Quantitative proteomics of delirium cerebrospinal fluid.

Delirium is a common cause and complication of hospitalization in older people, being associated with higher risk of future dementia and progression of existing dementia. However relatively little data are available on which biochemical pathways are dysregulated in the brain during delirium episodes, whether there are protein expression changes common among delirium subjects and whether there are any changes which correlate with the severity of delirium. We now present the first proteomic analysis of delirium cerebrospinal fluid (CSF), and one of few studies exploring protein expression changes in delirium. More than 270 proteins were identified in two delirium cohorts, 16 of which were dysregulated in at least 8 of 17 delirium subjects compared with a mild Alzheimer's disease neurological control group, and 31 proteins were significantly correlated with cognitive scores (mini-mental state exam and acute physiology and chronic health evaluation III). Bioinformatics analyses revealed expression changes in several protein family groups, including apolipoproteins, secretogranins/chromogranins, clotting/fibrinolysis factors, serine protease inhibitors and acute-phase response elements. These data not only provide confirmatory evidence that the inflammatory response is a component of delirium, but also reveal dysregulation of protein expression in a number of novel and unexpected clusters of proteins, in particular the granins. Another surprising outcome of this work is the level of similarity of CSF protein profiles in delirium patients, given the diversity of causes of this syndrome. These data provide additional elements for consideration in the pathophysiology of delirium as well as potential biomarker candidates for delirium diagnosis.

Malnutrition screening and early nutrition intervention in hospitalised patients in acute aged care: a randomised controlled trial.

OBJECTIVES: High rates of malnutrition have been reported in the older hospitalized patient population. This is recognised to impact on patient outcomes and health costs. This study aimed to assess the impact of nutrition screening and intervention on these parameters. DESIGN: Randomised controlled prospective study. SETTING: The study was performed in the acute geriatric medicine wards of the Prince of Wales Hospital, Sydney Australia. PARTICIPANTS: All patients admitted to these wards under a geriatrician with an expected length of stay of at least 72 hours were considered for the study. INTERVENTION: Patients were screened on admission for malnutrition using the Mini Nutritional Assessment (MNA) tool and randomly assigned to control or intervention groups. Intervention patients were immediately commenced on a malnutrition care plan (MCP). Control patients were only commenced on a MCP if referred by clinical staff. MEASUREMENTS: Length of stay (LOS), weight change and frequency of readmission to hospital were compared between the groups. RESULTS: 143 patients were screened. 119 were identified as malnourished (MN) or at risk of malnutrition (AR). Overall LOS was not different between the two groups (control v. intervention: 13.4 ± 1.3 days v. 12.5 ± 1.2 days, p=0.64). However there was a significant decrease in LOS in the MN (control v. intervention: 19.5 ± 3 days v. 10.6 ± 1.6 days, p=0.013) and a trend to reduced readmissions. There was no difference in weight change over admission between the groups. Without screening, clinical staff identified only a small proportion of malnourished patients (35% of MN and 20% of AR). CONCLUSIONS: Malnutrition in the older hospital population is common. Malnutrition screening on hospital admission facilitated targeted nutrition intervention, however length of stay and re-presentations were only reduced in older malnourished patients with an MNA score less than 17.

Recruitment of volunteers to improve vitality in the elderly: the REVIVE study.

BACKGROUND: Delirium is a common problem for frail, older patients in hospital and a marker of poor outcome and mortality. The aim of this study was to test a volunteer-mediated delirium prevention programme for efficacy, cost-effectiveness and sustainability on an Australian geriatric ward. METHODS: Two controlled before-and-after studies were conducted. In study 1, 37 patients (>70 years, admitted to the geriatric wards) were enrolled during 5 months in 2003 for intensive individual study. Twenty-one patients received usual care and 16 patients received the volunteer-mediated intervention of daily orientation, therapeutic activities, feeding and hydration assistance, vision and hearing protocols. In study 2, we examined the effects of a general implementation for the whole department by measuring use of assistants in nursing, who were employed for individual nursing of delirious patients. RESULTS: In study 1, we found a lower incidence (intervention vs control, 6.3% vs 38%; P = 0.032) and lower severity of delirium (1.2 vs 5.1; P = 0.045). There was a trend towards decreased duration of delirium (5.0 vs 12.5; P = 0.64). In study 2, use of assistants in nursing was reduced by 314 h per month suggesting a total annual saving of 129,186 Australian dollars for the hospital. CONCLUSION: The programme prevents delirium and improves outcomes for elderly inpatients. Cost-effectiveness supports the continuation of the programme and extension to other geriatric units.

Implications of decreasing surgical lengths of stay.

