Eastern Health

Clinical deterioration

Background
Patients who need inpatient rehabilitation after initial acute hospital care for illness or surgery frequently have a complex journey through different healthcare sectors. For the majority of patients, rehabilitation requires moving from an acute care hospital to a stand-alone hospital where rehabilitation services are provided. If their condition deteriorates during rehabilitation, they will be transferred to an acute care hospital for further assessment and care.

Aim/objective/s
To describe characteristics and outcomes of emergency interhospital transfers from subacute to acute hospital care.

Method
Prospective case-time-control study conducted in 21 wards in eight subacute healthcare facilities from five health services in Victoria, Australia. Cases were patients with an emergency interhospital transfer from subacute to acute hospital care. For every case, two inpatients from the same subacute care ward on the same day of emergency transfer were randomly selected as controls. Admission episode was the unit of measurement and data were collected prospectively.

Results
Data were collected for 603 transfers in 557 patients and 1160 control patients. Unplanned emergency transfers from subacute to acute care hospitals were:

• associated with poor outcomes: 81% of transferred patients were readmitted to acute care with a median readmission length of stay (LOS) of 8 days.⁽³⁾Compared to control patients, transfer patients had higher in-hospital mortality (14.9% vs 2.3%, p<0.001); and more unplanned intensive care unit (ICU) admission(s) (4.3% vs 0.5%, p<0.001) and rapid response team (RRT) call(s) (20.4% vs 7.5%, p<0.001) during their health service stay.¹  Compared to patients for full resuscitation, patients with not-for-CPR or limitations of medical treatment orders were more likely to have rapid response team calls during acute care readmission or to die during hospitalisation. Patients who were not-for-CPR were less likely to be readmitted to acute care and more likely to return to subacute care than patients with  limitations of medical treatment orders or for full resuscitation.²
• resource intensive: 75% of transfers were by emergency ambulance;¹and 76% of transferred patients required emergency department (ED) care with a median ED LOS of 6 hours.¹ One in eleven transfers (8.9%) occurred within one day of subacute care admission.³
• predictable: when adjusted for age and health service, ³2 vital sign abnormalities in subacute care (Adjusted Odds Ratio (AOR)=8.7, 95%CI: 6.3-12.0, p<0.001) and clinical deterioration events (unplanned ICU admission, RRT or cardiac arrest team calls) during the initial acute care admission (AOR=1.4, 95%CI: 1.0-1.9, p=0.029) increased transfer risk (4, 5); and transfer risk decreased with higher functional independence (AOR=0.99, 95% CI: 0.98-0.99, p=0.009).^1,4

Conclusion
Patients who require an emergency interhospital transfer from subacute to acute hospital care have hospital admission rates and in-hospital mortality. Clinical instability during the first acute care admission (serious adverse events or increased surveillance) may prompt reassessment of patient suitability for movement to a separate subacute care hospital. Serious adverse events in acute care should be a key consideration in decisions about the location of subacute care delivery. During subacute care, 15.7% of cases had vital signs fulfilling organisational rapid response team activation criteria, yet missed rapid response team activations were common suggesting that further consideration of the criteria and strategies to optimise recognition and response to clinical deterioration in subacute care are needed.

Outputs

1. Considine J, Street M, Bucknall T, et al. Characteristics and outcomes of emergency interhospital transfers from subacute to acute care for clinical deterioration. International Journal for Quality in Health Care2019; 31(2): 117-24.
2. Street M, Dunning T, Bucknall T, et al. Resuscitation status and characteristics and outcomes of patients transferred from subacute care to acute care hospitals: a multi-site prospective cohort study. J Clin Nurs2020; 29(7-8): 1302-11.
3. Considine J, Street M, Hutchinson AM, et al. Timing of emergency interhospital transfers from subacute to acute care and patient outcomes: a prospective cohort study. International Journal of Nursing Studies2019; 91(March): 77-85.
4. Considine J, Street M, Hutchinson AM, et al. Vital sign abnormalities as predictors of clinical deterioration in subacute care patients: a prospective case-time-control study. International Journal of Nursing Studies2020; 108: 103612.

Reducing unplanned hospital readmissions

Background
Unplanned hospital readmissions may result from exacerbation of underlying disease or potentially preventable failure of care provision. For patients and carers, unplanned hospital readmissions are distressing, inconvenient and increase risk of iatrogenic harm such as falls, medication errors, delirium, or poor hydration and nutrition. For the healthcare system, unplanned hospital readmissions are costly and result in potentially avoidable resource utilisation.

