 23.2% based on SAPS II score. The correlation between SAPS II predicted and observed death rates was accurate and statistically significant (Rho = 1.0, p < 0.001). Co-management was performed with several medical and surgical teams, with an increase in perioperative comanagement of 22.7% (p = 0.014). The number of training residents in ImCU increased from 4.3% to 30.4% (p = 0.002) CONCLUSIONS: An ImCU led by hospitalists showed encouraging results regarding patient survival and SAPS II is an useful tool for prognostic evaluation in this population. Intermediate care serves as an expansion of role for hospitalists; and clinicians, trainees and patients may benefit from co-management and teaching opportunities at this unique level of care.

The hospital-based, post-acute geriatric evaluation and management unit: the experience of the acute geriatric unit in Trieste.

In 2005, the Azienda Ospedaliero-Universitaria of Trieste (AOUT) activated the hospital-based post-acute geriatric evaluation and management unit (PAGEMU). The purpose of the study is to illustrate the activities of the PAGEMU, and to evaluate the effects of personalized and multidisciplinary care on geriatric inpatients. The evaluation for admission in PAGEMU included general admitting criteria, co-morbidity, autonomy, and assessment of the patient's pre-morbid functional status. During the stay, inpatients completed their treatment plan, comprehensive geriatric assessment was carried out, and rehabilitation and nutritional interventions were implemented. If necessary, a new diagnostic-therapeutic plan was provided. A number of 826 patients were evaluated for admission in PAGEMU (612 patients from surgical departments and 214 from medical wards). The mean length of stay was 19.55 days. Re-evaluation of patients at discharge showed a statistically significant improvement in co-morbidity and in self-sufficiency, not in cognitive or mood status. PAGEMU is a valid model both for patient-oriented and for management-oriented objectives, shortening the length of stay in acute care settings and increasing hospital turnover.

Actividad de una unidad de cuidados respiratorios intermedios dependiente de un servicio de neumología / Activity of an Intermediate Respiratory Care Unit Attached to a Respiratory Medicine Department

Introducción y objetivo: El desarrollo de la ventilación no invasiva (VNI) ha aumentado la complejidad de los pacientes ingresados en los servicios de neumología. Por ello, en España y Europa se están incorporando unidades especiales para el seguimiento y tratamiento de pacientes con enfermedades respiratorias graves: las unidades de cuidados respiratorios intermedios (UCRI). El objetivo del presente estudio ha sido describir la actividad de una UCRI dependiente de un servicio de neumología. Esta información puede ser un punto de referencia útil que facilite la implementación de las UCRI en otros hospitales del Sistema Nacional de Salud español. Métodos: De enero a diciembre de 2006, ambos inclusive, se recogió de forma prospectiva y sistemática la actividad realizada en la UCRI del Hospital Universitario Son Dureta. Resultados: Ingresaron 206 pacientes, cuya edad media (±desviación estándar) era de 65±14 años. Los Servicios de Urgencias y Neumología y la Unidad de Cuidados Intensivos (UCI) aportaron, respectivamente, el 67, el 14 y el 12% de todos los ingresos. Los principales diagnósticos de ingreso fueron: agudización de la enfermedad pulmonar obstructiva crónica (EPOC, con 97 casos; 47,1%), neumonía (n=39; 18,9%) e insuficiencia cardíaca (n=17; 8,2%). Del total de pacientes, 121 (59%) precisaron VNI. La estancia media fue de 5±5 días. El 79,1% recibió el alta a camas de hospitalización convencional del propio Servicio de Neumología, el 7,8% requirió ingreso posterior en la UCI y el 9,7% falleció. De los pacientes con agudización de la EPOC (edad media: 66,5±10 años; estancia media: 4,6±4,5 días), el 67% precisó VNI, el 7,2% requirió un ingreso posterior en la UCI y el 8,2% falleció(AU)

Conclusiones: En nuestro país es viable la creación de una UCRI dependiente del servicio de neumología. Estas unidades permiten desarrollar una alta actividad asistencial con un bajo porcentaje de fracasos terapéuticos. La agudización de la EPOC fue el diagnóstico de ingreso más habitual en nuestra UCRI, y la necesidad de tratamiento con VNI, el criterio de ingreso más frecuente(AU)

