Ang Mo Kio Thye Hua Kwan Hospital

Background: Catheter-associated urinary tract infection (CAUTI) is a common hospital acquired infection which can lead to prolonged hospitalisation and mortality. Ang Mo Kio-Thye Hua Kwan Hospital is a 360-bedded Community Hospital in Singapore, providing inpatient rehabilitation and subacute care. The majority of patients are geriatric and referred from tertiary hospitals.

Chinese-based cultures have many distinctive traditions associated with the end of life, including limitations around the use of language. As in Western countries, palliative care services have developed in Chinese-based cultures in response to local needs. Language too has developed locally with little agreement on how palliative care is titled and described. This opinion paper raises the many complexities in endeavouring to understand how palliative care is portrayed in Chinese-based cultures.

ObjectivesThe relationship between disability and comorbidity on mortality is widely perceived as additive in clinical models of frailty.DesignNational data were retrospectively extracted from medical records of community hospital.Data SourcesThere were of 12,804 acutely-disabled patients admitted for inpatient rehabilitation in Singapore rehabilitation community hospitals from 1996 through 2005 were followed up for death till 31 December 2011.Outcome MeasureCox proportional-hazards regression to assess the interaction of comorbidity and disability at discharge on all-cause mortality.ResultsDuring a median follow-up of 10.9 years, there were 8,565 deaths (66.9%). The mean age was 73.0 (standard deviation: 11.5) years. Independent risk factors of mortality were higher comorbidity (p<0.001), severity of disability at discharge (p<0.001), being widowed (adjusted hazard ratio [aHR]: 1.38, 95% confidence interval [CI]:1.25–1.53), low socioeconomic status (aHR:1.40, 95%CI:1.29–1.53), discharge to nursing home (aHR:1.14, 95%CI:1.05–1.22) and re-admission into acute care (aHR:1.54, 95%CI:1.45–1.65). In the main effects model, those with high comorbidity had an aHR = 2.41 (95%CI:2.13–2.72) whereas those with total disability had an aHR = 2.28 (95%CI:2.12–2.46). In the interaction model, synergistic interaction existed between comorbidity and disability (p<0.001) where those with high comorbidity and total disability had much higher aHR = 6.57 (95%CI:5.15–8.37).ConclusionsPatients with greater comorbidity and disability at discharge, discharge to nursing home or re-admission into acute care, lower socioeconomic status and being widowed had higher mortality risk. Our results identified predictive variables of mortality that map well onto the frailty cascade model. Increasing comorbidity and disability interacted synergistically to increase mortality risk.

ObjectivesTo (1) identify social and rehabilitation predictors of nursing home placement, (2) investigate the association between effectiveness and efficiency in rehabilitation and nursing home placement of patients admitted for inpatient rehabilitation from 1996 to 2005 by disease in Singapore.DesignNational data were retrospectively extracted from medical records of community hospital.Data SourcesThere were 12,506 first admissions for rehabilitation in four community hospitals. Of which, 8,594 (90.3%) patients were discharged home and 924 (9.7%) patients were discharged to a nursing home. Other discharge destinations such as sheltered home (n = 37), other community hospital (n = 31), death in community hospital (n = 12), acute hospital (n = 1,182) and discharge against doctor’s advice (n = 24) were excluded.Outcome MeasureNursing home placement.ResultsThose who were discharged to nursing home had 33% lower median rehabilitation effectiveness and 29% lower median rehabilitation efficiency compared to those who were discharged to nursing homes. Patients discharged to nursing homes were significantly older (mean age: 77 vs. 73 years), had lower mean Bathel Index scores (40 vs. 48), a longer median length of stay (40 vs. 33 days) and a longer time to rehabilitation (19 vs. 15 days), had a higher proportion without a caregiver (28 vs. 7%), being single (21 vs. 7%) and had dementia (23 vs. 10%). Patients admitted for lower limb amputation or falls had an increased odds of being discharged to a nursing home by 175% (p<0.001) and 65% (p = 0.043) respectively compared to stroke patients.ConclusionsIn our study, the odds of nursing home placement was found to be increased in Chinese, males, single or widowed or separated/divorced, patients in high subsidy wards for hospital care, patients with dementia, without caregivers, lower functional scores at admission, lower rehabilitation effectiveness or efficiency at discharge and primary diagnosis groups such as fractures, lower limb amputation and falls in comparison to strokes.

Most stroke research has studied rehabilitation effectiveness and rehabilitation efficiency separately and not investigated the potential trade-offs between these two indices of rehabilitation. To determine whether there is a trade-off between independent factors of rehabilitation effectiveness and rehabilitation efficiency. Using a retrospective cohort study design, we studied all stroke patients (n = 2810) from two sub-acute rehabilitation hospitals from 1996 to 2005, representing 87·5% of national bed-years during the same period. Independent predictors of poorer rehabilitation effectiveness and log rehabilitation efficiency were • older age • race-ethnicity • caregiver availability • ischemic stroke • longer time to admission • dementia • admission Barthel Index score, and • length of stay. Rehabilitation effectiveness was lower in females, and the gender differences were significantly lower in those aged ≤70 years (β -4·7 (95% confidence interval -7·4 to -2·0)). There were trade-offs between effectiveness and efficiency with respect to admission Barthel Index score and length of stay. An increase of 10 in admission Barthel Index score predicted an increase of 3·6% (95% confidence interval 3·2-4·0) in effectiveness but a decrease of 0·04 (95% confidence interval -0·05 to -0·02) in log efficiency (a reduction of efficiency by 1·0 per 30 days). An increase in log length of stay by 1 (length of stay of 2·7 days) predicted an increase of 8·0% (95% confidence interval 5·7-10·3) in effectiveness but a decrease of 0·82 (95% confidence interval -0·90 to -0·74) in log efficiency (equivalent to a reduction in efficiency by 2·3 per 30 days). For optimal rehabilitation effectiveness and rehabilitation efficiency, the admission Barthel Index score was 30-62 and length of stay was 37-41 days. There are trade-offs between effectiveness and efficiency during inpatient sub-acute stroke rehabilitation with respect to admission functional status and length of stay.