An overview of patient cases which have problems with discharge from Mater Dei Hospital

Introduction

Within Mater Dei Hospital, there are a number of patients who exist in a state of metaphorical “limbo”. These patients lack the degree of health which would enable them to be discharged back home safely and in good conscious. However, they are not able to take care of themselves and thus require long term care. Whilst long term is being sourced, these patients reside at Mater Dei hospital, and occupy a bed which is normally required for more acute patients. These patients are collectively and colloquially known as “social cases”. Mater Dei Hospital, in Msida, is Malta’s main Acute General teaching hospital. A study of these patients was carried out over the months of August and September 2016, and this sought to elucidate more information about the common factors which exist within this population, as well as to see whether these patients developed psychiatric problems or required psychiatric medication as a reaction to their long stay?

Aim

To identify common factors amongst cases with problems to be discharged, to identify if these patients were started on psychiatric medication whilst residing in Mater Dei and to optimise the treatment of these patients.

Method

The criteria used to define the population were that the patient had been an inpatient for more than 30 days and that the patient had been flagged for long term care. Fifty seven patients (n=57) met the criteria when the entire patient list from Medical wards 1 through 9 and Day-Care was analysed. Thus the files were obtained and the data charted.

Results

Patients were distributed evenly from all-over Malta. The majority of patients lie within the 81-90 age group with the 91-100 group being the second largest group. Only 2% of patients were under 60. The vast majority (82%) were female. 50% of patients were taken care of by their families whilst 41% of patients lived alone. Only 9% lived with their spouse. Most patients (65%) lived in terraced houses. Very few patients made use of support services prior to their admission to Mater Dei Hospital.  Most patients were partially dependent as identified by the Barthel Index. Very few patients (4%) had discernible risk factors such as smoking and drinking alcohol. The length of stay of most patients was 30 to 50 days and 70 to 100 days (Figure 1). The vast majority of patients (92%) were admitted as emergency cases. A number of patients had a stay well beyond 200 days. Interestingly, 52% of all patients were started on psychiatric medication. Moreover, most patients were admitted with a complaint of acute confusion or lethargy and dehydration (Figure 3).

Figure 1

Figure 3

Discussion

Geographically, as expected, larger concentrations of patients were seen to be originating from the more traditional, heavily populated districts within the central and harbour regions. Fewer patients were seen to be originating from the peripheries of the island and this finding, tallies with observed housing patterns and trends¹. This also correlates with the fact that most patients lived in terraced houses (65%). Interestingly, a number of patients were referred from homes from the elderly when the home could no longer care for the individual. However, the fact that a fairly even distribution was observed could reflect the limited sample size. Vis-a-vis age, this pattern reflects the life expectancy of the Maltese population which in 2015 was 79 for men and 83 for women. This is especially significant when view in tandem with the patient’s gender, which showed that the overwhelming majority of patients were female. It is with interest that one views the home situation of these social cases. Very few lived with their spouse and most lived alone which indicates that the spouse had died, and again, this is in keeping with the expected life expectancies. Moreover, a number of patients were taken care of by their families and were only brought to hospital when the burden of care grew too great. The vast majority of patients did not make use of domiciliary services nor had any idea that they existed. Of the patients’ who did use them, home nursing was the most popular option and this was used mainly for washing purposes or stoma changes. One could postulate that better marketing of these services would enable patients to stay longer in the community.

The length of stay of these patients is quite long with a large number of patients requiring extended periods of care. This reflects the saturated state of the system but it also highlights an area for improvement and where investment is needed. Most patients were admitted as an emergency and this reflects the frailty of these patients health. However, the fact that confusion and lethargy were the most common reasons for admission is a cause for concern, since this indicates that there is deterioration in general condition as opposed to new onset pathology. Finally, 52% of patients were started on psychiatric medication during their stay in Mater Dei Hospital. The picture reflects that intention behind these was sedation as evidenced by the drugs chosen, namely Haloperidol, Lorazepam, Bromazepam and Olanzapine (Figure 2). The use of haloperidol follows the NICE guidelines which state that in a person with delirium is considered to be a risk to themselves or other, and that verbal and non-verbal de-escalation techniques have failed, one should consider giving short-term haloperidol, or if contra-indicated, olanzapine.

Figure 2

Limitations 

A larger sampler size would add more weight to the results.

Recommendations

Greater investment within long term care is required since this is impinging on the health care system. Moreover, increased marketing of the available domiciliary services would support patients within the community for a longer time and thus decrease the burden on secondary care. Moreover, better marketing could change the prevailing mentality that exists within the community. Furthermore, optimising the said services to patients’ needs and requests would increase their uptake.  Community physiotherapy and occupational therapy would again decrease the chance of patients becoming wards of the hospital. Finally, most psychiatric medications in this population are started by members of the Department of Medicine. It would be beneficial if psychiatric input was obtained in these decisions. Moreover, continued medical education, provided by the Psychiatry Department, in this area, would be beneficial to all concerned.

References

1. "Housing Statistics." Housing Statistics - Statistics Explained. Eurostat, 29 Apr. 2017. Web. 28 Apr. 2017.
2. "Delirium: Prevention, Diagnosis and Management." Delirium: Prevention, Diagnosis and Management | Guidance and Guidelines | NICE. NICE, 28 Apr. 2017. Web. 28 Apr. 2017

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