Background and objectiveWith the development of noninvasive ventilation (NIV), patients with increasingly complex needs have been admitted to respiratory medicine departments. For this reason, such departments in Spain and throughout Europe have been adding specialized respiratory intermediate care units (RICUs) for monitoring and treating patients with severe respiratory diseases. The aim of the present study was to describe the activity of such a RICU. The description may be of use in facilitating the setting up of RICUs in other hospitals of the Spanish National Health Service. MethodsA systematic record of activity carried out in the RICU of the Hospital Universitario Son Dureta between January and December 2006 was kept prospectively. ResultsOf 206 patients with a mean (SD) age of 65 (14) years admitted to the unit, 67% came from the emergency department, 14% from the respiratory medicine department, and 12% from the intensive care unit (ICU). The most common admission diagnoses were exacerbated chronic obstructive pulmonary disease (COPD) (n=97, 47.1%), pneumonia (n=39, 18.9%), heart failure (n=17, 8.2%), and pulmonary vascular diseases (n=18, 8.7%). One hundred twenty-one patients (59%) required NIV. Mean length of stay in the RICU was 5 (5) days. Patients were discharged to the conventional respiratory ward in 79.1% of the cases; 7.8% required subsequent admission to the ICU, and 9.7% died. Of the patients with exacerbated COPD (mean age, 66.5 [10] years; mean length of stay, 4.6 [4.5] days), 67% required NIV, 7.2% required subsequent admission to the ICU, and 8.2% died. ConclusionsThe creation of a RICU by a respiratory medicine department is viable in Spain. Such units make it possible to treat a large number of patients with a low rate of therapeutic failures. Exacerbated COPD was the most common diagnosis on admission to our RICU, and the need for NIV the most common criterion for admission(AU)

Prevalence of depression and anxiety symptoms in elderly patients admitted in post-acute intermediate care.

OBJECTIVES: Depression and anxiety symptoms are common in medically ill older patients. We investigated the prevalence and predictors of depression and anxiety symptoms in older patients admitted for further rehabilitation in post acute intermediate care. DESIGN: Observational cohort study. SETTING: An intermediate care unit, North West of England. PARTICIPANTS: One hundred and seventy-three older patients (60 male), aged mean (SD) 80 (8.1) years, referred for further rehabilitation to intermediate care. MEASUREMENTS: Depression and anxiety symptoms were assessed by the Hospital Anxiety and Depression Scale, and severity of depression examined by the Montgomery Asberg Depression Rating Scale. Physical disability was assessed by the Nottingham Extended ADL Scale and quality of life by the SF-36. RESULTS: Sixty-five patients (38%) were identified with depressive symptoms, 29 (17%) with clinical depression, 73 (43%) with anxiety symptoms, and 43 (25%) with clinical anxiety. 15 (35%) of the latter did not have elevated depression scores (9% of the sample). Of those with clinical depression, 14 (48%) were mildly depressed and 15 (52%) moderately depressed. Longer stay in the unit was predicted by severity of depression, physical disability, low cognition and living alone (total adjusted R2 = 0.24). CONCLUSIONS: Clinical depression and anxiety are common in older patients admitted in intermediate care. Anxiety is often but not invariably secondary to depression and both should be screened for. Depression is an important modifiable factor affecting length of stay. The benefits of structured management programmes for anxiety and depression in patients admitted in intermediate care are worthy of evaluation.

Intermediate care and older people.

Intermediate care services are taking on an increasingly significant role in the rehabilitation and care of older people. It is vital that nurses and other members of the healthcare team have a good understanding of intermediate care.

Utilidad de una Unidad de Cuidados Intermedios en un Hospital Comarcal / Usefulness of an intermediate Care Unit in a District Hospital

La política sanitaria actual tiende a la reducción de costes. En función de la presión asistencial se asignan los recursos y esto tiene una gran importancia en las denominadas “camas de críticos”, fundamentalmente las de las Unidades de Cuidados Intensivos (UCI), consideradas en general como “costosas”. Alternativas a las UCIs son aquellas unidades con monitorización suficiente para satisfacer las necesidades del paciente, fundamentalmente de aquellos que requieren procedimientos de diagnóstico y manejo de enfermería, pero no un cuidado médico estricto con el consiguiente ahorro económico. La presente revisión tiene como objeto la valoración de distintos puntos en relación a estas unidades, conviniendo en su posible utilidad en hospitales de segundo nivel o comarcales (AU)

Current health care policy shows a definite trend toward cost reduction. Resources are assigned in the light of assistential pressure, and this has a considerable impact on the socalled “critical patients beds”, mainly those in Intensive Care Units (ICU´s), which are generally considered to be “expensive”. An alternative to ICU´s might be the establishment of units with monitoring capabilities sufficient for satisfying the patients needs and requirements, mainly in those patients requiring diagnostic procedures and nursing management but not a strict medical care, with the corresponding econocmic savings. The present review has the aim to assess a number of aspect in relation to such units, stressing their possible usefulness in second-level or district hospitals (AU)

New practices in the transitional care center improve outcomes for babies and their families.

Assuming sole responsibility of parenting a high-risk infant after a prolonged hospital stay can be a complex and traumatic event, especially when the infant is discharged with residual health care problems requiring medical management and treatment at home. A parent's ability to successfully transition the management of their infant's care from hospital to home depends on a collaborative discharge process where parents are ongoing, full participants. The Transitional Care Center environment makes learning comfortable for parents, allows parental care-giver mastery to occur, and fosters family integration. Favorable clinical outcomes concurrent with decreased lengths of hospital stays and readmission rates have been demonstrated.