Care in the Community: A COVID-19 initiative to reduce hospital re-presentations among community-dwelling people.

OBJECTIVE: The COVID-19 pandemic has had a substantial impact on the utilisation of hospital and emergency department (ED) services. We examined the effect of a rapid response service on hospital re-presentations among people discharged from the ED and short-stay wards at a tertiary referral hospital. METHODS: This retrospective cohort study compared 112 patients who completed the Care in the Community program with 112 randomly selected controls. Both cases and controls were discharged from hospital between September 2020 and June 2021. Intervention patients were evaluated by a multidisciplinary team, who implemented a goal-directed program of up to 4-weeks duration. Logistic regression, negative binomial regression and Cox proportional hazards regression were used to evaluate outcomes at 28 days and at 6 months. RESULTS: The median time between referral and the first home visit was 3.9 days. In adjusted analyses, the intervention reduced hospital re-presentations at 28 days (odds ratio: .40, 95% confidence interval (CI): .17-.94) and lengthened the time to the first hospital re-presentation (hazard ratio: .59, 95% CI: .38-.92). Although the intervention did not reduce the total number of hospital re-presentations at 6 months (adjusted incidence rate ratio: .73, 95% CI: .49-1.08), it reduced total time spent in hospital by 303 days (582 vs. 885). CONCLUSIONS: This study is among the first to investigate the effect of a community-based intervention on hospital re-presentations during the COVID-19 pandemic. It provides evidence that a sustainable 4-week intervention is associated with reduced hospital re-presentations and time spent in hospital.

Does Case-Finding for Admission to Aged Care Rapid Investigation and Assessment Unit for Older Patients Improve Hospital Length of Stay? Evaluation of ARIA Unit.

Introduction: Many older people present to emergency departments annually, often with complex geriatric syndromes, yet current acute care models and traditional admissions process may under-serve their needs. The multidisciplinary Aged Care Rapid Investigation and Assessment (ARIA) Unit seeks to bridge this gap, by actively identifying and assessing patients. Methods: A prospective case-control study was undertaken at a single-centre tertiary referral institution. Patients were eligible for inclusion in ARIA group if admitted to ARIA via case-finding by the geriatrician or Aged Care Services Emergency Team, whilst standard geriatric admissions formed the control group. This study evaluates whether ARIA reduced hospital length-of-stay (LOS) and representation rates. Results: 370 patients were included (185 each arm) with similar baseline demographics, frailty scores, and Charlson Comorbidity Indices. Patients admitted to ARIA had significantly shorter hospital LOS than those via standard pathway (3.3 days [IQR2.2-5.8] vs 7.5 days [IQR4.2-13.7], p < 0.00001). There were no significant differences in 90-day representation rates (n = 66 [35.7%] vs n = 64 [34.6%], p = 0.82). Discussion/Conclusion: Introduction of an ARIA unit with a targeted approach to frontline geriatric services and case-finding is associated with improved LOS of older acute hospital patients. An economical cost analysis of this study would be beneficial in exploring potential financial savings.

Relationship between intracranial pressure and phase contrast cine MRI derived measures of intracranial pulsations in idiopathic normal pressure hydrocephalus.

Phase contrast cine MRI with determination of pulsatile aqueductal cerebrospinal fluid (CSF) stroke volume and flow velocity has been suggested to assess intracranial pulsations in idiopathic normal pressure hydrocephalus (iNPH). We aimed to compare this non-invasive measure of pulsations to intracranial pressure (ICP) pulse wave amplitude from continuous ICP monitoring. We hypothesised that a significant correlation between these two markers of intracranial pulsations exists. Fifteen patients with suspected iNPH had continuous computerised ICP monitoring with calculation of mean ICP pulse wave amplitude (MWA) from time-domain analysis. MRI measured CSF aqueductal stroke volume and peak flow velocity. Mean MWA was 5.4mmHg (range 2.3-12.4mmHg). Mean CSF stroke volume and peak flow velocity were 65µl (range 3-195µl) and 9.31cm/s (range 1.68-15.0cm/s), respectively. No significant correlation between the invasive and non-invasive measures of pulsations existed (Spearman r=-0.30 and r=-0.27, respectively; p>0.05). We observed marked intra-individual fluctuation of MWA during continuous ICP monitoring of an average of 6.0mmHg (range 2.8-12.2mmHg). The results suggest a complex interplay between measures of pulsations derived from snapshot MRI measurements and continuous computerised ICP measurements, as no significant relationship existed in our data. Further study is needed to better understand the temporal profile of CSF MRI flow studies, as substantial variation in MWA over the course of several hours of ICP monitoring is common, suggesting that these physiologic fluctuations might obscure MRI snapshot measures of intracranial pulsations.

