In a recent letter published in the Australian Health Review, Donna Markham, the general Manager of Allied Health points out that allied health workers are in an ideal position to lead the reform necessary for the health care system of the future. Why is this the case?
Firstly, she says, the allied health workforce is renowned for providing holistic person-centred care. This is a key element of new organizational models of health care delivery that sees the patient at the centre of integrated, comprehensive care. Furthermore, allied health workers have acknowledged strengths in disease prevention, health promotion, andrehabilitation. These are attributes that can significantly impact patient care and decrease health care costs. Markham sees these strengths as an opportunity to shift the focus for reform away from the acute setting and into the community to develop a more sustainable health care system.
Health care reform also depends on reshaping the workforce to be more effective, efficient and accessible. Allied health is in a position to lead in this area as well due to its recent experience with the introduction of allied health assistant roles to fulfil the unmet need for assistants across different allied health disciplines. Advanced practice roles have also been introduced that support the delegation of tasks from nursing and medical colleagues.
Australia’s population is increasing, getting older, living longer, and suffering more fromchronic disease. The demands placed on the health care system urges reform, and to quoteMarkham, “ allied health is in the front seat to lead the changes that the health system is screaming out for”.
D Markham, ‘Allied health: leaders in health care reform.’ Australian Health Review 2015;39: 248.
Article taken from HITH Journal Club, Issue No. 21 October 2015
A recent study by Tappen and co-workers from the American aged care system has examined the issue of transferring a nursing home resident to hospital upon deterioration in their condition. The reason for this focus stems from a previous study that has shown as many as two thirds of transferrals from a nursing home to an acute care setting may be avoidable.
What are the factors that influence the decision on whether to transfer a patient? Those of the patient, their family, and care workers all come into play. Tappen cites that in quality improvement reports from 30 nursing homes in America two of the three most frequent reasons given by staff for avoidable or possibly avoidable transfer to hospital were: (1) insistence by nursing home residents and their families; and (2) communication gaps amongnursing staff, primary care providers and families.
It has been suggested that family members are often poorly informed about the resident’s condition and treatment options available within the nursing home. This leads to insistence on hospitalization based on a belief that the transfer is beneficial. However there is little published data that investigates this decision-making.
Tappen and co-workers have therefore conducted semi-structured interviews of nursing homeresidents, their families and staff in 19 nursing home in Florida. They investigated: (a) their preferences on whether the resident should receive hospital or nursing home treatment; (b) their preferred degree of involvement in the decision; and (c) how much prior thought had been given to the decision about whether to transfer. Responses were coded, and merged with sociodemographic data for analysis.
Whilst staff overwhelmingly preferred keeping residents in the nursing home, residents were evenly divided between the options of wishing to be transferred to hospital upon deterioration in their condition, preferring to stay in the nursing home, and an intermediate position to these two options. More African American residents preferred acute care transfer whereas European American residents were evenly distributed across these preferences. More Hispanic and Afro-Caribbean residents preferred remaining in the nursing home.
The majority of nursing home residents and a half of family members had not given thought to a potential future decision concerning transfer to hospital upon a change in their condition, but residents had strong opinions about the degree of involvement they should have in this decision.
These findings suggest there is scope for education to improve decision-making and reduceavoidable hospital admissions due to family and resident insistence. The authors’ recommendation is that conversations about what to do if an acute change occurs should be held in advance. A resident and family appreciation of the quality of care available within the home, and of the risks associated with acute care –such as hospital acquired infections, may improve both the patients quality of life, and prevent unnecessary health care expenditure.
RM Tappen, SM Worch, D Elkins, DJ Hain, CM Moffa, G Sullivan, Remaining in the nursing home versus transfer to acute care: resident, family and staff preferences. Journal of Gerontoligical Nursing, 2014;40:48-57.
Article taken from HITH Journal Club, Issue No. 20 April 2015
An article was published at Open Access Publishing London about a systemic review of treatment of cellulitis in Hospital in the Home authored by DA Lasschuit, D Kuzmich and GA Caplan.
