Abstract
Background
The COVID-19 pandemic is recognised as having a significant impact on older people, particularly on those within nursing homes. Prior to the pandemic, a significant focus was ...placed on the application of a social model of care within nursing homes. We know that COVID-19 has required the stringent application of infection prevention and control measures as well as the provision of increased amounts of clinical care. This has resulted in the recent stronger application of a medical model of care within nursing homes.
Methods
A roundtable event attended by twenty-six people took place. Attendees represented clinical Gerontology, the Irish College of General Practitioner, Sage Family Forum, The Health Information and Quality Authority, Nursing Homes Ireland and nursing home providers. A number of presentations were made, and a roundtable discussion took place about the model of nursing home care post pandemic. Key messages from presentations and the discussion were captured. A report was compiled and shared with attendees to check for accuracy.
Results
The following key messages were identified:
1. Social care is a cornerstone of nursing home care
2. Increased integration of nursing homes within the wider health and social care system is required
3. Increased access to services for nursing home residents is required
4. Regulatory reform is required
5. Resourcing of nursing home care needs to be appropriately addressed
6. The nursing home sector need to be included in conversations around policy and service development affecting nursing home care in Ireland.
Conclusion
Nursing homes are an essential part of the healthcare system in Ireland and have been shown to be adaptable throughout the course of the pandemic. A one size fits all approach is an unlikely fit for purpose approach as we look towards the future with COVID-19.
Abstract
Background
The COVID-19 pandemic fundamentally changed the way rehabilitation services are delivered, with focus placed on individual in-room therapy and cessation of group sessions. Sparks ...Innovation and National Lottery funding was obtained to implement the ‘In-Room Rehabilitation and Well-being Initiative’. This provided patients with individual physiotherapy equipment to use in their room thus maximizing time spent active during periods of isolation. We aim to describe service innovation occurring in a post-acute geriatric rehabilitation hospital during the COVID-19 era, and the resultant patient outcomes.
Methods
Rehabilitation was provided to patients in-line with evidence-based practice and national infection prevention and control guidelines. Patients who were deemed appropriate by the multi-disciplinary team were provided with in-room therapy equipment. Prospective data was collected on service and patient outcomes. Functional outcome measurements were collected on admission and discharge and compared using a paired t-test.
Results
Rehabilitation was provided to 260 patients, average age 80.5 years (range 63–98) with 46.5% male. The majority of patients were admitted with ortho-geriatric diagnoses or general deconditioning following illness (70%). The patients were complex with multiple medical, functional, and psychosocial care needs, as indicated by an average Rehabilitation Complexity Score of 11/20, with 100% of patients requiring daily therapy. Average length of stay (LOS) was 30.7 days (range 3–169), with 85% of patients discharged home. Performance in activities of daily living (Barthel Index: 62 vs 79, p < 0.0001), and mobility (Cumulative Ambulatory Score: 3.8 vs 5.3, p < 0.0001) significantly improved from admission to discharge.
Conclusion
Despite ward closures, disruption to rehabilitation due to COVID-19 illness, and limitations on group therapies, our service achieved positive patient outcomes through innovation and delivery of high-quality evidence-based rehabilitation. Compared to the past eight years, 2020 had the lowest LOS and highest number of patients discharged home.
Abstract
Background
The Health and Social Care Professionals budget was augmented to develop rehabilitation services that facilitated hospital discharges. Early Supported discharge (ESD) for stroke ...is a proven model of best care for stroke patients with mild to moderate disability (Langhorne et al., 2005). A pilot was implemented with the team consisting of an Occupational Therapist, Speech and Language Therapist, Physiotherapist and Medical Social Worker.
Methods
The service facilitated an early discharge from the hospital with the delivery of specialist stroke rehabilitation in the home. Therapy is provided with the same intensity and expertise that would be received in hospital and is available for up to 8 weeks, it was provided using a blended model of domiciliary care and the introduction of telehealth in response to COVID 19.
Data was recorded for 100 service users using an excel spreadsheet. Data was recorded to measure number of new referrals, length of stay, bed days released back into the hospital system, mode of service delivery and functional outcomes. A cost analysis was completed. Service user experience was captured using questionnaires.
