Improving hospital outcomes in patients admitted from

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Improving hospital outcomes in patients admitted from

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Age and Ageing 2012; 41: 670–673 doi: 10.1093/ageing/afs045 Published electronically 2 April 2012

© The Author 2012. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: [email protected]

Improving hospital outcomes in patients admitted from residential aged care: results from a controlled trial

1Internal Medicine and Aged Care, Royal Brisbane and Women’s Hospital, 3rd Floor, James Mayne Building, Royal Brisbane and Women’s Hospital, Herston, Brisbane, Queensland 4029, Australia 2University of Queensland School of Medicine, Brisbane, Australia 3Queensland Institute of Medical Research, Herston, Queensland, Australia
Address correspondence to: A. M. Mudge. Tel: (+61) 7 34360854; Fax: (+61) 7 36467800. Email: [email protected]

Background: residents of aged care are old, frail and frequently require hospital management of intercurrent illness, but hospital outcomes are poor. Objective: to identify the impact of an interdisciplinary care model on medical inpatients admitted from residential aged care (RAC). Design: pre-planned subgroup analysis of controlled trial. Setting: general medical units of a teaching hospital in Brisbane, Australia. Subjects: consecutive patients aged over 65 admitted from RAC (n = 189) or the community (n = 815). Methods: all admitted general medical patients were allocated by existing cyclical roster to control (usual care) or intervention units (interdisciplinary care consisting of improved allied health staffing, consistent teams, daily team meetings and early discharge planning). Patient characteristics and outcomes of care were compared between RAC and community subgroups. In the RAC subgroup, outcomes were compared between the control and intervention groups. Results: patients admitted from RAC had much higher in-hospital mortality (13 versus 6%) and 6-month mortality (35 versus 17%) than those from community. RAC residents receiving the intervention had a significant reduction in in-hospital mortality (4 versus 22% P < 0.001) sustained at 6 months (28 versus 44% P = 0.02). Conclusions: poor hospital outcomes for RAC residents may reflect prevailing models of inpatient care.
: residential aged care, nursing home, interdisciplinary care, elderly

Residential aged care facilities (RACF, including nursing homes and residential care homes) provide care for 4–6% of people aged over 65 in Australia and other developed countries, although organisation and funding of care differs between health systems [1–3]. These facilities care for aged people with high levels of comorbidity and functional and cognitive disability. It is estimated that 20–62% of residents in RACF are hospitalised per year [1, 4–6], and referral, admission and mortality rates are higher than community-living counterparts [3, 6–11]. International literature has focused on

avoiding hospital admissions [12], but recent Australian studies suggest that only a small proportion of nursing home presentations are inappropriate and unavoidable [13, 14]. In Australia, residents of RACF receive primary health care from general practitioners who are funded by Medicare reimbursement and visit the RACF as part of their communitybased practice, but are not employed by the facility. In the event of acute illness, the resident may referred by the RACF manager or the general practitioner to a hospital emergency department, where they are assessed and, if necessary, admitted to general hospital wards the same as community-living patients. Few hospitals have acute geriatric units.


