Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Its time to shift the focus away from hospital care
- Raghu S Raju (7 July 2005)
-
greater demand of beds and staff in community hospitals.
- Sudhendra Prabhu (8 August 2005)
-
personal experience of a community hospital
- joanna m howard MB ChB (11 August 2005)
-
Comparable staffing?
- Kalman M Kafetz (11 August 2005)
-
Looking after the older adult: focus should be on expertise
- Sunku H Guptha (11 August 2005)
-
Challenges to proving (and improving) the efficacy of intermediate care
- Yih Y Sitoh, Ian YO Leong (19 August 2005)
|
|
|||
|
Raghu S Raju, Doctor CF14 4XW
Send response to journal:
|
Britain is known to have the best social care system in the world and if community hospitals can survive and thrive anywhere, it is here. A significant proportion of the hospitals beds in the NHS are occupied by patients admitted because of social, not medical reaasons. If some of these beds are made available for the real needy, by shifting this faction of population to some appropriate form of intermediary care (including community hospitals),at any point of their care (from admission to discharge), it would do a great favour to the NHS in tackling its problem of inadequate hospital beds. Community hospitals are definitely providing some relief to the already overburdened hospital doctors and staff and helping focus more on the care nearer to the patient and away from the hospital(1)and(2).The paper by John Green et al, gives us another reason for carrying on with the one of most promising mode of intermediary care. Though suggested from study conducted by P Cook et al(3), that the bed availability in DGH(District General Hospital) are only slightly influenced by community hospitals and admissions to community hospitals are rather dependent on their distance from the surgeries, it is evident that it still has a significant impact[(1)and(2)]. Important issue at present would be to monitor the community hospitals for their functioning and ensure that they are effectively(4)serving their purpose and not raising doubts(5) about the importance of existence of community hospitals or other modes of intermediary care. Its amazing to see that the community hospitals have stood the time against all odds and lets hope that in the future, they accomplish their goals and succeed in their endeavour. 1. Sebat F et al PMID: 15888853 [PubMed - indexed for MEDLINE] 2. Jourdain P et al PMID: 14714349 [PubMed - indexed for MEDLINE] 3. Age and Ageing, Vol 27, 357-361, Copyright © 1998 by British Geriatrics Society 4. Yap LK et al PMID: 12568426 [PubMed - indexed for MEDLINE] 5. BMJ Vetter doi: 10.1136/bmj.38524.543137.7C Competing interests: None declared |
|||
|
|
|||
|
Sudhendra Prabhu, SHO -
Send response to journal:
|
My personal experience of working in community hospital was fantastic. Elderly patients in busy DGH do not get as much attention from the members of the staff as they would in a community hospital. Also patients are more likely to get confused due to constant transfer into diferent wards and also have higher probablity of acquiring infections. At community based hospitals these people remain under one team one particular ward and are attended to by rehabilitation team rather than general physicians or geriatricians who are better experienced. Unfortunately we do not have enough manpower to run these setup more efficiently. There is also an option for GP's to admit patients directly into these community beds under their care and request for team input as and when required, which would then cut out admission to acute beds which can be better used for acute medical patients.Also there is need for a change in the outlook in the mangement of these elderly patients at DGH such that receive same priority as any other patient. with regards Dr Prabhu S U Competing interests: None declared |
|||
|
|
|||
|
joanna m howard MB ChB, semi-retired self-employed PO10 8SF
Send response to journal:
|
I had an excellent experience as a patient in a community hospital, after a period in an acute surgical ward. I was not quite ready to go home and manage on my own, and at the same time I was certainly not needing to be blocking an acute orthopaedic bed. In the two weeks I was there, I had the kind of help (meals provided, help with bathing etc) that left me free to concentrate on the exercise that would get me back to safe living. This was helped by the fact that the physios were based on site and had the time to give us high quality attention and encouragement. I was also much nearer my friends and neighbours who could bring clean clothes etc. Our GP called in regularly as many of us were his patients. I can't think of a better solution to the "intermediate" stage that many of us need. It was not well-publicicised, and not the automatic next step in the hospital discharge proces, which is surprising. This particular hospital is likely to be closed for financial reasons. I am sure that if well-managed and if the opportunity cost is worked out, this kind of facility would be an asset rather than a drain. Competing interests: None declared |
|||
|
|
|||
|
Kalman M Kafetz, Consultant Physician, Department of Medicine For Elderly People Whipps Cross University Hospital, London, E11 1NR,UK
Send response to journal:
|
Can Dr Green and colleagues tell us if the staffing in the two units, both nursing and therapy, were comparable? More rehabilitation staff in the community unit may have improved function. Fewer nursing staff may have encouraged patients to do more for themselves. Competing interests: None declared |
|||
|
|
|||
|
Sunku H Guptha, Consultant Physician Medicine for the Elderly, Edith Cavell Hospital, Peterborough PE3 9GZ
Send response to journal:
|
