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Fernández-Montalbán P, Martínez-Flores S, Mir-Montero M, Arribas López JR, Bibiano-Guillén C, Brañas F. Impact of a geriatric intervention based on the Comprehensive Geriatrics Assessment on avoidable admissions in older patients at risk evaluated in the Emergency Department. Rev Esp Geriatr Gerontol 2024; 59:101512. [PMID: 38852228 DOI: 10.1016/j.regg.2024.101512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 03/04/2024] [Accepted: 05/03/2024] [Indexed: 06/11/2024]
Abstract
OBJECTIVE To know the impact of a geriatric intervention based on the Comprehensive Geriatric Assessment (CGA) on avoidable admissions in older patients at risk evaluated in the Emergency Department. METHOD Prospective observational unicenter study. We included patients, from October 1, 2018 to January 31, 2020, over 75 years who were attended at the Emergency Department with a Triage Risk Screening Tool (TRST) score≥2. All patients were evaluated by a geriatrician through the CGA. The reasons for going to the Emergency room were collected and also the main intervention carried out by Geriatrics, whether admission or discharge was indicated and whether the admission was avoidable. We did a cost analysis calculating this by (bed/day×average stay×number of admissions avoided). RESULTS We included 260 patients, 66% were women and the mean age was 86 years. 73.5% patients had polypharmacy, the mean Charlson index was 2.5 (5.6). 63.3% were independent for walking and 20.8% independent for basic activities of daily living. 59% had cognitive impairment. 91.5% lived at home. The most frequent reason for visiting the Emergency room was decline of general state in 22% and the most frequent intervention carried out by Geriatrics was assistance in the decision making process in 35.4% followed by referral to a preferential outpatient geriatric care circuit in 32.7%. Other interventions carried out by Geriatrics was assistance in clarifying diagnosis (4.2%), assistance in pharmacological adjustment (8.5%), referral to a standard geriatric care pathway (13.1%), telephone follow-up (4.2%) and/or coordination with Social Services for care planning (11.2%). Including all patients, 29.2% required hospital admission and 70.8% were discharged. 40% admissions were avoided, which meant more than 540 thousand euros saved. CONCLUSIONS A standardized CGA coordinated by Geriatrics in older patients at risk of suffering adverse events in the Emergency room reduces admissions and costs, so it should therefore be established as a recommendation of good clinical practice.
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Affiliation(s)
| | | | - María Mir-Montero
- Emergency Department, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - José Ramón Arribas López
- Internal Medicine Department, Hospital Universitario La Paz, Madrid, Spain; School of Medicine, Universidad Autónoma de Madrid, Spain; AIDS and Infectious Disease Research Group, IdiPAZ, Spain
| | | | - Fátima Brañas
- Geriatrics Department, Hospital Universitario Infanta Leonor, Madrid, Spain; Fundación para la Investigación e Innovación Biomédica del Hosp, Univ. Infanta Leonor y Hospital del Sureste, Spain; Universidad Complutense, Madrid, Spain
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Kolk D, MacNeil Vroomen JL, Melis RJF, Ridderikhof ML, Buurman BM. Assessing dynamical resilience indicators in older adults: a prospective feasibility cohort study. Eur Geriatr Med 2024; 15:445-451. [PMID: 38280089 PMCID: PMC10997544 DOI: 10.1007/s41999-023-00904-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 11/21/2023] [Indexed: 01/29/2024]
Abstract
PURPOSE Measuring dynamical resilience indicators based on time series data may improve the prediction of health deterioration in older adults after hospital discharge. We examined the feasibility of an intensive prospective cohort study examining dynamical resilience indicators based on time series data of symptoms and physical activity in acutely ill older adults who visited the Emergency Department (ED). METHODS This is a prospective cohort study with time series data from symptom questionnaires and activity trackers. Thirty older adults (aged 75.9 ± 5.5 years, 37% female) who were discharged from the ED of a tertiary hospital in the Netherlands were included in the study. We monitored self-reported symptoms using a daily online questionnaire, and physical activity using an activity tracker for 30 days. Descriptive data on participant eligibility and adherence to and acceptability of the assessments were collected. RESULTS Of 134 older patients visiting the ED, 109/134 (81%) were eligible for inclusion and 30/109 (28%) were included. Twenty-eight (93%) of the included participants completed follow-up. Regarding the adherence rate, 78% of participants filled in the questionnaire and 80% wore the activity tracker. Three (10%) participants completed fewer than three questionnaires. Most participants rated the measurements as acceptable and seven (23%) participants experienced an adverse outcome in the 30 days after discharge. CONCLUSION Such an intensive prospective cohort study examining dynamical resilience indicators in older adults was feasible. The quality of the collected data was sufficient, some adjustments to the measurement protocol are recommended. This study is an important first step to study resilience in older adults.
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Affiliation(s)
- Daisy Kolk
- Department of Elderly Care Medicine, Amsterdam UMC, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, De Boelelaan 1117, PO Box 7057, 1007 MB, Amsterdam, The Netherlands.
- Section of Geriatric Medicine, Amsterdam UMC, Internal Medicine, Amsterdam Public Health Research Institute, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Janet L MacNeil Vroomen
- Section of Geriatric Medicine, Amsterdam UMC, Internal Medicine, Amsterdam Public Health Research Institute, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - René J F Melis
- Department of Geriatric Medicine/Radboud Alzheimer Centre, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Milan L Ridderikhof
- Amsterdam UMC, Emergency Medicine, Amsterdam Movement Sciences Research Institute, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Bianca M Buurman
- Section of Geriatric Medicine, Amsterdam UMC, Internal Medicine, Amsterdam Public Health Research Institute, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- ACHIEVE-Center of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
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Rosario BH, Quah JL, Chang TY, Barrera VC, Lim A, Sim LE, Conroy S, Dhaliwal TK. Validation of the Hospital Frailty Risk Score in older adults hospitalized with community-acquired pneumonia. Geriatr Gerontol Int 2024; 24 Suppl 1:135-141. [PMID: 37846810 DOI: 10.1111/ggi.14697] [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] [Received: 07/07/2023] [Revised: 09/03/2023] [Accepted: 09/24/2023] [Indexed: 10/18/2023]
Abstract
AIM Frailty results from age-associated declines in physiological reserve and function and is prevalent in older people. Our aim is to examine the association of the Hospital Frailty Risk Score (HFRS) with adverse events in older patients hospitalized with community-acquired pneumonia (CAP) and hypothesise that frailty is a comparable predictor of outcomes in CAP versus traditional severity indices such as CURB-65. METHODS Retrospective review of electronic medical records in patients ≥65 years with CAP admitted to a tertiary hospital from 1 January to 30 April 2021. Patients were identified using ICD codes for CAP and categorized as high risk (>15), intermediate risk (5-15) and low risk (<5) of frailty using the HFRS. RESULTS Of 429 patients with CAP, 53.8% male, mean age of 82.9 years, older patients (85 vs. 79.7 years, P < 0.001) were at higher risk of frailty. Using the HFRS, 47.6% were deemed at high risk, 35.9% at intermediate risk, and 16.6% at low risk of frailty. Multivariate logistic regression shows that HFRS was more strongly associated (≥7 days, OR 1.042, CI 1.017-1.069) than CURB-65 (OR 0.995, CI 0.810-1.222) with long hospital length of stay (LOS), while CURB-65 (Confusion, Urea >7mmol/L, Respiratory rate >30, Blood pressure, age => 65 years old) was more strongly associated with mortality at 30, 90 and 365 days, compared with the HFRS. Comparing the values for the area under the receiver operator characteristic curve, the HFRS was found to be a better predictor of long LOS, while CURB-65 remains a better predictor of mortality. CONCLUSIONS Patients with high risk of frailty have higher healthcare utilization and HFRS is a better predictor of long LOS than CURB-65 but CURB-65 was a better predictor of mortality. Geriatr Gerontol Int 2024; 24: 135-141.
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Affiliation(s)
- Barbara H Rosario
- Department of Geriatric Medicine, Changi General Hospital, Singapore, Singapore
| | - Jessica Lishan Quah
- Department of Respiratory Medicine, Changi General Hospital, Singapore, Singapore
| | - Ting Yu Chang
- National University of Singapore, Singapore, Singapore
| | | | - Aileen Lim
- Health Systems Intelligence, Changi General Hospital, Singapore, Singapore
| | - Lydia Euphemia Sim
- Health Systems Intelligence, Changi General Hospital, Singapore, Singapore
| | - Simon Conroy
- University College London, London, United Kingdom
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Conroy S, Brailsford S, Burton C, England T, Lalseta J, Martin G, Mason S, Maynou-Pujolras L, Phelps K, Preston L, Regen E, Riley P, Street A, van Oppen J. Identifying models of care to improve outcomes for older people with urgent care needs: a mixed methods approach to develop a system dynamics model. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-183. [PMID: 37830206 DOI: 10.3310/nlct5104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Background We aimed to understand urgent and emergency care pathways for older people and develop a decision support tool using a mixed methods study design. Objective(s), study design, settings and participants Work package 1 identified best practice through a review of reviews, patient, carer and professional interviews. Work package 2 involved qualitative case studies of selected urgent and emergency care pathways in the Yorkshire and Humber region. Work package 3 analysed linked databases describing urgent and emergency care pathways identifying patient, provider and pathway factors that explain differences in outcomes and costs. Work package 4 developed a system dynamics tool to compare emergency interventions. Results A total of 18 reviews summarising 128 primary studies found that integrated social and medical care, screening and assessment, follow-up and monitoring of service outcomes were important. Forty patient/carer participants described emergency department attendances; most reported a reluctance to attend. Participants emphasised the importance of being treated with dignity, timely and accurate information provision and involvement in decision-making. Receiving care in a calm environment with attention to personal comfort and basic physical needs were key. Patient goals included diagnosis and resolution, well-planned discharge home and retaining physical function. Participants perceived many of these goals of care were not attained. A total of 21 professional participants were interviewed and 23 participated in focus groups, largely confirming the review evidence. Implementation challenges identified included the urgent and emergency care environment, organisational approaches to service development, staff skills and resources. Work package 2 involved 45 interviews and 30 hours of observation in four contrasting emergency departments. Key themes relating to implementation included: intervention-related staff: frailty mindset and behaviours resources: workforce, space, and physical environment operational influences: referral criteria, frailty assessment, operating hours, transport. context-related links with community, social and primary care organisation and management support COVID-19 pandemic. approaches to implementation service/quality improvement networks engaging staff and building relationships education about frailty evidence. The linked databases in work package 3 comprised 359,945 older people and 1,035,045 observations. The most powerful predictors of four-hour wait and transfer to hospital were age, previous attendance, out-of-hours attendance and call handler designation of urgency. Drawing upon the previous work packages and working closely with a wide range of patient and professional stakeholders, we developed an system dynamics tool that modelled five evidence-based urgent and emergency care interventions and their impact on the whole system in terms of reducing admissions, readmissions, and hospital related mortality. Limitations Across the reviews there was incomplete reporting of interventions. People living with severe frailty and from ethnic minorities were under-represented in the patient/carer interviews. The linked databases did not include patient reported outcomes. The system dynamics model was limited to evidence-based interventions, which could not be modelled conjointly. Conclusions We have reaffirmed the poor outcomes frequently experienced by many older people living with urgent care needs. We have identified interventions that could improve patient and service outcomes, as well as implementation tools and strategies to help including clinicians, service managers and commissioners improve emergency care for older people. Future work Future work will focus on refining the system dynamics model, specifically including patient-reported outcome measures and pre-hospital services for older people living with frailty who have urgent care needs. Study registrations This study is registered as PROSPERO CRD42018111461. WP 1.2: University of Leicester ethics: 17525-spc3-ls:healthsciences, WP 2: IRAS 262143, CAG 19/CAG/0194, WP 3: IRAS 215818, REC 17/YH/0024, CAG 17/CAG/0024. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme [project number 17/05/96 (Emergency Care for Older People)] and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 14. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Simon Conroy
- Geriatrician, George Davies Centre, University of Leicester, Leichester, UK
| | - Sally Brailsford
- Southampton Business School, University of Southampton, Southampton, UK
| | - Christopher Burton
- Academic Unit of Medical Education, University of Sheffield, Sheffield, UK
| | - Tracey England
- Health Sciences, University of Southampton, Southampton, UK
| | - Jagruti Lalseta
- Leicester Older Peoples' Research Forum, University of Leicester, Leicester, UK
| | - Graham Martin
- Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | - Suzanne Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Kay Phelps
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Louise Preston
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Emma Regen
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Peter Riley
- Leicester older peoples' research forum, University of Leicester, Leicester, UK
| | - Andrew Street
- Department of Health Policy, London School of Economics, London, UK
| | - James van Oppen
- Department of Health Sciences, University of Leicester, Leicester, UK
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Green RK, Nieser KJ, Jacobsohn GC, Cochran AL, Caprio TV, Cushman JT, Kind AJH, Lohmeier M, Shah MN. Differential Effects of an Emergency Department-to-Home Care Transitions Intervention in an Older Adult Population: A Latent Class Analysis. Med Care 2023; 61:400-408. [PMID: 37167559 PMCID: PMC10176501 DOI: 10.1097/mlr.0000000000001848] [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: 05/13/2023]
Abstract
BACKGROUND Older adults frequently return to the emergency department (ED) within 30 days of a visit. High-risk patients can differentially benefit from transitional care interventions. Latent class analysis (LCA) is a model-based method used to segment the population and test intervention effects by subgroup. OBJECTIVES We aimed to identify latent classes within an older adult population from a randomized controlled trial evaluating the effectiveness of an ED-to-home transitional care program and test whether class membership modified the intervention effect. RESEARCH DESIGN Participants were randomized to receive the Care Transitions Intervention or usual care. Study staff collected outcomes data through medical record reviews and surveys. We performed LCA and logistic regression to evaluate the differential effects of the intervention by class membership. SUBJECTS Participants were ED patients (age 60 y and above) discharged to a community residence. MEASURES Indicator variables for the LCA included clinically available and patient-reported data from the initial ED visit. Our primary outcome was ED revisits within 30 days. Secondary outcomes included ED revisits within 14 days, outpatient follow-up within 7 and 30 days, and self-management behaviors. RESULTS We interpreted 6 latent classes in this study population. Classes 1, 4, 5, and 6 showed a reduction in ED revisit rates with the intervention; classes 2 and 3 showed an increase in ED revisit rates. In class 5, we found evidence that the intervention increased outpatient follow-up within 7 and 30 days (odds ratio: 1.81, 95% CI: 1.13-2.91; odds ratio: 2.24, 95% CI: 1.25-4.03). CONCLUSIONS Class membership modified the intervention effect. Population segmentation is an important step in evaluating a transitional care intervention.
