Dr Judy Lowthian is the Principal Research Fellow at the Bolton Clarke Research Institute, formerly known as RSL Care + Royal District Nursing Service Research Institute. She also holds an appointment at the School of Public Health and Preventive Medicine at Monash University and an honorary appointment with Alfred Health.
Her research is underpinned by an allied health background and her specific interest is health services research designed to improve the quality and safety of care for older people. In the past five years, Judy has been the recipient of $2.6M in competitive grants and prizes/awards. She serves on national and international committees that focus on improving geriatric emergency care.
Determining best practice for safe discharge of older emergency patients: the Safe Elderly Emergency Discharge (SEED) project
The Safe Elderly Emergency Discharge (SEED) project was established with the objective of determining best practice for safe discharge of older emergency patients.
This multi-component project comprised (i) a systematic review to determine the evidence for emergency care transitional care models; (ii) prospective cohort study of community-dwelling patients aged ≥65 years who were discharged home from a metropolitan Melbourne ED, to determine risk factors for post-discharge adverse outcomes, including unplanned 30 day return to ED and functional decline; and (iii) clinician focus groups and interviews to determine barriers and enablers to best practice care.
(i) The evidence review identified no appreciable benefit for unplanned 30-day ED re-attendance (OR 1.32, 95% CI 0.99-1.76; N=1389), 30-day unplanned hospital admission (OR 0.90, 95% CI 0.70-1.16; N=1389), or mortality up to 18 months (OR 1.04, 95% CI 0.83-1.29; N=1794). Study variability precluded analysis of impact on functional decline and care home admission.
(ii) 959 community-dwelling patients were recruited and followed at 30 days:
- 15% returned to ED within 30 days: independent risk factors were COPD (OR 1.78,95%CI 1.02-3.11); moderate cognitive impairment (OR 2.07 95%CI 1.09-3.90); previous ED visit (OR 2.11,95%CI 1.43-3.12); and low acuity (OR 2.34,95%CI 1.10-4.99). Aged ≥85 years was associated with reduced risk (OR 0.81,95%CI 0.70-0.93).
- 34% experienced functional decline, comprising 17% becoming more dependent in personal activities of daily living (ADL), 17.5% more dependent in instrumental ADL, and 18% suffering deterioration in cognitive function. Independently associated factors were: any level of dependence prior to the visit in personal ADL (OR 3.21,95%CI 2.26 to 4.53), or in IADL (OR 6.69,95%CI 4.31 to 10.38). There was a 68% decline in relative odds for those with any dependency in IADL who used an aid for mobility (OR 0.32,95%CI 0.14 to 0.7).
(i) Barriers and challenges to care included time targets, knowledge and education, cognitive impairment and the environmental concerns. Facilitators included team work and family involvement.
Older discharged emergency patients have high rates of adverse events. Early intervention with functional assessments and appropriate implementation of support services could reduce adverse outcomes. Integration of researchers, clinicians, patients and carers in the design and evaluation of future interventions is recommended.