Search

Identifying frequent users' (≥3admissions/year) associated factors in an emergency department (ED), using a comprehensive geriatric assessment (CGA), describing the characteristics of patients over 65 years of age.A cross-sectional study was performed between August 2017 and June 2018 in an ED in Lisbon, Portugal. CGA was applied and completed with clinical records. Clinical, functional, mental and social scores were created based in Portuguese Society of Internal Medicine, and a statistical model was developed.CGA was applied to 426 patients over 64 years old in an ED. The mean age was 79.3, 84.7% had multimorbidity. 51.2%, 75.6%, and 40% had dependence on basic, instrumental, and walking activities, respectively. 52% had depressive symptoms, 65.7% had cognitive impairment, 63% were undernourished/at risk for malnutrition. 33.1% were socially at risk. Polypharmacy was present with a use on average of 6.5 drugs daily. Social, clinical, functional, and mental scores were unfavourable in 48.6%, 79.6%, 54.9% and 83.1% of the population, respectively. There were 2.7 hospital admissions/year and 39.9% were frequent ED users (≥3/year). The logistic regression model was weak, but showed that patients with polypharmacy, elevated Charlson Comorbidity index and an impairment nutritional status presented higher risk of being frequent users.This study showed that 97.1% of patients had needs that would justify an interventional care plan. This intervention should be extended to primary care and nursing homes. While not providing a robust model, our study has indicated nutritional problems, polypharmacy, and an elevated Charlson index as the features with more weight in frequent users' admissions.

Cancellations of elective operations on the day of the surgery reflect the efficiency and quality within organisations, and have a significant clinical, social and economic impact, not only for the patient and their families, but also for healthcare institutions. This study assesses the extent of these cancellations in one public Portuguese hospital, through case quantification and identification of the causes, origin, as well as its predictability according to the sociodemographic variables of the patient and interventions used to decrease it.Non-experimental descriptive quantitative methodology - longitudinal and retrospective - of operation cancellation cases on the day of the surgery, from the 1st of January to the 31st of December 2018.The rate of cancellations of elective surgeries on the same day of the operation was 2.9% with variations among different surgical specialties; cancelled operations are more frequent in female patients, in patients aged between 50 and 80 years old, physical status classified as II or III according to the American Society of Anesthesiology, and without anaesthetic pre assessment or preoperative consultations; the three most relevant causes for cancellations are: lack of operative time, scarcity of beds and/or medical equipment, and changes in health status; most of which can be avoided and are the responsibility of the institution.Different reasons for cancellation of elective operations reflect a variety of upstream and downstream processes causing cancellation of surgeries and whose origin/imputability is related to both the institution and patients.The rate of cancellations of elective surgeries on the same day of the operation is relatively low, but the causes are often preventable, thus justifying the generalization of cancellation reduction strategies.Introdução: Os cancelamentos de cirurgias eletivas que ocorrem no próprio dia da cirurgia acarretam importantes consequências clínicas, sociais e económicas, individuais e familiares, mas também institucionais, e refletem processos de eficiência e qualidade das organizações. Este estudo pretende avaliar a dimensão dos cancelamentos no dia da cirurgia numa instituição do Serviço Nacional de Saúde, quantificando-os, identificando as causas, origem e previsibilidade, na relação com variáveis sociodemográficas e intervenções dedicadas à sua redução.Material e Métodos: Metodologia quantitativa descritiva, de abordagem não experimental, longitudinal e de dimensão temporal retrospetiva, relativa aos episódios com cancelamentos cirúrgicos no dia da cirurgia, decorridos no período compreendido entre 1 de janeiro e 31 de dezembro de 2018.Resultados: A taxa de cancelamento no próprio dia foi de 2,9%, variando entre as especialidades cirúrgicas, maioritariamente em doentes do sexo feminino, na faixa etária dos 50 aos 80 anos, com estado físico II ou III, segundo a American Society of Anestesiology, e sem consulta pré-anestésica ou pré-operatória prévias; as três causas de cancelamentos mais evidentes são: a falta de tempo operatório, a falta de camas e/ou materiais e a alteração do estado de saúde, a maioria das quais evitáveis e imputáveis à instituição.Discussão: Os múltiplos motivos de cancelamento refletem uma variedade de processos a montante e a jusante, que culminam no cancelamento cirúrgico, e cuja a origem/imputabilidade se dispersa entre a instituição e o próprio doente.Conclusão: A taxa de cancelamento de cirurgias eletivas no próprio dia da operação é relativamente baixa, mas as causas são frequentemente evitáveis, justificando a generalização de estratégias de redução dos cancelamentos.

