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1.
BMJ Open ; 8(12): e023172, 2018 12 16.
Artigo em Inglês | MEDLINE | ID: mdl-30559156

RESUMO

OBJECTIVE: To examine changes in places of dementia-related death following implementation of the national dementia plan and other policy initiatives. DESIGN: Observational study. SETTING: Japan between October 1996 and September 2016. Four major changes in health and social care systems were identified: (1) the public long-term care insurance programme (April 2000); (2) community centres as a first access point for older residents (April 2006); (3) medical care system for older people (April 2008) and (4) the national dementia plan (April 2013). PARTICIPANTS: 9 60 423 decedents aged 65 years or older whose primary cause of death was Alzheimer's disease, vascular or other types of dementia or senility. MAIN OUTCOME MEASURES: Place of death which was classified into 'hospital', 'intermediate geriatric care facility' (rehabilitation facility aimed at home discharge), 'nursing home' or 'own home'. RESULTS: The annual number of deaths at hospital was consistently increased over time from 1996 to 2016 (age-adjusted OR: 6.01; 95% CI 5.81 to 6.21 versus home deaths). Controlling for individual characteristics, regional supply of hospital and nursing home beds and other changes in health and social care systems, death from dementia following the national dementia plan was likely to occur in hospital (adjusted OR: 1.21; 95% CI 1.18 to 1.24), intermediate geriatric care facility (adjusted OR: 1.53; 95% CI 1.48 to 1.58) or nursing home (adjusted OR: 1.64; 95% CI 1.60 to 1.69) rather than at home. CONCLUSIONS: As the number of deaths from dementia increased over the decades, in-hospital deaths increased regardless of the national dementia plan. Further strategies should be explored to improve the availability of palliative and end-of-life care at patients' places of residence.


Assuntos
Serviços de Saúde Comunitária/estatística & dados numéricos , Atestado de Óbito , Demência/mortalidade , Implementação de Plano de Saúde/estatística & dados numéricos , Mortalidade Hospitalar , Assistência de Longa Duração/estatística & dados numéricos , Programas Nacionais de Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Doença de Alzheimer/mortalidade , Serviços de Saúde Comunitária/organização & administração , Feminino , Implementação de Plano de Saúde/organização & administração , Humanos , Instituições para Cuidados Intermediários/organização & administração , Instituições para Cuidados Intermediários/estatística & dados numéricos , Japão , Assistência de Longa Duração/organização & administração , Masculino , Programas Nacionais de Saúde/organização & administração , Assistência Terminal/organização & administração , Assistência Terminal/estatística & dados numéricos
2.
Patient Educ Couns ; 101(8): 1337-1350, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29551564

RESUMO

OBJECTIVE: Although the concept of patient participation has been discussed for a number of years, there is still no clear definition of what constitutes the multidimensional concept, and the application of the concept in an intermediate care (IC) context lacks clarity. Therefore this paper seeks to identify and explore the attributes of the concept, to elaborate ways of understanding the concept of patient participation for geriatric patients in the context of IC. METHODS: Walker and Avant's model of Concept analysis [1] based on a literature review. RESULTS: Patient participation in the context of IC can be defined as a dynamic process emphasizing the person as a whole, focusing on the establishment of multiple alliances that facilitate individualized information and knowledge exchange, and ensuring a reciprocal engagement in activities within flexible and interactive/dynamic organizational structures. CONCLUSION: Patient participation in IC means involving patients and their relatives in holistic interdisciplinary collaborative decision-making. The results highlight the complexity of patient participation and contribute to a greater understanding of the influence of organizational structure and management. PRACTICAL IMPLICATIONS: The present study may provide a practical framework for researchers, policy makers and health professionals to facilitate patient participation in IC services.


