Digital divide or digital exclusion? Do allied health professionals' assumptions drive use of telehealth?

INTRODUCTION: Telehealth use within allied health services currently lacks structure and consistency, ultimately affecting who can, and cannot, access services. This study aimed to investigate the factors influencing allied health professionals' (AHP) selection of consumers and appointments for telehealth. METHODS: This study was conducted across 16 allied health departments from four Australian hospitals. Semi-structured focus groups were conducted with 58 AHPs. Analysis was underpinned by Qualitative Description methodology with inductive coding guided by Braun and Clarke's thematic analysis approach. RESULTS: Six themes were identified that influenced AHPs' evaluation of telehealth suitability and selection of consumers. These included the following: (1) ease, efficiency and comfort of telehealth for clinicians; (2) clear benefits of telehealth for the consumer, yet the consumers were not always given the choice; (3) consumers' technology access and ability; (4) establishing and maintaining effective therapeutic relationships via telehealth; (5) delivering clinically appropriate and effective care via telehealth; and (6) external influences on telehealth service provision. A further theme of 'assumption versus reality' was noted to pervade all six themes. DISCUSSION: Clinicians remain the key decision makers for whether telehealth is offered within allied health services. Ease and efficiency of use is a major driver in AHP's willingness to use telehealth. Assumptions and pre-conceived frames-of-reference often underpin decisions to not offer telehealth and present major barriers to telehealth adoption. The development of evidence-based, decision-support frameworks that engage the consumer and clinician in determining when telehealth is used is required. Services need to actively pursue joint decision-making between the clinician and consumer about service delivery preferences.

Malnutrition prevalence in a medical assessment and planning unit and its association with hospital readmission.

OBJECTIVE: To investigate malnutrition prevalence on presentation to a Medical Assessment and Planning Unit (MAPU) in a setting designed to prevent hospital admission, the association of nutritional status with hospital readmission at 90 days, and agreement of nutritional risk between the Malnutrition Screening Tool (MST) and Subjective Global Assessment (SGA). METHODS: Prospective longitudinal cohort study of consecutive patients admitted to MAPU during the first 6 weeks of operation. The main outcome measures were prevalence of malnutrition and hospital readmission at 90 days. Sensitivity and specificity of the MST was assessed against the criterion standard of SGA. RESULTS: The mean participant age was 62 years (n = 153, s.d. 17.4 years) with 50% male (77/153, 95% CI 42-58%). According to the SGA, 17% (95% CI 8-26%) were assessed as malnourished on admission. The MST identified that 18% (95% CI 12-24%) were at nutritional risk, and participants screening positive for nutritional risk had significantly increased odds of hospital readmission at 90 days (OR 3.4, 95% CI, 1.3-9.1, P < 0.029). The MST was practical and successfully identified patients assessed as malnourished within the MAPU setting (sensitivity 73%, specificity 76%, negative predictive value 93%, positive predictive value 38%). CONCLUSIONS: Malnutrition is a significant problem in a MAPU setting, and patients screened at nutritional risk are at significantly higher risk of hospital readmission within 90 days.

Malnutrition associated with increased risk of frail mechanical falls among older people presenting to an emergency department.

OBJECTIVE: To identify associations between malnutrition falls risk and hospital admission among older people presenting to ED. METHODS: A prospective convenience sample of patients, aged 60 years or more, presenting to an Australian tertiary teaching hospital ED were included in this cross-sectional study. Malnutrition Screening Tool and Subjective Global Assessment tool were administered to 126 non-consecutive participants. Participants were categorized as non-fallers, frail mechanical or active mechanical fallers. Self-reported falls in past 6 months and hospital admission were documented. RESULTS: Participant age and sex (median age 74, interquartile range 65-82 years; male 59%, 74/126, 95% CI 50-67%) were representative of older people presenting to the ED. Malnutrition prevalence was 15% (19/126, 95% CI 9-21%). There was an increased risk of being assessed as malnourished when a frail mechanical faller relative to: a non-faller (relative risk [RR]: 1.5, 95% CI 1.0-2.3, P= 0.001), an active mechanical faller (RR: 3.1, 95% CI 1.0-10.9, Fisher's Exact test P= 0.02) or a non-faller and active mechanical faller combined (RR: 1.5, 95% CI 1.0-2.1, P= 0.001). Malnourished participants had an increased risk of self-reported falls over 6 months (RR: 1.5, 95% CI 1.0-2.5, P= 0.03). There was over five times the risk of hospital admission if malnourished than if well-nourished (RR: 5.3, 95% CI 1.4-20.0, Fisher's exact test P= 0.001). The Malnutrition Screening Tool captured 84% (16/19, 95% CI 78-92%) of participants assessed as malnourished by Subjective Global Assessment. CONCLUSIONS: Older people presenting to ED should be nutritionally screened. Malnutrition prevalence of 15% was documented and was associated with an increased risk of frail mechanical falls and hospital admission. The Malnutrition Screening Tool was a simple and practical screen for ED.

Length of stay patterns for patients of an acute care hospital: implications for nutrition and food services.

OBJECTIVE: Shortened hospital average length of stay (ALOS) has been used to justify rationalisation of some services, but, by definition, some patients stay for longer than the average. The objective of this study was to explore lengths of stay and proportions of hospital occupied bed-days (OBDs) of those admitted for longer time periods to inform service planning. METHODS: The proportion and ALOS of overnight separations at an Australian tertiary hospital were assessed for admissions of up to 4 days and 4 days or more. This was repeated for 7, 14 and 28 days. The proportion of OBD's for each time period was determined. RESULTS: While the proportion of total hospital patients staying for 4, 7, 14 and 28 days or more is relatively small (21.9%, 13.5%, 6.2%, 2.6%, respectively), they represent a large proportion of OBD's (74.9%, 67.2%, 50.8%, 34.2%) with an ALOS of 14.0, 20.3, 33.7, and 54.4 days, respectively. The majority of long-stay patients were in acute care. CONCLUSION: Substantial proportions of OBD's are due to patients admitted for time periods far greater than reflected by ALOS. Hospitals need to rethink how to optimally accommodate the nutrition and food requirements of the large patient numbers admitted for longer time periods, many of whom are at increased risk of malnutrition.