Dear Editor The randomised controlled trial by Green et al is an important advance on the debate on where and how best to look after older adults requiring admission due to an acute illness.[1] The authors found benefit with regards to independence with activities of daily living when patients were admitted to a locality based community hospital compared to usual inpatient care in a hospital based rehabilitation ward. The two groups were identical with regards to baseline characteristics, cognitive function and although there is no definite data provided in the hospital based group, we assume and it is implied in the article that the therapy given to the patients was equivalent in both groups with regards to length of treatment and number of staff per patient. Given these similarities it is difficult to understand the difference in outcome between the two groups. The authors unfortunately do not offer any explanation. There is definite evidence showing benefit from therapy by a unit based team in patients with stroke. This benefit however is not seen when stroke patients are treated by expert stroke liaison teams and this is largely due to difference in expertise between nursing and therapy staff based permanently on a dedicated stroke unit opposed to staff on an ordinary medical ward with patients with a range of illness.[2,3] It is possible that a similar difference in expertise among the nursing and therapy staff influenced the outcome in Green et al study. There is also a difference in lay out of wards in community hospital providing more stimuli and room to engage in independent activities. In the absence of any explanation by the authors for the difference in the outcome in the two groups it is important not to generalise their findings. It would be particularly disadvantageous to older adults if as a result of this study there is a tendency to either admit them directly or shifting them from hospital wards more rapidly to community hospitals especially to wards that do not as a minimum mirror the medical, nursing and therapy expertise provided in this study. References 1. John Green, John Young, Anne Forster et al. Effects of locality based community hospital care on independence in older people needing rehabilitation: randomised controlled trial. BMJ 2005; 331: 317 – 322. 2. Evans A, Perez I, Harraf F et al. Can differences in management processes explain different outcomes between stroke unit and stroke-team care? Lancet 2001; 358: 1586-92. 3. Evans A, Harraf F, Donaldson N, et al. Randomized controlled study of stroke unit care versus stroke team care in different stroke subtypes. Stroke 2002; 33: 449-55. Competing interests: None declared |
|||
|
|
|||
|
Yih Y Sitoh, Visiting Consultant Department of Geriatric Medicine, Tan Tock Seng Hospital, 11 jalan tan Tock Seng, Singapore (308433), Ian YO Leong
Send response to journal:
|
Dear Editor, There is currently a dearth of publications concerning the efficacy of what has variously been referred to as intermediate care, transitional care or sub-acute care services [1, 2]. We would thus like to commend Green et al on their valiant effort to study this complex area of health services research in their recent publication [3]. There are, however, a few areas that the authors may wish to further elaborate upon, which may add to the value of their work. Firstly, it will be useful to clarify the casemix encountered in both groups of subjects as differing admitting diagnoses will clearly impact upon eventual functional outcomes, even if their pre-admission functional status were similar. Secondly, it will be interesting to consider how the outcomes vary with age and comorbidities, as both factors have been shown to affect the outcomes of rehabilitation in older persons [4, 5]. Thirdly, it will be helpful to provide greater insight into the level of staffing and system of care provided within both the control group and the intervention group so as to help readers ascertain the different components at the service, operator and treatment levels that may have contributed to the difference in outcomes [6]. Lastly, it is interesting to note that, whilst the authors have demonstrated a modest difference in functional outcomes between the study groups using the Nottingham extended activities of daily living scale, such a difference is not evident when comparing the Barthel index of both groups. While it remains true that it will be challenging to consistently and convincingly substantiate the benefits of intermediate care [7], it is highly likely that such a system of care is here to stay, in spite of the much stated need to provide evidence-based care. Nonetheless comfort may perhaps be drawn from the fact that much of what we know about the benefits of geriatric evaluation and management is based on studies that focused on the provision of multidisciplinary assessment and intervention at the sub-acute phase of illness [8,9]. The efforts of Green et al are indeed worthy of further emulation. References 1. Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc.2003;51:549-55 2. Carpenter I, Gladman JR, Parker SG, Potter J. Clinical and research challenges of intermediate care. Age and Ageing 2002;31:97-100 3. Green J, Young J, Forster A, Mallinder K, Bogle S, Lowson K, Small N. Effects of locality based community hospital care on independence in older people needing rehabilitation: randomised controlled trial. BMJ. 2005;331:317-22 4. Giaquinto S. Comorbidity in post-stroke rehabilitation. Eur J Neurol. 2003;10(3):235-8. 5. Landi F, Bernabei R, Russo A, Zuccala G, Onder G, Carosella L, Cesari M, Cocchi A. Predictors of rehabilitation outcomes in frail patients treated in a geriatric hospital. J Am Geriatr Soc. 2002;50(4):679-84. 6. Langhorne P, Legg L. Evidence behind stroke rehabilitation. J Neurol Neurosurg Psychiatry. 2003;74 S4:iv18-iv21. 7. Whyte J. Clinical trials in rehabilitation: what are the obstacles? Am J Phys Med Rehabil. 2003;82(10 S):S16-21. 8. Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet. 1993;342(8878):1032-6. 9. Cohen HJ, Feussner JR, Weinberger M, Carnes M, Hamdy RC, Hsieh F et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med. 2002;346(12):905-12. Competing interests: None declared |
|||