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Affiliation(s)
- Rebecca K Green
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health
| | - Kenneth J Nieser
- Department of Population Health Sciences, School of Medicine and Public Health
| | - Gwen C Jacobsohn
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health
| | - Amy L Cochran
- Department of Population Health Sciences, School of Medicine and Public Health
- Department of Mathematics, University of Wisconsin-Madison, Madison, WI
| | | | - Jeremy T Cushman
- Department of Public Health Sciences
- Department of Emergency Medicine, University of Rochester Medical Center; Rochester, NY
| | - Amy J H Kind
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison
- Center for Health Disparities Research
- Wisconsin Alzheimer's Disease Research Center, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Michael Lohmeier
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health
- Department of Population Health Sciences, School of Medicine and Public Health
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison
- Center for Health Disparities Research
- Wisconsin Alzheimer's Disease Research Center, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Zhou JG, Cameron PA, Dipnall JF, Shih K, Cheng I. Using network analyses to characterise Australian and Canadian frequent attenders to the emergency department. Emerg Med Australas 2023; 35:225-233. [PMID: 36216495 DOI: 10.1111/1742-6723.14103] [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] [Received: 05/15/2022] [Revised: 08/12/2022] [Accepted: 09/20/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To explore and compare the characteristics of frequent attenders to the ED at an Australian and a Canadian tertiary hospitals by utilising a network analysis approach. METHODS We conducted a retrospective population-based study using administrative data over the 2018 and 2019 calendar years. Participants were from a tertiary hospital in Melbourne, Australia, and Toronto, Canada. Frequent attenders were defined as patients with four or more visits in 12 months. Characteristics of younger (18-39 years), middle-aged (40-69 years) and older (70 years and older) frequent attenders were described using descriptive statistics and network analyses. RESULTS Younger frequent attenders were characterised by mental illness and substance use, while older frequent attenders had high rates of physical (including chronic) diseases. Middle-aged frequent attenders were characterised by a combination of mental and physical illnesses. These findings were observed at both hospitals. Across all age groups, the network analyses between the Melbourne and Toronto hospitals were different. Among older frequent attender visits, more diagnoses were associated with high triage acuity at the Toronto hospital than at the Melbourne hospital. Some associations were similar at both sites, for example, the negative correlation between high triage acuity and joint pain. CONCLUSION Younger, middle-aged and older frequent attenders have distinct characteristics, made readily apparent by using network analyses. Future interventions to reduce ED visits should consider the heterogeneity of frequent attenders who have needs specific to their age, presenting problems and jurisdiction.
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Affiliation(s)
- Jonathan G Zhou
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter A Cameron
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Alfred Emergency and Trauma Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Joanna F Dipnall
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Melbourne, Victoria, Australia
| | - Kingsley Shih
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ivy Cheng
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Shu T, Huang J, Deng J, Chen H, Zhang Y, Duan M, Wang Y, Hu X, Liu X. Development and assessment of scoring model for ICU stay and mortality prediction after emergency admissions in ischemic heart disease: a retrospective study of MIMIC-IV databases. Intern Emerg Med 2023; 18:487-497. [PMID: 36683131 DOI: 10.1007/s11739-023-03199-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/09/2023] [Indexed: 01/23/2023]
Abstract
Ischemic heart disease (IHD) is the leading cause of death and emergency department (ED) admission. We aimed to develop more accurate and straightforward scoring models to optimize the triaging of IHD patients in ED. This was a retrospective study based on the MIMIC-IV database. Scoring models were established by AutoScore formwork based on machine learning algorithm. The predictive power was measured by the area under the curve in the receiver operating characteristic analysis, with the prediction of intensive care unit (ICU) stay, 3d-death, 7d-death, and 30d-death after emergency admission. A total of 8381 IHD patients were included (median patient age, 71 years, 95% CI 62-81; 3035 [36%] female), in which 5867 episodes were randomly assigned to the training set, 838 to validation set, and 1676 to testing set. In total cohort, there were 2551 (30%) patients transferred into ICU; the mortality rates were 1% at 3 days, 3% at 7 days, and 7% at 30 days. In the testing cohort, the areas under the curve of scoring models for shorter and longer term outcomes prediction were 0.7551 (95% CI 0.7297-0.7805) for ICU stay, 0.7856 (95% CI 0.7166-0.8545) for 3d-death, 0.7371 (95% CI 0.6665-0.8077) for 7d-death, and 0.7407 (95% CI 0.6972-0.7842) for 30d-death. This newly accurate and parsimonious scoring models present good discriminative performance for predicting the possibility of transferring to ICU, 3d-death, 7d-death, and 30d-death in IHD patients visiting ED.
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Affiliation(s)
- Tingting Shu
- Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Jian Huang
- Graduate School, Guangxi University of Chinese Medicine, Nanning, China
| | - Jiewen Deng
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Huaqiao Chen
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Zhang
- College of Medical Informatics, Chongqing Medical University, Chongqing, China
- Medical Data Science Academy, Chongqing Medical University, Chongqing, China
| | - Minjie Duan
- College of Medical Informatics, Chongqing Medical University, Chongqing, China
- Medical Data Science Academy, Chongqing Medical University, Chongqing, China
| | - Yanqing Wang
- The First College of Clinical Medicine, Chongqing Medical University, Chongqing, China
| | - Xiaofei Hu
- Department of Radiology, Southwest Hospital, Third Military Medical University (Army Medical University), No. 30, Gaotan Yanzheng Street, Shapingba District, Chongqing, 400038, China.
| | - Xiaozhu Liu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 288, Tiantian Avenue, Nan'an District, Chongqing, 400010, China.
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Belmin J, Villani P, Gay M, Fabries S, Havreng-Théry C, Malvoisin S, Denis F, Veyron JH. Real-world implementation of an eHealth system based on an artificial intelligence designed to predict and reduce emergency department visits by older adults: pragmatic trial. J Med Internet Res 2022; 24:e40387. [PMID: 35921685 PMCID: PMC9501682 DOI: 10.2196/40387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 07/28/2022] [Accepted: 07/30/2022] [Indexed: 11/25/2022] Open
Abstract
Background Frail older people use emergency services extensively, and digital systems that monitor health remotely could be useful in reducing these visits by earlier detection of worsening health conditions. Objective We aimed to implement a system that produces alerts when the machine learning algorithm identifies a short-term risk for an emergency department (ED) visit and examine health interventions delivered after these alerts and users’ experience. This study highlights the feasibility of the general system and its performance in reducing ED visits. It also evaluates the accuracy of alerts’ prediction. Methods An uncontrolled multicenter trial was conducted in community-dwelling older adults receiving assistance from home aides (HAs). We implemented an eHealth system that produces an alert for a high risk of ED visits. After each home visit, the HAs completed a questionnaire on participants’ functional status, using a smartphone app, and the information was processed in real time by a previously developed machine learning algorithm that identifies patients at risk of an ED visit within 14 days. In case of risk, the eHealth system alerted a coordinating nurse who could then inform the family carer and the patient’s nurses or general practitioner. The primary outcomes were the rate of ED visits and the number of deaths after alert-triggered health interventions (ATHIs) and users’ experience with the eHealth system; the secondary outcome was the accuracy of the eHealth system in predicting ED visits. Results We included 206 patients (mean age 85, SD 8 years; 161/206, 78% women) who received aid from 109 HAs, and the mean follow-up period was 10 months. The HAs monitored 2656 visits, which resulted in 405 alerts. Two ED visits were recorded following 131 alerts with an ATHI (2/131, 1.5%), whereas 36 ED visits were recorded following 274 alerts that did not result in an ATHI (36/274, 13.4%), corresponding to an odds ratio of 0.10 (95% IC 0.02-0.43; P<.001). Five patients died during the study. All had alerts, 4 did not have an ATHI and were hospitalized, and 1 had an ATHI (P=.04). In terms of overall usability, the digital system was easy to use for 90% (98/109) of HAs, and response time was acceptable for 89% (98/109) of them. Conclusions The eHealth system has been successfully implemented, was appreciated by users, and produced relevant alerts. ATHIs were associated with a lower rate of ED visits, suggesting that the eHealth system might be effective in lowering the number of ED visits in this population. Trial Registration clinicaltrials.gov NCT05221697; https://clinicaltrials.gov/ct2/show/NCT05221697.
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Affiliation(s)
- Joël Belmin
- Hôpital Charles Foix, Assistance Publique-Hôpitaux de Paris, Ivry-sur-Seine, FR.,Laboratoire Informatique Médicale et Ingénierie des Connaissances en eSanté (UMRS 1142), Institut National de la Santé et de la Recherche Médicale and Sorbonne Université, Paris, France, Paris, FR
| | - Patrick Villani
- Unité de médecine interne, gériatrie et thérapeutique, Assistance Publique-Hôpitaux de Marseille, Marseille, FR.,Université Aix-Marseille, Centre National de la Recherche Scientifique, Etablissement Français du Sang, Anthropologie bio-culturelle, Droit, Ethique et Santé, Marseille, FR
| | - Mathias Gay
- Communauté professionnelle de santé Itinéraire Santé, Marseille, FR
| | - Stéphane Fabries
- Intervenants Libéraux et Hospitaliers Unis pour le Patient, Marseille, FR
| | - Charlotte Havreng-Théry
- Laboratoire Informatique Médicale et Ingénierie des Connaissances en eSanté (UMRS 1142), Institut National de la Santé et de la Recherche Médicale and Sorbonne Université, Paris, France, Paris, FR.,PRESAGE, 72 boulevard de Sébastopol, Paris, FR
| | | | - Fabrice Denis
- Institut Inter-Régional de Cancérologie Jean Bernard, Le Mans, FR
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Conneely M, Leahy S, Dore L, Trépel D, Robinson K, Jordan F, Galvin R. The effectiveness of interventions to reduce adverse outcomes among older adults following Emergency Department discharge: umbrella review. BMC Geriatr 2022; 22:462. [PMID: 35643453 PMCID: PMC9145107 DOI: 10.1186/s12877-022-03007-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/30/2022] [Indexed: 12/04/2022] Open
Abstract
Background Population ageing is increasing rapidly worldwide. Older adults are frequent users of health care services including the Emergency Department (ED) and experience a number of adverse outcomes following an ED visit. Adverse outcomes include functional decline, unplanned hospital admission and an ED revisit. Given these adverse outcomes a number of interventions have been examined to improve the outcomes of older adults following presentation to the ED. The aim of this umbrella review was to evaluate the effectiveness of ED interventions in reducing adverse outcomes in older adults discharged from the ED. Methods Systematic reviews of randomised controlled trials investigating ED interventions for older adults presenting to the ED exploring clinical, patient experience and healthcare utilisation outcomes were included. A comprehensive search strategy was employed in eleven databases and the PROSPERO register up until June 2020. Grey literature was also searched. Quality was assessed using the A MeaSurement Tool to Assess Systematic Reviews 2 tool. Overlap between systematic reviews was assessed using a matrix of evidence table. An algorithm to assign the Grading of Recommendations Assessment, Development and Evaluation to assess the strength of evidence was applied for all outcomes. Results Nine systematic reviews including 29 randomised controlled trials were included. Interventions comprised of solely ED-based or transitional interventions. The specific interventions delivered were highly variable. There was high overlap and low methodological quality of the trials informing the systematic reviews. There is low quality evidence to support ED interventions in reducing functional decline, improving patient experience and improving quality of life. The quality of evidence of the effectiveness of ED interventions to reduce mortality and ED revisits varied from very low to moderate. Results were presented narratively and summary of evidence tables created. Conclusion Older adults are the most important emerging group in healthcare for several economic, social and political reasons. The existing evidence for the effectiveness of ED interventions for older adults is limited. This umbrella review highlights the challenge of synthesising evidence due to significant heterogeneity in methods, intervention content and reporting of outcomes. Higher quality intervention studies in line with current geriatric medicine research guidelines are recommended, rather than the publication of further systematic reviews. Trial registration UMBRELLA REVIEW REGISTRATION: PROSPERO (CRD42020145315). Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03007-5.