Kris Vanhaecht,1,2 Cathy Lodewijckx,1 Walter Sermeus,1 Marc Decramer,3,4 Svin Deneckere,1,5 Fabrizio Leigheb,6 Paulo Boto,7 Seval Kul,8 Deborah Seys,1 Massimiliano Panella1,6 1Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven – University of Leuven, 2Department of Quality Management, University Hospitals Leuven, 3Department of Clinical and Experimental Medicine, KU Leuven – University of Leuven, 4University Hospitals Leuven, Leuven, 5Medical Department, Delta Hospitals Roeselare, Roeselare, Belgium; 6Department of TranslationalMedicine, University of Eastern Piedmont, Vercelli, Italy; 7Department of Health Services Policy and Management, Centro de Investigação em Saúde Pública, Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal; 8Department of Biostatistics, School of Medicine, University of Gaziantep, Gaziantep, Turkey Purpose: Current in-hospital management of exacerbations of COPD is suboptimal, and patient outcomes are poor. The primary aim of this study was to evaluate whether implementation of a care pathway (CP) for COPD improves the 6months readmission rate. Secondary outcomes were the 30days readmission rate, mortality, length of stay and adherence to guidelines. Patients and methods: An international cluster randomized controlled trial was performed in Belgium, Italy and Portugal. General hospitals were randomly assigned to an intervention group where a CP was implemented or a control group where usual care was provided. The targeted population included patients with COPD exacerbation. Results: Twenty-two hospitals were included, whereof 11 hospitals (n=174 patients) were randomized to the intervention group and 11 hospitals (n=168 patients) to the control group. The CP had no impact on the 6months readmission rate. However, the 30days readmission rate was significantly lower in the intervention group (9.7%; 15/155) compared to the control group (15.3%; 22/144) (odds ratio =0.427; 95% confidence interval 0.222–0.822; P=0.040). Performance on process indicators was significantly higher in the intervention group for 2 of 24 main indicators (8.3%). Conclusion: The implementation of this in-hospital CP for COPD exacerbation has no impact on the 6months readmission rate, but it significantly reduces the 30days readmission rate. Keywords: COPD, care pathway, readmission, quality improvement, cluster randomized controlled trial

BACKGROUND: Adherence to guidelines for patients with proximal femur fracture is suboptimal. OBJECTIVE: To evaluate the effect of a care pathway for the in-hospital management of older geriatric hip fracture patients on adherence to guidelines and patient outcomes. DESIGN: The European Quality of Care Pathways study is a cluster randomized controlled trial. SETTING: 26 hospitals in Belgium, Italy and Portugal. SUBJECTS: Older adults with a proximal femur fracture (n = 514 patients) were included. METHODS: Hospitals treating older adults (>65) with a proximal femur fracture were randomly assigned to an intervention group, i.e. implementation of a care pathway, or control group, i.e. usual care. Thirteen patient outcomes and 24 process indicators regarding in-hospital management, as well as three not-recommended care activities were measured. Adjusted and unadjusted regression analyses were conducted using intention-to-treat procedures. RESULTS: In the intervention group 301 patients in 15 hospitals were included, and in the control group 213 patients in 11 hospitals. Sixty-five percent of the patients were older than 80 years. The implementation of this care pathway had no significant impact on the thirteen patient outcomes. The preoperative management improved significantly. Eighteen of 24 process indicators improved, but only two improved significantly. Only for a few teams a geriatrician was an integral member of the treatment team. DISCUSSION: Implementation of a care pathway improved compliance to evidence, but no significant effect on patient outcomes was found. The impact of the collaboration between surgeons and geriatricians on adherence to guidelines and patient outcomes should be studied. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00962910. ispartof: Injury vol:49 issue:8 pages:1581-1586 ispartof: location:Netherlands status: Published online

Despite the availability of clinical guidelines on the prevention and treatment of geriatric hip fractures, the percentage of recommended care received by patients is low. We conducted an importance-performance analysis for prioritizing interventions to improve the in-hospital management of these patients.A secondary data analysis was conducted on the in-hospital treatment of 540 geriatric hip fracture patients in 34 hospitals in Belgium, Italy, and Portugal. First, we assessed the level of expert consensus on the process indicators composing international guidelines on hip fracture treatment. Second, guideline adherence on in-hospital care was evaluated within and across hospitals. Third, an importance-performance analysis was conducted, linking expert consensus to guideline adherence.Level of expert consensus was high (above 75%) for 12 of 22 process indicators identified from the literature. There is large between and within hospital variation in guideline adherence for these indicators and for none of the 540 patients were all 22 process indicators adhered to. Importance-performance analysis demonstrated that three indicators that had a high level of expert consensus also had a high level of adherence (above 80%). Nine indicators, most of which have been previously linked to patient outcomes, had a high level of expert consensus but a consistently low level of adherence across hospitals and are identified as priority areas for improvement.Guideline adherence for the treatment of geriatric hip fracture patients is remarkably suboptimal. Importance-performance analysis is a useful strategic approach to assist practitioners and healthcare managers to improve the quality of care.

