Early Warning Scores to Support Continuous Wireless Vital Sign Monitoring for Complication Prediction in Patients on Surgical Wards: Retrospective Observational Study.

BACKGROUND: Wireless vital sign sensors are increasingly being used to monitor patients on surgical wards. Although early warning scores (EWSs) are the current standard for the identification of patient deterioration in a ward setting, their usefulness for continuous monitoring is unknown. OBJECTIVE: This study aimed to explore the usability and predictive value of high-rate EWSs obtained from continuous vital sign recordings for early identification of postoperative complications and compares the performance of a sensor-based EWS alarm system with manual intermittent EWS measurements and threshold alarms applied to individual vital sign recordings (single-parameter alarms). METHODS: Continuous vital sign measurements (heart rate, respiratory rate, blood oxygen saturation, and axillary temperature) collected with wireless sensors in patients on surgical wards were used for retrospective simulation of EWSs (sensor EWSs) for different time windows (1-240 min), adopting criteria similar to EWSs based on manual vital signs measurements (nurse EWSs). Hourly sensor EWS measurements were compared between patients with (event group: 14/46, 30%) and without (control group: 32/46, 70%) postoperative complications. In addition, alarms were simulated for the sensor EWSs using a range of alarm thresholds (1-9) and compared with alarms based on nurse EWSs and single-parameter alarms. Alarm performance was evaluated using the sensitivity to predict complications within 24 hours, daily alarm rate, and false discovery rate (FDR). RESULTS: The hourly sensor EWSs of the event group (median 3.4, IQR 3.1-4.1) was significantly higher (P<.004) compared with the control group (median 2.8, IQR 2.4-3.2). The alarm sensitivity of the hourly sensor EWSs was the highest (80%-67%) for thresholds of 3 to 5, which was associated with alarm rates of 2 (FDR=85%) to 1.2 (FDR=83%) alarms per patient per day respectively. The sensitivity of sensor EWS-based alarms was higher than that of nurse EWS-based alarms (maximum=40%) but lower than that of single-parameter alarms (87%) for all thresholds. In contrast, the (false) alarm rates of sensor EWS-based alarms were higher than that of nurse EWS-based alarms (maximum=0.6 alarm/patient/d; FDR=80%) but lower than that of single-parameter alarms (2 alarms/patient/d; FDR=84%) for most thresholds. Alarm rates for sensor EWSs increased for shorter time windows, reaching 70 alarms per patient per day when calculated every minute. CONCLUSIONS: EWSs obtained using wireless vital sign sensors may contribute to the early recognition of postoperative complications in a ward setting, with higher alarm sensitivity compared with manual EWS measurements. Although hourly sensor EWSs provide fewer alarms compared with single-parameter alarms, high false alarm rates can be expected when calculated over shorter time spans. Further studies are recommended to optimize care escalation criteria for continuous monitoring of vital signs in a ward setting and to evaluate the effects on patient outcomes.

Transparency in hip fracture recovery over institutional boundaries: The transmural monitoring pathway.

OBJECTIVES: To develop a transmural pathway for healthcare professionals across institutions to monitor the recovery of hip fracture patients. The secondary objectives were to evaluate the pathway's feasibility and initial outcomes. DESIGN: Prospective cohort study. METHOD: Stakeholders of the hospital and geriatric rehabilitation institutions implemented a transmural monitoring pathway in which different geriatric health domains were monitored during three phases: The in-hospital, inpatient rehabilitation, and outpatient follow-up phase. The outcomes for the first 291 patients and the feasibility of the pathway were evaluated. If the outcomes of the clinimetrics significantly improved over time, progress in functional recovery was assumed. Feasibility was assessed according to the rate of adherence to the clinimetric tests. RESULTS: During the in-hospital phase, patients showed a decline in functional level (the Katz index of independence in Activities of Daily Living (Katz-ADL) pre-fracture vs. discharge: 0 (0-2) vs. 4 (4-5), P < 0.001). Patients, in which 78.6% (n = 140) had cognitive impairment and 41.2% had malnutrition, showed the most progress (Katz-ADL 2 (1-3)) during the inpatient rehabilitation phase. In the outpatient follow-up phase, recovery remained ongoing, but most patients had not returned to their pre-fracture functional levels (Katz-ADL 1 (1-3)). The pathway feasibility during the first phase was excellent (>85%), whereas room for improvement existed during other phases (<85%). CONCLUSION: The transmural monitoring pathway provides insight into the entire recovery process for all involved healthcare professionals. Patients showed the most progress during the rehabilitation phase. The pathway feasibility was excellent during the in-hospital phase, but improvements could be made during other phases.

