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Dresden SM. Optimizing the Care of Persons Living with Dementia in the Emergency Department. Clin Geriatr Med 2023; 39:599-617. [PMID: 37798067 DOI: 10.1016/j.cger.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Emergency department (ED) care for persons living with dementia (PLWD) involves the identification of dementia or cognitive impairment, ED care which is sensitive to the specific needs of PLWD, effective communication with PLWD, their care partners, and outpatient clinicians who the patient and care-partner know and trust, and care-transitions from the emergency department to other health care settings. The recommendations in this article made based on wide-ranging heterogeneous studies of various interventions which have been studied primarily in single-site studies. Future research should work to incorporate promising findings from interventions such as hospital at home, or ED to home Care Transitions Intervention.
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Affiliation(s)
- Scott M Dresden
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Center for Healthcare Studies and Outcomes Research, 211 East Ontario Street, Suite 200, Chicago, IL 60611, USA.
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Buzzell M, Chen A, Hoffstaetter T, Thompson DA, George SJ, Landis G, Silpe J, Etkin Y. Early Follow-Up after Arteriovenous Fistula Creation is Associated with Improved Access-Related Outcomes. Ann Vasc Surg 2023; 95:203-209. [PMID: 37121342 DOI: 10.1016/j.avsg.2023.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/07/2023] [Accepted: 04/12/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Up to 60% of arteriovenous fistulas (AVF) require intervention to assist maturation, which prolongs the time until it can be used for hemodialysis (HD). Current guidelines recommend early postoperative AVF examination to detect and address immaturity to decrease time to maturation. This study evaluates how the timing of postoperative follow-up to assess AVF maturity affects patients' outcomes. METHODS All patients who underwent AVF creation between 2017 and 2021 in an academic medical center were retrospectively reviewed, excluding patients lost to follow-up or not on HD. Outcomes were compared between patients that had delayed follow-up to assess AVF maturity, >8 weeks post surgery, versus early follow-up, <8 weeks post-surgery. AVF evaluation for maturity consisted of physical examination and duplex ultrasound. Primary endpoints were time to first cannulation (interval from AVF creation to first successful cannulation) and time to catheter-free dialysis (interval from AVF creation to central venous catheter removal). RESULTS A total of 400 patients were identified: 111 in the delayed follow-up group and 289 in the early follow-up group. The median time to follow-up was 78 days (interquartile range [IQR], 66-125) in the delayed follow-up group versus 39 days (IQR, 36-47) in the early follow-up group, (P < 0.0001). The maturation rate was 87% in the delayed follow-up group versus 81% in the early follow-up group, (P = 0.1) and both groups had similar rates of interventions to assist maturation (66% vs. 57%, P = 0.2). The early follow-up group had a significantly shorter median time to first cannulation (50 vs. 88 days; P < 0.0001) and shorter time to catheter-free HD (75 vs. 118 days; P <0.0001). At 4 months after AVF creation, the incidence of first cannulation was 74% in the early follow-up group versus 63% in the delayed follow-up group (P = 0.001). Similarly, the incidence of catheter-free dialysis was 65% in the early follow-up group versus 50% in the delayed follow-up group at 4 months postoperatively, (P = 0.036). CONCLUSIONS Early postoperative follow-up for evaluation of fistula maturation is associated with reduced time to first successful cannulation of AVF for HD and reduced time to catheter-free dialysis.
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Affiliation(s)
- Mariah Buzzell
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Adrian Chen
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Tabea Hoffstaetter
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Dane A Thompson
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Sam J George
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Gregg Landis
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Jeffrey Silpe
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Yana Etkin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.