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10
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Kularatna S, Wong J, Senanayake S, Brain D, Greenslade J, Parsonage W, Jun D, McPhail S. Financial Costs of Emergency Department Presentations for Australian Patients With Heart Disease in the Last 3 Years of Life. Health Serv Insights 2022; 15:11786329221091038. [PMID: 35431555 PMCID: PMC9008821 DOI: 10.1177/11786329221091038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 03/11/2022] [Indexed: 11/17/2022] Open
Abstract
Aims: This study described emergency department (ED) resource use patterns and associated costs among patients with heart disease in their last 3 years of life in a high-income country. Methods: This study used linked data from ED and death registry databases in Australia. A random sample of 1000 patients who died due to any cause in 2017, and who had been living with heart disease for at least the prior 10-years were included. The outcomes of interest were number of ED presentations over each of the last 3 years prior to death and relative cost contributions of ED-related items. Results: The number of patients needing ED care and number of ED presentations per patient increased as patients were closer to death, with 85% experiencing at least one ED presentation in their last year of life. Mean per patient ED presentation cost increased with each year closer to death. Costs related to labor, pathology, patient travel, and goods and services contributed more than 85% of the total cost in each of the 3 years. Conclusion: The increase in cost burden as patients neared death was attributable to more frequent ED presentations per person rather than more expensive ED presentations. The scope of this study was limited to ED presentations, and may not be representative of heart-disease-related end-of-life care more broadly.
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Affiliation(s)
- Sanjeewa Kularatna
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - Jessie Wong
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - Sameera Senanayake
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - David Brain
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - Jaimi Greenslade
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - William Parsonage
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Metro North Health, QLD, Australia
| | - Deokhoon Jun
- Department of Rehabilitation and Health Promotion, Daegu University, Kyungsan City, South Korea
| | - Steven McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Clinical Informatics Directorate, Metro South Health, Brisbane, QLD, Australia
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11
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Jacobsohn GC, Jones CMC, Green RK, Cochran AL, Caprio TV, Cushman JT, Kind AJH, Lohmeier M, Mi R, Shah MN. Effectiveness of a care transitions intervention for older adults discharged home from the emergency department: A randomized controlled trial. Acad Emerg Med 2022; 29:51-63. [PMID: 34310796 PMCID: PMC8766871 DOI: 10.1111/acem.14357] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/06/2021] [Accepted: 07/20/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Improving care transitions following emergency department (ED) visits may reduce post-ED adverse events among older adults (e.g., ED revisits, decreased function). The Care Transitions Intervention (CTI) improves hospital-to-home transitions; however, its effectiveness at improving post-ED outcomes is unknown. We tested the effectiveness of the CTI with community-dwelling older adult ED patients, hypothesizing that it would reduce revisits and increase performance of self-management behaviors during the 30 days following discharge. METHODS We conducted a randomized controlled trial among patients age ≥ 60 discharged home from one of three EDs in two states. Intervention participants received a minimally modified CTI, with a home visit 24 to 72 h postdischarge and one to three phone calls over 28 days. We collected demographic, health status, and psychosocial data at the initial ED visit. Medication adherence and knowledge of red flag symptoms were assessed via phone survey. Care use and comorbidities were abstracted from medical records. We performed multivariate regressions for intention-to-treat and per-protocol (PP) analyses. RESULTS Participant characteristics (N = 1,756) were similar across groups: mean age 72.4 ± 8.6 years and 53% female. Of those randomized to the intervention, 84% completed the home visit. Overall, 12.4% of participants returned to the ED within 30 days. The CTI did not significantly affect odds of 30-day ED revisits (adjusted odds ratio [AOR] = 0.97, 95% confidence interval [CI] = 0.72 to 1.30) or medication adherence (AOR = 0.89, 95% CI = 0.60 to 1.32). Participants receiving the CTI (PP) had increased odds of in-person follow-up with outpatient clinicians during the week following discharge (AOR = 1.24, 95% CI = 1.01 to 1.51) and recalling at least one red flag from ED discharge instructions (AOR = 1.34 95% CI = 1.05 to 1.71). CONCLUSIONS The CTI did not reduce 30-day ED revisits but did significantly increase key care transition behaviors (outpatient follow-up, red flag knowledge). Additional research is needed to explore if patients with different conditions benefit more from the CTI and whether decreasing ED revisits is the most appropriate outcome for all older adults.
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Affiliation(s)
- Gwen C Jacobsohn
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Courtney M C Jones
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Rebecca K Green
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Amy L Cochran
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Thomas V Caprio
- Division of Geriatrics, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Jeremy T Cushman
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Amy J H Kind
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
- William S. Middleton Veterans Affairs Geriatrics Research, Education, and Clinical Center, Madison, Wisconsin, USA
| | - Michael Lohmeier
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Ranran Mi
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
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12
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Driesen B, Merten H, Barendregt R, Bonjer HJ, Wagner C, Nanayakkara PWB. Root causes and preventability of emergency department presentations of older patients: a prospective observational study. BMJ Open 2021; 11:e049543. [PMID: 34348952 PMCID: PMC8340285 DOI: 10.1136/bmjopen-2021-049543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE More older patients are presenting to the emergency department (ED). It is important to know why these patients present and if the ED is the best place for them to receive the care they need. The primary aim of this study was to identify organisational-related, technical-related, healthcare worker-related and patient-related factors leading to ED presentations of older patients. The secondary aim was to determine patients' and caregivers' perspectives on what kinds of ED presentations are potentially preventable. DESIGN This is a prospective observational study. A root cause analysis was performed by the Prevention and Recovery Information System for Monitoring and Analysis method. It used basic administrative data collected from patient records and interviews of patients, general practitioners (GPs) and physicians at the ED. SETTING The ED of an academic hospital in the Netherlands. PARTICIPANTS 100 older patients (aged ≥70 years) who attended the ED between November 2017 and March 2018. RESULTS In 100 patients presenting to the ED, 159 factors that contributed to presentation were identified; most of these factors were related to underlying diseases (59%) and patient-related factors (18%). These presentations were considered potentially preventable by 23% of the physicians at the ED and 21% of the GPs, but only 10% of the patients. In only four cases was there overall agreement between the patients and the healthcare workers. CONCLUSION The most frequent underlying factors contributing to an ED presentation in older patients are disease-related and patient-related. The low percentage of ED presentations considered potentially preventable shows that a 'preventable ED presentation' is difficult to define and therefore interventions to reduce them are unlikely to be simple. Novel solutions within the acute care pathway are required in order to deliver care of optimal quality and safety to older patients.
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Affiliation(s)
- Babiche Driesen
- Emergency Medicine, Amsterdam UMC - Locatie VUMC, Amsterdam, The Netherlands
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC - Locatie VUMC, Amsterdam, The Netherlands
| | - Hanneke Merten
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC - Locatie VUMC, Amsterdam, The Netherlands
- Acute Care Network North-West, Amsterdam UMC - Locatie VUMC, Amsterdam, The Netherlands
| | - Rosalie Barendregt
- Section of General and Acute Medicine, Department of Internal Medicine, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
| | - H Jaap Bonjer
- Department of Surgery, Amsterdam UMC - Locatie VUMC, Amsterdam, The Netherlands
| | - Cordula Wagner
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC - Locatie VUMC, Amsterdam, The Netherlands
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Prabath W B Nanayakkara
- Section of General and Acute Medicine, Department of Internal Medicine, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
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13
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Lou X, Xu H. The effectiveness of an emergency department nursing intervention on psychological symptoms and self-care capacities: A randomized controlled study protocol. Medicine (Baltimore) 2021; 100:e24763. [PMID: 34032691 PMCID: PMC8154481 DOI: 10.1097/md.0000000000024763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 01/25/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND We carried out a randomized trial of an emergency department (ED)-based nursing intervention to evaluate the impact of an ED nursing intervention on ED revisits, patient perceptions of continuity of care, illness perceptions, self-care capacities and psychological symptoms. METHOD We conducted a randomized controlled trial to compare the ED-based intervention with usual care. The protocol was reviewed and approved by the Research Ethics Board of the Huzhou Central Hospital & Affiliated Central Hospital Huzhou University (K901923-021), each participant signed a written consent before participating, and SPIRIT guidelines were followed throughout. To be eligible, patients ready for discharge from the ED had to be at risk for ED return based on 2 criteria: at least one ED visit during the year prior to the initial visit, and current treatment with at least 6 medications. Exclusion criteria included cognitive problems (e.g., dementia) that would preclude provision of informed consent either noted in the medical chart or identified based on the clinical judgment of the project nurse. To avoid multiple interveners for the same patient, we also excluded patients already receiving other regular follow-up (e.g., at a specialized clinic in the hospital or from external resources). The major outcomes were assessed with the Heart Continuity of Care Questionnaire, the Illness Perception Questionnaire-Revised, the Therapeutic Self-Care Tool, the Hospital Anxiety and Depression Scale, and the Self-Reported Medication-Taking Scale. RESULTS Two hundred patients who met the inclusion criteria were included in our study, Table 1 showed the effects of nursing intervention on measures of clinical outcomes. DISCUSSION The ED is a major entry point into the health care system of many countries. Unnecessary ED revisits may result in overcrowding, increased waiting time, and failure to provide appropriate emergency care. The ED-based interventions literature focuses primarily on service use and ways to reduce ED revisits, with very little focus on impacting secondary outcomes. Because of their potential link with health service utilization, secondary outcomes such as perceived continuity of care, illness perceptions, self-care capacities, psychological symptoms and medication adherence might influence ED revisits. Future research was needed to better understand the complex relationship between ED utilization and a variety of intermediary factors in order to develop interventions that will optimize ED utilization.
