Department of Community Health Systems, School of Nursing, Indiana University, Indianapolis, Indiana.
RESPECT (Research in Palliative and End-of-Life Communication and Training) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana.
J Am Geriatr Soc. 2019 Aug;67(8):1649-1655. doi: 10.1111/jgs.15927. Epub 2019 Apr 23.
BACKGROUND/OBJECTIVES: The Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project is a successful, multicomponent demonstration project to reduce potentially avoidable hospitalizations of long-stay nursing facility residents. Systematic advance care planning (ACP) is a core component of the intervention, based on research suggesting ACP is associated with decreased hospitalizations of nursing facility residents. The purpose of this study was to describe associations between ACP documentation resulting from the OPTIMISTIC intervention and hospitalizations.
Specially trained project nurses were embedded in 19 nursing facilities and systematically engaged in ACP as part of a larger demonstration project.
Residents (n = 1482) enrolled in the demonstration project for a minimum of 30 days between January 1, 2015, and June 30, 2016.
ACP status: (1) Physician Orders for Scope of Treatment (POST) comfort measures or do not hospitalize (DNH) orders; (2) ACP orders with no hospitalization limit (eg, code status only); and (3) no ACP (potentially avoidable and all-cause hospitalizations per 1000 resident days).
Residents with POST comfort measures/DNH orders (33.2% or n = 493) were less likely than residents with no ACP (14.7% or n = 218) to experience a potentially avoidable hospitalization (P = .001) or all-cause hospitalization (P = .001). These differences became statistically nonsignificant after adjusting for age, functional status, and cognitive functioning.
In this successful multicomponent demonstration project to reduce potentially avoidable hospitalizations, ACP outcomes were not associated with hospitalization rates of nursing facility residents after adjusting for resident characteristics. These findings highlight the challenge of measuring the contributions of individual components of complex, multicomponent interventions. Associations between lower hospitalization rates and ACP completion may be influenced by contextual factors, such as clinical expertise and resources to manage acute conditions leading to hospitalization, in addition to interventions to increase ACP. J Am Geriatr Soc 67:1649-1655, 2019.
背景/目的：优化患者转院，提高医疗质量，改善症状：改变机构护理（OPTIMISTIC）项目是一项成功的、多方面的示范项目，旨在减少长期护理机构居民潜在可避免的住院治疗。系统的预先护理计划（ACP）是干预的核心组成部分，这是基于研究表明 ACP 与护理机构居民的住院率降低有关。本研究的目的是描述 OPTIMISTIC 干预措施产生的 ACP 文件与住院之间的关联。
经过专门培训的项目护士被嵌入到 19 个护理机构中，并作为一个更大的示范项目的一部分，系统地参与 ACP。
2015 年 1 月 1 日至 2016 年 6 月 30 日期间，至少入住 30 天的 1482 名参与示范项目的居民。
ACP 状态：（1）医生开具的治疗范围指令（POST）舒适措施或不进行住院治疗（DNH）指令；（2）没有住院治疗限制的 ACP 指令（例如，仅代码状态）；以及（3）没有 ACP（潜在可避免和所有原因的住院治疗每 1000 名居民天）。
与没有 ACP（14.7%或 n=218）的居民相比，具有 POST 舒适措施/DNH 医嘱的居民（33.2%或 n=493）发生潜在可避免的住院治疗（P=0.001）或所有原因的住院治疗（P=0.001）的可能性更小。在调整年龄、功能状态和认知功能后，这些差异变得没有统计学意义。
在这项成功的、多方面的示范项目中，为了减少潜在可避免的住院治疗，在调整居民特征后，护理机构居民的 ACP 结果与住院率没有关联。这些发现强调了衡量复杂、多方面干预措施中各个组成部分贡献的挑战。较低的住院率与 ACP 完成之间的关联可能受到临床专业知识和管理导致住院的急性疾病的资源等环境因素的影响，以及增加 ACP 的干预措施。美国老年学会杂志 67:1649-1655,2019。
