Adverse Events in Older Medical Hospital Inpatients
Adverse Events in Older Medical Hospital Inpatients
Purpose Large international studies have shown that older hospital inpatients are at particular risk of adverse events. The purpose of this review was to synthesize data from studies designed to assess the scale and nature of this harm, with the ultimate aim of informing the development of new safety and quality measurement tools to facilitate improved hospital care for these vulnerable patients.
Data sources, study selection and data extraction A systematic search using Ovid SP and other sources was carried out, rigorous inclusion and exclusion criteria were applied and quality assessment of included studies was conducted. Data were synthesized to give a picture of the incidence, types, causes, preventability and outcomes of adverse events in older medical inpatients.
Results of data synthesis Nine relevant studies were identified. A wide range of adverse event incidences were reported, from 5.29 to 6.2% in re-analyses of large adverse event studies, to 60% in studies in which the development of 'geriatric syndromes' (e.g. falls, delirium, incontinence) was also considered to be adverse events. Important causative factors other than age included clinical complexity, co-morbidity, illness severity, reduced functional ability and lower quality of care. Adverse events in older people lead to unnecessary interventions with resultant complications and increased length of stay.
Conclusion More work is needed to understand the complex nature of adverse events in older inpatients. We must tailor safety measurement and improvement strategies to address challenges presented by the complexity of the geriatric syndromes and the processes of care encountered by older inpatients.
Patient safety is at the heart of medicine, and in recent decades, following high-profile events and landmark international reports such as 'An Organisation with a Memory' in the UK and 'To Err is Human' in the USA, rigorous academic study has deepened our understanding of the incidence, underlying causes and outcomes of health care-associated harm. Concurrently, the demographics of hospital inpatient populations reflect our increasingly ageing societies. For example, in the UK, the Wanless Social Care report estimated that by 2026 the number of people in England aged over 85 years will have increased by two-thirds, compared with a 10% increase in the overall population. This will inevitably impact on hospital services, as it is currently people over 65 years account for 60% of acute hospital admissions and 70% of bed days in NHS hospitals. The picture is similar across the world, and consequently we need to focus on improving the management of conditions associated with old age, such as frailty and dementia, and to improve the safety and quality of hospital care of all patients with these conditions.
Information is, of course, available about the incidence of some of the single types of adverse events affecting older people in hospitals, such as adverse drug events (published rates vary from 31.9% to 37%) or falls (affecting 4.8/1000 bed days in the UK according to incident reporting data), but these give us only a snapshot of single conditions, rather than an overview of hospital-associated harm in this population.
Several large, international, retrospective adverse event studies have been carried out over recent decades with the aim of building a picture of the scale of health care-associated harm in hospital populations of all ages. The majority of these studies used a two-stage retrospective case record review process to identify the occurrence of 'adverse events' (discrete, measurable units of harm). Where the effect of age was investigated, data from these studies demonstrate incontrovertibly that older people experience more adverse events than their younger counterparts in hospital. In studies where the underlying causes of the higher incidence of adverse events in older people were explored, analysis showed that factors other than age alone, such as co-morbidity and complexity, were important.
Although these are useful insights, due to their aims and nature, the large-scale adverse event studies were not designed to specifically look at safety in older medical inpatients. The methodologies used did not address the challenges of defining and identifying adverse events in such a frail patient group, characterized by multiple pre-existing conditions and complex hospital admissions. This is illustrated by the fact that many studies excluded patients who were severely unwell or deemed to be dying. It can be argued, therefore, that they provide limited information which we can use to direct targeted patient safety efforts for older people.
The objective of this review was to systematically investigate the published literature for studies that were designed specifically to examine the scale, types, causes, preventability and outcomes of adverse events in older medical inpatients. The purpose of this was to build a more detailed picture of health care-associated harm in this frail and vulnerable group in order to inform future safety measurement and improvement work tailored to these patients.
Abstract and Introduction
Abstract
Purpose Large international studies have shown that older hospital inpatients are at particular risk of adverse events. The purpose of this review was to synthesize data from studies designed to assess the scale and nature of this harm, with the ultimate aim of informing the development of new safety and quality measurement tools to facilitate improved hospital care for these vulnerable patients.
Data sources, study selection and data extraction A systematic search using Ovid SP and other sources was carried out, rigorous inclusion and exclusion criteria were applied and quality assessment of included studies was conducted. Data were synthesized to give a picture of the incidence, types, causes, preventability and outcomes of adverse events in older medical inpatients.
Results of data synthesis Nine relevant studies were identified. A wide range of adverse event incidences were reported, from 5.29 to 6.2% in re-analyses of large adverse event studies, to 60% in studies in which the development of 'geriatric syndromes' (e.g. falls, delirium, incontinence) was also considered to be adverse events. Important causative factors other than age included clinical complexity, co-morbidity, illness severity, reduced functional ability and lower quality of care. Adverse events in older people lead to unnecessary interventions with resultant complications and increased length of stay.
Conclusion More work is needed to understand the complex nature of adverse events in older inpatients. We must tailor safety measurement and improvement strategies to address challenges presented by the complexity of the geriatric syndromes and the processes of care encountered by older inpatients.
Introduction
Patient safety is at the heart of medicine, and in recent decades, following high-profile events and landmark international reports such as 'An Organisation with a Memory' in the UK and 'To Err is Human' in the USA, rigorous academic study has deepened our understanding of the incidence, underlying causes and outcomes of health care-associated harm. Concurrently, the demographics of hospital inpatient populations reflect our increasingly ageing societies. For example, in the UK, the Wanless Social Care report estimated that by 2026 the number of people in England aged over 85 years will have increased by two-thirds, compared with a 10% increase in the overall population. This will inevitably impact on hospital services, as it is currently people over 65 years account for 60% of acute hospital admissions and 70% of bed days in NHS hospitals. The picture is similar across the world, and consequently we need to focus on improving the management of conditions associated with old age, such as frailty and dementia, and to improve the safety and quality of hospital care of all patients with these conditions.
Information is, of course, available about the incidence of some of the single types of adverse events affecting older people in hospitals, such as adverse drug events (published rates vary from 31.9% to 37%) or falls (affecting 4.8/1000 bed days in the UK according to incident reporting data), but these give us only a snapshot of single conditions, rather than an overview of hospital-associated harm in this population.
Several large, international, retrospective adverse event studies have been carried out over recent decades with the aim of building a picture of the scale of health care-associated harm in hospital populations of all ages. The majority of these studies used a two-stage retrospective case record review process to identify the occurrence of 'adverse events' (discrete, measurable units of harm). Where the effect of age was investigated, data from these studies demonstrate incontrovertibly that older people experience more adverse events than their younger counterparts in hospital. In studies where the underlying causes of the higher incidence of adverse events in older people were explored, analysis showed that factors other than age alone, such as co-morbidity and complexity, were important.
Although these are useful insights, due to their aims and nature, the large-scale adverse event studies were not designed to specifically look at safety in older medical inpatients. The methodologies used did not address the challenges of defining and identifying adverse events in such a frail patient group, characterized by multiple pre-existing conditions and complex hospital admissions. This is illustrated by the fact that many studies excluded patients who were severely unwell or deemed to be dying. It can be argued, therefore, that they provide limited information which we can use to direct targeted patient safety efforts for older people.
The objective of this review was to systematically investigate the published literature for studies that were designed specifically to examine the scale, types, causes, preventability and outcomes of adverse events in older medical inpatients. The purpose of this was to build a more detailed picture of health care-associated harm in this frail and vulnerable group in order to inform future safety measurement and improvement work tailored to these patients.