Relevant articles, including randomised controlled trials, were included in the review.
The article concluded that the Treatment of cellulitis in hospital in the home is practical, safe, well tolerated and efficacious.
Cellulitis results in high morbidity and severe financial costs to healthcare providers worldwide. Hospital visits due to the infection are increasing in Australia, the United Kingdom and the United States, with average lengths of stay of up to a week. This clinical review, published in the British Medical Journal, summarises recent evidence in the diagnosis and management of the condition.
The majority of cellulitis cases are caused by Streptococcus pyogenes or Staphylococcus aureus, with a recent review finding that S aureus caused more than half of all cellulitis cases; the two organisms together accounting for 78% of cases reviewed. Antibiotic resistance is on the rise, with studies showing a majority of S aureus infections in the US - up to 74% in some hospitals - are now CA-MSRA.
As cellulitis often presents with similar symptoms to other conditions – 28% of cellulitis patients in a recent study had been incorrectly diagnosed – further investigations are often recommended to aid diagnosis. This review finds neither blood investigations nor blood cultures to be clinically useful for cellulitis diagnosis, with available evidence suggesting wound swabs to be the most accurate microbiological diagnostic tool. Imaging has also been shown to be useful in cellulitis diagnosis and management, with ultrasound able to detect occult abscesses and thus ensure that drainage is used (and is only used) when necessary. Magnetic resonance imaging can be used to confirm suspected cases of necrotising fasciitis.
A recent Cochrane review analysed 25 randomised controlled trials of cellulitis interventions but drew no definitive conclusions on the optimal antibiotics, duration or route of administration. However, national guidelines in the US and the UK recommend treatment of typical cellulitis with amoxicillin or flucloxacillin. The rise in CA-MRSA should be taken into account, however; the Infectious Diseases Society of America now recommends that patients with pus-forming cellulitis be treated with antibiotics that target CA-MRSA. Of these, doxycycline and minocycline have been shown to be effective in 95% of patients with CA-MSRA, with clindamycin also effective, but possibly problematic, and linezolid and vancomycin effective for patients requiring hospitalisation.
It is possible that many more cellulitis patients could be treated outside of hospitals. The new Dundee classification system provides an alternative to the widely-used Eron classification system for cellulitis diagnosis and treatment. If assessed under the Dundee criteria, 70% of patients that would be hospitalised under the Eron system would be managed instead as outpatients. Indeed, a recent Scottish study found that 43% of patients hospitalised for cellulitis were overtreated and could have been managed as outpatients on oral antibiotics.
The Cochrane review mentioned above highlighted the need for further evaluation of oral versus intravenous antibiotics and the efficiency of outpatient parenteral antibiotic therapy (OPAT). One study of 344 cellulitis patient treated by a UK OPAT service found that 87% of patients were cured, with a readmission rate of only 6.3%. Conservative estimates costed OPAT at 41% of inpatient costs, and this study's authors concluded that clinicians should use OPAT where available.
Phoenix G, Das S, Joshi M, Diagnosis and management of cellulitis, British Medical Journal. 2012; 345:38-42: e4955.
Article taken from HITH Journal Club, Issue No. 17 April 2014
In this study, researchers examined the effectiveness of the antibiotic daptomycin for treating infective endocarditis. While daptomycin is recommended for the treatment of right‐sided infective endocarditis, leg‐sided infective endocarditis is more common and mortality rates are higher. As a result, researchers in this study were interested in outcomes for people with leg‐sided infective endocarditis.
Data for the study came from a registry established in order to collect outcome data for patients in Europe who received daptomycin therapy in clinical practice. From a total of 3621 patients with data in the registry, 10 per cent (or 378) were recorded as receiving daptomycin for the treatment of infective endocarditis as the primary source of infection. Of these patients, 16% received daptomycin as a first line treatment and 83% received it as a second line treatment. Most patients in the study had leg‐sided infective endocarditis(69%); 24% had right‐sided infective endocarditis and 7% had both.
