Feasibility of direct discharge from the coronary/intermediate care unit after acute myocardial infarction.
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OBJECTIVES: This investigation was designed to determine the feasibility and cost-effectiveness of direct discharge from the coronary/intermediate care unit (CICU) in 497 consecutive patients with an acute myocardial infarction (AMI). BACKGROUND: Although patients with an AMI are traditionally treated in the CICU followed by a period on the medical ward, the latter phase can likely be incorporated within the CICU. METHODS: All patients were considered for direct discharge from the CICU with appropriate patient education. The 6-week postdischarge course was evaluated using a structured questionnaire by a telephone interview. RESULTS: There were 497 patients (men = 353; women = 144; age 63.5 +/- 0.6 years) in the study, with 29 in-hospital deaths and a further 11 deaths occurring within 6 weeks of discharge. The mode length of CICU stay was 4.0 days (mean 5.1 +/- 0.2 days): 1 to 2 (12%), 3 (19%), 4 (21%), 5 (14%), 6 to 7 (19%) and > or = 7 (15%) days, respectively with 87.2% discharged home directly. Of the 425 patients surveyed, 119 (28.0%) indicated that they had made unscheduled return visits (URV) to a hospital or physician's office: 10.6% to an emergency room, 9.4% to a physician's office and 8.0% readmitted to a hospital. Of these URV, only 14.3% occurred within 48 h of discharge. Compared to historical controls, the present management strategy resulted in a cost savings of Cdn. $4,044.01 per patient. CONCLUSIONS: Direct discharge from CICU is a feasible and safe strategy for the majority of patients that results in considerable savings. (+info)
Improving long-term rehabilitation.
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The long-term problems of stroke are both physical and mental. Rehabilitation (active promotion of recovery), maintenance (active prevention of deterioration), and care (support for those with disabilities) are intertwined elements of service provision aimed at reducing these problems. Over time, the prevention of deterioration becomes dominant. Currently there is interest in 'intermediate care'--services aiming to provide choices other than inadequate care at home, inappropriate care in hospital, or expensive care in long-term institutions. There is also interest in stroke coordinators to manage community services. These developments have exposed problems of inequity (e.g. minority groups) and service provision (e.g. a shortage of trained staff). This had led to experiments in novel approaches such as generic workers and co-workers. There is interest too in examining ways in which the social and built environment can be altered to increase the participation of disabled people in society. (+info)
Therapeutic nursing or unblocking beds? A randomised controlled trial of a post-acute intermediate care unit.
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OBJECTIVES: To compare post-acute intermediate care in an inpatient nurse-led unit with conventional post-acute care on general medical wards of an acute hospital and to examine the model of care in a nurse-led unit. DESIGN: Randomised controlled trial with six month follow up. SETTING: Urban teaching hospital and surrounding area, including nine community hospitals. PARTICIPANTS: 238 patients accepted for admission to nurse-led unit. INTERVENTIONS: Care in nurse-led unit or usual post-acute care. MAIN OUTCOME MEASURES: Patients' length of stay, functional status, subsequent move to more dependent living arrangement. RESULTS: Inpatient length of stay was significantly longer in the nurse-led unit than in general medical wards (14.3 days longer (95% confidence interval 7.8 to 20.7)), but this difference became non-significant when transfers to community hospitals were included in the measure of initial length of stay (4.5 days longer (-3.6 to 12.5)). No differences were observed in mortality, functional status, or living arrangements at any time. Patients in the nurse-led unit received significantly fewer minor medical investigations and, after controlling for length of stay, significantly fewer major reviews, tests, or drug changes. CONCLUSIONS: The nurse-led unit seemed to be a safe alternative to conventional management, but a full accounting of such units' place in the local continuum of care and the costs associated with acute hospitals managing post-acute patients is needed if nurse-led units are to become an effective part of the government's recent commitment to intermediate care. (+info)
Intermediate care--a challenge to specialty of geriatric medicine or its renaissance?
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The specialism of geriatric medicine has developed considerably in the last half of the twentieth century. In Great Britain it has emerged from its sombre beginnings in Victorian poor law institutions to become one of the largest specialities in medicine encompassing a wide range of disciplines and interests. More recently, there has been a parallel development in "intermediate care" a sweeping phrase that encompasses a wide diversity of practices in a plethora of venues. Although there is considerable attraction in minimising the duration of hospital stay by older people, there is a real risk of intermediate care being used as a euphemism for indeterminate neglect. For older people to benefit from appropriate treatment and care, the lessons learnt by earlier generations of geriatricians, and supported by the international evidence base should not be disregarded. Elderly people need a full multi-disciplinary assessment (comprehensive geriatric assessment) and continued involvement of skilled and trained personnel in their continuing care (geriatric evaluation and management). The recommendations of the British Geriatrics Society on intermediate care are commended and should be adhered to by all planners and providers of intermediate care. There is considerable logic in developing ways in which the two developments can be integrated to build upon the best features of both. (+info)
Intermediate care--a good thing?