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Moe J, O'Sullivan F, McGregor MJ, Schull MJ, Dong K, Holroyd BR, Grafstein E, Hohl CM, Trimble J, McGrail KM. Identifying subgroups and risk among frequent emergency department users in British Columbia. J Am Coll Emerg Physicians Open 2021; 2:e12346. [PMID: 33532752 PMCID: PMC7823092 DOI: 10.1002/emp2.12346] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 12/01/2020] [Accepted: 12/11/2020] [Indexed: 01/25/2023] Open
Abstract
Objective: Frequent emergency department (ED) users are heterogeneous. We aimed to identify subgroups and assess their mortality. Methods: We identified patients ≥18 years with ≥1 ED visit in British Columbia from April 1, 2012 to March 31, 2015, and linked to hospitalization, physician billing, prescription, and mortality data. Frequent users were the top 10% of patients by ED visits. We employed cluster analysis to identify frequent user subgroups. We assessed 365-day mortality using Kaplan-Meier curves and conducted Cox regressions to assess mortality risk factors within subgroups. Results: We identified 4 subgroups. Subgroup 1 ("Elderly") had median age 77 years (interquartile range [IQR]: 66-85), 5 visits/year (IQR: 4-6), median 8 prescription medications (IQR: 5-11), and 24.7% mortality. Subgroup 2 ("Mental Health and Alcohol Use") had median age 48 years (IQR: 34-61), 13 visits/year (IQR: 10-16), and 12.3% mortality. They made a median 31 general practitioner visits (IQR: 19-51); however, only 23.7% received a majority of services from 1 primary care physician. Subgroup 3 ("Young Mental Health") had median age 39 years (IQR: 28-51), 5 visits/year (IQR: 4-6), and 2.2% mortality. Subgroup 4 ("Short-term") had median age 50 years (IQR: 34-65), 4 visits/year (IQR: 4-5) regularly spaced over a short term, and 1.4% mortality. Male sex (all subgroups), long-term care ("Mental Health and Alcohol Use;" "Young Mental Health"), and rural residence ("Elderly" in long-term care; "Young Mental Health") were associated with increased mortality. Conclusions: Our results identify frequent user subgroups with varying mortality. Future research should explore subgroups' unmet needs and tailor interventions toward them.
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Affiliation(s)
- Jessica Moe
- Department of Emergency Medicine, University of British ColumbiaDepartment of Emergency Medicine, Vancouver General HospitalVancouverBritish ColumbiaCanada
| | - Fiona O'Sullivan
- Department of Emergency MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Margaret J. McGregor
- Department of Family PracticeUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Michael J. Schull
- Institute for Clinical Evaluative SciencesDepartment of MedicineUniversity of TorontoTorontoOntarioCanada
| | - Kathryn Dong
- Department of Emergency MedicineUniversity of AlbertaEdmontonAlbertaCanada
| | - Brian R. Holroyd
- Department of Emergency MedicineEmergency Strategic Clinical Networ, Alberta Health ServicesUniversity of AlbertaEdmontonAlbertaCanada
| | - Eric Grafstein
- Department of Emergency MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Corinne M. Hohl
- Department of Emergency Medicine, University of British ColumbiaDepartment of Emergency Medicine, Vancouver General HospitalVancouverBritish ColumbiaCanada
| | - Johanna Trimble
- Patients for Patient Safety CanadaRoberts CreekVancouverBritish ColumbiaCanada
| | - Kimberlyn M. McGrail
- Population Data BCSchool of Population and Public Health, University of British ColumbiaVancouverBritish ColumbiaCanada
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15
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Moe J, O'Sullivan F, McGregor MJ, Schull MJ, Dong K, Holroyd BR, Grafstein E, Hohl CM, Trimble J, McGrail KM. Characteristics of frequent emergency department users in British Columbia, Canada: a retrospective analysis. CMAJ Open 2021; 9:E134-E141. [PMID: 33653768 PMCID: PMC8034376 DOI: 10.9778/cmajo.20200168] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Frequent emergency department users disproportionately account for rising health care costs. We aimed to characterize frequent emergency department users in British Columbia, Canada. METHODS We performed a retrospective analysis using health administrative databases. We included patients aged 18 years or more with at least 1 emergency department visit from 2012/13 to 2015/16, linked to hospital, physician billing, prescription and mortality data. We used annual emergency department visits made by the top 10% of patients to define frequent users (≥ 3 visits/year). RESULTS Over the study period, 13.8%-15.3% of patients seen in emergency departments were frequent users. We identified 205 136 frequent users among 1 196 353 emergency department visitors. Frequent users made 40.3% of total visits in 2015/16. From 2012/13 to 2015/16, their visit rates per 100 000 BC population showed a relative increase of 21.8%, versus 13.1% among all emergency department patients. Only 1.8% were frequent users in all study years. Mental illness accounted for 8.2% of visits among those less than 60 years of age, and circulatory or respiratory diagnoses for 13.3% of visits among those aged 60 or more. In 2015/16, frequent users were older and had lower household incomes than nonfrequent users; the sex distribution was similar. Frequent users had more prescriptions (median 9, interquartile range [IQR] 5-14 v. 1, IQR 1-3), primary care visits (median 15, IQR 9-27 v. 7, IQR 4-12) and hospital admissions (median 2, IQR 1-3 v. 1, IQR 1-1), and higher 1-year mortality (10.2% v. 3.5%) than nonfrequent users. INTERPRETATION Emergency department use by frequent users increased in BC between 2012/13 and 2015/16; these patients were heterogenous, had high mortality and rarely remained frequent users over multiple years. Our results suggest that interventions must account for heterogeneity and address triggers of frequent use episodes.
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Affiliation(s)
- Jessica Moe
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Fiona O'Sullivan
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Margaret J McGregor
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Michael J Schull
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Kathryn Dong
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Brian R Holroyd
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Eric Grafstein
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Corinne M Hohl
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Johanna Trimble
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Kimberlyn M McGrail
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
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Dufour I, Dubuc N, Chouinard MC, Chiu Y, Courteau J, Hudon C. Profiles of Frequent Geriatric Users of Emergency Departments: A Latent Class Analysis. J Am Geriatr Soc 2020; 69:753-761. [PMID: 33156527 DOI: 10.1111/jgs.16921] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/02/2020] [Accepted: 10/15/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Frequent geriatric users of emergency departments (EDs) represent a complex and heterogeneous population. Identifying their specific subgroups would allow the development of interventions better customized to their needs and characteristics. Thus, this study aimed to develop profiles of frequent geriatric ED users using the individual characteristics of patients. DESIGN This was a retrospective cohort study. SETTING Databases from the Régie de l'assurance maladie du Québec (RAMQ) were utilized. PARTICIPANTSThis study included individuals aged 65 years or older living in the community in the Province of Quebec (Canada), who consulted in an ED at least four times in the year after an ED index date (an ED visit, chosen randomly, during an index period of January 1, 2012 to December 31, 2013) and who had received a diagnosis of ambulatory care-sensitive conditions (ACSCs) in the 2 years preceding the index date. MEASUREMENTS A latent class analysis was used to identify subgroups of frequent geriatric ED users according to their individual characteristics, including ACSC type, dementia, mental health disorders, cancer diagnosis, and comorbidity index. RESULTS The study cohort consisted of 21,393 frequent geriatric ED users. Four groups of frequent geriatric ED users were identified: people with low comorbidity (39.0%), comprising the individuals with the lowest number of physical and mental health conditions; people with cancer (32.7%); people with pulmonaryand cardiac diseases (18.1%); and people with dementia or mental health disorders (10.2%), composed of individuals with the highest proportion of common and severe mental health disease, as well as dementia. This group accounts for the highest use of overall healthcare services. CONCLUSION These profiles will be useful in developing customized interventions addressing the needs of each subgroup of frequent geriatric ED users. More research is needed to bridge the remaining gaps, especially regarding the healthiest frequent geriatric users of EDs.
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Affiliation(s)
- Isabelle Dufour
- École des sciences infirmières, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Canada
| | - Nicole Dubuc
- École des sciences infirmières, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Canada
| | | | - Yohann Chiu
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Canada
| | - Josiane Courteau
- Groupe de recherche PRIMUS, Centre de recherche du Centre hospitalier universitaire de Sherbrooke (CRCHUS), Sherbrooke, Canada
| | - Catherine Hudon
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Canada
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17
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Preston L, van Oppen JD, Conroy SP, Ablard S, Buckley Woods H, Mason SM. Improving outcomes for older people in the emergency department: a review of reviews. Emerg Med J 2020; 38:882-888. [DOI: 10.1136/emermed-2020-209514] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 07/01/2020] [Accepted: 08/26/2020] [Indexed: 02/01/2023]
Abstract
BackgroundThere has been a recognised trend of increasing use of emergency and urgent care and emergency departments (EDs) by older people, which is marked by a substantial evidence base reporting interventions for this population and guidance from key organisations. Despite this, outcomes for this population remain suboptimal. A plethora of reviews in this area provides challenges for clinicians and commissioners in determining which interventions and models of care best meet people’s needs. The aim of this review was to identify effective ED interventions which have been reported for older people, and to provide a clear summary of the myriad reviews and numerous intervention types in this area.MethodsA review of reviews, reporting interventions for older people, either initiated or wholly delivered within the ED.ResultsA total of 15 review articles describing 83 primary studies met our content and reporting standards criteria. The majority (n=13) were systematic reviews (four using meta-analysis.) Across the reviews, 26 different outcomes were reported with inconsistency. Follow-up duration varied within and across the reviews. Based on how authors had reported results, evidence clusters were developed: (1) staff-focused reviews, (2) discharge intervention reviews, (3) population-focused reviews and (4) intervention component reviews.ConclusionsThe evidence base describing interventions is weak due to inconsistent reporting, differing emphasis placed on the key characteristics of primary studies (staff, location and outcome) by review authors and varying quality of reviews. No individual interventions have been found to be more promising, but interventions initiated in the ED and continued into other settings have tended to result in more favourable patient and health service outcomes. Despite many interventions reported within the reviews being holistic and patient focused, outcomes measured were largely service focused.PROSPERO registration numberPROSPERO CRD42018111461.
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18
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Driesen BEJM, Merten H, Wagner C, Bonjer HJ, Nanayakkara PWB. Unplanned return presentations of older patients to the emergency department: a root cause analysis. BMC Geriatr 2020; 20:365. [PMID: 32962646 PMCID: PMC7510142 DOI: 10.1186/s12877-020-01770-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 09/10/2020] [Indexed: 12/02/2022] Open
Abstract
Background In line with demographic changes, there is an increase in ED presentations and unplanned return presentations by older patients (≥70 years). It is important to know why these patients return to the ED shortly after their initial presentation. Therefore, the aim of this study was to provide insight into the root causes and potential preventability of unplanned return presentations (URP) to the ED within 30 days for older patients. Methods A prospective observational study was conducted from February 2018 to November 2018 in an academic hospital in Amsterdam. We included 83 patients, aged 70 years and older, with an URP to the ED within 30 days of the initial ED presentation. Patients, GPs and doctors at the ED were interviewed by trained interviewers and basic administrative data were collected in order to conduct a root cause analysis using the PRISMA-method. Results One hundred fifty-one root causes were identified and almost half (49%) of them were disease-related. Fifty-two percent of the patients returned to the ED within 7 days after the initial presentation. In 77% of the patients the URP was related to the initial presentation. Patients judged 17% of the URPs as potentially preventable, while doctors at the ED judged 25% and GPs 23% of the URPs as potentially preventable. In none of the cases, there was an overall agreement from all three perspectives on the judgement that an URP was potentially preventable. Conclusion Disease-related factors were most often identified for an URP and half of the patients returned to the ED within 7 days. The majority of the URPs was judged as not preventable. However, an URP should trigger healthcare workers to focus on the patient’s process of care and their needs and to anticipate on potential progression of disease. Future research should assess whether this may prevent that patients have to return to the ED.
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Affiliation(s)
- Babiche E J M Driesen
- Department of Emergency Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands. .,Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, Amsterdam, 1081 BT, The Netherlands.
| | - Hanneke Merten
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, Amsterdam, 1081 BT, The Netherlands
| | - Cordula Wagner
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, Amsterdam, 1081 BT, The Netherlands.,Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118-124, Utrecht, 3513 CR, The Netherlands
| | - H Jaap Bonjer
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands
| | - Prabath W B Nanayakkara
- Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands
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19
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Leaker H, Fox L, Holroyd-Leduc J. The Impact of Geriatric Emergency Management Nurses on the Care of Frail Older Patients in the Emergency Department: a Systematic Review. Can Geriatr J 2020; 23:250-256. [PMID: 32904804 PMCID: PMC7458600 DOI: 10.5770/cgj.23.408] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background Frail older adults are high users of emergency departments (EDs). Many Canadian EDs have hired Geriatric Emergency Management (GEM) nurses in an effort to improve care to older adults. Methods We conducted a systematic review to determine the impact of GEM nurses on care provided to frail older adults. We searched MEDLINE, Embase, CINAHL, and Cochrane databases. A grey literature search was also conducted. Inclusion criteria were English-language, evaluation of GEM nurse or geriatric-trained nurse assessments of older adults (age ≥ 65 years) within the ED, and reported clinical and/or health system outcomes. The PRISMA statement was followed, and article quality was assessed using GRADE. Results 5,115 citations and 191 full text articles were screened; 8 articles from 7 different studies were included. Study quality varied between very low to high. Five included studies analyzed the effect of GEM nurses on ED revisits, with most finding they decreased revisits. Four included studies analyzed the effect of GEM nurses on hospital admissions/readmissions, demonstrating variable impact. One study looked at the cost-effectiveness and found the cost to be negligible. The impact on patient-specific outcomes was less clear. Conclusions GEM nurses may be an effective option to help in the management of frail older adults in the ED.