A recent study at the Prince of Wales Hospital (PoW) compared health outcomes and user satisfaction for conventional clinical pathways with a shortened pathway incorporating day of surgery admission (DOSA), early discharge and post acute care domiciliary visits for two high volume, elective surgical procedures (herniorrhaphy and laparoscopic cholecystectomy). This paper quantifies cost differences between the control and intervention groups for nursing salaries and wages, other ward costs, pathology and imaging. The study verified and measured the lower resource use that accompanies a significant reduction in length of stay (LOS). Costs of pre- and post-operative domiciliary visits were calculated and offset against savings generated by the re-engineered clinical pathway. Average costs per separation were at least $239 (herniorrhaphy) and $265 (laparoscopic cholecystectomy) lower for those on the DOSA pathway with domiciliary post acute care.

A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients.

OBJECTIVE: To test the cost effectiveness of Hospital in the Home compared to hospital admission for acute medical conditions. METHOD: Randomised controlled trial at the Prince of Wales Hospital, Sydney, from October 1995 to February, 1997; 100 patients with acute medical conditions admitted through the Emergency Department. RESULTS: The Hospital in the Home (HITH) group costs per separation ($1,764, CI 95% $1,416-$2,111, n = 50) were significantly lower (p < 0.0001, Mann-Whitney U-Wilcoxon Rank Sum) than the control group hospital separation ($3,614, CI 95% $2,881.37-$4,347.27, n = 47) with no significant difference in clinical outcomes, and comparable or better user satisfaction. CONCLUSION: Given the favourable clinical outcomes the HITH model produces at a lower cost, the cost-effectiveness of the care mode is high, and the allocative efficiency favourable. IMPLICATIONS: As a care model and critical pathway, HITH offers hospitals real bed day savings that can either be used to rationalise resource usage for a given level of activity, or increase throughput.

Use of pathology services in re-engineered clinical pathways.

A significant proportion of pathology tests ordered in hospital are unnecessary. Specific measures targeting the increasing appropriateness of pathology service use have been shown to decrease overall ordering of laboratory tests. However, it is not clear whether general programmes to improve quality of care will have any impact on the use of pathology services. Use of pathology services was compared within two separate prospective controlled clinical trials of re-engineered clinical pathways for both elective (surgical) patients and acute unplanned (medical) admissions. Trial One was a controlled trial of a re-engineered surgical service. Booked patients in the treatment group were admitted on the day of surgery, care was guided by a clinical pathway, and patients were discharged early with domiciliary post-acute care. Controls were admitted on the day before surgery, treated according to usual practice and discharged according to surgeons' preferences. In Trial Two, acute medical patients admitted to hospital through the Emergency Department (ED) were randomised into a treatment (Hospital in the Home) or a control (inpatient) care pathway. In both studies, patients on the re-engineered clinical pathways were well matched demographically and clinically. Health outcomes and satisfaction ratings were comparable. Seventy per cent fewer laboratory tests were ordered in the elective surgery intervention group (P < 0.0001), while the treatment group of the acute medical patients had 25% fewer tests ordered (P = 0.0133). Pooled results also showed a significantly lower rate of test ordering (P < 0.001) for the treatment group (Mann-Whitney U-Wilcoxon ranked sum test). The findings of these audits of controlled, prospective trials suggested overuse of laboratory tests in New South Wales public hospitals, and that savings can be generated by using clinical pathways and applying clinical criteria to the ordering of tests without adversely affecting health outcomes.

Principles of community psychiatry.

Our primary goal in community psychiatry is to satisfy the service needs of a bounded population for whose mental health we have accepted responsibility and accountability. We base our programs on public health practice models: These direct us to focus on segments of our population which are currently exposed to harmful biopsycho-social factors that increase their risk of becoming mentally ill. We focus on preventing psychosocial problems or their consequences by reducing their population rates: either the incidence of new cases (primary prevention), the prevalence of all existing cases (secondary prevention), and the rates of residual disability (tertiary prevention). We increase our efficiency and effectiveness by organizing our program on the basis of crisis theory which demands that we reach out to people in crisis and provide them with immediate guidance and help to master their current difficulties during the short period when they are open to influence and amenable to change in ways that have long term mental health consequences. We spread our own influence by organizing support groups and we multiply many-fold our impact on the huge problems involved in covering the needs of our population by recruiting the collaboration of other professional caregivers and non-professional helpers. We enhance the mental health component in the daily work of all caregiving agencies and institutions and individual professionals in the community through education and mental health consultation and collaboration. We also reach out to assist non-professional caregiving individuals and organizations, especially those who provide mutual help to fellow sufferers. In our latest work we are currently identifying harmful practices in our caregiving systems that actually harm those people whom we are trying to help. We are in the process of developing methods for reducing this system-generated damage.

Four studies of crisis in parents of prematures. 1965.