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In this paper, the intermediate care concept will be developed, and a new definition proposed. The evidence on effectiveness will be summarised, focusing on comprehensive geriatric assessment, admission avoidance, nurse-led units for post-acute care, and supported early discharge arrangements. It is a working premise of the paper that, in principle, intermediate care is not only a "good" but also a necessary "thing". However, with the exception of comprehensive assessment, the evidence for many services that fall under the broad rubric of intermediate care is lacking, inconclusive or negative. The implications of this for both practice and research will be discussed. (+info)
Elderly Canadians residing in long-term care hospitals: Part I. Medical and dental status.
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BACKGROUND: Oral diseases and conditions have been identified as a significant problem for elderly residents of long-term care (LTC) hospitals in developed countries, yet little recent information is available for the Canadian population. OBJECTIVE: To describe the medical, dietary, oral microbial, oral hygiene and dental status of elderly Canadians living in LTC hospitals in Vancouver and surrounding communities. METHODS: A sample of 369 elderly dentate hospital residents (mean age 83.9 years, 281 women [76.2%]) were examined, and their medical status and medications, oral status and type of hospital were documented. Oral hygiene practices and diet (specifically intake of refined carbohydrates) were evaluated. Subjects with xerostomia and subjects taking medications with hyposalivary side effects were identified, and salivary Streptococcus mutans and Lactobacillus were cultured. RESULTS: The mean plaque index was 1.3; men had a higher plaque index than women and residents of extended care hospitals had a higher plaque index than those in intermediate care hospitals. The mean bacterial score per millilitre of saliva was 9.7 105 colony-forming units (CFU) for Streptococcus mutans and 1.6 105 CFU for Lactobacillus. On average, each subject had 6.3 sound teeth, and 9.3 teeth had been restored. CONCLUSIONS: Although almost half of the subjects had visited a dental office in their community within the past 5 years, the elderly hospital residents in this study had few remaining teeth and suffered from poor oral hygiene. Prevention strategies (such as diet, oral hygiene and antimicrobial agents) rather than dental interventions (such as restorations and extractions) alone may be needed to control oral diseases in this susceptible population. (+info)
Elderly Canadians residing in long-term care hospitals: Part II. Dental caries status.
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BACKGROUND: Dental caries has been identified as a significant problem for elderly residents of long-term care (LTC) hospitals in developed countries, yet little recent information is available for the Canadian population. OBJECTIVE: To document the caries status of elderly dentate residents of intermediate and extended LTC hospitals in Vancouver and surrounding communities. METHODS: A dentist examined the teeth of 369 elderly dentate hospital residents (coronal and root surfaces) for caries. The medical, dietary, oral microbial, oral hygiene and dental status of the same subjects are documented and discussed in a companion article. RESULTS: Two hundred and ninety (78.6%) of the subjects had at least one carious lesion; 186 (50.4%) had coronal caries and 254 (68.8%) had root caries. On average, each subject had 3.8 carious teeth. The residents of extended LTC hospitals had significantly more carious coronal surfaces. Lactobacillus scores were correlated with the DMFS (decayed, missing, filled surfaces), the number of carious coronal lesions, the number of carious surfaces and the plaque index, but Streptococcus mutans scores were correlated only with DMFT (decayed, missing, filled teeth). CONCLUSIONS: Overall, the prevalence of dental caries among the elderly residents of LTC hospitals in this study was high, although almost half of the subjects had visited community dentists within the previous 5 years. Caries prevention strategies (specifically diet, oral hygiene and antimicrobial agents) rather than treatment alone may be needed to control caries in this susceptible population. (+info)
Developing intermediate care provided by general practitioners with a special interest: the economic perspective.
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The concept of intermediate care is part of the National Health Service (NHS) modernization agenda to make services more flexible and accessible. One objective is for the general practitioner with a special interest (GPwSI) to provide a variety of extended services in a primary care setting that have been traditionally provided in secondary care. This development is underpinned by the hope that primary care organisations (PCOs) will provide more effective and efficient care in local settings, but, as with other skill-mix changes, the process has developed ahead of an evidence base of effectiveness or cost-effectiveness. This paper considers intermediate care from an economic perspective and provides healthcare commissioners with a background that can facilitate resource allocation decisions. It cautions that, unless the economic issues are carefully considered, there is a danger that services may be introduced that are thought to be efficient, when in fact they may not be so. (+info)