Assuntos
Serviços de Saúde para Idosos/organização & administração , Instituições para Cuidados Intermediários/organização & administração , Participação do Paciente , Garantia da Qualidade dos Cuidados de Saúde/organização & administração , Idoso , Tomada de Decisões , Humanos , Equipe de Assistência ao Paciente/organização & administração , Relações Profissional-Paciente
6.
Ann Am Thorac Soc ; 14(3): 384-391, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28033032

RESUMO

RATIONALE: Cardiorespiratory insufficiency (CRI) is a term applied to the manifestations of loss of normal cardiorespiratory reserve and portends a bad outcome. CRI occurs commonly in hospitalized patients, but its risk escalation patterns are unexplored. OBJECTIVES: To describe the dynamic and personal character of CRI risk evolution observed through continuous vital sign monitoring of individual step-down unit patients. METHODS: Using a machine learning model, we estimated risk trends for CRI (defined as exceedance of vital sign stability thresholds) for each of 1,971 admissions (1,880 unique patients) to a 24-bed adult surgical trauma step-down unit at an urban teaching hospital in Pittsburgh, Pennsylvania using continuously recorded vital signs from standard bedside monitors. We compared and contrasted risk trends during initial 4-hour periods after step-down unit admission, and again during the 4 hours immediately before the CRI event, between cases (ever had a CRI) and control subjects (never had a CRI). We further explored heterogeneity of risk escalation patterns during the 4 hours before CRI among cases, comparing personalized to nonpersonalized risk. MEASUREMENTS AND MAIN RESULTS: Estimated risk was significantly higher for cases (918) than control subjects (1,053; P ≤ 0.001) during the initial 4-hour stable periods. Among cases, the aggregated nonpersonalized risk trend increased 2 hours before the CRI, whereas the personalized risk trend became significantly different from control subjects 90 minutes ahead. We further discovered several unique phenotypes of risk escalation patterns among cases for nonpersonalized (14.6% persistently high risk, 18.6% early onset, 66.8% late onset) and personalized risk (7.7% persistently high risk, 8.9% early onset, 83.4% late onset). CONCLUSIONS: Insights from this proof-of-concept analysis may guide design of dynamic and personalized monitoring systems that predict CRI, taking into account the triage and real-time monitoring utility of vital signs. These monitoring systems may prove useful in the dynamic allocation of technological and clinical personnel resources in acute care hospitals.


Assuntos
Cuidados Críticos/métodos , Hospitalização/estatística & dados numéricos , Instituições para Cuidados Intermediários/normas , Monitorização Fisiológica/métodos , Sinais Vitais , Adulto , Idoso , Feminino , Indicadores Básicos de Saúde , Hospitais de Ensino , Humanos , Instituições para Cuidados Intermediários/organização & administração , Modelos Logísticos , Aprendizado de Máquina , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica/normas , Pennsylvania , Estudo de Prova de Conceito , Medição de Risco/métodos , Triagem
9.
Respiration ; 90(3): 235-42, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26160422

RESUMO

BACKGROUND: Respiratory intermediate care units (RICUs) are specialized areas aimed at optimizing the cost-benefit ratio of care. No data exist about the impact of opening a RICU on hospital outcomes. OBJECTIVES: We wondered if opening a RICU may improve the outcomes of patients with acute respiratory failure (ARF), acute exacerbation of chronic obstructive pulmonary disease (AECOPD), or community-acquired pneumonia (CAP). METHODS: We analyzed the discharge abstracts of 2,372 admissions to the RICU and internal medicine units (IMUs) for ARF, AECOPD, and CAP. The IMUs at the Hospital of Trieste comprise emergency and internal wards. In order to investigate the determinants of outcomes, a matched case-control study was performed using clinical records. RESULTS: The in-hospital mortality rate was lower in the RICU vs. IMUs (5.4 vs. 19.1%, p = 0.0001). Statistical differences did not change when comparing the RICU with the emergency and internal wards. After adjusting for potential confounders, the risk of death for patients with CAP, AECOPD, or ARF was significantly higher in the IMUs than in the RICU (OR 6.90, 3.19, and 6.7, respectively, p < 0.04). Both the frequency of transfer to the ICU (6 vs. 12%, p = 0.0001, OR 0.38) and the hospital stay (9.3 vs. 12.1 days, p = 0.0001) were reduced in patients admitted to the RICU compared to those admitted to non-RICUs. Significant differences were found in care management concerning chest physiotherapy, mechanical ventilation, antibiotics, and corticosteroids. CONCLUSIONS: The opening of a RICU may be advantageous to reduce in-hospital mortality, the need for ICU admission, and the hospital stay of patients with AECOPD, CAP, and ARF. Better use of care resources contributed to better patient management in the RICU.


