Trajectories and predictors of functional decline of hospitalised older patients

Huang, Hsuan-Rong; Chang, Chia Ming; Liu, Li Fan; Lin, Huey Shyan; Chen, Ching Huey

doi:10.1111/jocn.12055

Cited by 47 publications

(45 citation statements)

References 45 publications

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“…For example, the default 'lying in bed' behaviours expected of patients may mask, or contribute to, the complication of hypoactive delirium. Other default acute medical practices such as intravenous lines, catheters, and blood pressure monitors may be 'tethers' that are inappropriate for older confused patients who may benefit more from mobility and normalcy for maintenance and rehabilitation, rather than acute, corrective interventions (Borbasi et al, 2006, Huang et al, 2013.…”

Section: Complex Older Patients Slow the Flow With Associated Risks mentioning

confidence: 99%

‘Failure to Maintain’: A theoretical proposition for a new quality indicator of nurse care rationing for complex older people in hospital

Bail

Grealish

2016

International Journal of Nursing Studies

123

132

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Complex older patients represent about half of all acute public hospital admissions in Australia. People with dementia are a classic example of complex older patients, and have been identified to have higher rates of hospital-acquired complications. Complications contribute to poorer patient outcomes, and increase length of stay and cost to hospitals. The care for older people with dementia is complex, and this has been attributed to: their cognitive response to being hospitalised; their limited ability to self-care; and lack of nursing engagement with the family caregiver. Registered nurses can offer simultaneous assessment and intervention to prevent or mitigate hospital-acquired complications. However, it is known that when demand for nursing care exceeds supply, care is prioritised according to acute medical need. Consequently some basic but essential nursing care activities such as patient mobility, communication, skin care, hydration and nutrition are implicitly rationed. This paper offers a theoretical proposition of 'Failure to Maintain' as a conceptual framework to indicate implicit care rationing by nurses. Care rationing contributes to functional and cognitive decline of complex older patients, which then contributes to higher rates of hospital acquired complications. Four key hospital acquired complications: pressure injuries, pneumonia, urinary tract infections and delirium are proposed as measurable indicators of 'Failure to Maintain'. Hospital focus on throughput constrains nurses to privilege predictable, solvable and medically-related procedures and processes that will lead to efficient discharge over patient mobility, communication, skin care, hydration and nutrition. This privileging, also known as implicit rationing, is theoretically and physiologically associated with a rise in the incidence of complications such as pressure injuries, pneumonia, urinary tract infection, and delirium. Complex older patients, including those with dementia, are at higher risk of the complications, therefore should have higher delivery of prophylactic intervention (ie have higher care needs). 'Failure to Maintain' offers a conceptual framework that is inclusive of, and sensitive to, this vulnerable population. Implicit rationing is occurring and it likely contributes to functional and cognitive decline in complex older patients and hospital-acquired complications. However, the lack of patient functional ability data at admission and discharge for hospitalised patients, and lack of usable ward and hospital level nurse staffing and workload data makes it difficult to monitor, understand and improve quality of care. Current research in the fields of acute geriatrics and nursing work environments show promise through enabling multidisciplinary team communication, and facilitating clinical autonomy to provide patient focussed care, and avoid 'Failing to Maintain'. The research field of acute geriatrics can understand and act on the risk modification role of nurses, including controlling for nurse staffing and work env...

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Section: Complex Older Patients Slow the Flow With Associated Risks mentioning

confidence: 99%

‘Failure to Maintain’: A theoretical proposition for a new quality indicator of nurse care rationing for complex older people in hospital

Bail

Grealish

2016

International Journal of Nursing Studies

123

132

View full text Add to dashboard Cite

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“…In these studies, functional decline between hospital admission and discharge occurred in 7% to 17% of older inpatients (Barnes et al., ; Covinsky et al., ; Mudge et al., ; Wakefield & Holman, ). However, as these studies were conducted in countries with different health care systems, generalisation is limited (Zelada, Salinas, & Baztàn, [Peru], Boyd et al., [United States], Mudge et al., [Australia], Huang, Chang, Liu, Lin, & Chen, [Taiwan]). A better understanding of functional trajectories in older patients hospitalised within a specific health care system is a necessary step towards developing interventions to prevent or limit decline during hospitalisation.…”

Section: Introductionmentioning

confidence: 99%

Functional trajectories of older patients admitted to an Acute Care Unit for Elders

D'Onofrio

Büla

Rubli

et al. 2017

Int J Older People Nursing

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“…These lesions reduce mobility and independence and increase the risk of premature death. Among hospitalised patients aged over 65 years, the number of falls suffered in the previous year is a significant predictor of functional impairment, with a negative impact on the performance of basic activities of daily life [3]. …”

Section: Introductionmentioning

confidence: 99%

Diagnostic validity of the STRATIFY and Downton instruments for evaluating the risk of falls by hospitalised acute-care patients: a multicentre longitudinal study

Aranda-Gallardo

Luna-Rodríguez

Vazquez-Blanco

et al. 2017

BMC Health Serv Res

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BackgroundFalls are major adverse events in hospitals. The appropriateness of using risk assessment instruments for falls in hospitals has recently been questioned, although the research performed in this respect presents some methodological shortcomings. The purpose of the present study is to evaluate the accuracy of the Downton and STRATIFY instruments to determine the risk of falls and to predict their incidence in acute care hospitals in the public health system in Andalusia (Spain).MethodsA longitudinal, multicentre prospective study was made of a cohort of patients recruited between May 2014 and March 2016. The risk of falls was assessed using each of the above instruments during the first 24 h after hospital admittance, with later re-evaluations every 72 h until discharge. Descriptive statistics were obtained, bivariate and multivariate analysis were performed. The diagnostic validity of the process was assessed by calculations of sensitivity, specificity, positive and negative predictive values and ratios of positive and negative likelihood. ROC curve analysis was performed for both instruments.ResultsFor this study, 1247 patients were recruited, of whom 977 completed all the follow-up assessments. Twenty-three of these patients (2.35%) suffered 24 falls. ROC curve analysis showed that the optimal cut-off point for each assessment instrument was below that described by the authors: AUC STRATIFY = 0.69 (95% CI: 0.57–0.8); AUC Downton = 0.6 (95% CI: 0.48–0.72). With a cut-off point of 1, the sensitivity of STRATIFY was 47.6% and its specificity, 85%. With a cut-off point of 2, Downton presented a sensitivity of 66.7% and a specificity of 55.3%.ConclusionsThe Downton and STRATIFY falls risk assessment instruments presented little utility as means of detecting the risk of falls among a sample of adult patients admitted to acute care hospitals. Fall prevention in hospitals should be based on the study of individual risk factors.

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Trajectories and predictors of functional decline of hospitalised older patients

Abstract: Clinical nurses can integrate the finding of this study with Comprehensive Geriatric Assessment to tailor intervention to restore older patient's physical function during hospitalisation.

Cited by 47 publications

References 45 publications

‘Failure to Maintain’: A theoretical proposition for a new quality indicator of nurse care rationing for complex older people in hospital

‘Failure to Maintain’: A theoretical proposition for a new quality indicator of nurse care rationing for complex older people in hospital

Functional trajectories of older patients admitted to an Acute Care Unit for Elders

Diagnostic validity of the STRATIFY and Downton instruments for evaluating the risk of falls by hospitalised acute-care patients: a multicentre longitudinal study

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