Department of Medicine and Geriatrics, Shatin Hospital, Hong Kong SAR, China; Department of Community Geriatrics Assessment Team, Prince of Wales Hospital, Hong Kong SAR, China.
Department of Medicine and Geriatrics, Shatin Hospital, Hong Kong SAR, China; Department of Community Geriatrics Assessment Team, Prince of Wales Hospital, Hong Kong SAR, China.
J Am Med Dir Assoc. 2014 Apr;15(4):287-9. doi: 10.1016/j.jamda.2013.11.019. Epub 2014 Feb 6.
This study aimed to promote quality end-of-life (EOL) care for nursing home residents, through the establishment of advance care plan (ACP) and introduction of a new care pathway. This pathway bypassed the emergency room (ER) and acute medical wards by facilitating direct clinical admission to an extended-care facility.
An audit on a new clinical initiative that entailed the Community Geriatrics Outreach Service, ER, acute medical wards, and an extended-care facility during winter months in Hong Kong.
The participants were older nursing home residents enrolled in an EOL program. We monitored the ratio of clinical to emergency admissions, ACP compliance rate, average length of stay (ALOS) in both acute hospital and an extended-care facility, and mortality rates.
A total of 76 patients were hospitalized from January to March 2013. Of them, 30 (39%) were directly admitted to the extended-care facility, either through the liaison of Community Geriatrics Outreach Service (group A, 19/76, 25%) or transferred from the ER (group B, 11/76, 14%). The remaining 46 patients (group C, 61%) were admitted via the ER to acute medical wards following the usual pathway, followed by transfer to an extended-care facility if indicated. The ACP compliance rate was nearly 100%. In the extended-care unit, groups A and C had similar ALOS of 11.8 and 11.1 days, respectively, whereas group B had a shorter stay of 7.6 days. The ALOS of group C in acute medical wards was 3.5 days. The in-hospital mortality rates were comparable in groups A and C of 26% and 28%, respectively, whereas group B had a lower mortality rate of 18%.
Nearly 40% of EOL patients could be managed entirely in an extended-care setting without compromising the quality of care and survival. A greater number of patients may benefit from the EOL program by improving the collaboration between community outreach services and ER; and extending hours for direct clinical admission to an extended-care facility.
本研究旨在通过建立预先医疗指示（ACP）和引入新的护理途径，为养老院居民提供优质的临终关怀。该途径绕过急诊室（ER）和急性内科病房，通过直接将患者收治到长期护理机构来实现。
对香港冬季期间社区老年科外展服务、急诊室、急性内科病房和长期护理机构开展的一项新的临床举措进行审计。
参与者为参加临终关怀项目的老年养老院居民。我们监测了临床入院与急诊入院的比例、ACP 遵从率、急性医院和长期护理机构的平均住院时间（ALOS）以及死亡率。
2013 年 1 月至 3 月期间共有 76 名患者住院。其中，30 名（39%）通过社区老年科外展服务（A 组，19/76，25%）或从急诊室（B 组，11/76，14%）直接收治到长期护理机构。其余 46 名患者（C 组，61%）通过急诊室进入急性内科病房，然后根据需要转入长期护理机构。ACP 遵从率接近 100%。在长期护理病房中，A 组和 C 组的 ALOS 分别为 11.8 天和 11.1 天，相似，而 B 组的住院时间较短，为 7.6 天。C 组在急性内科病房的 ALOS 为 3.5 天。A 组和 C 组的院内死亡率分别为 26%和 28%，相似，而 B 组的死亡率较低，为 18%。
近 40%的临终关怀患者可以在长期护理环境中得到完全管理，而不会影响护理质量和生存率。通过改善社区外展服务与急诊室之间的合作，并延长直接收治到长期护理机构的时间，可以使更多的患者受益于临终关怀计划。