Assuntos
Mortalidade Hospitalar , Instituições para Cuidados Intermediários/organização & administração , Pneumonia/mortalidade , Doença Pulmonar Obstrutiva Crônica/mortalidade , Doença Pulmonar Obstrutiva Crônica/terapia , Insuficiência Respiratória/terapia , Adulto , Idoso , Estudos de Casos e Controles , Causas de Morte , Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/mortalidade , Infecções Comunitárias Adquiridas/terapia , Intervalos de Confiança , Feminino , França , Hospitais Gerais , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Razão de Chances , Pneumonia/diagnóstico , Pneumonia/terapia , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/mortalidade , Medição de Risco , Análise de Sobrevida , Resultado do Tratamento
10.
Br J Community Nurs ; 20(2): 74-9, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25651281

RESUMO

In the UK, intermediate care (IC) is conceived as a range of service models aimed at 'care closer to home' and involves the expansion and development of community health and social services. Intermediate care in Denmark is more clearly defined, where approximately 45% of all the counties in Denmark have established a community-based IC unit in which public health-care services are offered to older people who have completed their hospital treatment. The impact of this organisational initiative is yet to be explored. In particular, the knowledge of the patient perspective is sparse and contradictory. The aim of the study was to explore how older people experience being in an IC unit after hospital discharge and before returning to their home. Data were drawn from 12 semi-structured interviews. Transcripts were analysed using a phenomenological approach. The essence of being in an IC unit was envisioned as 'moments of conditional relief' that emerged from the following constituents: 'accessible, embracing care', 'a race against time', 'meals-conventions with modifications', 'contact on uneven terms', 'life on others' terms', and 'informal but essential help'.


Assuntos
Serviços de Saúde Comunitária/organização & administração , Instituições para Cuidados Intermediários/organização & administração , Idoso , Idoso de 80 Anos ou mais , Dinamarca , Gerenciamento Clínico , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade
11.
Am J Respir Crit Care Med ; 191(2): 186-93, 2015 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-25494358

RESUMO

RATIONALE: Little is known about the utility of provision of high-dependency care (HDC) that is in a geographically separate location from a primary intensive care unit (ICU). OBJECTIVES: To determine whether the availability of HDC in a geographically separate unit affects patient flow or mortality for critically ill patients. METHODS: Admissions to ICUs in the United Kingdom, from 2009 to 2011, who received Level 3 intensive care in the first 24 hours after admission and subsequently Level 2 HDC. We compared differences in patient flow and outcomes for patients treated in hospitals providing some HDC in a geographically separate unit (dual HDC) with patients treated in hospitals providing all HDC in the same unit as intensive care (integrated HDC) using multilevel mixed effects models. MEASUREMENTS AND MAIN RESULTS: In 192 adult general ICUs, 21.4% provided dual HDC. Acute hospital mortality was no different for patients cared for in ICUs with dual HDC versus those with integrated HDC (adjusted odds ratio, 0.94 [0.86-1.03]; P = 0.16). Dual HDC was associated with a decreased likelihood of a delayed discharge from the primary unit. However, total duration of critical care and the likelihood of discharge from the primary unit at night were increased with dual HDC. CONCLUSIONS: Availability of HDC in a geographically separate unit does not impact acute hospital mortality. The potential benefit of decreasing delays in discharge should be weighed against the increased total duration of critical care and greater likelihood of a transfer out of the primary unit at night.


