Fractures costly to state hospital system

Low-trauma fractures in patients with osteoporosis has cost Western Australian hospitals more than $100 million over a decade. The findings point to a vital need for programs to prevent recurrent fractures, according to the researchers.
			The index admissions over the study period cost a total of $57 million, while readmissions cost almost $48 million

Re-fractures common

The researchers studied data on osteoporotic fractures in 5326 patients aged 50 and older admitted to WA hospitals between 2002 and 2011. They found that 38% of those patients had a re-fracture requiring admission. A total of 23% of all patients with an initial fracture had one re-fracture episode, 8.5% had two and 6.8% had three or more re-factures episodes requiring readmission.

The study found the cumulative probability of readmission within six months of the index admission was 20% for males, and 17% for females.

The index admissions over the study period cost a total of $57 million, while readmissions cost almost $48 million, according to findings in the Australian and New Zealand Journal of Public Health.

And the average cost per readmission rose linearly over the decade, due to patients needing progressively longer stays in hospital.

The authors said it was critical to initiate preventive interventions after a patient’s first fracture, given both the trajectory of increasing costs for the state health system and the benefits to patients’ health.

“These data highlight the need for system reform initiatives to stem the flow of recurrent factures among people with osteoporosis,” they wrote.

Hip fracture discharge and death discrepancies

Patients with hip fracture face an increased risk of early mortality after discharge if they have a long hospital stay rather than being sent home early, a US study shows.

The study analysed mortality rates at 30 days after hospital discharge among 188,208 patients aged 50 and over admitted to hospital for hip fracture in New York State from 2000 to 2011.

Hospital stays of 11‒14 days were associated with a 32% increased odds of death 30 days after discharge, compared with hospital stays lasting one to five days, the study found.

The odds increased to 103% for hospital stays longer than 14 days, according to findings in the BMJ.

The authors said the findings contrasted with a recent Swedish study that found a shortened hospital stay was associated with increased rates of early mortality among patients with hip fracture.

The longer length of hospital stay found in the US study may be a result of patients’ medical comorbidities or complications occurring in the hospital that delayed a safe, early discharge, they suggested.

“This critical difference suggests prolonging admission to hospital would not improve mortality outcomes in a New York state population,” they wrote, adding that the findings may not apply to different health systems.

Falls prevention strategies falling short

Australian researchers have suggested new solutions are needed to reduce patient falls while in hospital, after a program of nurse-led interventions failed to have any impact on patients’ risk of falling.

The “6-PACK program” included a fall risk tool and individualised use of one or more of six interventions: “falls alert” sign; supervision of patients in the bathroom; ensuring patients’ walking aids are within reach; a toileting regimen; use of a low bed, or use of a bed/chair alarm.

Participating wards in six Australian hospitals, involving a total of 46,245 patient admissions, were randomly assigned to receive either the program, or usual care, over a 12-month period. During the study period, 1831 falls and 613 fall injuries were recorded, according to findings in BMJ Open.

However, the intervention was found to have no effect on falls or fall injuries. The fall rate on intervention wards was 7.46 per 1000 occupied bed days, compared with 7.03 per 1000 occupied bed days in control wards, and the rate of all injuries was 2.33 and 2.53 per 1000 occupied bed days respectively.

“Although the substantial harm and negative consequences of inpatient falls are unquestionable, high-quality evidence showing the effectiveness of preventive interventions for falls in acute wards is lacking,” the authors wrote.

Meanwhile, another study across medical and surgical wards in nine acute care hospitals in Australia found that clinical audit and feedback was an effective way of improving falls prevention practices ‒ but it failed to impact fall rates.

In the study, a clinical leader assessed falls prevention practices, identified barriers to compliance with best practice – such as insufficient falls education for staff --and implemented falls prevention strategies, including multidisciplinary staff education sessions.

There was 50.4% compliance with falls prevention audit criteria initially, which increased to 74.5% at follow up about four months later, and was sustained at a second follow up another five-six months later, findings in the International Journal for Quality in Health Care show.

Despite the sustained practice improvement, the study found the reported fall rates remained unchanged ‒ a finding the authors suggested might be explained by the intervention leading to improved reporting of falls.

An alternative to hospital for elderly pneumonia patients

Hospital in The Home services may be a safe and effective alternative to hospital treatment for aged care facility residents with pneumonia, an Australian study suggests.

In the study, 60 patients with nursing home acquired pneumonia were treated within their aged care facilities under the Victorian Hospital in the Home (HITH) program, while 54 controls were treated in hospital.

The state’s HITH program provides seven-day, 24-hour service, can administer oxygen and intravenous antibiotics and fluids, and includes pathology and mobile radiology services. Medical staff can visit patients each day, and one or two daily nursing visits are made.

There were no differences in the median length of stay between the HITH patients and those treated in hospital, according to findings in the MJA,  and similar proportions of patients in the two groups were given intravenous fluids and supplemental oxygen.

