Considine Julie, Street Maryann, Hutchinson Alison M, Mohebbi Mohammadreza, Rawson Helen, Dunning Trisha, Botti Mari, Duke Maxine M, Hutchison Anastasia F, Bucknall Tracey
School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Eastern Health Partnership, Deakin University, Geelong, Australia.
School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Eastern Health Partnership, Deakin University, Geelong, Australia.
Int J Nurs Stud. 2020 Aug;108:103612. doi: 10.1016/j.ijnurstu.2020.103612. Epub 2020 May 11.
Emergency interhospital transfers from inpatient subacute care to acute care occur in 8% to 17.4% of admitted patients and are associated with high rates of acute care readmission and in-hospital mortality. Serious adverse events in subacute care (rapid response team or cardiac arrest team calls) and increased nursing surveillance are the strongest known predictors of emergency interhospital transfer from subacute to acute care hospitals. However, the epidemiology of clinical deterioration across sectors of care, and specifically in subacute care is not well understood.
To explore the trajectory of clinical deterioration in patients who did and did not have an emergency interhospital transfer from subacute to acute care; and develop an internally validated predictive model to identify the role of vital sign abnormalities in predicting these emergency interhospital transfers.
This prospective, exploratory cohort study is a subanalysis of data derived from a larger case-time-control study.
Twenty-two wards of eight subacute care hospitals in five major health services in Victoria, Australia. All subacute care hospitals were geographically separate from their health services' acute care hospitals.
All patients with an emergency transfer from inpatient rehabilitation or geriatric evaluation and management unit to an acute care hospital within the same health service were included. Patients receiving palliative care were excluded.
Study data were collected between 22 August 2015 and 30 October 2016 by medical record audit. The Cochran-Mantel-Haenszel test and bivariate logistic regression analysis were used to compare cases with controls and to account for health service clustering effect.
Data were collected on 603 transfers (557 patients) and 1160 controls. Adjusted for health service, ≥2 vital sign abnormalities in subacute care (adjusted odds ratio=8.81, 95% confidence intervals:6.36-12.19, p<0.001) and serious adverse events during the first acute care admission (adjusted odds ratio=1.28, 95% confidence intervals:1.08-1.99, p=0.015) were the clinical factors associated with increased risk of emergency interhospital transfer. An internally validated predictive model showed that vital sign abnormalities can fairly predict emergency interhospital transfers from subacute to acute care hospitals.
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.
住院患者从亚急性护理转至急性护理的紧急院际转运发生率为8%至17.4%，且与急性护理再入院率和住院死亡率较高相关。亚急性护理中的严重不良事件（快速反应团队或心脏骤停团队呼叫）以及加强护理监测是已知的从亚急性护理医院紧急转至急性护理医院的最强预测因素。然而，各护理环节中临床病情恶化的流行病学情况，尤其是亚急性护理中的情况，目前尚不清楚。
探讨有和没有从亚急性护理紧急转至急性护理的患者的临床病情恶化轨迹；并建立一个内部验证的预测模型，以确定生命体征异常在预测这些紧急院际转运中的作用。
这项前瞻性探索性队列研究是对来自一项更大的病例 - 时间 - 对照研究数据的子分析。
澳大利亚维多利亚州五个主要医疗服务机构中八家亚急性护理医院的22个病房。所有亚急性护理医院在地理位置上均与其医疗服务机构的急性护理医院分开。
纳入所有在同一医疗服务机构内从住院康复或老年评估与管理单元紧急转至急性护理医院的患者。接受姑息治疗的患者被排除。
通过病历审核在2015年8月22日至2016年10月30日期间收集研究数据。采用 Cochr an - Mantel - Haenszel检验和双变量逻辑回归分析来比较病例与对照，并考虑医疗服务机构的聚类效应。
收集了603例转运（557名患者）和1160名对照的数据。在调整了医疗服务机构因素后，亚急性护理中≥2项生命体征异常（调整比值比 = 8.81，95%置信区间：6.36 - 12.19，p < 0.001）以及首次急性护理入院期间的严重不良事件（调整比值比 = 1.28，95%置信区间：1.08 - 1.99，p = 0.015）是与紧急院际转运风险增加相关的临床因素。一个内部验证的预测模型表明，生命体征异常能够较好地预测从亚急性护理医院到急性护理医院的紧急院际转运。
急性护理中的严重不良事件应是决定亚急性护理地点时的关键考虑因素。在亚急性护理期间，15.7%的病例生命体征符合机构快速反应团队启动标准，但错过快速反应团队启动的情况很常见，这表明需要进一步考虑优化亚急性护理中对临床病情恶化的识别和反应的标准及策略。