Better hospital outcomes for nursing home patients

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Studies report higher mortality in patients hospitalised from nursing homes compared with community-living patients [7, 9, 11]. It is unclear whether changes in inpatient care can improve these outcomes. Although acute geriatric units incorporating principles of early assessment, interdisciplinary care and integrated discharge planning have been associated with improved outcomes for older patients [15], most studies have excluded patients admitted from RACF [16–19].
The aims of the current study were:
to compare characteristics and outcomes of acute medical inpatients admitted from RACF and community; and to measure the impact of an interdisciplinary care intervention on outcomes of RACF residents admitted acutely to general medical wards.
The study is a planned subgroup analysis of a controlled trial of interdisciplinary care in general medical patients in a metropolitan teaching hospital in Brisbane, Australia. Trial design, participants and outcomes have been reported previously [20]. All consecutive general medical inpatients admitted through the Emergency Department January–June 2003 were allocated by a cyclical administrative bed management system to one of four medical units. Clinical staff, researchers and patients had no influence over the unit allocation decision, determined only by day and time of admission. Two units continued usual medical care, while two units implemented a model of care including greater allied health staffing, consistent interdisciplinary teams, structured daily interdisciplinary meetings and explicit discharge planning (Supplementary data are available in Age and Ageing online, Table S1).
Participants were prospectively enrolled by a research nurse. Information was collected from medical and nursing admission assessments and included demographics, usual residence and risk factors for poor hospital outcomes in the elderly, including previous admission, assistance with activities of daily living (ADL), and a history of falls, dementia or incontinence [21]. Participants were classified as community living or from RACF (low-level facilities which provide accommodation and meals, or high-level facilities with 24 h nursing care). Primary diagnosis assigned by the medical team, length of stay under the general medical service and discharge destination were obtained from medical and nursing notes at the time of hospital discharge. Cost-weight, a case-mix measure based on the diagnostic-related group assigned by health information officers and including co-morbidities and complications, was recorded as a surrogate for disease severity [22].
Mortality at 6 months was obtained from the state-wide death registry. The 6-month length of stay included the index hospital length of stay plus readmissions, hospital unit transfers and rehabilitation stays within 6 months of

admission. Unplanned readmissions to the same hospital were identified 6 months after discharge using the hospital admissions database.
The study was approved by the Royal Brisbane and Women’s Hospital Human Research Ethics Committee. Individual patient consent was not required, because the study relied on existing clinical assessments, the intervention did not pose risk of harm but offered public good, and it was important to include patients with cognitive and language impairments who might be otherwise excluded. The current analysis is restricted to participants aged 65 or older.
Outcomes were summarised and compared between community-living and RACF participants using contingency tables and chi-squared testing for categorical variables and t-test for continuous variables. Characteristics and outcomes in RACF patients were compared between the control and intervention groups. A multivariate logistic regression model was fitted for mortality, examining the impact of RACF status after adjusting for age, cost-weight, baseline dependency and dementia, and testing for interaction with intervention status. Analyses were conducted using SPSS version 17.0.

During the 24-week trial period, 1,004 general medical patients aged 65 years and older were enrolled. Of these, 92 (9.2%) came from low-level RACF, 97 (9.7%) from high-level RACF and 815 (81.1%) from community. Characteristics are summarised in Table 1. RACF patients were older, with greater levels of physical and cognitive impairment. Infections were the major cause of admission for RACF patients (Supplementary data are available in Age and Ageing online, Figure S1). In-hospital and 6-month mortality were significantly higher in RACF patients (hospital 12.7 versus 6.0%, P = 0.001; 6 months 35.4 versus 17.1%, P < 0.001). A trend to the shorter length of stay (7.7 versus 8.7 days, P = 0.20) and fewer readmissions (28.5 versus 33.7%)

Table 1. Admission characteristics of study participants admitted from the community and from residential aged care facilities (low level and high level)

Community Low level

High level

(n = 815)



. . . . . . . . . . . . . . . . . . . . . . . . .(n.=.92.). . . . .(n.=.9.7). . . .

Age, mean years (SD)

80.0 (7.6)

84.3 (7.4)

83.2 (7.3)

Female (%)

459 (56.3)

65 (70.7)

62 (63.9)

Cost-weight, mean (SD) 1.8 (1.5)

1.8 (1.0)

2.1 (1.2)

Previous hospital

109 (13.4)

15 (16.3)

13 (13.4)

admission (%)

Dependent in 1 or more 202/744 (27.2) 55/81(67.9) 85/90 (94.4)

ADL pre-admission (%)

Dementia (%)

88 (10.8)

31 (33.7)

51 (52.6)

Incontinence (%)

110 (13.5)

26 (28.3)

46 (47.4)

History of falls (%)

265 (32.5)

37 (40.2)

23 (23.7)