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Gettel CJ, Falvey JR, Gifford A, Hoang L, Christensen LA, Hwang U, Shah MN. Emergency Department Care Transitions for Patients With Cognitive Impairment: A Scoping Review. J Am Med Dir Assoc 2022; 23:1313.e1-1313.e13. [PMID: 35247358 PMCID: PMC9378565 DOI: 10.1016/j.jamda.2022.01.076] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES We aimed to describe emergency department (ED) care transition interventions delivered to older adults with cognitive impairment, identify relevant patient-centered outcomes, and determine priority research areas for future investigation. DESIGN Systematic scoping review. SETTING AND PARTICIPANTS ED patients with cognitive impairment and/or their care partners. METHODS Informed by the clinical questions, we conducted systematic electronic searches of medical research databases for relevant publications following published guidelines. The results were presented to a stakeholder group representing ED-based and non-ED-based clinicians, individuals living with cognitive impairment, care partners, and advocacy organizations. After discussion, they voted on potential research areas to prioritize for future investigations. RESULTS From 3848 publications identified, 78 eligible studies underwent full text review, and 10 articles were abstracted. Common ED-to-community care transition interventions for older adults with cognitive impairment included interdisciplinary geriatric assessments, home visits from medical personnel, and telephone follow-ups. Intervention effects were mixed, with improvements observed in 30-day ED revisit rates but most largely ineffective at promoting connections to outpatient care or improving secondary outcomes such as physical function. Outcomes identified as important to adults with cognitive impairment and their care partners included care coordination between providers and inclusion of care partners in care management within the ED setting. The highest priority research area for future investigation identified by stakeholders was identifying strategies to tailor ED-to-community care transitions for adults living with cognitive impairment complicated by other vulnerabilities such as social isolation or economic disadvantage. CONCLUSIONS AND IMPLICATIONS This scoping review identified key gaps in ED-to-community care transition interventions delivered to older adults with cognitive impairment. Combined with a stakeholder assessment and prioritization, it identified relevant patient-centered outcomes and clarifies priority areas for future investigation to improve ED care for individuals with impaired cognition, an area of critical need given the current population trends.
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Affiliation(s)
- Cameron J Gettel
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA.
| | - Jason R Falvey
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Angela Gifford
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Ly Hoang
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA; Department of Medicine (Geriatrics and Gerontology), University of Wisconsin-Madison, Madison, WI, USA; Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA; Center for Health Disparities Research, University of Wisconsin-Madison, Madison, WI, USA; Wisconsin Alzheimer's Disease Research Center, University of Wisconsin-Madison, Madison, WI, USA
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Hansen TK, Pedersen LH, Shahla S, Damsgaard EM, Bruun JM, Gregersen M. Effects of a new early municipality-based versus a geriatric team-based transitional care intervention on readmission and mortality among frail older patients - a randomised controlled trial. Arch Gerontol Geriatr 2021; 97:104511. [PMID: 34479071 DOI: 10.1016/j.archger.2021.104511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 01/22/2023]
Abstract
Purpose Previous studies reported reduced risk of readmission, mortality and shorter length of hospital stay (LOS) among geriatric patients receiving an early (<24h), hospital-based geriatric team intervention after discharge. The objective of this study was to compare a novel, early municipality-based, nurse-led and general practitioner (GP)-supported transitional care intervention (TCI) to an established hospital-based TCI among frail, older, geriatric patients. Material and methods A randomised controlled trial was conducted within a single geriatric department and the adjacent municipality. Inclusion criteria: acutely admitted, frail patients 75+ years old. Eligible patients were randomly allocated (1:1) to the two TCIs. Primary outcome was 30-day unplanned readmission. Secondary outcomes were 90-day all-cause mortality and LOS. Stratified analysis according to type of dwelling was made. Odds ratios (OR) with 95% confidence intervals (CI), and number needed to treat (NNT) were reported. Results 3,103 patients (median age (IQR): 85 (80-90); 57% female) were included. Readmission rates were 22% in the municipality-based intervention (n=332/1,545), and 18% in the hospital-based intervention (n=276/1,558); OR was 1.27, 95% CI (1.06-1.52), p=0.008 and NNT=27. OR for cohabiting patients was 1.47, 95% CI (1.02-2.08); p=0.035. No significant difference was observed in mortality (22% vs. 21%; OR=1.05, 95% CI (0.89-1.25), p=0.577) or LOS (median (IQR): 6 (2-8) vs. 6 (2-8) days, p=0.1787). Conclusions The new municipality-based, nurse-led and GP-supported intervention was inferior to the hospital-based geriatric team intervention in preventing 30-day readmission among frail, geriatric patients. There was no significant difference between the two interventions in regard to 90-day mortality or LOS.
