Infection in the elderly is a huge issue whose treatment usually has partial and specific approaches. It is, moreover, one of the areas where intervention can have the most success in improving the quality of life of older patients. In an attempt to give the widest possible focus to this issue, the Health Sciences Foundation has convened experts from different areas to produce this position paper on Infection in the Elderly, so as to compare the opinions of expert doctors and nurses, pharmacists, journalists, representatives of elderly associations and concluding with the ethical aspects raised by the issue. The format is that of discussion of a series of pre-formulated questions that were discussed by all those present. We begin by discussing the concept of the elderly, the reasons for their predisposition to infection, the most frequent infections and their causes, and the workload and economic burden they place on society. We also considered whether we had the data to estimate the proportion of these infections that could be reduced by specific programmes, including vaccination programmes. In this context, the limited presence of this issue in the media, the position of scientific societies and patient associations on the issue and the ethical aspects raised by all this were discussed.
Background: As hospitals consolidate into networks, systems grapple with standardization of care delivery. As part of a comprehensive quality improvement program, our health system developed a process bundle comprising 5 interventions for hospitalized heart failure patients. We studied the baseline variation in fidelity of process delivery across our network comprising an academic medical center, tertiary community center, and community hospitals. Methods: Through a series of meetings and literature review, key cardiology, operational, and quality leadership from 5 hospitals developed a bundle of process interventions designed to support optimal, patient-centered care for hospitalized heart failure patients. The 5 bundle interventions were: 1) cardiology consultation, 2) heart failure education, 3) 7-day follow-up appointment with primary care or cardiology printed on discharge instructions, 4) 72-hour post-discharge telephone call placed, and 5) arrived to 7-day follow-up visit. For patients having a principal diagnosis of heart failure, systematic chart review was used to assess metric completion. One-way ANOVA on ranks was used to analyze variation of metric completion among the hospitals, and the Mann-Whitney U test with Bonferroni correction was used to compare hospital pairs. Results: During the 3 month study period, 780 heart failure patients across our network were discharged alive. We noted significant variation in fidelity among interventions, ranging from an 81% (634 of 780) rate of cardiology consultation, to a 36% (210 of 581) rate of 7-day follow-up with primary care or cardiology across the network. All five processes were completed in 12% (52 of 426) of patients, with 51% (217 of 426) of patients receiving 2 or 3 interventions. Furthermore, analysis by one-way ANOVA on ranks demonstrated highly statistically significant variation among the 5 hospitals within each of the 5 process bundle metrics. Pairwise comparisons demonstrated significant differences among pairs of hospitals on these metrics. Conclusions: This study demonstrates that in a large academic health system, significant variation exists in fidelity of care delivery for a 5 component heart failure care bundle. Future work will focus on eliminating barriers to care delivery, and understanding the impact of the process bundle on outcomes including 30-day readmissions, home days, and patient satisfaction. Opportunity exists to share best practices among hospitals to improve system-wide performance and outcomes.
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