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A. M. Mudge et al.
Figure 1. Percentage of participants from community (n = 815) and RACF (n = 189) who died during or within 6 months of hospital admission, by the intervention group. *P < 0.001 compared with control, **P = 0.02 compared with control.
contributed to fewer hospital bed days in 6 months in RACF patients (13.6 versus 18.1 days, P = 0.02).
Characteristics of RACF patients allocated to the control and intervention group were similar (Supplementary data are available in Age and Ageing online, Table S2 and Figure S2). As shown in Figure 1, patients allocated to the intervention had dramatically reduced in-hospital mortality (4.1 versus 22.1%, P < 0.001), and this difference was sustained at 6 months (28.2 versus 44.2%, P = 0.02). As a result, 6-month readmissions (32.7 versus 22.4%, P = 0.15) and bed day use (14.7 versus 12.3 days, P = 0.24) were nonsignificantly increased. Multivariate models confirmed RACF as a significant predictor of mortality and demonstrated statistically significant interaction between intervention status and residence (Supplementary data are available in Age and Ageing online, Table S3).
Almost one-fifth of patients aged over 65 in this study came from RACF [23, 24]. These patients were older and more likely to have ADL dependency and dementia [9], and infections were common diagnoses [5, 11]. RACF residents had mortality rates much higher than community-living patients. Previous studies of hospital or general medical admissions of RACF residents have reported similarly high in-hospital mortality rates of 12–27% [5, 6, 9, 11, 13], and have shown higher mortality than community-living patients after adjusting for other differences [7, 9].
Our new model of care resulted in marked reduction in in-hospital mortality in this patient group, which remained significant at 6 months. Few previous studies have reported clinical outcomes resulting from changing the model of care for RACF patients. Two studies of RACF patients cared for

in ‘acute care for elders’ models have reported very low mortality, although this may reflect patient selection for these specialist units [10, 25]. Barrick et al. reported similar mortality (12%) in RACF patients admitted to an acute geriatrics unit compared with those admitted to another ward or hospital [26]. Other studies of ‘acute care for elders’ have only enrolled small numbers of RACF patients and have not reported outcomes separately [23, 24].
Hospitalised RAC patients are a selected group; they have already passed through the ‘filter’ of review in the community and assessment in the emergency department. Our findings suggest that the hospital mortality in this group is poor partly because the usual model of medical ward care does not meet their complex needs. Interdisciplinary care resulted in similar in-hospital mortality rates for RAC residents as for community-dwelling older people. Importantly, the absolute mortality difference was sustained at 6 months, suggesting that the reasons for hospitalisation were correctly identified as acute reversible deterioration. While the study may provoke important questions about the societal value and cost of this mortality difference, the results challenge prevailing assumptions that RAC patients are too frail to benefit from these models of care [16, 27], and that hospital is necessarily a dangerous place for this patient group [12, 28, 29].
We acknowledge that this study is a secondary analysis. Information was obtained from routine medical and nursing documentation, allowing waiver of individual patient consent and ensuring appropriate representation of RACF patients who are often excluded or under-represented in research because of consent requirements. The cost-weight index was used a measure of severity. Although this measure is used for economic purposes, it was designed with clinician input to reflect severity [22] and is a strong predictor of mortality. Group assignment was non-randomised, but participant characteristics were similar between groups and neither clinical nor research staff could influence group allocation, which was a purely administrative decision.
Using a prospective, controlled design in a general medical population, this study makes an important contribution to the existing literature regarding poor outcomes in RACF patients, demonstrating that high mortality rates may reflect the model of care rather than just baseline vulnerability. Residential care is an increasing source of hospital referrals, and improvements in the model of care can make hospitals a safer place for this vulnerable subgroup.
Key points
• Outcomes are poor for residential aged care patients admitted to usual hospital care.
• Mortality was significantly reduced in RACF patients in this model of organised interdisciplinary care.
• These findings challenge prevailing assumptions about the dangers of hospitalisation in this vulnerable subgroup.


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Better hospital outcomes for nursing home patients

Conflicts of interest
None declared.
Supplementary data
Supplementary data mentioned in the text is available to subscribers in Age and Ageing online.
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Received 2 September 2011; accepted in revised form
8 February 2012

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