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Affiliation(s)
- Hannah Leaker
- Faculty of Nursing, University of Calgary, Calgary, AB
| | - Loralee Fox
- Faculty of Nursing, University of Calgary, Calgary, AB
| | - Jayna Holroyd-Leduc
- Department of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB
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20
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Effectiveness of hospital avoidance interventions among elderly patients: A systematic review. CAN J EMERG MED 2020; 22:504-513. [DOI: 10.1017/cem.2020.4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
ABSTRACTObjectiveOlder patients with complex care needs and limited personal and social resources are heavy users of emergency department (ED) services and are often admitted when they present to the ED. Updated information is needed regarding the most effective strategies to appropriately avoid ED presentation and hospital admission among older patients.MethodsThis systematic review aimed to identify interventions that have demonstrated effectiveness in decreasing ED use and hospital admissions in older patients. We conducted a comprehensive literature search within Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials from database inception to July 2019 with no language restrictions. Interventional study designs conducted in populations of 65 years and older were included. Primary outcomes were ED visits and hospital admissions. Secondary outcomes included hospital readmission, mortality, cost, and patient-reported outcomes.ResultsOf 7,943 citations reviewed for eligibility, 53 studies were included in our qualitative synthesis, including 26 randomized controlled trials (RCT), 8 cluster-RCTs, and 19 controlled before-after studies. Data characterization revealed that community-based strategies reduced ED visits, particularly those that included comprehensive geriatric assessments and home visits. These strategies reported decreases in mean ED use (for interventions versus controls) ranging from -0.12 to -1.32 visits/patient. Interventions that included home visits also showed reductions in hospital admissions ranging from -6% to -14%. There was, however, considerable variability across individual studies with respect to outcome reporting, statistical analyses, and risk of bias, which limited our ability to further quantify the effect of these interventions.ConclusionVarious interventional strategies to avoid ED presentations and hospital admissions for older patients have been studied. While models of care that include comprehensive geriatric assessments and home visits may reduce acute care utilization, the standardization of outcome measures is needed to further delineate which parts of these complex interventions are contributing to efficacy. The potential effects of multidisciplinary team composition on patient outcomes also warrant further investigation.
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21
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McGrath J, Almeida P, Law R. The Whittington Frailty Pathway: improving access to comprehensive geriatric assessment: an interdisciplinary quality improvement project. BMJ Open Qual 2019; 8:e000798. [PMID: 31803856 PMCID: PMC6887502 DOI: 10.1136/bmjoq-2019-000798] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/16/2019] [Accepted: 11/01/2019] [Indexed: 11/13/2022] Open
Abstract
National guidelines mandate identification and tailored management of patients living with frailty who attend the acute hospital setting. We describe using quality improvement (QI) techniques to embed a system that allowed identification of frailty in older patients attending the emergency department (ED), creation of a clinical pathway to facilitate comprehensive geriatric assessment and appropriate same-day discharge of suitable patients. Integration of Clinical Frailty Scale (CFS) scoring within an electronic record system, a continuing programme of education and awareness, and dedicated project staff allows patients to be identified for an ambulatory frailty pathway. Our results show a sustained improvement over 9 months of the project, with 73% of patients over the age of 75 years presenting to ED by ambulance now receiving a CFS score. Over 300 patients have been identified, transferred to ambulatory care and treated via a new frailty pathway, with an admission rate for this cohort of 14%, compared with an overall admission rate of 50% for patients over 75 years. We report a decrease in overall ED admission of 1%. Analysis of patients discharged through this same-day pathway showed a 7-day ED reattendance rate of 15.1% and a 30-day readmission rate of 18.9%, which are comparable with current pathways. Consultant review estimated 87% of patients to have avoided a longer admission. Patient and staff satisfaction indicates this pathway to be feasible and acceptable to users. Our data suggest an ambulatory frailty pathway can deliver significant admission avoidance while maintaining low readmission rates. Similar schemes in other hospitals should consider using QI approaches to implementation of frailty pathways.
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Affiliation(s)
- John McGrath
- Islington GP Federation, NHS Islington CCG, London, UK.,Care of the Older Person department, Whittington Hospital NHS Trust, London, UK
| | - Paula Almeida
- Care of the Older Person department, Whittington Hospital NHS Trust, London, UK
| | - Ruth Law
- Care of the Older Person department, Whittington Hospital NHS Trust, London, UK
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22
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Hesselink G, Sir Ö, Schoon Y. Effectiveness of interventions to alleviate emergency department crowding by older adults: a systematic review. BMC Emerg Med 2019; 19:69. [PMID: 31747917 PMCID: PMC6864956 DOI: 10.1186/s12873-019-0288-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 11/06/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The growing demand for elderly care often exceeds the ability of emergency department (ED) services to provide quality of care within reasonable time. The purpose of this systematic review is to assess the effectiveness of interventions on reducing ED crowding by older patients, and to identify core characteristics shared by successful interventions. METHODS Six major biomedical databases were searched for (quasi)experimental studies published between January 1990 and March 2017 and assessing the effect of interventions for older patients on ED crowding related outcomes. Two independent reviewers screened and selected studies, assessed risk of bias and extracted data into a standardized form. Data were synthesized around the study setting, design, quality, intervention content, type of outcome and observed effects. RESULTS Of the 16 included studies, eight (50%) were randomized controlled trials (RCTs), two (13%) were non-RCTs and six (34%) were controlled before-after (CBA) studies. Thirteen studies (81%) evaluated effects on ED revisits and four studies (25%) evaluated effects on ED throughput time. Thirteen studies (81%) described multicomponent interventions. The rapid assessment and streaming of care for older adults based on time-efficiency goals by dedicated staff in a specific ED unit lead to a statistically significant decrease of ED length of stay (LOS). An ED-based consultant geriatrician showed significant time reduction between patient admission and geriatric review compared to an in-reaching geriatrician. CONCLUSION Inter-study heterogeneity and poor methodological quality hinder drawing firm conclusions on the intervention's effectiveness in reducing ED crowding by older adults. More evidence-based research is needed using uniform and valid effect measures. TRIAL REGISTRATION The protocol is registered with the PROSPERO International register of systematic reviews: ID = CRD42017075575).
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Affiliation(s)
- Gijs Hesselink
- Emergency Department, Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, P.O. Box 9101, 114 IQ healthcare, Nijmegen, HB 6500 The Netherlands
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ health care, P.O. Box 9101, 114 IQ healthcare, Nijmegen, HB 6500 the Netherlands
| | - Özcan Sir
- Emergency Department, Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, P.O. Box 9101, 114 IQ healthcare, Nijmegen, HB 6500 The Netherlands
| | - Yvonne Schoon
- Emergency Department, Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, P.O. Box 9101, 114 IQ healthcare, Nijmegen, HB 6500 The Netherlands
- Department of Geriatrics, Radboud university medical center, Nijmegen, The Netherlands
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23
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Ignatyev Y, Mundt AP, von Peter S, Heinze M. Hospital length of stay among older people treated with flexible and integrative psychiatric service models in Germany. Int J Geriatr Psychiatry 2019; 34:1557-1564. [PMID: 31276239 DOI: 10.1002/gps.5165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 06/29/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Since 2012, a new law (§64b, Book V of the Social Security Code [SGB V]) regulates the implementation of flexible and integrative psychiatric treatment projects (FIT64b) in Germany. FIT64b allows rapid discharge of patients from inpatient to outpatient settings and cost reductions of hospital stays. Several psychiatric centres exclusively provide FIT64b; others provide FIT64b alongside with standard health care. The aim of the study was to assess the average hospital length of stay (AHLS) of older patients with mental illness included in FIT64b projects. METHODS A secondary data analysis was conducted using administrative data from eight German mental health centres providing FIT64b. The effects of gender, age, type of centre, and main diagnosis on AHLS were calculated for all older patients with age 65 years or older (n = 3495) treated in FIT64b in the year 2016. Data were analysed with descriptive statistics and robust multiway procedures. RESULTS The AHLS of older people with mental illness was 4.8 (SD = 11.5) days. The AHLS was shorter in centres exclusively providing FIT64b than in centres providing FIT64b alongside with standard health care: 3.2 (SD = 6.4) vs 8.4 (SD = 17.8) days, P = .001. This difference was particularly marked among patients with schizophrenia spectrum disorders, mood disorders, and neurotic, stress-related, and somatoform disorders. CONCLUSIONS FIT64b relates to very short AHLS even among older people. Centres using FIT64b alongside with standard health care usually provide standard care to most patients, which could lead to lower fidelity in the implementation of FIT64b.
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Affiliation(s)
- Yuriy Ignatyev
- Department of Psychiatry and Psychotherapy, Immanuel Klinik Rüdersdorf, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
| | - Adrian P Mundt
- Medical Faculty, Universidad Diego Portales, Santiago, Chile.,Medical School, Universidad San Sebastián, Puerto Montt, Chile
| | - Sebastian von Peter
- Department of Psychiatry and Psychotherapy, Immanuel Klinik Rüdersdorf, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
| | - Martin Heinze
- Department of Psychiatry and Psychotherapy, Immanuel Klinik Rüdersdorf, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
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24
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Taylor A, Broadbent M, Wallis M, Marsden E. The predictive validity of the interRAI ED screener for predicting re-presentation within 28 days for older adults at a regional hospital emergency department. Australas Emerg Care 2019; 22:149-155. [DOI: 10.1016/j.auec.2019.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 04/14/2019] [Accepted: 04/24/2019] [Indexed: 11/26/2022]
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25
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Lago L, Westley-Wise V, Mullan J, Lambert K, Zingel R, Carrigan T, Triner W, Eagar K. Here one year, gone the next? Investigating persistence of frequent emergency department attendance: a retrospective study in Australia. BMJ Open 2019; 9:e027700. [PMID: 31230013 PMCID: PMC6596941 DOI: 10.1136/bmjopen-2018-027700] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Patients are presenting to emergency departments (EDs) with increasing complexity at rates beyond population growth and ageing. Intervention studies target patients with 12 months or less of frequent attendance. However, these interventions are not well targeted since most patients do not remain frequent attenders. This paper quantifies temporary and ongoing frequent attendance and contrasts risk factors for each group. DESIGN Retrospective population-based study using 10 years of longitudinal data. SETTING An Australian geographic region that includes metropolitan and rural EDs. PARTICIPANTS 332 100 residents visited any ED during the study period. MAIN OUTCOME MEASURE Frequent attendance was defined as seven or more visits to any ED in the region within a 12-month period. Temporary frequent attendance was defined as meeting this threshold only once, and ongoing more than once. Risk factors for temporary and ongoing frequent attenders were identified using logistic regression models for adults and children. RESULTS Of 8577 frequent attenders, 80.1% were temporary and 19.9% ongoing (12.9% repeat, 7.1% persistent). Among adults, ongoing were more likely than temporary frequent attenders to be young to middle aged (aged 25-64 years), and less likely to be from a high socioeconomic area or be admitted. Ongoing frequent attenders had higher rates of non-injury presentations, in particular substance-related (OR=2.5, 99% CI 1.1 to 5.6) and psychiatric illness (OR=2.9, 99% CI 1.8 to 4.6). In comparison, children who were ongoing were more likely than temporary frequent attenders to be aged 5-15 years, and were not more likely to be admitted (OR=2.7, 99% CI 0.7 to 10.9). CONCLUSIONS Future intervention studies should distinguish between temporary and ongoing frequent attenders, develop specific interventions for each group and include rigorous evaluation.
