Dwyer Rosamond, Stoelwinder Just, Gabbe Belinda, Lowthian Judy
School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
J Am Med Dir Assoc. 2015 Jul 1;16(7):551-62. doi: 10.1016/j.jamda.2015.03.007. Epub 2015 Apr 28.
With an aging population, a growing number of older adults experience physical or cognitive decline that necessitates admission to residential aged care facilities (RACF). Each year a considerable proportion of these residents has at least 1 emergency transfer to hospital, which may result in a number of adverse outcomes. Rates of transfer from RACF to hospital can vary considerably between different RACFs suggesting the presence of potentially modifiable risk factors for emergency department (ED) transfer.
A systematic and comprehensive search of the peer-reviewed literature using 4 electronic databases was conducted. Included papers were those reporting on determinants of unplanned transfer to hospital for elderly people (aged 65 years and above) living in RACFs. Studies were assessed for quality and key concepts and themes extracted.
There are both individual patient factors and health system factors, which influence rates of transfer to hospital for elderly RACF residents. For individuals, increased risk of ED transfer has been associated with presence of particular comorbidities such as chronic airways disease, congestive cardiac failure, and diabetes; presence of indwelling devices; absence of an advance care plan; and reduced functional ability. For organizations, "for profit" facilities and those with poorer staff to patient ratios also have higher rates of transfer to hospital, compared with those owned by not-for-profit organizations and those with improved registered nurse and medical practitioner staffing.
This review has identified a number of potentially modifiable patient and organizational factors that should reduce the need for burdensome transfer to the ED and improve the quality of both acute care and end-of-life care for this population of frail, elderly individuals. A number of these determinants, including facility staffing, the role of specialist geriatricians, and advance directives, should be further examined, ideally through interventional trials to evaluate their impact on the pre-hospital and emergency management of these patients.
随着人口老龄化，越来越多的老年人出现身体或认知功能衰退，需要入住老年护理机构（RACF）。每年，这些居民中有相当一部分人至少有一次紧急转院至医院的情况，这可能会导致一些不良后果。不同的老年护理机构从RACF转院至医院的比例差异很大，这表明存在一些可能可改变的导致急诊（ED）转院的风险因素。
使用4个电子数据库对同行评审文献进行了系统全面的检索。纳入的论文是那些报道居住在RACF中的老年人（65岁及以上）非计划转院至医院的决定因素的文章。对研究进行质量评估，并提取关键概念和主题。
个体患者因素和卫生系统因素都会影响老年RACF居民转院至医院的比例。对于个体而言，急诊转院风险增加与特定合并症的存在有关，如慢性气道疾病、充血性心力衰竭和糖尿病；体内留置装置的存在；没有预先护理计划；以及功能能力下降。对于机构而言，与非营利组织所有的机构以及注册护士和医生配备更好的机构相比，“营利性”机构以及医护人员与患者比例较低的机构转院至医院的比例也更高。
本综述确定了一些可能可改变的患者和机构因素，这些因素应能减少转至急诊的繁重需求，并改善这一脆弱老年人群体的急性护理和临终护理质量。其中一些决定因素，包括机构人员配备、老年病专科医生的作用以及预先指示，应进一步研究，理想情况下通过干预试验来评估它们对这些患者院前和急诊管理的影响。
