Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Transitional Care
- Elliot Epstein (13 November 2005)
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Wording of conclusion could be misleading
- john sharvill (13 November 2005)
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Transitional care for the elderly: at what cost?
- Martin J. Connolly (14 November 2005)
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Intermediate care can be safe and reduce hospital use, but is it and does it?
- John R Gladman (16 November 2005)
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The definition of delay in transfer of care is subjective
- Eamonn M Eeles, Karl Davis, Praveen Pathmanaban, Rhian Morse (18 November 2005)
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Elderly Care - lessons to be learnt from paediatrics?
- Elizabeth F Robinson (25 November 2005)
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Elliot Epstein, Consultant Physician Walsall Manor Hospital WS29PS
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Crotty el al report that transitional care can reduce length of stay, without adverse effects. I note that patients recruited were awaiting long -term care, but the placement was not available at that particular time. I was impressed by the services available for these patients. These included assessment by a specialist therapy team, early multidisciplinary team involvement, goal setting, 24-hour medical on-call cover and weekly review by a specialist in rehabilitation. From my experiences, patients awaiting placement in acute hospitals do not receive this level of care. The positive results of this study may be a consequence of superior resources available for these patients occupying a transitional care bed. Transitional care may only be effective in practice if this high level of care is available. Competing interests: None declared |
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john sharvill, gp deal england ct14 7au
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This article fits in with current NHS push for use of 'intermediate care'. What it appears to show is that there is delayed ultimate disharge to permanent placement with a slight reduction to discharge to own home and a slight increase in mortality with transitional care. Costs and funding are not described. Is the transitional care actually hospital care but in a differnet setting? I agree it seems to unblock beds- that is because they are being provided somewhere else and the funding and cost issues need to be explained. Competing interests: None declared |
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Martin J. Connolly, Senior Lecturer in Medicine, University of Manchester Manchester Royal Infirmary, M13 9WL
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EDITOR- Crotty and colleagues are to be congratulated for pointing out that off-site ‘transitional care’ facilities for elderly patients already assessed as needing residential care placement, only reduce length of hospital stay at the expense of delaying eventual transfer to a long-term care facility [1]. However their assertion that such transfer resulted in no difference in mortality rates or readmission rates or in the proportion of patients who eventually returned to their own homes is potentially misleading, as the study was not powered to detect such differences. Sample size was calculated only to detect “a mean reduction in length of stay of 10 days (SD 25) in the treatment group” i.e. to test the hypothesis that opening a new off-site facility and transferring in- patients to this facility would reduce length of stay (arguably a ‘given’). Over the four-month follow-up period patients in the treatment group in fact had a 12% relative increase in readmissions (28% in treatment group vs. 25% in the control group), a 22% relative reduction in chances of returning to their own home (7% treatment vs. 9% controls) and nearly 4% relative ‘excess’ mortality (28% treatment vs. 27% controls). As these (and other) potentially adverse outcomes are the basis of much of the controversy that surrounds this area, Crotty’s results contribute to the debate in terms of the design, and powering, of future studies. References [1] Crotty M, Whitehead CH, Wundke R, Giles LC, Ben-Tovim D. Transitional care facility for elderly people in hospital awaiting a long- term care bed: randomised controlled trial. BMJ 2005;331:1110-3. Martin J. Connolly
Competing interests: None declared |
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John R Gladman, Reader in the Medicine of Older People University of Nottingham
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Crotty and colleagues showed that transitional, or intermediate, care facilities can be used to divert older people safely from hospital to a care home setting [1]. Our RCT found similar findings [2] but we could not exclude the possibility that such transitional care increases long term institutionalisation over a longer period of follow-up (12 months, compared to 4 months in Crotty and colleagues’ study). Young’s whole system study in Leeds [3] showed that intermediate care services increased hospitalisation. So, intermediate care sometimes can reduce hospitalisation and sometimes does not. It is not guaranteed to lead to outcomes that are equivalent to those of the services being replaced. This inconsistency of the evidence base raises the question of whether findings obtained in controlled research studies of services can be generalised to other times and settings. If not, the fears raised by Professors Ebrahim [4], Grimley Evans and Tallis [5] about the quality of care for older people in intermediate care services cannot be put to rest simply because some demonstration projects have shown acceptable findings. Things might be different outside the setting of a controlled study, just as they are between different trials. For example, and I cannot give much detail while complaints are being investigated, I can report that in the same