Results
From September 2020 to July 2021, 100 patients accessed ESD with a reduction of 7.2 days in hospital stay per patient. Improvements in pre- and post- rehabilitation scores on the FIM/FAM were evident. Very positive feedback regarding the rehabilitation experience was captured within the patient satisfaction questionnaire. Therapy delivery was 60% face to face, 37% via telehealth and 3% outpatient appointments. Telehealth received good compliance but with varying reports of experience in comparison to face to face.
Conclusion
ESD provided in the home environment facilitated earlier discharge from hospital with positive outcomes for the hospital and service users. Telehealth ensured that rehabilitation was maintained throughout the pandemic. Telehealth increased access for patients residing outside of the catchment area. However service user preference remains face to face.
Abstract
Background
The geriatric day hospital (GDH) provides outpatient medical, nursing and rehabilitation care to older adults. Historically the main focus has been on rehabilitation. This ...project’s objective was to evaluate how the GDH adapted during the COVID-pandemic to provide acute medical care to older adults.
Methods
This is a pre and post COVID-19 comparative study. Referral source, multidisciplinary-team input and admission rates were evaluated for all new patient referrals from April 1st to May 31st 2019 (pre-pandemic) and compared to April 1st to May 31st 2020 (during-pandemic). This service evaluation project was approved by the local Research and Innovation Office.
Results
There was a 37.7% reduction in the number of new patient referrals for 2020 compared to 2019, p < 0.00; Geriatric medicine referrals reduced by 46.5%, emergency department referrals reduced by 61.5%; community referrals increased 15-foldAL1. There were no differences in patients referred in terms of gender (p = 0.069), mean age (80.9(SD7.6) vs 79.1(SD6.6), p = 0.092), median conditions (5(IQR3.75–7) vs 6(IQ4–8), p = 0.329) and median medications (8(IQR5–11) vs 8 (IQR5.25–9), p = 0.600). Those referred pre-pandemic were frailer according to the clinical frailty score; median 5(IQR5–6) vs 5(IQR4–6), p = 0.013. In 2020, there was a significant reduction in referrals for physiotherapy (72.9% vs 37.3%, p < 0.001), occupational therapy (58.5% vs 37.8%, p = 0.005) and social work (47.5% vs 26.7%, p = 0.004). Clinical nutrition and speech and language remained the same, 16.1% vs 12%, p = 0.430 and 9.3% vs 12%, p = 0.552, respectively. In 2020, patients referred had significantly fewer attendances; median 4(IQR2–7) vs 3(IQR1–5), p = 0.002. There was no difference in admission rates between 2019 and 2020 (3.3% vs 7.9%, p = 0.149).
Conclusion
During the COVID-Pandemic, the GDH evolved to provide more acute ambulatory medical care to avoid admissions. The GDH continues to adapt as the pandemic evolves and older adults needs change. Further comparative analysis will be required.
Abstract
Background
The coronavirus 2019 (COVID-19) pandemic impacted significantly on the lives of older adults in Ireland, including the cancellation or postponement of healthcare services. This ...study examined the relationship between healthcare delay and older adults (50 years and over) with chronic conditions in Ireland.
Methods
This study used data from the Irish Longitudinal Study on Ageing (TILDA) COVID-19 study and previous waves of TILDA. The COVID-19 study data was collected between July 2020 and November 2020. Taking existing healthcare demand into account, logistic regression analysis was used to examine the relationship between healthcare delay and older adults with chronic conditions. Additional analysis, using multinomial logit regression, explored the reasons for healthcare delay, whether the delays were on the participants behalf or the health service provider.
Results
In total, 31.6% of participants reported healthcare delay. Older adults with two or more chronic conditions were more likely to experience healthcare delay than those with no chronic conditions. In the second analysis, older adults with two or more chronic conditions were more likely to have healthcare delayed by the provider and were also more likely to delay their own healthcare than those with no chronic conditions. Additionally, some other groups were more likely to experience healthcare delay such as: people aged 70 years and over, females, those with problematic alcohol consumption, those with third-level education, those who had visited the GP and those who reported polypharmacy. While older adults living with others and those living outside Dublin were less likely to experience healthcare delay.
Conclusion
The findings suggest that some groups of older adults may have been impacted more than others by healthcare delay during the pandemic. Policy and practice should focus on effective strategies to support the healthcare needs of these older adults going forward. Additionally, future research should examine the implications of healthcare delay on health outcomes.