[Are the older patients with a hip fracture better off with a multidisciplinary approach?] / Is de oudere patiënt met heupfractuur beter af door multidisciplinaire behandeling?

Integrated orthogeriatric treatment, led by a nurse practitioner, is an important step forward in the improvement of care for older people with a hip fracture. In this paper we reflect on the study of Van Leendert et al. Their main findings are similar to the literature with a significantly reduced 1-year mortality rate in the orthogeriatric group compared to the standard care group. However, there are some remarks to be made regarding the patient characteristics that are unbalanced in favor of the orthogeriatric group, with an overrepresentation of a certain type of fracture, indicating potentially more vulnerable patients in the standard care group. Although a significant step forward, we also address that still face major challenges, that technology might be an enabler for further improvement but that it might also be time to introduce a new perspective on recovery that makes better use of the dynamics of the system.

Early Predictors for Discharge to Geriatric Rehabilitation after Hip Fracture Treatment of Older Patients.

OBJECTIVE: To investigate early predictors for discharge to a geriatric rehabilitation department at a skilled nursing home in older patients after hospitalization for hip fracture surgery. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Data from 21,176 patients with hip fracture aged ≥70 years, who were registered in the Dutch Hip Fracture Audit database between January 1, 2017, and December 31, 2019, were included. METHODS: Patients were categorized into 3 discharge groups: home (n=7326), rehabilitation (n=11,738), and nursing home (n=2112). Age, gender, Pre-Fracture Mobility Score (PFMS), premorbid Katz index of independence in Activities of Daily Living (Katz-ADL), history of dementia, American Society of Anesthesiologists physical status classification (ASA score), type of anesthesia, fracture type, surgical treatment, and cotreatment by a geriatrician were gathered. Multinomial regression analysis was used to assess for early predictors. RESULTS: Higher age, poor premorbid mobility, lower premorbid Katz-ADL, no history of dementia, ASA score 3-5, general anesthesia, intramedullary implant, and cotreatment by a geriatrician were independent predictors for discharge to geriatric rehabilitation vs discharge home. Identical predictors were found for discharge to a nursing home vs discharge home. History of dementia and premorbid Katz-ADL were distinguishing factors; a higher premorbid Katz-ADL and a history of dementia were associated with a higher risk of discharge to a nursing home vs discharge home. The multinomial regression model correctly predicted 86%, 38.6%, and 2.4% of the patients in the rehabilitation group, home group, and nursing home group, respectively. CONCLUSIONS AND IMPLICATIONS: This study showed that age, PFMS, premorbid Katz-ADL, surgical treatment, ASA score, type of anesthesia, history of dementia, and cotreatment by a geriatrician were independent early predictors for discharge to geriatric rehabilitation vs discharge home in older patients after hip fracture surgery. Identical predictors were found as predictors for discharge to a nursing home vs discharge home, except for history of dementia and premorbid Katz-ADL.

[Multidisciplinary integrated care pathway for elderly patients with hip fractures: implementation results from Centre for Geriatric Traumatology, Almelo, The Netherlands]. / Multidisciplinair zorgpad voor oudere patiënten met een heupfractuur: resultaten van implementatie in het Centrum voor Geriatrische Traumatologie, Almelo.

OBJECTIVE: To evaluate the effects of the implementation of a multidisciplinary treatment approach at Hospital Group Twente in Almelo, Netherlands, of hip fracture patients aged 65 years and older. DESIGN: Historical comparative cohort study. METHOD: Two groups of patients with hip fractures were retrospectively compared. One of these groups had been treated in 2009 according to the new, multidisciplinary treatment approach; the other in 2007 by usual means. Observations included the duration of hospital stay, as well as the numbers of complications, readmissions and consultations by other specialities. RESULTS: Included were 101 patients from 2009 and 69 from 2007. In 2009, the mean duration of hospital stay was 1 day longer than in 2007. Patients admitted to a nursing home for rehabilitation increased by 16 percentage points. The incidence of minor complications decreased by 7 percentage points; that of severe complications, 5 percentage points. The diagnosis of delirium was made significantly more often (15 percentage points more; p-value: 0.051). The rate of death decreased by 5 percentage points. The number of readmissions within 30 days declined by 14 percentage points (p-value: 0.001). Due to geriatric co-treatment (co-managed care), consultations by various specialities were fewer per patient. CONCLUSION: No reduction in the duration of hospital stay was achieved by implementation of the multidisciplinary treatment approach. It did appear that a relationship with better short-term treatment outcomes for the elderly with hip fractures existed.