Guideline adherence rates for the treatment of chronic obstructive pulmonary disease (COPD) exacerbation are low. The aim of this study is to perform an importance-performance analysis as an approach for prioritisation of interventions by linking guidelines adherence rates to expert consensus rates for the in-hospital management of COPD exacerbation. We illustrate the relevance of such approach by describing variation in guideline adherence across indicators and hospitals. A secondary data analysis of patients with an acute COPD exacerbation admitted to Belgian, Italian and Portuguese hospitals was performed. Twenty-one process indicators were used to describe adherence to guidelines from patient record reviews. Expert consensus on the importance for follow-up of these 21 indicators was derived from a previous Delphi study. Three of the twenty-one indicators had high level of expert consensus and a high level of adherence. Eleven of the twenty-one indicators had high level of expert consensus but a low level of adherence. For none of the 378 patients included in this study were all process indicators adhered to, patients received 41.0% of the recommended care on average, and only 34.1% of the patients received 50% or more of the care they should receive. There was also a large variation within and between hospitals regarding the care received. This study confirms the findings of previous studies, indicating that COPD exacerbations are largely undertreated. Importance-performance analysis provides a decision-making tool for prioritising indicators. All hospitals in this study would benefit from having in place a quality framework for systematic follow-up of these indicators. peerreview_statement: The publishing and review policy for this title is described in its Aims & Scope. aims_and_scope_url: http://www.tandfonline.com/action/journalInformation?show=aimsScope&journalCode=icop20 ispartof: COPD vol:14 issue:2 pages:156-163 ispartof: location:England status: published

The aim of this paper was to perform a systematic overview of secondary literature studies on care pathways (CPs) for hip fracture (HF). The online databases MEDLINE-PubMed, Ovid-EMBASE, CINAHL-EBSCO-host, and The Cochrane Library were searched. A total of six papers, corresponding to six secondary studies, were included but only four secondary studies were HF-specific and thus assessed. Secondary studies were evaluated for patients' clinical outcomes. There were wide differences among the studies that assessed the effects of CPs on HF patients, with some contrasting clinical outcomes reported. Secondary studies that were non-specific for CPs and included other multidisciplinary care approaches as well showed, in some cases, a shorter hospital length of stay (LOS) compared to usual care; studies that focused on promoting early mobilization showed better outcomes of mortality, morbidity, function, or service utilization; CPs mainly based on intensive occupational therapy and/or physical therapy exercises improved functional recovery and reduced LOS, with patients also discharged to a more favorable discharge destination; CPs principally focused on early mobilization improved functional recovery. A secondary study specifically designed for CPs showed lower odds of experiencing common complications of hospitalization after HF. In conclusion, although our overview suggests that CPs can reduce significantly LOS and can have a positive impact on different outcomes, data are insufficient for formal recommendations. To properly understand the effects of CPs for HF, a systematic review is needed of primary studies that specifically examined CPs for HF.

We performed a systematic review for primary studies on care pathways (CPs) for hip fracture (HF). The online databases MEDLINE-PubMed, Ovid-EMBASE, CINAHL-EBSCO host, and The Cochrane Library (Cochrane Central Register of Clinical Trials, Health Technology Assessment Database, NHS Economic Evaluation Database) were searched. Two researchers reviewed the literature independently. Primary studies that met predefined inclusion criteria were assessed for their methodological quality. A total of 15 publications were included: 15 primary studies corresponding with 12 main investigations. Primary studies were evaluated for clinical outcomes, process outcomes, and economic outcomes. The studies assessed a wide range of outcome measures. While a number of divergent clinical outcomes were reported, most studies showed positive results of process management and health-services utilization. In terms of mortality, the results provided evidence for a positive impact of CPs on in-hospital mortality. Most studies also showed a significantly reduced risk of complications, including medical complications, wound infections, and pressure sores. Moreover, time-span process measures showed that an improvement in the organization of care was achieved through the use of CPs. Conflicting results were observed with regard to functional recovery and mobility between patients treated with CPs compared to usual care. Although our review suggests that CPs can have positive effects in patients with HF, the available evidence is insufficient for formal recommendations. There is a need for more research on CPs with selected process and outcome indicators, for in-hospital and postdischarge management of HF, with an emphasis on well-designed randomized trials.

Background Proximal femur fracture (PFF) is associated with considerable morbidity and mortality. The European Quality of Care Pathway (EQCP) study on PFF (NCT00962910) was designed to determine how care pathways (CP) for hospital treatment of PFF affect consistency of care, adherence to evidence-based key interventions, and clinical outcome. Methods/Design An international cluster-randomized controlled trial (cRCT) will be performed in Belgium, Ireland, Italy and Portugal. Based on power analyses, a sample of 44 hospital teams and 437 patients per arm will be included in the study. In the control arm, usual care will be provided. Experimental teams will implement a care pathway which will include three active components: a formative evaluation of quality and organization of the care setting, a set of evidence-based key interventions, and support of the development and implementation of the CP. Main outcome will be the six-month mortality rate. Discussion The EQCP study constitutes the first international cRCT on care pathways. The EQCP project was designed as both a research and a quality improvement project and will provide a real-world framework for process evaluation to improve our understanding of why and when CP can really work. Trial registration number NCT00962910