Assuntos
Cuidados Críticos/organização & administração , Estado Terminal/mortalidade , Mortalidade Hospitalar , Unidades de Terapia Intensiva/organização & administração , Instituições para Cuidados Intermediários/organização & administração , Transferência de Pacientes/organização & administração , APACHE , Estudos de Coortes , Custos e Análise de Custo , Cuidados Críticos/economia , Cuidados Críticos/estatística & dados numéricos , Estado Terminal/terapia , Grupos Diagnósticos Relacionados/estatística & dados numéricos , Feminino , Humanos , Unidades de Terapia Intensiva/economia , Unidades de Terapia Intensiva/estatística & dados numéricos , Instituições para Cuidados Intermediários/economia , Instituições para Cuidados Intermediários/estatística & dados numéricos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Transferência de Pacientes/métodos , Transferência de Pacientes/estatística & dados numéricos , Medição de Risco , Reino Unido/epidemiologia
13.
Age Ageing ; 44(2): 182-4, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25377746

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 , 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 , Determinação de Necessidades de Cuidados de Saúde , Satisfação do Paciente , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Medicina Estatal/organização & administração , Reino Unido
14.
BMC Anesthesiol ; 14: 76, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25276092

RESUMO

BACKGROUND: Improvement of appropriate bed use and access to intensive care (ICU) beds is essential in optimizing utilization of ICU capacity. The introduction of an intermediate care unit (IMC) integrated in the ICU care may improve this utilization. METHOD: In a before-after prospective intervention study in a university hospital mixed ICU, the impact of introducing a six-bed mixed IMC unit supervised and staffed by ICU physicians was investigated. Changes in ICU utilization (length of stay, frequency of mechanical ventilation use), nursing workload assessed byTISS-28 score, as well as inappropriate bed use, accessibility of the ICU (number of referrals), and clinical outcome indicators (readmission and mortality rates) were measured. RESULTS: During 17 months, data of 1027 ICU patients were collected. ICU utilization improved significantly with an increased appropriate use of ICU beds. However, the number of referrals, readmissions to the ICU and mortality rates did not decrease after the IMC was opened. CONCLUSION: The IMC contributed to a more appropriate use of ICU facilities and did result in a significant increase in mean nursing workload at the ICU.


Assuntos
Unidades de Terapia Intensiva/organização & administração , Instituições para Cuidados Intermediários/organização & administração , Adulto , Idoso , Eficiência Organizacional , Feminino , Hospitais Universitários , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Enfermeiras e Enfermeiros , Readmissão do Paciente/estatística & dados numéricos , Estudos Prospectivos , Respiração Artificial/estatística & dados numéricos , Resultado do Tratamento , Carga de Trabalho
15.
Soc Sci Med ; 119: 27-35, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25137645

RESUMO

There is growing international interest in the geography of health care provision, with health care providers searching for alternatives to acute hospitalization. In Norway, the government has recently legislated for municipal authorities to develop local health services for a selected group of patients, with a quality equal to or better than that provided by hospitals for emergency admissions. General practitioners in Hallingdal, a rural district in southern Norway, have for several years referred acutely somatically ill patients to a community hospital, Hallingdal sjukestugu (HSS). This article analyzes patients' perceived quality of HSS to demonstrate factors applicable nationally and internationally to aid in the development of local alternatives to general hospitals. We used a mixed-methods approach with questionnaires, individual interviews and a focus group interview. Sixty patients who were taking part in a randomized, controlled study of acute admissions at HSS answered the questionnaire. Selected patients were interviewed about their experiences and a focus group interview was conducted with representatives of local authorities, administrative personnel and health professionals. Patients admitted to HSS reported statistically significant greater satisfaction with several care aspects than those admitted to the general hospital. Factors highlighted by the patients were the quiet and homelike atmosphere; a small facility which allowed them a good overall view of the unit; close ties to the local community and continuity in the patient-staff relationship. The focus group members identified some overarching factors: an interdisciplinary and holistic approach, local ownership, proximity to local general practices and close cooperation with the specialist health services at the hospital. Most of these factors can be viewed as general elements relevant to the development of local alternatives to acute hospitalization both nationally and internationally. This study indicates that perceived quality should be one of the main motivations for developing alternatives to general hospital admissions.


