Care in specialist medical and mental health unit compared with standard care for older people with cognitive impairment admitted to general hospital: randomised controlled trial (NIHR TEAM trial)
Care in specialist medical and mental health unit compared with standard care for older people with cognitive impairment admitted to general hospital: randomised controlled trial (NIHR TEAM trial)
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DOI：
10.1136/bmj.f4132
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发表时间：
2013-07-02
影响因子：
105.7
通讯作者：
Harwood, Rowan H.
中科院分区：
文献类型：
--
作者：
Goldberg, Sarah E.;Bradshaw, Lucy E.;Harwood, Rowan H.
目的建立和评价认知障碍老年人综合医院急性医疗护理的最佳实践模式。设计一项随机对照试验，以适应繁忙的急性医疗入院系统施加的限制。在英国设立大型急性综合医院。研究对象为600名65岁以上的急性医疗住院患者，他们在入院时被认定为“困惑”。干预参与者被随机分配到专科医疗和精神卫生单元，旨在为精神障碍或痴呆症患者提供最佳实践护理，或标准护理(急性老年科或普通内科病房)。专家小组的特点包括由医疗和精神卫生专业人员共同配备人员；加强工作人员在精神错乱、痴呆症和以人为中心的痴呆症护理方面的培训；提供有组织的有目的的活动；修改环境以满足认知障碍者的需求；预防精神错乱；以及对家庭护理采取积极和包容的方法。主要结果衡量主要结果：随机分组后90天内在家中度过的天数。次要结果：有组织的非参与者观察，以确定患者的经历；家庭护理人员对医院护理的满意度。结果专科病房组和标准护理组在家中度过的天数没有显著差异(中位数51天比45天，差值95%可信区间-12到24；P=0.3)。中位指数住院天数分别为11天和11天，死亡率分别为22%和25%(-9%到4%)，再入院指数分别为32%和35%(-10%到5%)，新入院疗养院的比例分别为20%和28%(-16%到0)。患者回家的中位数为70.5天，而在家的中位数为71.0天(-6.0至6.5天)。专科病房的患者在积极情绪或投入上花费的时间明显更多(79%比68%，2%到20%；P=0.03)，并经历了更多满足情感和心理需求的员工互动(每次观察的中位数为4v1；P<；0.001)。更多的家庭照顾者对护理感到满意(总体91%比83%，2%到15%；P=0.004)，严重不满意的情况减少(5%比10%，-10%到0；P=0)。患者的经历和照顾者的满意度可能是衡量虚弱老年人生命即将结束时成功与否的更合适的衡量标准。
Objective To develop and evaluate a best practice model of general hospital acute medical care for older people with cognitive impairment.Design Randomised controlled trial, adapted to take account of constraints imposed by a busy acute medical admission system.Setting Large acute general hospital in the United Kingdom.Participants 600 patients aged over 65 admitted for acute medical care, identified as "confused" on admission.Interventions Participants were randomised to a specialist medical and mental health unit, designed to deliver best practice care for people with delirium or dementia, or to standard care (acute geriatric or general medical wards). Features of the specialist unit included joint staffing by medical and mental health professionals; enhanced staff training in delirium, dementia, and person centred dementia care; provision of organised purposeful activity; environmental modification to meet the needs of those with cognitive impairment; delirium prevention; and a proactive and inclusive approach to family carers.Main outcome measures Primary outcome: number of days spent at home over the 90 days after randomisation. Secondary outcomes: structured non-participant observations to ascertain patients' experiences; satisfaction of family carers with hospital care. When possible, outcome assessment was blind to allocation.Results There was no significant difference in days spent at home between the specialist unit and standard care groups (median 51 v 45 days, 95% confidence interval for difference -12 to 24; P = 0.3). Median index hospital stay was 11 versus 11 days, mortality 22% versus 25% (-9% to 4%), readmission 32% versus 35% (-10% to 5%), and new admission to care home 20% versus 28% (-16% to 0) for the specialist unit and standard care groups, respectively. Patients returning home spent a median of 70.5 versus 71.0 days at home (-6.0 to 6.5). Patients on the specialist unit spent significantly more time with positive mood or engagement (79% v 68%, 2% to 20%; P = 0.03) and experienced more staff interactions that met emotional and psychological needs (median 4 v 1 per observation; P < 0.001). More family carers were satisfied with care (overall 91% v 83%, 2% to 15%; P = 0.004), and severe dissatisfaction was reduced (5% v 10%, -10% to 0%; P = 0.05).Conclusions Specialist care for people with delirium and dementia improved the experience of patients and satisfaction of carers, but there were no convincing benefits in health status or service use. Patients' experience and carers' satisfaction might be more appropriate measures of success for frail older people approaching the end of life.