The responses of 86 families to the birth of a premature baby have been investigated in four linked studies in order to refine the concept and understanding of crisis. Patterns of the grappling behavior during the crisis were identified which enabled accurate predictions of the short-term mental health outcome. Psychological tasks presented by the stress of premature delivery were also identified. The adequacy with which these tasks were accomplished was predictive of the patterns of early maternal care and mother-child relationships. Results indicate that this type of study is relevant to studies of the causation of mental health and mental illness and to preventive intervention. Certain methodologic and research implications are derived from these studies and point to further research effort which is now practical and desirable.

Decreasing lengths of stay: the cost to the community.

BACKGROUND: Patients who are discharged earlier from hospital frequently require support from professional and unpaid carers at home after discharge. Hospitals save money per patient by discharging earlier, but it is not known whether the costs to community services and unpaid caters outweigh the savings to the hospital. METHODS: We prospectively studied the total costs, patient satisfaction, time off work and pain scores of 224 patients who underwent elective herniorrhaphy or laparoscopic cholecystectomy and who lived locally before and after re-engineering the elective surgical service. The components of the re-engineered surgical service were a peri-operative unit, pre-admission anaesthetic assessment based on self-reported questionnaires, day of surgery admissions, enhanced patient education, clinical pathways, and post-acute care. RESULTS: The patients treated through the re-engineered surgical service had a significantly shorter length of stay (LOS) (mean LOS: 2.2 vs 3.2 days; P < 0.001) but neither they nor their carers required more time off work. Significant determinants of time off work were smoking, heavy lifting at work and a higher pain score at day 7. Patients treated through the re-engineered surgical service recorded significantly higher satisfaction with their treatment. The cost saving to the hospital outweighed the cost of increased services provided in the community, so that the overall cost of providing treatment was over $200 less per patient through the re-engineered service. CONCLUSIONS: This study demonstrates that changes in care provision that result in shorter LOS and greater cost effectiveness may better meet patients' needs than existing systems.

Attitudes to osteoporosis and hormone replacement therapy among elderly women.

This study compares the attitudes toward osteoporosis and its treatment between a group of elderly women admitted to hospital for therapy of an osteoporotic fracture and a control group admitted for joint replacement surgery. We surveyed 97 women (64 with a fracture, and 33 controls) and found that the two groups of patients demonstrated a similar risk factor profile for osteoporosis and poor knowledge of osteoporosis and its available treatments, including hormone replacement therapy (HRT). By selecting a control group of women with no recent fracture, we hoped to highlight the effect of sustaining a recent fracture on attitudes to treatment. Initially only 10% (8 in the fracture group and 2 in the control group) were interested in treatment for osteoporosis, but those women who had been admitted with a fracture were significantly more receptive to education about osteoporosis and to the offer of further investigation and treatment of osteoporosis (38 versus 10, p = 0.007). We conclude that it is worthwhile offering education, screening and treatment to elderly patients who present with a fracture.

Effect of hormone replacement therapy on left ventricular hypertrophy.

The mechanisms behind the reduction in cardiovascular morbidity and mortality in postmenopausal women receiving hormone replacement therapy are not fully understood. In this case-control study, we report a statistically significant lower left ventricular mass in a group of elderly women who were receiving hormone replacement therapy for >10 years than in age-matched controls.

Hospital in the home: a randomised controlled trial.

OBJECTIVES: To compare treatment of acute illness at home and in hospital, assessing safety, effect on geriatric complications, and patient/carer satisfaction. DESIGN: Randomised controlled trial. SETTING: A tertiary referral hospital affiliated with the University of New South Wales. PARTICIPANTS: 100 patients (69% older than 65 years) with a variety of acute conditions, who were assessed in the emergency department as requiring admission to hospital. INTERVENTIONS: Patients were allocated at random to be treated by a hospital-in-the-home (HIH) service in their usual residence or to be admitted to hospital. MAIN OUTCOME MEASURES: Geriatric complications (confusion, falls, urinary incontinence or retention, faecal incontinence or constipation, phlebitis and pressure areas), patient/carer satisfaction, adverse events, and death. RESULTS: There was a lower incidence of confusion (0 v. 20.4% [95% CI, 9.1%-31.7%]; P = 0.0005), urinary complications (incontinence or retention) (2.0% [95% CI, -1.8%, 5.8%] v. 16.3% [95% CI, 6.0%, 26.6%]; P = 0.01), and bowel complications (incontinence or constipation) (0 v. 22.5% [95% CI, 10.7%, 34.1%]; P = 0.0003) among HIH-treated patients. No significant difference in number of adverse events and deaths (to 28 days after discharge) in the two groups was found (although numbers were small). Patient and carer satisfaction was significantly higher in the HIH group. CONCLUSIONS: Home treatment appears to provide a safe alternative to hospitalisation for selected patients, and may be preferable for some older patients. We found high levels of both patient and carer satisfaction with home treatment.