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Affiliation(s)
- Luise Lago
- Centre for Health Research Illawarra Shoalhaven Population, Faculty of Business, University of Wollongong, Wollongong, New South Wales, Australia
| | - Victoria Westley-Wise
- Centre for Health Research Illawarra Shoalhaven Population, Faculty of Business, University of Wollongong, Wollongong, New South Wales, Australia
- Planning Performance Management and Information Unit, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Judy Mullan
- Centre for Health Research Illawarra Shoalhaven Population, Faculty of Business, University of Wollongong, Wollongong, New South Wales, Australia
| | - Kelly Lambert
- Centre for Health Research Illawarra Shoalhaven Population, Faculty of Business, University of Wollongong, Wollongong, New South Wales, Australia
| | - Rebekah Zingel
- Planning and Strategic Commissioning, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Thomas Carrigan
- Emergency Medicine, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Wayne Triner
- Emergency Medicine, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Kathy Eagar
- Australian Health Services Research Institute, Faculty of Business, University of Wollongong, Wollongong, New South Wales, Australia
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26
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Chen D, Torstrick AM, Crupi R, Schwartz JE, Frankel I, Brondolo E. Reducing emergency department visits among older adults. JOURNAL OF INTEGRATED CARE 2019. [DOI: 10.1108/jica-02-2018-0011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
There is mixed evidence regarding the efficacy of low-intensity integrated care interventions in reducing the use of emergency services and costs of care. The purpose of this paper is to examine the effects of a low-intensity intervention formulated for older adults and delivered in an urban medical center serving low-income individuals.
Design/methodology/approach
The intervention included an initial evaluation of stress, psychiatric symptomatology and health habits; potential referrals for lifestyle management and psychiatric treatment; and training for physicians about the impact of lifestyle change in older adults. Participants included older adults (at or above 50 years of age) seen as outpatients in an urban medical center serving a low-income community (n=945). Participants were entered into the intervention at any point during this two-year period. Mixed models analyses examined all visits for all enrolled individuals over a two-year period, comparing visits before the individual received the initial intervention evaluation to those received after this evaluation. Outcomes included total health care costs incurred, average cost per visit, and emergency department (ED) usage within the facility.
Findings
The intervention was associated with reduced likelihood of emergency department use and reduced costs per visit following the intervention. These effects were seen across all participants.
Research limitations/implications
Limitations of the study include the lack of control group.
Practical implications
This program is easy to disseminate and could improve the quality of care and costs.
Originality/value
This study is among the few available to document a decrease in medical costs, as well as decreased ED utilization following a low-intensity integrated care intervention.
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Affiliation(s)
- Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Simon P Mooijaart
- Institute for Evidence Based Medicine in Old Age, Leiden University Medical Centre, Leiden, Netherlands
| | - Katie Gallacher
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Jennifer K Burton
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Schain A, Rees C, Medina C, Eyler R, Glenney S, Rodko E, Cassese J, Shellman J, Malcolm M. Reducing Risks for Older Adults With an Interprofessional Community-Academic Partnership: A Case Study. Home Healthc Now 2018; 36:362-368. [PMID: 30383595 DOI: 10.1097/nhh.0000000000000696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
As the older adult population in the United States increases and diversifies, understanding and reducing risks for hospitalization and institutionalization can reduce burdens for this vulnerable population. Using evidence-based assessment tools to understand medical, psychosocial, pharmacologic, and functional status can aid an interprofessional team to best evaluate older adults at risk. By providing culturally competent care for a diversifying older adult demographic, attention to social determinants can improve health equity for this population. This article describes in a case study exemplar, how one such interprofessional collaborative practice program, Geriatric Outreach and Training with Care (GOT Care!) provides a comprehensive assessment for high-risk older adults, identifies and documents these risks, and shares recommendations and rationale with the primary care provider toward risk reduction and improvement of outcomes.
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Affiliation(s)
- Alexandra Schain
- Alexandra Schain, MS, AGNP-BC, APRN, is GOT Care! Project Curriculum Development Coordinator, University of Connecticut School of Nursing, Storrs, Connnecticut. Catherine Rees, MPH, is Director of Community Benefit, Middlesex Hospital, Middletown, Connecticut. Catherine Medina, PhD, LCSW, is an Associate Professor, University of Connecticut School of Social Work, Hartford, Connecticut. Rachel Eyler, PharmD, is an Assistant Clinical Professor, University of Connecticut School of Pharmacy, Storrs, Connecticut. Susan Glenney, DPT, is a Clinical Assistant Professor in Residence, University of Connecticut College of Agriculture, Health and Natural Resources, Storrs, Connecticut. Eric Rodko, LMSW, is Executive Director, St. Luke's Community Services, Middletown, Connecticut. Jason Cassese, MA, MSW, is a GOT Care! Project: Benefits and Case Coordinator, St. Luke's Community Services, Middletown, Connecticut. Juliette Shellman, PhD, RN, APHN-BC, is a GOT Care! Project: Program Evaluator, and Associate Professor, University of Connecticut School of Nursing, Storrs, Connecticut. Millicent Malcolm, DNP, APRN, GNP-BC, FAANP, is a GOT Care! Project: Principle Investigator and Project Director, and Assistant Clinical Professor, University of Connecticut School of Nursing, Storrs, Connecticut
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29
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Palmer K, Onder G. Comprehensive geriatric assessment: Benefits and limitations. Eur J Intern Med 2018; 54:e8-e9. [PMID: 29472049 DOI: 10.1016/j.ejim.2018.02.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 02/15/2018] [Indexed: 11/15/2022]
Affiliation(s)
| | - Graziano Onder
- Fondazione Universitaria Policlinico A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy.
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30
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Walters K, Frost R, Kharicha K, Avgerinou C, Gardner B, Ricciardi F, Hunter R, Liljas A, Manthorpe J, Drennan V, Wood J, Goodman C, Jovicic A, Iliffe S. Home-based health promotion for older people with mild frailty: the HomeHealth intervention development and feasibility RCT. Health Technol Assess 2018; 21:1-128. [PMID: 29214975 DOI: 10.3310/hta21730] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Mild frailty or pre-frailty is common and yet is potentially reversible. Preventing progression to worsening frailty may benefit individuals and lower health/social care costs. However, we know little about effective approaches to preventing frailty progression. OBJECTIVES (1) To develop an evidence- and theory-based home-based health promotion intervention for older people with mild frailty. (2) To assess feasibility, costs and acceptability of (i) the intervention and (ii) a full-scale clinical effectiveness and cost-effectiveness randomised controlled trial (RCT). DESIGN Evidence reviews, qualitative studies, intervention development and a feasibility RCT with process evaluation. INTERVENTION DEVELOPMENT Two systematic reviews (including systematic searches of 14 databases and registries, 1990-2016 and 1980-2014), a state-of-the-art review (from inception to 2015) and policy review identified effective components for our intervention. We collected data on health priorities and potential intervention components from semistructured interviews and focus groups with older people (aged 65-94 years) (n = 44), carers (n = 12) and health/social care professionals (n = 27). These data, and our evidence reviews, fed into development of the 'HomeHealth' intervention in collaboration with older people and multidisciplinary stakeholders. 'HomeHealth' comprised 3-6 sessions with a support worker trained in behaviour change techniques, communication skills, exercise, nutrition and mood. Participants addressed self-directed independence and well-being goals, supported through education, skills training, enabling individuals to overcome barriers, providing feedback, maximising motivation and promoting habit formation. FEASIBILITY RCT Single-blind RCT, individually randomised to 'HomeHealth' or treatment as usual (TAU). SETTING Community settings in London and Hertfordshire, UK. PARTICIPANTS A total of 51 community-dwelling adults aged ≥ 65 years with mild frailty. MAIN OUTCOME MEASURES Feasibility - recruitment, retention, acceptability and intervention costs. Clinical and health economic outcome data at 6 months included functioning, frailty status, well-being, psychological distress, quality of life, capability and NHS and societal service utilisation/costs. RESULTS We successfully recruited to target, with good 6-month retention (94%). Trial procedures were acceptable with minimal missing data. Individual randomisation was feasible. The intervention was acceptable, with good fidelity and modest delivery costs (£307 per patient). A total of 96% of participants identified at least one goal, which were mostly exercise related (73%). We found significantly better functioning (Barthel Index +1.68; p = 0.004), better grip strength (+6.48 kg; p = 0.02), reduced psychological distress (12-item General Health Questionnaire -3.92; p = 0.01) and increased capability-adjusted life-years [+0.017; 95% confidence interval (CI) 0.001 to 0.031] at 6 months in the intervention arm than the TAU arm, with no differences in other outcomes. NHS and carer support costs were variable but, overall, were lower in the intervention arm than the TAU arm. The main limitation was difficulty maintaining outcome assessor blinding. CONCLUSIONS Evidence is lacking to inform frailty prevention service design, with no large-scale trials of multidomain interventions. From stakeholder/public perspectives, new frailty prevention services should be personalised and encompass multiple domains, particularly socialising and mobility, and can be delivered by trained non-specialists. Our multicomponent health promotion intervention was acceptable and delivered at modest cost. Our small study shows promise for improving clinical outcomes, including functioning and independence. A full-scale individually RCT is feasible. FUTURE WORK A large, definitive RCT of the HomeHealth service is warranted. STUDY REGISTRATION This study is registered as PROSPERO CRD42014010370 and Current Controlled Trials ISRCTN11986672. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 73. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kate Walters
- Department of Primary Care and Population Health, University College London, London, UK
| | - Rachael Frost
- Department of Primary Care and Population Health, University College London, London, UK
| | - Kalpa Kharicha
- Department of Primary Care and Population Health, University College London, London, UK
| | - Christina Avgerinou
- Department of Primary Care and Population Health, University College London, London, UK
| | | | - Federico Ricciardi
- Department of Statistical Science, University College London, London, UK
| | - Rachael Hunter
- Department of Primary Care and Population Health, University College London, London, UK
| | - Ann Liljas
- Department of Primary Care and Population Health, University College London, London, UK
| | - Jill Manthorpe
- Social Care Workforce Research Unit, King's College London, London, UK
| | - Vari Drennan
- Centre for Health and Social Care Research, Kingston University and St George's, University of London, London, UK
| | - John Wood
- Department of Primary Care and Population Health, University College London, London, UK
| | - Claire Goodman
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Ana Jovicic
- Department of Primary Care and Population Health, University College London, London, UK
| | - Steve Iliffe
- Department of Primary Care and Population Health, University College London, London, UK
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Vilpert S, Monod S, Jaccard Ruedin H, Maurer J, Trueb L, Yersin B, Büla C. Differences in triage category, priority level and hospitalization rate between young-old and old-old patients visiting the emergency department. BMC Health Serv Res 2018; 18:456. [PMID: 29907110 PMCID: PMC6003168 DOI: 10.1186/s12913-018-3257-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 05/30/2018] [Indexed: 11/18/2022] Open
Abstract
Background Emergency Department (ED) are challenged by the increasing number of visits made by the heterogeneous population of elderly persons. This study aims to 1) compare chief complaints (triage categories) and level of priority; 2) to investigate their association with hospitalization after an ED visit; 3) to explore factors explaining the difference in hospitalization rates among community-dwelling older adults aged 65–84 vs 85+ years. Methods All ED visits of patients age 65 and over that occurred between 2005 and 2010 to the University of Lausanne Medical Center were analyzed. Associations of hospitalization with triage categories and level of priority using regressions were compared between the two age groups. Blinder-Oaxaca decomposition was performed to explore how much age-related differences in prevalence of priority level and triage categories contributed to predicted difference in hospitalization rates across the two age groups. Results Among 39′178 ED visits, 8′812 (22.5%) occurred in 85+ patients. This group had fewer high priority and more low priority conditions than the younger group. Older patients were more frequently triaged in “Trauma” (20.9 vs 15.0%) and “Home care impossible” (10.1% vs 4.2%) categories, and were more frequently hospitalized after their ED visit (69.1% vs 58.5%). Differences in prevalence of triage categories between the two age groups explained a quarter (26%) of the total age-related difference in hospitalization rates, whereas priority level did not play a role. Conclusions Prevalence of priority level and in triage categories differed across the two age groups but only triage categories contributed moderately to explaining the age-related difference in hospitalization rates after the ED visit. Indeed, most of this difference remained unexplained, suggesting that age itself, besides other unmeasured factors, may play a role in explaining the higher hospitalization rate in patients aged 85+ years. Electronic supplementary material The online version of this article (10.1186/s12913-018-3257-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah Vilpert
- FORS Swiss Centre of Expertise in Social Sciences, University of Lausanne, Géopolis, 1015, Lausanne, Switzerland.