New medical diagnoses and length of stay of acutely unwell older patients: Implications for funding models.

AIM: To examine the relationship between newly made medical diagnoses and length of stay (LOS) of acutely unwell older patients. METHODS: Consecutive patients admitted under the care of four geriatricians were randomly allocated to a model development sample (n = 937) or a model validation sample (n = 855). Cox regression was used to model LOS. Variables considered for inclusion in the development model were established risk factors for LOS and univariate predictors from our dataset. Variables selected in the development sample were tested in the validation sample. RESULTS: A median of five new medical diagnoses were made during a median LOS of 10 days. New diagnoses predicted an increased LOS (hazard ratio 0.90, 95% confidence interval 0.88-0.92). Other significant predictors of increased LOS in both samples were malnutrition and frailty. CONCLUSIONS: Identification of new medical diagnoses may have implications for Diagnosis Related Groups-based funding models and may improve the care of older people.

Understanding how advance care planning is approached in the residential aged care setting: a continuum model of practice as an explanatory device.

OBJECTIVE: To gain an understanding of how advance care planning (ACP) is understood and approached by managers of residential aged care facilities. METHODS: Qualitative interviews with managers from 41 residential aged care facilities from South Western Sydney, Australia. Content and thematic analysis of interview transcripts. RESULTS: The majority of facilities do not have a systematic approach to ACP, but tend to initiate discussions about end-of-life treatments late in a resident's illness. There are varying degrees to which these discussions are used in ongoing care planning or made explicit if the resident is transferred to hospital. A number of factors are identified that support the implementation of ACP. CONCLUSION: A continuum model of practice is proposed that describes four broad approaches to practice under the domains of initiation, scope, follow-up and documentation of ACP as well as the organisational leadership adopted around ACP.

Admission variables predicting short lengths of stay of acutely unwell older patients: relevance to emergency and medical short-stay units.

OBJECTIVE: To help develop criteria to identify older patients suitable for admission to medical short-stay units, by determining predictors of length of stay (LOS) of 3 days or less. METHODS: The data were prospectively collected from consecutive older patients admitted from the emergency department of a university hospital to an acute geriatric medicine service. Data included active medical diagnoses, the Modified Barthel Index (MBI), the Timed Up and Go (TUG) test, and demographic information. Logistic regression was used to model the probability of LOS of 3 days or less (short LOS). RESULTS: Among 2036 patients discharged alive from hospital (mean age, 82 years; median LOS, 7 days), 398 had a short LOS (median, 2 days), while 1638 had a long LOS (median, 9 days). In logistic regression analysis, the main independent predictors of short LOS were an MBI score > 15/20 (OR, 2.98; 95% CI, 1.97-4.49), ability to perform the TUG test (OR, 2.08; 95% CI, 1.34-3.24) and absence of delirium (OR, 2.66; 95% CI, 1.56-4.54). Patients without infection, anaemia, gastrointestinal disorder and stroke were also more likely to have a short LOS in multivariate analysis (all P < 0.05). CONCLUSION: Preserved function, measured using the MBI and TUG, and the absence of delirium are strong predictors of short LOS. In conjunction with early, skilled clinical evaluation, these criteria could be used to select older patients presenting to the emergency departments for admission to short-stay units.

pH changes in root dentin after intracanal placement of improved calcium hydroxide containing gutta-percha points.

The in vitro pH changes in root dentin over a period of 2 weeks was investigated in 48 extracted bicuspids after intracanal placement of either Roeko Calcium Hydroxide Plus Points, aqueous calcium hydroxide paste, or gutta-percha points (control group) after root canal preparation. Microelectrodes were placed in outer and inner root dentin at cervical, middle, and apical thirds of the root to measure the pH at 1 h, 2 h, 3 h, 1 day, 3 days, 7 days, and 14 days. Roeko Calcium Hydroxide Plus Points reached a peak inner dentine pH of 11.67 and a peak outer dentine pH of 10.82 at 3 h. In addition, Roeko Calcium Hydroxide Plus Points maintained an outer dentine pH above 9.5 for approximately 2 days, whereas the aqueous calcium hydroxide paste did not reach this pH. However, the alkalinity in dentin with Roeko Calcium Hydroxide Plus Points was maintained for 7 days only, whereas aqueous calcium hydroxide paste maintained an alkaline environment throughout the 2-week period.