There were no significant differences in overall mortality at 30 days for the two groups after adjusting for baseline differences. However, in-patient mortality was lower for HITH patients (while they were an inpatient of the HITH service), but the unadjusted post-discharge 30-day mortality was higher.

The authors suggested this may be due to factors such as HITH continuing intravenous antibiotic treatment for longer than hospitals, or to HITH patients being discharged to their usual care providers after active treatment was stopped and palliation had begun, whereas patients in hospital may be given palliation there.

The study authors said the proportion of the hospital workload associated with treating aged care home patients was set to increase, and suggested HITH could be a “targeted and effective” way of delivering care equivalent to that provided in hospital.

“This requires well resourced, intensive, medically based HITH, supported by hospital level technologies, such as intravenous therapies, expert staff and mobile x-ray facilities, as well as the willingness to meet the challenge of switching care models for the high level of disease severity with which these patients inevitably present,” they wrote.

SEPSIS KILLS program leads to early intervention

A program aimed at better managing the increasing incidence of sepsis within NSW hospital emergency departments (EDs) has led to earlier diagnosis and more urgent treatment of patients suspected to have the potentially fatal condition, new findings show.
			The data demonstrating that patients with sepsis were being managed earlier and more urgently showed the program had been a success

Program expanded following success

The Clinical Excellence Commission (CEC) implemented the SEPSIS KILLS program in 2011, to promote the skills and knowledge needed for recognising and managing patients with sepsis in the NSW EDs. The program focuses on the principle of “Recognise, Resuscitate, Refer”.

Data from 97 EDs, which submitted more than 13,000 records on patients with a provisional diagnosis of sepsis between 2011 and 2013, showed that the proportion of patients receiving intravenous antibiotics within 60 minutes of triage increased from 29.3% in 2009‒2011, to 52.2% in 2013, according to findings in the MJA.

The percentage of patients for whom a second litre of intravenous fluid was started within 60 minutes increased from 10.6% to 27.5%, while the proportion of patients triaged as needing to be seen either immediately or within 10 minutes also rose following the introduction of the program.

The authors said the data demonstrating that patients with sepsis were being managed earlier and more urgently showed the program had been a success.

There was a decrease in overall mortality from 19.3% in 2009‒2011 to 14.1% in 2013. While the mortality rate for patients with severe sepsis admitted to either intensive care or a ward did not change significantly over time, the study found that the proportion of patients with uncomplicated sepsis transferred to a ward increased and the mortality rate after transfer increased from 3.2% in 2009‒2011 to 6.2% in 2013.

The high proportion of patients with sepsis being treated on wards may be the result of under-appreciation of the potential mortality of sepsis, together with the practical problem of intensive care unit bed availability, the authors said. They called for a shift in research focus to managing sepsis on the ward.

The SEPSIS KILLS program was extended to hospital wards in 2014 and a 48-hour management plan has also been implemented.

Meanwhile, a US study showed that a multidisciplinary sepsis quality improvement program that focused on the earlier identification of sepsis, early administration of antibiotics and a mandatory education program throughout all hospital units and services, resulted in a 4.6% drop in sepsis mortality in one hospital.

Septic patients had shorter ICU stays, shorter overall hospital stays and reduced hospital costs as a result or the program, according to the findings in the American Journal of Medical Quality.

Discharge information sheet boosts communication

Giving patients a bedside “leaving hospital information sheet” can improve communication between patients, their families and their treating team, an Australian study finds.

The study authors said communication was a common barrier to discharge, particularly in regard to a patient’s discharge date or destination.

They trialled the use of a laminated information sheet placed behind the patient’s bed in a stroke-neurological rehabilitation ward at a Victorian hospital, which included the name of the patient’s key clinician, the estimated date of discharge and the likely discharge destination.

The information sheets resulted in significant improvement in patients’ knowledge of their key clinician for team-patient communication (31% prior to introduction of the sheet compared with 75% after), in correctly identifying who that key clinician was (47% vs 79%), and in correctly reporting their anticipated discharge date (54% vs 86%), according to findings in Internal Medicine Journal.

There was also significant improvement in the family’s knowledge of the anticipated discharge date. While the researchers said the implementation of the sheet was suboptimal, with 18% of staff not utilising it, those staff who did use it reported that it assisted with communication about discharge details.

“We believe the ‘Leaving Hospital Information Sheet’ has the potential to be used across many other hospital settings, especially rehabilitation and aged-care hospitals where patients can have long admissions and uncertain discharge destinations,” the authors wrote, adding that it would also be used to improve communication in acute hospital wards.

Further studies were needed to determine whether the sheet could prevent unnecessary delays in discharge, they said.

Study shows poor compliance with NSW caesarean policy

More than one-third of prelabour, repeat caesarean sections among low-risk women occur before 39 weeks gestation, despite a clear policy to the contrary, a new study shows.