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Affiliation(s)
| | | | - Seham Shahla
- Medical Department, Randers Regional Hospital, Randers, Denmark
| | - Else Marie Damsgaard
- Department of Geriatrics, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Meldgaard Bruun
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Merete Gregersen
- Department of Geriatrics, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Hamel C, Garritty C, Hersi M, Butler C, Esmaeilisaraji L, Rice D, Straus S, Skidmore B, Hutton B. Models of provider care in long-term care: A rapid scoping review. PLoS One 2021; 16:e0254527. [PMID: 34270578 PMCID: PMC8284811 DOI: 10.1371/journal.pone.0254527] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/28/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION One of the current challenges in long-term care homes (LTCH) is to identify the optimal model of care, which may include specialty physicians, nursing staff, person support workers, among others. There is currently no consensus on the complement or scope of care delivered by these providers, nor is there a repository of studies that evaluate the various models of care. We conducted a rapid scoping review to identify and map what care provider models and interventions in LTCH have been evaluated to improve quality of life, quality of care, and health outcomes of residents. METHODS We conducted this review over 10-weeks of English language, peer-reviewed studies published from 2010 onward. Search strategies for databases (e.g., MEDLINE) were run on July 9, 2020. Studies that evaluated models of provider care (e.g., direct patient care), or interventions delivered to facility, staff, and residents of LTCH were included. Study selection was performed independently, in duplicate. Mapping was performed by two reviewers, and data were extracted by one reviewer, with partial verification by a second reviewer. RESULTS A total of 7,574 citations were screened based on the title/abstract, 836 were reviewed at full text, and 366 studies were included. Studies were classified according to two main categories: healthcare service delivery (n = 92) and implementation strategies (n = 274). The condition/ focus of the intervention was used to further classify the interventions into subcategories. The complex nature of the interventions may have led to a study being classified in more than one category/subcategory. CONCLUSION Many healthcare service interventions have been evaluated in the literature in the last decade. Well represented interventions (e.g., dementia care, exercise/mobility, optimal/appropriate medication) may present opportunities for future systematic reviews. Areas with less research (e.g., hearing care, vision care, foot care) have the potential to have an impact on balance, falls, subsequent acute care hospitalization.
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Affiliation(s)
- Candyce Hamel
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Chantelle Garritty
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mona Hersi
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Claire Butler
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Leila Esmaeilisaraji
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Danielle Rice
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sharon Straus
- Department of Medicine, University of Toronto and St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Becky Skidmore
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Brian Hutton
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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Hansen TK, Shahla S, Damsgaard EM, Bossen SRL, Bruun JM, Gregersen M. Mortality and readmission risk can be predicted by the record-based Multidimensional Prognostic Index: a cohort study of medical inpatients older than 75 years. Eur Geriatr Med 2021; 12:253-261. [PMID: 33570735 DOI: 10.1007/s41999-021-00453-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/15/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To examine the predictive value of the record-based Multidimensional Prognostic Index (MPI) on mortality, readmission and length of hospital stay (LOS) among older medical inpatients. METHODS A cohort of medical inpatients aged ≥ 75 years was rated using the record-based MPI to assess frailty retrospectively. 90-day and 1-year mortality hazard ratios (HRs) were calculated in a sex- and age-adjusted Cox proportional hazards model. 30-day readmission relative risk (RR) estimates were calculated in a binary regression model with mortality as a competing risk. Discrimination was expressed by the area under the receiver operating characteristic (ROC) curve. Median LOS was calculated using the non-parametric Kruskal-Wallis one-way ANOVA. RESULTS In total, 1190 patients with a median age of 83 years were included. 50% were male. 335 patients (28%) were categorized as non-frail (MPI score 0.0-0.33), 522 (44%) moderately frail (MPI score 0.34-0.66) and 333 (28%) severely frail (MPI score 0.67-1.0). 90-day mortality HR was 7.4 (95% confidence interval (CI) 2.9-18.6, p < 0.001) for the moderately frail and 18.5 (95% CI 7.5-46.1, p < 0.001) for the severely frail compared with the non-frail. ROC area was 0.76 (95% CI 0.72-0.80). Similarly, 1-year mortality HR was 3.3 (95% CI 2.2-5.0, p < 0.001) for the moderately frail and 7.1 (95% CI 4.7-10.6, p < 0.001) for the severely frail. 30-day readmission RR was 2.1 (95% CI 1.5-2.9, p < 0.001) for the moderately frail and 1.8 (95% CI 1.3-2.6, p = 0.001) for the severely frail. LOS was significantly longer with increasing MPI score (p < 0.001). CONCLUSION The record-based MPI assessed at discharge predicts dose-dependent post-discharge mortality and readmission risk and is associated with LOS in older medical inpatients.
