Comprehensive Geriatric Assessment

Two studies look at the prevention and treatment ofClostridium difficile infection (CDI), and 4 address intensive care unit (ICU) topics related to transfusion thresholds in severe gastrointestinal bleeding, prone positioning in acute respiratory distress syndrome (ARDS), a drug cocktail for cardiac arrest, and the controversial practice of screening for methicillin-resistant Staphylococcus aureus (MRSA) infection. Three studies address optimum inpatient management of diabetes and exacerbations of chronic obstructive pulmonary disease (COPD) and heart failure. Finally, because no hospital medicine year in review would be complete without a study on venous thromboembolism (VTE), we highlight a study that examined the merits of extended VTE prophylaxis with aspirin versus low-molecular-weight heparin (LMWH) in patients undergoing elective hip replacement

Hospitals are considered a setting ill-prepared for end of life issues; therefore, use of such acute care services has to be considered an indicator of poor quality end of life care. This study examines predictors of ERVH prior to death among HPC home care clients. 

Methods: A retrospective cohort study of a sample of 764 HPC home care clients who received services from a community care access centre (CCAC) in southern Ontario, Canada.

All clients were assessed using the Resident Assessment Instrument for Palliative Care (interRAI PC) as part of normal clinical practice between April 2008 and July 2010. The Andersen-Newman framework for health service utilization was used as a conceptual model for the basis of this study.

Logistic regression and Cox regression analyses were carried out to identify predictors of ERVH. 

Results: Half of the HPC clients had at least one or more ERVH (n = 399, 52.2%). Wish to die at home (OR = 0.54) and advanced care directives (OR = 0.39) were protective against ERVH.

Unstable health (OR = 0.70) was also associated with reduced probability, while infections such as prior urinary tract infections (OR = 2.54) increased the likelihood of ERVH. Clients with increased use of formal services had reduced probability of ERVH (OR = 0.55). 

Conclusions: Findings of this study suggest that predisposing characteristics are nearly as important as need variables in determining ERVH among HPC clients, which challenges the assumption that need variables are the most important determinants of ERVH.

Ongoing assessment of HPC clients is essential in reducing ERVH, as reassessments at specified intervals will allow care and service plans to be adjusted with clients'changing health needs and end of life preferences.