Nursing Assessment and Intevention for Older People after Acute Medical Admission

Bidragets oversatte titel: Sygeplejefaglig vurdering og intervention til ældre mennesker efter indlæggelse i akut medicinsk modtageafdeling

    Publikation: AfhandlingPh.d.-afhandling


    Geriatric patients recently discharged from hospital are at risk of unplanned readmissions and admission to nursing home. The risk increases when they are discharged directly from Emergency Department (ED). Time pressure there often requires focus on the presenting problem, although 80 % of geriatric patients have complex and often unresolved caring needs. To ensure seamless transition from the ED to the patients’ home, assessment and intervention carried out by an aged care nursing specialist is suggested as a model for assessing unresolved caring needs. Thus, the aim of this thesis was to examine the use and effect of a two-stage model for structured nursing assessment and problem solving intervention, ISAR II, carried out immediately following discharge from ED and again after 30 days and 180 days in order to assess older peoples’ unresolved problems.
    This thesis comprises two separate studies. Study A presents a prospective and descriptive pilot study covering 30 days and 180 days follow-ups in which the ISAR II model for structured nursing assessment and problem solving intervention was tested; 154 older persons, 70 years and over participated, their mean age was 82 (SD 7.0) and 113 (73%) were female. Study B presents a randomised controlled study where it was investigated whether the ISAR II model is effective in preventing acute hospital readmissions, permanent admission to nursing home or mortality; 271 older persons 70 years and over were included. Their mean age was 82 (SD 6.6), 180 (66%) were female and 128 (32%) refused to participate. To identify the older persons who were in greatest need of assistance a screening instrument was used, ISAR I. ISAR I comprise six questions and when scoring 2 or more the older person was considered at increased risk of readmission to hospital or functional decline and thus offered to participate in our study.
    Intervention: After detecting the older people at risk who were planned to be discharged, the research nurse assessed physical, emotional, and cognitive functional status and did a brief standardised nursing assessment and intervention, ISAR II, developed by McCusker et al.. ISAR II comprises a checklist of physical, mental, medical and social problems. Focus was on unresolved problems that required medical intervention, new/different community assistant services, or comprehensive geriatric assessment. After assessment the nurse made relevant referrals to geriatric outpatient clinic, community health centre, primary physician, or arrangements with next-of-kin. The assessments and ISAR II were repeated at follow-up home visits 30 days and 180 days after discharge.
    In Study A, it was found that the rate of readmission to hospital was 22% after 30 days and 32% after 180 days. A decrease in participants’ unresolved problems was found from 2 at baseline to 0.5 at 180 days follow-up and an increase of 13% in participants receiving community service assistance from baseline to 30 days follow-up. The ISAR II model worked well in the ED and thus it should be investigated further in a randomised controlled study. In Study B no effect was found on acute readmission to hospital, permanent admission to nursing home, or death. Though, a tendency toward earlier readmission to hospital was found in the intervention group. Effect was found in emotional wellbeing as participants in the intervention group were less likely to be at risk of depression after 180 days measured by GDS5 (P=0.05). Also a significant difference was found in participants’ tiredness scores. While fewer reported they felt not tiered, more reported they felt tiered in four to six items in the control group (p<0.0001). Participants in both groups maintained their level of physical function. In the intervention group participants’ unresolved problems diminished from 2 to 0.6 at 180 days follow-up though no significant differences in assistance provided either by the community nurse or by home help was found. A subgroup analyses of participants with an ISAR I score of 2 showed that the intervention group had little though significant fewer readmissions in mean (0.5 vs. 1.0) at 180 days follow-up (p=0.03). During 180 days follow-up refusers were more likely to be admitted to hospital (p<0.0001) and die (p=0.006). The largest subgroup of refusers described themselves as “too ill”.
    Though only limited effect was found on readmission to hospital, it may be concluded that the ISAR II model worked well in a Danish ED setting. The older persons’ number of problems diminished with no increase in daily life support from the community services; and by structuring the nurses’ documentation, the exchange of information from hospital to community services focuses on the older peoples’ undetected problems, and may thus result in a safer return home. A decrease in risk of depression and tiredness was found, as well as prevention of readmission in the older people who were at least risk of readmission and functional decline. Thus, it is recommended that the aged care nursing specialist in the ED administers the ISAR II assessment and intervention on older persons with an ISAR I score of 2 or more to reveal the older persons problems, detect depression and prevent further tiredness.
    Not least, an important finding was that the older people who refused to participate in the study were more likely to be readmitted to hospital or to die within both 30 and 180 days after ED stay. Thus, we must keep in mind that when older persons state that they are “too ill” to participate in studies, they are credible and we must listen and assist them.
    Bidragets oversatte titelSygeplejefaglig vurdering og intervention til ældre mennesker efter indlæggelse i akut medicinsk modtageafdeling
    StatusUdgivet - dec. 2012


    • geriatrisk vurdering, geriatrisk intervention, opfølgning efter akut indlæggelse