Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, and the University of Oxford, Wolfson Building, Oxford, OX3 9DU, England.
Departments of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, England.
BMC Geriatr. 2021 Jan 6;21(1):8. doi: 10.1186/s12877-020-01942-9.
The development of ambulatory emergency care services, now called 'Same Day Emergency Care' (SDEC) has been advocated to provide sustainable high quality healthcare in an ageing population. However, there are few data on SDEC and the factors associated with successful ambulatory care in frail older people. We therefore undertook a prospective observational study to determine i) the clinical characteristics and frailty burden of a cohort in an SDEC designed around the needs of older patients and ii) the factors associated with hospital admission within 30-days after initial assessment.
The study setting was the multidisciplinary Abingdon Emergency Medical Unit (EMU) located in a community hospital and led by a senior interface physician (geriatrician or general practitioner). Consecutive patients from August-December 2015 were assessed using a structured paper proforma including cognitive/delirium screen, comorbidities, functional, social, and nutritional status. Physiologic parameters were recorded. Illness severity was quantified using the Systemic Inflammatory Response Syndrome (SIRS> 1). Factors associated with hospitalization within 30-days were determined using multivariable logistic regression.
Among 533 patients (median (IQR) age = 81 (68-87), 315 (59%) female), 453 (86%) were living at home but 283 (54%) required some form of care and 299 (56%) had Barthel< 20. Falls, urinary incontinence and dementia affected 81/189 (43%), 50 (26%) and 40 (21%) of those aged > 85 years." Severe illness was present in 148 (28%) with broadly similar rates across age groups. Overall, 210 (39%) patients had a hospital admission within 30-days with higher rates in older patients: 96 (87%) of < 65 years remained on an ambulatory pathway versus only 91 (48%) of ≥ 85 years (p < 0.0001). Factors independently associated with hospital admission were severe illness (SIRS/point, OR = 1.46,95% CI = 1.15-1.87, p = 0.002) and markers of frailty: delirium (OR = 11.28,3.07-41.44, p < 0.0001), increased care needs (OR = 3.08,1.55-6.12, p = 0.001), transport requirement (OR = 1.92,1.13-3.27), and poor nutrition (OR = 1.13-3.79, p = 0.02).
Even in an SDEC with a multidisciplinary approach, rates of hospital admission in those with severe illness and frailty were high. Further studies are required to understand the key components of hospital bed-based care that need to be replicated by models delivering acute frailty care closer to home, and the feasibility, cost-effectiveness and patient/carer acceptability of such models.
流动急诊护理服务（现称“当日急诊护理”）的发展旨在为老龄化人口提供可持续的高质量医疗服务。然而，关于当日急诊护理以及与体弱老年人门诊护理成功相关的因素，数据很少。因此，我们进行了一项前瞻性观察研究，目的是确定 i）满足老年患者需求而设计的当日急诊护理中，队列的临床特征和虚弱负担；ii）与初始评估后 30 天内住院相关的因素。
研究地点是位于社区医院的多学科阿宾顿急诊医疗单位（EMU），由一名资深接口医生（老年病医生或全科医生）领导。2015 年 8 月至 12 月连续评估的患者使用结构化纸质方案，包括认知/谵妄筛查、合并症、功能、社会和营养状况。记录生理参数。使用全身炎症反应综合征（SIRS>1）量化疾病严重程度。使用多变量逻辑回归确定与 30 天内住院相关的因素。
在 533 名患者（中位数（IQR）年龄=81（68-87）岁，315 名（59%）女性）中，453 名（86%）患者居家生活，但 283 名（54%）需要某种形式的护理，299 名（56%）巴氏量表<20 分。跌倒、尿失禁和痴呆影响了 189 名（43%）中的 81 名、50 名（26%）和 40 名（21%）≥85 岁的患者。148 名（28%）患者存在严重疾病，各年龄组的发病率大致相似。总体而言，30 天内有 210 名（39%）患者住院，老年患者的住院率更高：<65 岁的患者中有 96 人（87%）仍采用门诊途径，而≥85 岁的患者中只有 91 人（48%）（p<0.0001）。与住院相关的独立因素包括严重疾病（SIRS/点，OR=1.46，95%CI=1.15-1.87，p=0.002）和虚弱标志物：谵妄（OR=11.28，3.07-41.44，p<0.0001）、增加的护理需求（OR=3.08，1.55-6.12，p=0.001）、交通需求（OR=1.92，1.13-3.27）和营养不良（OR=1.13-3.79，p=0.02）。
即使在多学科的当日急诊护理中，严重疾病和虚弱患者的住院率仍然很高。需要进一步研究，以了解需要在家庭为基础的急性虚弱护理模式中复制的关键住院护理内容，以及这些模式的可行性、成本效益和患者/护理人员的可接受性。