Abstract
Background
COVID-19 has caused unprecedented challenges in nursing homes. In this narrative review, we aimed to describe factors that contributed to the spread and mortality of COVID-19 in ...nursing homes and provide an overview of responses that were implemented to try to overcome such challenges.
Methods
The MeSH terms ‘Nursing homes’ and ‘COVID-19’ were searched in MEDLINE Ovid, and English language articles were retrieved that were published between 1 March 2020 and 31 January 2021. Article titles and abstracts were screened by two reviewers, and the results of included articles were grouped by themes.
Results
The search retrieved 348 articles, of which 76 were included in the thematic review. 8 articles related to COVID-19 disease characteristics (e.g. asymptomatic transmission), 24 to resident-related factors (e.g. comorbidities, nutrition, cognition), 13 to facility characteristics (e.g. physical space, occupancy, for-profit status), 21 to staffing (e.g. staffing levels, staff-to-resident ratio, staff multi-employment), and 10 to external factors (e.g. availability of personal protective equipment, prevailing health and social care policies). In terms of responses, identified themes included widespread testing, isolation and cohorting of residents, staff protection and support, promotion of residents’ well-being, and technological innovations.
Conclusion
COVID-19 exerted severe challenges on the nursing home population and its staff. Both internal and external factors predisposed nursing homes to an increased propensity of spread. Numerous strategies were employed to attempt to mitigate the negative impacts. Substantial learning occurred that may not only aid future pandemic preparedness but improve quality of care for nursing home residents at all times.
Abstract
Background
‘Wish to Die’ (WTD) involves thoughts of or wishes for one’s own death or that one would be better off dead.
Assisted dying is the act of deliberately providing medical assistance ...to another person who wishes to end their own life. Currently, in Ireland, it is illegal to provide such assistance to people with WTD or suicidal ideation. However, a new bill that would legalise assisted dying for those with terminal illnesses, the Dying with Dignity Bill 2020, is due to be considered by lawmakers in Ireland in the coming months.
In order to inform discussion around this complex issue, we examine the prevalence and longitudinal course of WTD in a large population-representative sample of older people.
Methods
To define WTD, participants were asked: ‘In the last month, have you felt that you would rather be dead?’
Depressive symptoms were measured using the CES-D.
Mortality data were compiled by linking administrative death records to individual-level survey data from the study.
Results
At Wave 1, 3.5% of participants (279/8,174) reported WTD. Both persistent loneliness (OR 5.73 (95% CI 3.41–9.64)) and depressive symptoms (OR 6.12 (95% CI 4.33–8.67)) were independently associated with WTD.
Of participants who first reported WTD at Wave 1 or 2, 72% did not report WTD when reassessed after 2 years, and the prevalence of depressive symptoms (−44%) and loneliness (−19%) was more likely to decline in this group at follow-up.
Fifteen per cent of participants expressing WTD at Wave 1 died during a 6-year follow-up.
Conclusion
WTD amongst community-dwelling older people is frequently transient and is strongly linked with the course of depressive symptoms and loneliness.
An enhanced focus on improving access to mental health care and addressing social isolation in older people should therefore be a public health priority, particularly in the current context of the Covid-19 pandemic.
Abstract
Background
The aging population of Ireland continues to increase rapidly. As the age continues to increase, so too does the need for long-term care (LTC). In 2006 LTC utilisation was ...estimated between 4.4%–4.8% of the over 65s population. It was proposed that this would increase to between 4.8%–5.3% by 2021 (Wren et al., 2012). This study intended to explore if this projection was evident in discharges from an acute Care of the Older Person’s setting between 2016 and 2021.
Methods
A random selection approach was used to retrospectively review 45 patients seen by occupational therapy in an Irish acute Care of the Older Person’s service in 2016. Discharge destinations were recorded. These were then compared to the discharge destinations of 45 randomly selected patients open to occupational therapy in the same service during the first half of 2021.
Results
The review of 2016 found that 15.56% (n = 7) of those seen by occupational therapy discharged to a LTC facility, and 4.45% (n = 2) discharged home with a back-up LTC plan. Additionally, 33.33% (n = 15) transferred to a rehabilitation facility and 42.22% (n = 19) went home with community supports, 4.44% (n = 2) passed away.
Contrastingly, in 2021, 28.89% (n = 13) patients discharge to LTC with an additional 6.66% (n = 3) going home with 24/7 private care in place, and 4.45% (n = 2) went home with a LTC back-up plan. Just 22.22% (n = 10) went for rehabilitation and 26.67% (n = 12) went home with community supports. In 2021, 11.11% (n = 5) of those randomly selected passed away during their admission.