The researchers called for strategies to improve compliance with a NSW Ministry of Health policy directive that requires low-risk elective or pre-labour caesarean sections do not occur before 39 completed weeks’ gestation.

Of 15,163 prelabour repeat caesareans in low-risk women that occurred in NSW public hospitals between 2008 and 2011, 34.7% occurred before 39 weeks’ gestation, according to findings in Public Health Research & Practice.

Rates of early repeat caesareans varied greatly between hospitals, with adjusted rates ranging from 16.3% to 67.5%, the study found.

Adjusted rates of compliance with the policy ranged from 32.5% to 83.7%, and the authors said the findings suggested that the timing of low-risk prelabour caesareans was influenced by nonmedical factors.

“Patient preferences and physicians’ decision making vary, and may explain the remaining variation,” they wrote, adding that challenges in scheduling may also play a part.

Reducing the number of elective caesareans before 39 weeks gestation had been associated with a reduction in neonatal mortality, they said.

Internationally, strategies such as enforcing prohibition of elective caesareans before 39 weeks ‒ known as the “hard stop” approach ‒ had achieved some success.

“Further strategies, such as those implemented internationally, are required to improve adherence to this evidence based policy,” they wrote.

New gestational diabetes criteria ups cases by 20%

The introduction of a lower threshold for diagnosing gestational diabetes could increase diagnoses by 20%, but the health benefits for both mothers and infants may justify the increased burden on health services, an Australian study suggests.

The researchers assessed perinatal outcomes for women with gestational diabetes mellitis (GDM), as classified by the 1988 Australasian Diabetes in Pregnancy Society (ADIPS) criteria, compared with those diagnosed under the proposed International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria, which has been endorsed by some, but not all, Australian diabetes and obstetric bodies.

Concerns have been raised that the newer criteria, which include dropping the fasting blood glucose diagnostic cut-off from 5.5mmol/L to 5.1mmol/L and making a diagnosis if one-hour glucose is 10mmol/L or greater, and a two-hour glucose is 8.5mmol/L or greater, would see an increase in the incidence of GDM in Australia from around 9.6% of pregnancies to 13% of pregnancies, leading to a rise in costs and interventions.

The study showed that among 3571 pregnant women treated at King Edward Memorial Hospital in Perth, 466 (13%) met the criteria for the 1988 ADIPS criteria for GDM, while 16% would be diagnosed using the newer IADPSG criteria ‒ a 20% increase.

Findings in The Australian and New Zealand Journal of Obstetrics and Gynaecology showed that the group of women with potentially undiagnosed GDM were more obese, had increased gestational weight gain compared with women treated for GDM based on the 1988 criteria, and were at a 2.2-fold increased risk of delivering a macrosomic (large) baby ‒ a possible risk factor for later life obesity and type 2 diabetes in the offspring.

“The increase in diagnoses of GDM brought about by the introduction of the new diagnostic criteria would increase clinical workload, primarily for diabetes educators and dieticians,” the authors wrote. “However, the potential benefits in terms of dietary education, reduced gestational weight gain a well as the decreased incidence of macrosomia should translate into short- and long-term health benefits.”

They concluded that the increased costs of treating more women with gestational diabetes based on the lower diagnostic threshold may be offset by the health benefits gained.

What’s the optimal caesarean delivery rate?

Caesarean delivery rates of approximately 19% are associated with optimal levels of maternal and neonatal mortality, according to a study of data across 194 WHO member states.  The findings challenge the long-established WHO recommendation that caesarean delivery rates should not exceed 10 to 15 per 100 live births, the study suggested.
			The findings suggested that while some countries would benefit from strategies to boost surgical capacity and caesarean rates, others might see mortality benefits from reducing caesarean rates

Australian births by caesarean nearly one in three

The researchers gathered data from 194 WHO member states to examine the relationship between the population-level caesarean delivery rate and the resultant maternal and neonatal mortality rates.

They found that 45 countries had a caesarean delivery rate of 7.2 or lower per 100 live births, 48 had a rate between 7.2 and 19.1; 48 countries had a rate between 19.1 and 27.3  and 53 countries had rate greater than 27.3, according to findings in JAMA.

Australia’s caesarean rate, as at 2010, was 32.2 per 100 live births, similar to the US, while rates were as high as 50% in some South American countries like Brazil.

The authors said the findings suggested that while some countries would benefit from strategies to boost surgical capacity and caesarean rates, others might see mortality benefits from reducing caesarean rates.

Meanwhile, a study following up babies born in Scotland between 1993 and 2007 found that those born by planned caesarean (but not unscheduled caesarean delivery) compared with vaginal delivery had a small absolute increased risk of asthma requiring hospital admission, salbutamol inhaler prescription at age five years, and all-cause death by age 21.

There were no significant differences in risk of obesity at age five, inflammatory bowel disease, type 1 diabetes and cancer.

The researchers suggested exposure to maternal bowel flora may affect development of T-cell-mediated asthma, but said further research was needed to understand whether the associations they observed were causal.