For residential aged care home (RACH) patients admitted to hospital, delirium is common and associated with high burden of unplanned hospital readmissions resulting in increased patient distress, morbidity and mortality. A 12-month audit showed 18% of patients from RACH with delirium during hospitalisation had an unplanned hospital readmission to our institution within 28-days following hospital discharge.
Aim
Minimise delirium complications and reduce preventable hospital readmissions in recently discharged RACH patients following delirium during hospital admission.
Method
Post-discharge follow-up pathway (RESPOND) was implemented at our institution to target RACH patients admitted with delirium during hospitalisation. Two rounds of education and engagement sessions were undertaken with stakeholders and inpatient units over a three-month period. The hospital Residential In-Reach (RIR) service (Geriatricians and Clinical Nurse Consultants who assess RACH residents in their place of residence to avoid preventable hospital presentations) performed a delirium focused follow-up review of patients within 72-hours of discharge. Evaluation was performed following 12 months of implementation.
Results
50 patients were reviewed with a 28-day unplanned hospital readmission rate of 4%. Medication review resulted in medication adjustment or de-prescribing in 70% of reviews, and identification and management of delirium-related medical issues and complications occurred in 72% of reviews.
Conclusion
Optimising post-discharge support for RACH patients with delirium is highly beneficial. Implementing a post-discharge review resulted in a reduction in 28-day unplanned hospital readmissions and enabled earlier identification and management of delirium-related medical issues. Expanding this research on a broader scale would be valuable for integrating follow-up into routine clinical practice.