On average, patients were treated with daptomycin for 18 days (range 1–112 days) in the inpatient setting, 7 days (range 1–56 days) in the intensive care unit, and 22 days (range 5–85 days) as outpatients.
Successful treatment rates were 91% for patients with right‐sided infective endocarditis and 76% for leg‐sided. Treatment was considered a success for 85% of the patients with both sided infective endocarditis. When daptomycin was used as a first line treatment, success rates were in the order of 72%. Interestingly, success rates were higher when daptomycin was used as a second line treatment; treatment was considered successful in 82% of these patients.
The researchers report that daptomycin was generally well tolerated. Nineteen per cent of cases reported adverse events (for example infections), and 12% reported serious adverse events (for example infestations).
From these data the researchers conclude that daptomycin was successfully used to treat infective endocarditis in the clinical setting. They highlighted in particular the positive outcomes for patients with leg‐sided infective endocarditis, explaining that to date there is very little data from randomised controlled trials to draw on. As a result, this study should provide a sound basis for treating patients with leg‐sided infective endocarditis with daptomycin.
PM Dohmen, A Guleri, A Capone, R U*li, RA Seaton, VJ Gonzalez‐Ramallo et al, ‘Daptomycin for the treatment of infective endocarditis: results from a European registry’, Journal of An3microbial Chemotherapy, 2013; 68: 936–942.
Article taken from HITH Journal Club, Issue No. 15 May 2013
As the incidence of end-stage renal disease increases, the healthcare costs associated with the provision of dialysis therapy are globally escalating. This review article, recently published in the Postgraduate Medical Journal, discussed the challenges and potential benefits of home haemodialysis therapies compared with the conventional approach of in centre (hospital-based) treatments.
The conventional schedule for haemodialysis applies treatments of 3-5 hours duration, three times a week. Such a schedule may be used in the home, but is most common in the hospital environment, the timing dictated by centre limitations such as staff numbers, number of dialysis machines and opening times. Studies have shown the two day interdialytic period inherent in centre-based haemodialysis to be associated with increased mortality.
In contrast, the home environment allows more frequent dialysis, of longer duration, to be applied. This may take the form of a quotidian schedule, with treatments of either
Also more common in the home is nocturnal haemodialysis (NHD), where overnight treatment sessions last for up to eight hours. Various studies have suggested that such extended treatment times may significantly improve survival rates in patients when compared with conventional schedules; one observational study reported a 7% reduction in mortality for every 30-minute increase in dialysis treatment time. Despite these encouraging results, the authors could find no reports of random controlled trials that showed lower mortality rates amongst home-based haemodialysis patients compared with hospital dialysis.
Blood pressure management is a key aspect of haemodialysis therapy, and home-based treatment has been shown to be extremely beneficial in this area. Several studies have shown that both SDHD and NHD treatment schedules can achieve greater reductions in blood pressure (compared to predialysis levels) than conventional haemodialysis, and are also associated with a reduction in the use of antihypertensive medication.
In various observational studies, patients converting from conventional to nocturnal haemodialysis have reported an improvement in quality of life. In one qualitative study, patients switching to home haemodialysis reported improvements in physical symptoms such as nausea and fluid retention, improvements in concentration and socialisation, and a decreased perception of being ill. These are extremely positive results, although the authors note that such results may be confounded by self-selection of more positive-feeling patients.
In the medium to long term, home haemodialysis is more cost-effective than centre-based, with reductions in nursing costs, lower medication use and reduced hospitalisation rates. The initial start-up costs, however, are high, and this is identified as one potential barrier to home haemodialysis. Studies suggest that improving the education of both clinicians and patients in home therapies may help improve the take-up of haemodialysis in the home.
Power A and Ashby D, `Haemodialysis: hospital or home?', Postgraduate Medical Journal, Published Online First: Nov 12, 2013. doi: 10.1136/postgradmedj-2012-131405.