Re-engineering the elective surgical service of a tertiary hospital: a historical controlled trial.

OBJECTIVE: To study the clinical effects of re-engineering the processes associated with elective surgery. DESIGN: A prospective, historical controlled trial. Control patients were enrolled from March 1995 to January 1996, and postintervention patients from February 1996 to October 1996. SETTING: A major teaching, tertiary care hospital (Prince of Wales Hospital, Sydney). PATIENTS: 224 patients (123 before and 101 after the intervention) undergoing elective herniorrhaphy of laparoscopic cholecystectomy who lived in the local area. INTERVENTION: Introduction of a re-engineered surgical service consisting of preadmission assessment and education, admission on day of surgery, and postacute care after discharge. There were no changes to the operative methods or infection control procedures. MAIN OUTCOME MEASURES: Length of stay, operative complications, pain scores and patient satisfaction. RESULTS: The risk of a patient suffering one or more complications was reduced in the postintervention group (postintervention v. control patients: 25.7% v. 38.2%; relative risk [RR], 0.66; 95% confidence interval [CI], 0.44-0.98; P = 0.035) because of a reduced risk of wound infections (5.0% v. 16.3%; RR, 0.30; 95% CI, 0.12-0.78; P = 0.0075). Other complications (perioperative or postoperative) and pain scores were unchanged. Patients treated by the re-engineered service had a significantly shorter length of stay, reported a higher level of satisfaction with the preoperative and postdischarge care, and were more likely to say that they would have the same treatment again (92.9% v 82.6%; P = 0.037). CONCLUSIONS: Re-engineering surgical services, with an associated reduction in length of stay, does not lead to a deterioration in care and may decrease postoperative complications and increase patient satisfaction.

Risk of admission within 4 weeks of discharge of elderly patients from the emergency department--the DEED study. Discharge of elderly from emergency department.

OBJECTIVE: to identify risk factors for admission for patients aged 75 years and older after discharge from the emergency department (DEED: discharge of elderly from emergency department). DESIGN: Prospective evaluation of discharged elderly patients from the emergency department who were followed up after 4 weeks. SETTING: emergency department of a teaching hospital for 1 year. SUBJECTS: patients aged 75 and over discharged to their home or hostel. MAIN OUTCOME MEASURES: demographic data, indices of function and cognitive status and admission to hospital within 4 weeks. RESULTS: 468 patients aged 75 and over (mean age 81.7 years; range 75-98) were enrolled; 80 patients (17.1%) were admitted to hospital during the subsequent 4 weeks. Risk factors for admission included dependence in the following activities of daily living (relative risk; 95% confidence interval): bathing (2.41; 1.32-4.41); dressing (2.38; 1.22-4.63); stairs (1.60; 1.09-2.33); finance (1.66; 1.23-2.25); shopping (1.39; 1.12-1.73) and transport (1.61; 1.25-2.06), as well as use of a community nurse (1.88; 1.12-3.17). Logistic regression analysis found two variables to be significant in predicting admission or not: dependence in transport and use of a community nurse. CONCLUSIONS: older patients are at increased risk of readmission within 4 weeks of being sent home from the emergency department. It is possible to identify high-risk patients by a questionnaire. This allows targeting of these patients for more intensive follow-up in an attempt to ameliorate further deteriorations in their health.

A post-acute respiratory outreach service.

This paper describes an outreach nursing service for patients discharged from a Sydney hospital after treatment for an acute episode of chronic airflow limitation (CAL) and people referred for early exacerbation of the condition. In its first two years, 395 patients received the home-based service. The readmission rate of these patients within 28 days of discharge was approximately half that of the hospital's CAL patients in the year before the service was available. The cost of the outreach service in 1994-5 and 1995-6 was 36% and 61% lower respectively than the cost of hospitalizing the estimated 57 patients whose admission or readmission to hospital was avoided because their conditioned was managed at home by the outreach service.

Post acute care: can hospitals do better with less?

Judging by reports in medical magazines and journals, 'early discharge schemes', better termed 'post acute care', are not popular with doctors. However, government policy encourages earlier discharge from hospital, so that the choice facing clinicians is to discharge patients early with support, or early without support, or deal with the consequences of length of stay overruns. Fortunately, government funding for post acute care is increasing. There is a strong rationale for post acute care based on better patient outcomes and cost-effectiveness, but these desirable results will only be achieved if scrupulous attention is paid to detail, as embodied in the 10 principles of post acute care. To function optimally, post acute care should be coordinated by the hospital which provided the acute care.