Assuntos
Hospitalização/estatística & dados numéricos , Instituições para Cuidados Intermediários/organização & administração , Satisfação do Paciente , Encaminhamento e Consulta/organização & administração , Serviços de Saúde Rural/organização & administração , Idoso , Idoso de 80 Anos ou mais , Feminino , Grupos Focais , Humanos , Masculino , Pessoa de Meia-Idade , Noruega , Percepção , Qualidade da Assistência à Saúde
16.
Am J Respir Crit Care Med ; 190(11): 1210-6, 2014 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-25163008

RESUMO

Stepdown beds provide an intermediate level of care for patients with requirements somewhere between that of the general ward and the intensive care unit. Models of care include incorporation of stepdown beds into intensive care units, stand-alone units, or incorporation of beds into standard wards. Stepdown beds may be used to provide a higher level of care for patients deteriorating on a ward ("step-up"), a lower level of care for patients transitioning out of intensive care ("stepdown") or a lateral transfer of care from a recovery room for postoperative patients. These units are one possible strategy to improve critical care cost-effectiveness and patient flow without compromising quality, but these potential benefits remain primarily theoretical as few patient-level studies provide concrete evidence. This narrative review provides a general overview of the theory of stepdown beds in the care of hospitalized patients and a summary of what is known about their impact on patient flow and outcomes and highlights areas for future research.


Assuntos
Continuidade da Assistência ao Paciente/normas , Cuidados Críticos/métodos , Instituições para Cuidados Intermediários/normas , Continuidade da Assistência ao Paciente/economia , Continuidade da Assistência ao Paciente/organização & administração , Controle de Custos/métodos , Cuidados Críticos/economia , Cuidados Críticos/organização & administração , Comparação Transcultural , Humanos , Instituições para Cuidados Intermediários/economia , Instituições para Cuidados Intermediários/organização & administração
17.
Nurs Older People ; 26(3): 16-20, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24673323

RESUMO

Intermediate care services are usually intended for frail, older people and those with complex needs. Their aims are to avoid unnecessary hospital admission, help people regain independence after a hospital stay and prevent premature admission to long-term care. Services are time limited and delivered in patients' own homes, community hospitals and sometimes nursing homes. But, as Louise Hunt reports, the second national audit of intermediate care, published late last year, found capacity in England is just half of what is needed. There is also significant variation between localities in capacity outside hospital and in the balance of bed-based, home-based and re-enablement services. Two case studies are presented of intermediate care services where nurses play an important role in achieving positive outcomes for patients and saving the health service money.


Assuntos
Instituições para Cuidados Intermediários/organização & administração , Idoso , Demência/enfermagem , Humanos , Auditoria Médica , Recursos Humanos de Enfermagem , Admissão e Escalonamento de Pessoal , Reino Unido
18.
J Clin Nurs ; 23(3-4): 586-95, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23651433

RESUMO

AIMS AND OBJECTIVES: To explore the activities carried out and the conditions required to enable satisfactory work in an intermediate unit for patients aged 60 and older. BACKGROUND: In recent years, several intermediate units have been established to improve the clinical pathway from hospital to home for older patients. DESIGN: Qualitative study. METHODS: Data were obtained from interviews with eight patients and 16 healthcare providers working in the unit and from observations in six multidisciplinary meetings and six report meetings in the unit. Transcripts of interviews and field notes were analysed using a method for systematic text condensation. RESULTS: Care performed as a balance between relational, practical and moral aspects seems to be important to render good service to patients and to ensure the providers' job satisfaction. Most patients experienced their stay in the unit as positive. The providers highlighted 'suitable patients', an appropriate physical environment and communicating computer systems as significant factors for performing treatment and for providing nursing and rehabilitation in a caring manner. CONCLUSIONS: When environmental and organisational conditions exert pressure on the working situation, care as a practical activity seems to be prioritised at the expense of the two other aspects. The findings indicate that unfavourable environmental and organisational conditions impede patients' recovery process and thereby a good clinical pathway. RELEVANCE TO CLINICAL PRACTICE: To recruit, support and retain a multidisciplinary staff to the best interest of patients, it seems to be important to perform care work as a balance between relational, practical and moral activities.


Assuntos
Instituições para Cuidados Intermediários/organização & administração , Princípios Morais , Idoso , Humanos , Pessoa de Meia-Idade
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