| | - Stéfanie Monod
- Public Health Department of the Canton of Vaud, Av. des Casernes 2, Lausanne, 1014, Switzerland
| | - Hélène Jaccard Ruedin
- Réseau Santé Nord Broye, Center for Community Geriatrics, Av. des Sciences 1, 1400, Yverdon-les-Bains, Switzerland
| | - Jürgen Maurer
- Department of Economics, University of Lausanne, Internef, 1015, Lausanne, Switzerland
| | - Lionel Trueb
- Service of Emergency Medicine, University of Lausanne Medical Center (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Bertrand Yersin
- Service of Emergency Medicine, University of Lausanne Medical Center (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Christophe Büla
- Service of Geriatric Medicine and Geriatric Rehabilitation, University of Lausanne Medical Center (CHUV), Mont-Paisible 16, 1011, Lausanne, Switzerland
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Ferrat E, Bastuji-Garin S, Paillaud E, Caillet P, Clerc P, Moscova L, Gouja A, Renard V, Attali C, Breton JL, Audureau E. Efficacy of nurse-led and general practitioner-led comprehensive geriatric assessment in primary care: protocol of a pragmatic three-arm cluster randomised controlled trial (CEpiA study). BMJ Open 2018; 8:e020597. [PMID: 29654038 PMCID: PMC5898323 DOI: 10.1136/bmjopen-2017-020597] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Older patients raise therapeutic challenges, because they constitute a heterogeneous population with multimorbidity. To appraise this complexity, geriatricians have developed a multidimensional comprehensive geriatric assessment (CGA), which may be difficult to apply in primary care settings. Our primary objective was to compare the effect on morbimortality of usual care compared with two complex interventions combining educational seminars about CGA: a dedicated geriatric hotline for general practitioners (GPs) and CGA by trained nurses or GPs. METHODS AND ANALYSIS The Clinical Epidemiology and Ageing study is an open-label, pragmatic, multicentre, three-arm, cluster randomised controlled trial comparing two intervention groups and one control group. Patients must be 70 years or older with a long-term illness or with unscheduled hospitalisation in the past 3 months (750 patients planned). This study involves volunteering GPs practising in French primary care centres, with randomisation at the practice level. The multifaceted interventions for interventional arms comprise an educational interactive multiprofessional seminar for GPs and nurses, a geriatric hotline dedicated to GPs in case of difficulties and the performance of a CGA updated to primary care. The CGA is systematically performed by a nurse in arm 1 but is GP-led on a case-by-case basis in arm 2. The primary endpoint is a composite criterion comprising overall death, unscheduled hospitalisations, emergency admissions and institutionalisation within 12 months after inclusion. Intention-to-treat analysis will be performed using mixed-effects logistic regression models, with adjustment for potential confounders. ETHICS AND DISSEMINATION The protocol was approved by an appropriate ethics committee (CPP Ile-de-France IV, Paris, France, approval April 2015;15 664). This study is conducted according to principles of good clinical practice in the context of current care and will provide useful knowledge on the clinical benefits achievable by CGA in primary care. TRIAL REGISTRATION NUMBER NCT02664454; Pre-results.
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Affiliation(s)
- Emilie Ferrat
- Université Paris-EstCréteil (UPEC), DHU A-TVB, IMRB, EA 7376 CEpiA (Clinical Epidemiology andAgeing Unit), Créteil, France
- Université Paris-Est Créteil (UPEC), School ofMedicine, Primary Care Department, Créteil, France
| | - Sylvie Bastuji-Garin
- Université Paris-EstCréteil (UPEC), DHU A-TVB, IMRB, EA 7376 CEpiA (Clinical Epidemiology andAgeing Unit), Créteil, France
- AP-HP, Hôpital Henri-Mondor, Department of PublicHealth, Créteil, France
- AP-HP, Hôpital Henri-Mondor, Clinical Research Unit(URC Mondor), Créteil, France
| | - Elena Paillaud
- Université Paris-EstCréteil (UPEC), DHU A-TVB, IMRB, EA 7376 CEpiA (Clinical Epidemiology andAgeing Unit), Créteil, France
- AP-HP, HôpitalHenri-Mondor, Geriatric Department, Créteil, France
| | - Philippe Caillet
- Université Paris-EstCréteil (UPEC), DHU A-TVB, IMRB, EA 7376 CEpiA (Clinical Epidemiology andAgeing Unit), Créteil, France
- AP-HP, HôpitalHenri-Mondor, Geriatric Department, Créteil, France
| | - Pascal Clerc
- Université Paris-EstCréteil (UPEC), DHU A-TVB, IMRB, EA 7376 CEpiA (Clinical Epidemiology andAgeing Unit), Créteil, France
- Université de Versailles - saint Quentin en Yvelines, School of Medicine, Primary Care Department, Montigny-le-Bretonneux, France
| | - Laura Moscova
- Université Paris-Est Créteil (UPEC), School ofMedicine, Primary Care Department, Créteil, France
| | - Amel Gouja
- AP-HP, Hôpital Henri-Mondor, Clinical Research Unit(URC Mondor), Créteil, France
| | - Vincent Renard
- Université Paris-EstCréteil (UPEC), DHU A-TVB, IMRB, EA 7376 CEpiA (Clinical Epidemiology andAgeing Unit), Créteil, France
- Université Paris-Est Créteil (UPEC), School ofMedicine, Primary Care Department, Créteil, France
| | - Claude Attali
- Université Paris-EstCréteil (UPEC), DHU A-TVB, IMRB, EA 7376 CEpiA (Clinical Epidemiology andAgeing Unit), Créteil, France
- Université Paris-Est Créteil (UPEC), School ofMedicine, Primary Care Department, Créteil, France
| | - Julien Le Breton
- Université Paris-EstCréteil (UPEC), DHU A-TVB, IMRB, EA 7376 CEpiA (Clinical Epidemiology andAgeing Unit), Créteil, France
- Université Paris-Est Créteil (UPEC), School ofMedicine, Primary Care Department, Créteil, France
| | - Etienne Audureau
- Université Paris-EstCréteil (UPEC), DHU A-TVB, IMRB, EA 7376 CEpiA (Clinical Epidemiology andAgeing Unit), Créteil, France
- AP-HP, Hôpital Henri-Mondor, Department of PublicHealth, Créteil, France
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Frailty assessment in primary health care and its association with unplanned secondary care use: a rapid review. BJGP Open 2018; 2:bjgpopen18X101325. [PMID: 30564700 PMCID: PMC6181074 DOI: 10.3399/bjgpopen18x101325] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 08/14/2017] [Indexed: 11/24/2022] Open
Abstract
Background The growing frail, older population is increasing pressure on hospital services. This is directing the attention of clinical commissioning groups towards more comprehensive approaches to managing frailty in the primary healthcare environment. Aim To review the literature on whether assessment of frailty in primary health care leads to a reduction in unplanned secondary care use. Design & setting A rapid review involving a systematic search of Medline and Medline In-Process. Method Relevant data were extracted following the iterative screening of titles, abstracts, and full texts to identify studies in the primary or community healthcare setting which assessed the effect of frailty on unplanned secondary care use between January 2005–June 2016. Results The review included 11 primary studies: nine observational studies; one randomised controlled trial (RCT); and one non-randomised controlled trial (nRCT). Eight out of nine observational studies reported a positive association between frailty and secondary care utilisation. The RCT and nRCT reported conflicting findings. Conclusion Older people identified as frail in a primary healthcare setting were more likely to be admitted to hospital. Based on the limited and equivocal trial evidence, it is not possible to draw firm conclusions regarding appropriate tools for the identification and management of frail older people at risk of hospital admission.
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Marsden E, Craswell A, Taylor A, Coates K, Crilly J, Broadbent M, Glenwright A, Johnston C, Wallis M. Nurse-led multidisciplinary initiatives to improve outcomes and reduce hospital admissions for older adults: The Care coordination through Emergency Department, Residential Aged Care and Primary Health Collaboration project. Australas J Ageing 2018; 37:135-139. [PMID: 29614207 DOI: 10.1111/ajag.12526] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This article describes the Care coordination through Emergency Department, Residential Aged Care and Primary Health Collaboration (CEDRiC) project. METHODS CEDRiC is designed to improve the health outcomes for older people with an acute illness. It attempts this via enhanced primary care in residential aged care facilities, focused and streamlined care in the emergency department and enhanced intersectoral communication and referral. RESULTS Implementing this approach has the potential to decrease inappropriate hospital admissions while improving care for older people in residential aged care and community settings. CONCLUSION This article discusses an innovative way of caring for older adults in an ageing population utilising the existing evidence. A formal evaluation is currently underway.
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Affiliation(s)
- Elizabeth Marsden
- Sunshine Coast Hospital and Health Service, Sunshine Coast, Queensland, Australia
| | - Alison Craswell
- University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| | - Andrea Taylor
- Sunshine Coast Hospital and Health Service, Sunshine Coast, Queensland, Australia
| | - Kaye Coates
- Sundale Ltd., Sunshine Coast, Queensland, Australia
| | - Julia Crilly
- School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.,Gold Coast Health, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Marc Broadbent
- University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| | - Amanda Glenwright
- Central Queensland, Wide Bay and Sunshine Coast PHN, Sunshine Coast, Queensland, Australia
| | - Colleen Johnston
- University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| | - Marianne Wallis
- University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
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Hwang U, Dresden SM, Rosenberg MS, Garrido MM, Loo G, Sze J, Gravenor S, Courtney DM, Kang R, Zhu C, Vargas-Torres C, Grudzen CR, Richardson LD. Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use. J Am Geriatr Soc 2018; 66:459-466. [PMID: 29318583 PMCID: PMC6764445 DOI: 10.1111/jgs.15235] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To examine the effect of an emergency department (ED)-based transitional care nurse (TCN) on hospital use. DESIGN Prospective observational cohort. SETTING Three U.S. (NY, IL, NJ) EDs from January 1, 2013, to June 30, 2015. PARTICIPANTS Individuals aged 65 and older in the ED (N = 57,287). INTERVENTION The intervention was first TCN contact. Controls never saw a TCN during the study period. MEASUREMENTS We examined sociodemographic and clinical characteristics associated with TCN use and outcomes. The primary outcome was inpatient admission during the index ED visit (admission on Day 0). Secondary outcomes included cumulative 30-day admission (any admission on Days 0-30) and 72-hour ED revisits. RESULTS A TCN saw 5,930 (10%) individuals, 42% of whom were admitted. After accounting for observed selection bias using entropy balance, results showed that when compared to controls, TCN contact was associated with lower risk of admission (site 1: -9.9% risk of inpatient admission, 95% confidence interval (CI) = -12.3% to -7.5%; site 2: -16.5%, 95% CI = -18.7% to -14.2%; site 3: -4.7%, 95% CI = -7.5% to -2.0%). Participants with TCN contact had greater risk of a 72-hour ED revisit at two sites (site 1: 1.5%, 95% CI = 0.7-2.3%; site 2: 1.4%, 95% CI = 0.7-2.1%). Risk of any admission within 30 days of the index ED visit also remained lower for TCN patients at both these sites (site 1: -7.8%, 95% CI = -10.3% to -5.3%; site 2: -13.8%, 95% CI = -16.1% to -11.6%). CONCLUSION Targeted evaluation by geriatric ED transitions of care staff may be an effective delivery innovation to reduce risk of inpatient admission.