city where I led our RCT of a “safe” residential intermediate care service, it has been necessary to close one unit due to fears over patient safety and it remains at this moment closed to community, step-up, admissions on these grounds. It isn’t RCT evidence, but it is enough to show that intermediate care can be unsafe. We need high quality RCTs, such as that reported by Crotty and collegues, to show what is possible but we also need to establish the conditions that are necessary for success - those conditions that when not met lead to ineffective or unsafe care. These are likely to include skill-mix, team working practices, institutional policies and communication processes. This is likely to require a wide range of descriptive research methods such as systems analyses and case studies undertaken alongside controlled studies. Once these conditions for success have been established, we need a systematic quality assurance exercise to ensure that they are being met. If we do not do this, then we may find ourselves so blinded by policy pressure to keep older people out of hospital that we fail to do our jobs as clinicians as we collude with the provision of sub-standard care. 1 Crotty M, Whitehead CH, Wundke R, et al. Transitional care facility for elderly people in hospital awaiting a long term care bed: randomised controlled trial. BMJ doi:10.1136/bmj.38638.441933.63 (published 2 November 2005) 2 Fleming S, Blake H, Gladman JRF, Hart E, Lymbery M, Dewey ME, McCloughry H, Walker M, Miller P. A randomised controlled trial of a care home rehabilitation service to reduce long term institutionalisation for elderly people. Age Ageing 2004;33:384-390. 3 Young JB, Robinson M, Chell S, Sanderson D, Chaplin S, Burns E, Fear J. A whole system study of intermediate care services for older people Age Ageing 2005 34: 577-583. 4 Ebrahim S. New beginning for care for elderly people? Proposals for intermediate care are reinventing workhouse wards. BMJ 2001;323:337-8. 5 Evans JG, Tallis RC. A new beginning for care for elderly people? BMJ 2001;322:807-8. Competing interests: None declared |
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Eamonn M Eeles, Specialist Registrar Care of the Elderly Medicine Royal Glamorgan Hospital, Ynysmaerdy, Llantrisant. CF728XR, Karl Davis, Praveen Pathmanaban, Rhian Morse
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EDITOR-Crotty et al based their definition of delayed discharge in the trial of transitional care services on the grounds that patients were medically stable and ready for discharge1. The designation of delayed discharge depends on clinical judgement and is therefore subjective and may lack standardisation. We have recently undertaken a study to investigate the clinical opinion of colleagues involved in the discharge process locally on a single adapted clinical scenario of an elderly in- patient with medical and mental health needs. Respondents (n=31 out of 50) to the case-scenario questionnaire were asked: a. Was this case a delayed transfer of care? b. If so when and for what reason were they a delay in transfer of care? 5 persons stated that the case was at no time a delayed transfer of care. The remainder (26) identified the patient as a delayed transfer of care and showed a broad range in their interpretation of timing of delayed discharge (range 2-15 days out of potential 0-16 days, median 10.5 days, Interquartile range 9-12). There was poor agreement as to the reason for a delayed discharge under the categories of ‘healthcare assessment, healthcare arrangements, social or other’, and even if respondents shared the same estimation of day of discharge (only 6 respondents agreed on both timing and reason for delay). Crotty et al experienced similar difficulties in accurately identifying readiness for discharge to long term care with 7.3% of their sample discharged home and may therefore have been inappropriately classified as a delay in transfer of care. Both studies highlight the difficulty in clarification of delayed transfer of care which needs to be addressed in the methodology of future research in this area. The high mortality of patients defined as a delay in discharge by Crotty et al (27-28% of patients at 4 months) illustrates that therapeutic opportunities may be missed if the label of transfer of care is applied too early or inappropriately. 1 Crotty M, Whitehead C, Wundke R. Transitional care facility for elderly people in hospital awaiting a long term care bed: randomised controlled trial. BMJ 2005; 331:1110-3. Competing interests: None declared |
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Elizabeth F Robinson, senior house officer paediatrics St Thomas' Hospital, London SE1 7EH
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EDITOR - Crotty et al highlighted the benefits of transitional care facilities for elderly patients. This is one, certainly effective, approach in tackling the problem of increasing numbers of frail, elderly patients; but more is needed and fast if we are to keep apace with the demographic timebomb on which we are sitting. Maybe it is time that we viewed the very elderly and their carers as we do children and their parents in paediatric practice? It is common practice on paediatric wards for a bed to be made available for parents to stay overnight with their children to provide comfort and a familiar face in an alien environment. Many elderly and confused patients are as, if not more likely, as children to become disorientated and frightened in unfamiliar surroundings, particularly given the increased confusion often precipitated by the acute medical condition necessitating admission. The presence of a carer would not only alleviate patient anxiety but could potentially improve the nutrition of the patient during the admission, with assisted feeding; maintain motivation and provide continuity of care that would improve the speed and success with which the patient was discharged. Competing interests: None declared |
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