Aim/objective/s
To gain an understanding of the factors associated with unplanned hospital readmission ≤28 days of acute care discharge from a major Australian health service; to explore the reasons for unplanned hospital readmissions ≤1 day of acute care discharge, and determine what proportion of such unplanned hospital readmissions were potentially preventable; and To understand from a patient and carer perspective, what features of the discharge process could be improved to avoid early unplanned hospital readmission (≤72 hours of acute care discharge) and what elements of discharge planning could have enhanced the discharge experience.

Method
Program of research conducted at Eastern Health:

• A retrospective study of 20,575 acute care discharges ≤ 28 days of discharge.¹
• A medical record audit of 170 unplanned hospital readmissions ≤1 day.²
• Interviews with 29 patients and 7 carers who experienced an unplanned hospital readmission within 3 days of acute care discharge.³

Results

• The unplanned readmission rate was 7.4% (n = 1528) and 11.1% of readmitted patients were returned within 1 day. The factors associated with increased risk of unplanned readmission in _28 days for all patients were age ³65 years, emergency index admission, Charlson comorbidity index >1, presence of chronic disease or complications during the index admission, index admission length of stay (LOS) >2 days, hospital admission(s) or emergency department (ED) attendance(s) in the 6 months preceding the index admission. However, the factors associated with increased risk of increased risk of unplanned readmission≤28 days changed with each patient group (adult medical, adult surgical, obstetric and paediatric).¹
• Unplanned readmissions ≤1 day were more likely in paediatric patients; index discharges on weekends, from short stay unit (SSU) or against health professional advice; or when the readmission was for a similar Diagnosis Related Group. The significant predictors of unplanned readmission ≤1 day were index discharge against advice or from SSU, and 1–5 hospital admissions in the 6 months preceding index admission. Only 11.7% of unplanned readmissions ≤1 day were preventable. The median patient age was 57 years and comorbidities were uncommon (3.1%). Most patients (94.4%) lived at home and with others (78.9%). Friday was the most common day of index discharge (17.3%) and Saturday was the most common day of unplanned readmission (19.1%). The majority (94.4%) of readmissions were via the emergency department: 58.5% were for a like diagnosis and pain was the most common reason for readmission.²
• Patient and carer interviews resulted in five themes: ‘experiences of care’, ‘hearing and being heard’, ‘what’s wrong with me’, ‘not just about me’ and ‘all about going home’. There was considerable variability in patients’ and carers’ experiences of hospital care, discharge processes and early unplanned hospital readmission. Features of the discharge process that could be improved to potentially avoid early unplanned hospital readmission were better communication, optimal clinical care including ensuring readiness for discharge and shared decision-making regarding discharge timing and goals on returning home. The discharge experience could have been enhanced by improved communication between patients (and carers) and the healthcare team, not rushing the discharge process and a more coordinated approach to patient transport home from hospital.³

Conclusion
There were specific patient and index admission characteristics associated with increased risk of unplanned readmission in _28 days; however, these characteristics varied between patient groups, highlighting the need for tailored interventions. Advanced age, significant comorbidities and social isolation did not feature in patients with an unplanned readmission ≤1 day. One quarter of patients were discharged on a Friday or weekend, one quarter of readmissions occurred on a weekend, and pain was the most common reason for readmission raising issues about access to services and weekend discharge planning. The discharge process is complex and effective communication, shared decision-making and carer engagement in optimising hospital discharge and reducing early unplanned hospital readmissions is vital to reducing unplanned hospital readmissions.

Outputs

1. Considine J, Fox K, Plunkett D, Mecner M, O’Reilly M, Darzins P. Factors associated with unplanned readmissions in a major Australian health service. Aust Health Rev2019; 43(1): 1-9.
2. Considine J, Berry D, Newnham E, et al. Factors associated with unplanned readmissions within 1 day of acute care discharge: a retrospective cohort study. ‎BMC Health Serv Res2018; 18(1): 713.
3. Considine J, Berry D, Sprogis SK, et al. Understanding the patient experience of early unplanned hospital readmission following acute care discharge: a qualitative descriptive study. BMJ Open2020; 10(5): e034728.

Chair in Nursing
Prof. Julie Considine AO

Research Fellows
Dr Olumuyiwa Omonaiye
Dr Nantanit (Rainie) van Gulik
Ms Penny Casey

Deakin QPS
qps@deakin.edu.au

Eastern Health – Director
Professor Julie Considine
+61 3 9895 3177
Email Professor Considine

Eastern Health Partnership
Level 2, 5 Arnold Street
Box Hill, VIC 3128