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Affiliation(s)
- Troels Kjærskov Hansen
- Department of Geriatrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
- Medical Department, Randers Regional Hospital, Randers, Denmark.
| | - Seham Shahla
- Medical Department, Randers Regional Hospital, Randers, Denmark
| | - Else Marie Damsgaard
- Department of Geriatrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | | | - Jens Meldgaard Bruun
- Medical Department, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus N, Denmark
| | - Merete Gregersen
- Department of Geriatrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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Jørgensen SMD, Rubak TMM, Damsgaard EM, Dahlerup JF, Hvas CL. Faecal microbiota transplantation as a home therapy to frail older people. Age Ageing 2020; 49:1093-1096. [PMID: 32365381 PMCID: PMC7583516 DOI: 10.1093/ageing/afaa073] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Indexed: 01/01/2023] Open
Abstract
Background Clostridioides (Clostridium) difficile infection (CDI) is a leading cause of antibiotics-associated diarrhoea. Faecal microbiota transplantation (FMT) is effective for recurrent CDI and may be provided as a home treatment to frail, older people. Methods We present four consecutive patients with recurrent CDI, treated at home using nasojejunal tube-delivered or encapsulated donor faeces. The primary outcome was combined clinical resolution and a negative CD toxin test 8 weeks post-treatment. Results All four patients had severe CDI and all improved clinically following one FMT. Sustained resolution following one FMT was observed in one patient. Two patients had recurrence and received a second FMT using capsules; both achieved resolution. One patient who had recurrence declined from further FMT due to fear of relapse and was established on long-term vancomycin. No adverse events related to FMT were observed. Conclusion Frail older people may benefit from FMT. Home treatment is a viable option and may be considered both for clinical cure and for palliation.
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Affiliation(s)
| | | | | | - Jens Frederik Dahlerup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus N, Denmark
| | - Christian Lodberg Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus N, Denmark
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Pedersen LH, Gregersen M, Barat I, Damsgaard EM. Early geriatric follow-up visits to nursing home residents reduce the number of readmissions: a quasi-randomised controlled trial. Eur Geriatr Med 2018; 9:329-337. [PMID: 34654236 DOI: 10.1007/s41999-018-0045-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/13/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Nursing home residents have a high risk of being readmitted after hospitalisation. The objective of this study is to test whether an early geriatric follow-up visit can reduce readmissions among nursing home residents without increasing mortality. The main components of the intervention will also be quantified. MATERIALS AND METHOD A quasi-randomised controlled design. A population of nursing-home residents aged 75 years or older admitted to hospital with one of nine medical diagnoses. All patients received comprehensive geriatric assessment before discharge. The intervention comprised a visit by a nurse and a doctor from a geriatric team the first weekday after discharge. Control group patients were offered a follow-up visit by their general practitioner 7-14 days after discharge. RESULTS Six hundred and forty-eight patients were included in the study between June 1st 2014 and December 15th 2016. In the intervention group, 13% were readmitted within 30 days after discharge, compared to 19% in the control group (p = 0.04). Adjusted hazard ratio = 0.63 (95% CI 0.42-0.95). The median length of hospital stay was 1 day for both groups. Neither 30 nor 90-day mortality were affected by the intervention. The most commonly registered intervention element was direct person-to-person contact between hospital and nursing home staff or relatives, followed by changes in medication and blood tests. CONCLUSION Early geriatric follow-up visits to recently discharged nursing home residents are a safe and effective way of reducing readmissions. Communication, changes in medication, and blood tests were the most frequently performed elements.
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Affiliation(s)
- Lene Holst Pedersen
- Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Merete Gregersen
- Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Ishay Barat
- The Regional Hospital in Horsens, Sundvej 30, 8700, Horsens, Denmark
| | - Else Marie Damsgaard
- Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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