Conclusion
A significant increase of the number of inpatients discharging to LTC between 2016 and 2021 was found. These findings are greater than that previously proposed and may suggest that COVID-19 has caused a further increase in individuals requiring LTC. However, this sample size was small and other factors such as age, physical ability and cognition were not explored. Further studies are recommended.
Abstract
Background
Influenza vaccination, particularly for vulnerable, older adults, will have added importance this winter given the possibility of further waves of COVID-19 pandemic. Previous ...interventions at the study site noted poor awareness on the need for inpatient Influenza vaccination1. This study examines a vaccination reminder process using an electronic patient record (EPR) to identify high-priority eligible inpatients.
Methods
The study site is a 900-bed university teaching hospital with all clinical notes accessed via an EPR.
We included a convenience sample of 750 adults aged≥50 years (mean age 75.9 +/− 0.4 years, 48% female) and high-priority for influenza vaccination (Age > 65 years and/or length of stay (LOS) >30 days) from October 1st 2020 to January 12th 2021.
A live electronic dashboard identified eligible inpatients for vaccination, prompting vaccination reminders to the clinical teams via the antimicrobial pharmacist.
Data was collected retrospectively. Logistic regression models reporting odds ratios were used to assess the association of these reminders with vaccine uptake.
Results
Over one third (35%, 264/750) of high-priority patients received the Influenza vaccine while inpatients, including 40% aged ≥80 years.
The reminder was sent on 41% (305/750) of patients and was associated with an almost 50% higher likelihood of vaccination after adjusting for other covariates (Odds Ratio 1.48 (95% CI 1.00–2.20); p = 0.048).
Other factors independently associated with vaccination were advancing age (Odds Ratio 2.69 (95% CI 1.12–6.47) for age ≥ 80 years); LOS (4% higher likelihood of vaccination for every additional day in hospital) and admission under geriatric medicine (Odds Ratio 3.71 (95% CI 2.45–5.62) when compared to other specialities).
Conclusion
Our study shows relatively low uptake of inpatient Influenza vaccination and strategies to improve uptake are required. Reminders sent to clinical teams using the EPR appear to be an effective means of increasing Influenza vaccination and should be considered as part of this year’s inpatient vaccination drive.
Abstract
Background
The COVID19 pandemic highlighted deficiencies in information exchange around treatment escalation plans (TEP) in an intermediate care unit, based in a 30 bed independent care ...home, into which the hospital organisation assigns medical, pharmacy, physiotherapy, occupational therapy and social work teams to provide post-acute care rehabilitation for adults. Mean length of stay is 20 days and > 75% return home. Weekly bed turnover is approximately 15%.
TEP documentation is a component of RESTORE2 use, as recommended in the British Geriatric Society Good Practice Guide for Managing COVID19 in Care Homes.
Methods
Semi-structured interviews with nursing leaders and a weighted questionnaire for the whole nursing team were used to determine baseline levels of confidence around aspects of TEP.
An Ishikawa diagram analysed factors contributing to poor documentation and communication. The ‘Chain Of Care’ vision for care home environments incorporated the need for a TEP. Three iterations occurred. A post-implementation weighted questionnaire collated qualitative information on confidence change.
Results
Areas of greatest ‘swing’ towards INCREASED or SLIGHTLY INCREASED confidence around...: 90%, Cardiopulmonary Resuscitation (CPR) status clarity; 90%, treatment ‘ceiling of care’ e.g. ‘conveyance to the Emergency Department in any situation that the clinical team deem necessary’; 40%, conversations with out-of-hours services/external clinicians around appropriate actions; 30%, conversations with nominated persons around appropriate actions.
Conclusion
The TEP incorporates more than just CPR status and contributed to increased nursing team confidence in responding to the acutely deteriorating adult appropriately in a care home environment. Clear documentation of: capacity assessment; patient prioritisation (using ReSPECT principles); and agreed treatment escalation and limitation, enabled information exchange. Standardisation of language, and cross-fertilisation with Nursing Handover, facilitated conversations with external clinicians and nominated persons.
Tailoring the TEP to the care-home environment and rendering it generalisable to non-intermediate care, non-geriatrician supported care home microsystems was considered in the iterations.