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Affiliation(s)
- Ula Hwang
- Department of Emergency Medicine, Icahn School of Medicine
at Mount Sinai, New York, NY
- Brookdale Department of Geriatrics and Palliative Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY
- Geriatrics Research, Education and Clinical Center, James
J. Peters VA Medical Center, Bronx, NY
| | - Scott M. Dresden
- Department of Emergency Medicine, Northwestern University
Feinberg School of Medicine, Chicago, IL
| | - Mark S. Rosenberg
- Department of Emergency Medicine, St. Josephs Healthcare
System / New York Medical College, Paterson, NJ
| | - Melissa M. Garrido
- Brookdale Department of Geriatrics and Palliative Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY
- Geriatrics Research, Education and Clinical Center, James
J. Peters VA Medical Center, Bronx, NY
| | - George Loo
- Department of Emergency Medicine, Icahn School of Medicine
at Mount Sinai, New York, NY
| | - Jeremy Sze
- Department of Emergency Medicine, Icahn School of Medicine
at Mount Sinai, New York, NY
| | - Stephanie Gravenor
- Department of Emergency Medicine, Northwestern University
Feinberg School of Medicine, Chicago, IL
| | - D. Mark Courtney
- Department of Emergency Medicine, Northwestern University
Feinberg School of Medicine, Chicago, IL
| | - Raymond Kang
- Center for Healthcare Studies, Northwestern University,
Chicago, IL
| | - Carolyn Zhu
- Brookdale Department of Geriatrics and Palliative Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY
- Geriatrics Research, Education and Clinical Center, James
J. Peters VA Medical Center, Bronx, NY
| | - Carmen Vargas-Torres
- Department of Emergency Medicine, Icahn School of Medicine
at Mount Sinai, New York, NY
| | - Corita R. Grudzen
- Department of Emergency Medicine, New York University
School of Medicine, New York, NY
| | - Lynne D. Richardson
- Department of Emergency Medicine, Icahn School of Medicine
at Mount Sinai, New York, NY
- Department of Population Health Science and Policy, Icahn
School of Medicine at Mount Sinai
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Malik M, Moore Z, Patton D, O'Connor T, Nugent LE. The impact of geriatric focused nurse assessment and intervention in the emergency department: A systematic review. Int Emerg Nurs 2018; 37:52-60. [PMID: 29429847 DOI: 10.1016/j.ienj.2018.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 12/04/2017] [Accepted: 01/31/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND Nursing assessment of elderly patients is imperative in Emergency Departments (ED) while providing interventions that increase independence facilitating discharge to primary healthcare. AIMS To systematically review the impact of geriatric focused nurse assessment and intervention in the ED on hospital utilisation in terms of admission rate, ED revisits and length of hospital stay (LOHS). METHODS Search strategy used following databases; Cochrane, Medline, CINAHL, Embase, Scopus and Web of Knowledge; And terms; geriatric nurse assessment, nurse discharge planning, geriatric nurse specialist, nurse intervention, emergency department, accident and emergency, patient outcomes, discharge, admissions, readmissions, hospital utilization, hospitalization, length of stay/hospital stay. RESULTS Nine studies were included: seven RCTs and two prospective pre/post-intervention designed studies. Geriatric focused nursing assessment and interventions did not have a statistical impact on hospitalization, readmissions, LOHS and ED revisits. Risk screening and comprehensive geriatric assessment extending into primary care may reduce readmission rates but not affect hospitalization. An increase in ED visits in the intervention group at 30 days post-intervention was noted. CONCLUSION Inconsistencies in assessment and interventions for the older person in ED are apparent. Further research evaluating a standardised risk assessment tool and innovative interventions extending into primary healthcare is required.
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Affiliation(s)
- M Malik
- Emergency Department, St. James's Hospital, James's Street, Dublin 8, Ireland.
| | - Z Moore
- School of Nursing and Midwifery, Royal College of Surgeons in Ireland, 123 St. Stephens Green, Dublin 2, Ireland; University of Ghent, Belgium.
| | - D Patton
- School of Nursing and Midwifery, Royal College of Surgeons in Ireland, 123 St. Stephens Green, Dublin 2, Ireland.
| | - T O'Connor
- School of Nursing and Midwifery, Royal College of Surgeons in Ireland, 123 St. Stephens Green, Dublin 2, Ireland.
| | - L E Nugent
- School of Nursing and Midwifery, Royal College of Surgeons in Ireland, 123 St. Stephens Green, Dublin 2, Ireland.
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Gasperini B, Cherubini A, Pierri F, Barbadoro P, Fedecostante M, Prospero E. Potentially preventable visits to the emergency department in older adults: Results from a national survey in Italy. PLoS One 2017; 12:e0189925. [PMID: 29267333 PMCID: PMC5739429 DOI: 10.1371/journal.pone.0189925] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 12/05/2017] [Indexed: 11/24/2022] Open
Abstract
Background Despite older adults use emergency department more appropriately than other age groups, there is a significant share of admissions that can be considered potentially preventable. Objective To identify socio-demographic characteristics and health care resources use of older adults admitted to emergency department for a potentially preventable visit. Design Data come from the Multipurpose Survey “Health conditions and use of health services”, edition 2012–2013. A stratified multi-stage probability design was used to select a sample using municipal lists of households. Subject 50474 community dwelling Italians were interviewed. In this analysis, 27003 subjects aged 65 years or older were considered. Methods Potentially preventable visits were defined as an emergency department visit that did not result in inpatient admission. Independent variables were classified based on the socio-behavioral model of Andersen-Newman. Descriptive statistics and a logistic regression model were developed. Results In the twelve months before the interview 3872 subjects (14.3%) had at least one potentially preventable visit. Factors associated with an increased risk of a potentially preventable visit were older age (75–84 years: OR 1.096, CI 1.001–1.199; 85+years: OR 1.022, CI 1.071–1.391), at least one hospital admission (OR 3.869, IC 3.547–4.221), to waive a visit (OR 1.188, CI 1.017–1.389) or an exam (OR 1.300, CI 1.077–1.570). Factors associated with a lower risk were female gender (OR 0.893, CI 0.819–0.975), area of residence (Center: OR 0.850; CI 0.766–0.943; Islands: OR 0.617, CI 0.539–0.706, South: OR 0.560; CI 0.505–0.622), private paid assistance (OR 0.761, CI 0.602–0.962); a better health-related quality of life (PCS score 46–54: OR 0.744, CI 0.659–0.841; PCS score >55: OR 0.746, CI 0.644–0.865). Conclusions Our study identified several characteristics associated with an increased risk of potentially preventable visits to the emergency department. This might allow the development of specific interventions to prevent the access of at risk subjects to the emergency department.
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Affiliation(s)
- Beatrice Gasperini
- Department of Biomedical Sciences and Public Health, Section of Hygiene, Preventive Medicine and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Department of Geriatrics and Rehabilitation, Santa Croce Hospital, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Fano, Italy
- * E-mail:
| | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e Centro di ricerca per l’invecchiamento, IRCCS-INRCA, Ancona, Italy
| | - Francesca Pierri
- Department of Economy, Section of Statistics, University of Perugia, Perugia, Italy
| | - Pamela Barbadoro
- Department of Biomedical Sciences and Public Health, Section of Hygiene, Preventive Medicine and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Massimiliano Fedecostante
- Geriatria, Accettazione geriatrica e Centro di ricerca per l’invecchiamento, IRCCS-INRCA, Ancona, Italy
| | - Emilia Prospero
- Department of Biomedical Sciences and Public Health, Section of Hygiene, Preventive Medicine and Public Health, Università Politecnica delle Marche, Ancona, Italy
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Quantifying patient flow and utilization with patient flow pathway and diagnosis of an emergency department in Singapore. Health Syst (Basingstoke) 2017. [DOI: 10.1057/hs.2015.15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Saxon RL, Gray MA, Oprescu FI. Reducing geriatric outpatient waiting times: Impact of an advanced health practitioner. Australas J Ageing 2017; 37:48-53. [DOI: 10.1111/ajag.12459] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Robyn L Saxon
- Queensland Health; Brisbane Queensland Australia
- University of the Sunshine Coast; Sunshine Coast Queensland Australia
- Cluster for Health Improvement; University of the Sunshine Coast; Sunshine Coast Queensland Australia
| | - Marion A Gray
- University of the Sunshine Coast; Sunshine Coast Queensland Australia
- Cluster for Health Improvement; University of the Sunshine Coast; Sunshine Coast Queensland Australia
| | - Florin I Oprescu
- University of the Sunshine Coast; Sunshine Coast Queensland Australia
- Cluster for Health Improvement; University of the Sunshine Coast; Sunshine Coast Queensland Australia
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Ibrahim K, Owen C, Patel HP, May C, Baxter M, Sayer AA, Roberts HC. Can routine clinical data identify older patients at risk of poor healthcare outcomes on admission to hospital? BMC Res Notes 2017; 10:384. [PMID: 28797300 PMCID: PMC5553791 DOI: 10.1186/s13104-017-2705-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/29/2017] [Indexed: 11/11/2022] Open
Abstract
Objective Older patients who are at risk of poor healthcare outcomes should be recognised early during hospital admission to allow appropriate interventions. It is unclear whether routinely collected data can identify high-risk patients. The aim of this study was to define current practice with regard to the identification of older patients at high risk of poor healthcare outcomes on admission to hospital. Results Interviews/focus groups were conducted to establish the views of 22 healthcare staff across five acute medicine for older people wards in one hospital including seven nurses, four dieticians, seven doctors, and four therapists. In addition, a random sample of 60 patients’ clinical records were reviewed to characterise the older patients, identify risk assessments performed routinely on admission, and describe usual care. We found that staff relied on their clinical judgment to identify high risk patients which was influenced by a number of factors such as reasons for admission, staff familiarity with patients, patients’ general condition, visible frailty, and patients’ ability to manage at home. “Therapy assessment” and patients’ engagement with therapy were also reported to be important in recognising high-risk patients. However, staff recognised that making clinical judgments was often difficult and that it might occur several days after admission potentially delaying specific interventions. Routine risk assessments carried out on admission to identify single healthcare needs included risk of malnutrition (completed for 85% patients), falls risk (95%), moving and handling assessments (85%), and pressure ulcer risk assessments (88%). These were not used collectively to highlight patients at risk of poor healthcare outcomes. Thus, patients at risk of poor healthcare outcomes were not explicitly identified on admission using routinely collected data. There is a need for an early identification of these patients using a valid measure alongside staff clinical judgment to allow timely interventions to improve healthcare outcomes. Electronic supplementary material The online version of this article (doi:10.1186/s13104-017-2705-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kinda Ibrahim
- Academic Geriatric Medicine, University of Southampton, Southampton General Hospital, Tremona Road, Mailpoint 807, Southampton, SO16 6YD, UK. .,NIHR CLAHRC Wessex, Faculty of Health Science, University of Southampton, Highfield, Southampton, SO17 1BJ, UK.
| | - Charlotte Owen
- Academic Geriatric Medicine, University of Southampton, Southampton General Hospital, Tremona Road, Mailpoint 807, Southampton, SO16 6YD, UK.,University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK
| | - Harnish P Patel
- Academic Geriatric Medicine, University of Southampton, Southampton General Hospital, Tremona Road, Mailpoint 807, Southampton, SO16 6YD, UK.,University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK
| | - Carl May
- NIHR CLAHRC Wessex, Faculty of Health Science, University of Southampton, Highfield, Southampton, SO17 1BJ, UK
| | - Mark Baxter
- University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK
| | - Avan A Sayer
- Academic Geriatric Medicine, University of Southampton, Southampton General Hospital, Tremona Road, Mailpoint 807, Southampton, SO16 6YD, UK.,NIHR CLAHRC Wessex, Faculty of Health Science, University of Southampton, Highfield, Southampton, SO17 1BJ, UK.,Ageing Geriatrics & Epidemiology, Institute of Neuroscience, The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK.,NIHR Newcastle Biomedical Research Centre in Ageing and Chronic Disease, The Medical School, Newcastle University, Newcastle upon Tyne NHS Foundation Trust, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - Helen C Roberts
- Academic Geriatric Medicine, University of Southampton, Southampton General Hospital, Tremona Road, Mailpoint 807, Southampton, SO16 6YD, UK.,NIHR CLAHRC Wessex, Faculty of Health Science, University of Southampton, Highfield, Southampton, SO17 1BJ, UK.,University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK
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Credé SH, O'Keeffe C, Mason S, Sutton A, Howe E, Croft SJ, Whiteside M. What is the evidence for the management of patients along the pathway from the emergency department to acute admission to reduce unplanned attendance and admission? An evidence synthesis. BMC Health Serv Res 2017; 17:355. [PMID: 28511702 PMCID: PMC5433069 DOI: 10.1186/s12913-017-2299-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 05/08/2017] [Indexed: 11/17/2022] Open
Abstract
Background Globally, the rate of emergency hospital admissions is increasing. However, little evidence exists to inform the development of interventions to reduce unplanned Emergency Department (ED) attendances and hospital admissions. The objective of this evidence synthesis was to review the evidence for interventions, conducted during the patient’s journey through the ED or acute care setting, to manage people with an exacerbation of a medical condition to reduce unplanned emergency hospital attendance and admissions. Methods A rapid evidence synthesis, using a systematic literature search, was undertaken in the electronic data bases of MEDLINE, EMBASE, CINAHL, the Cochrane Library and Web of Science, for the years 2000–2014. Evidence included in this review was restricted to Randomised Controlled Trials (RCTs) and observational studies (with a control arm) reported in peer-reviewed journals. Studies evaluating interventions for patients with an acute exacerbation of a medical condition in the ED or acute care setting which reported at least one outcome related to ED attendance or unplanned admission were included. Results Thirty papers met our inclusion criteria: 19 intervention studies (14 RCTs) and 11 controlled observational studies. Sixteen studies were set in the ED and 14 were conducted in an acute setting. Two studies (one RCT), set in the ED were effective in reducing ED attendance and hospital admission. Both of these interventions were initiated in the ED and included a post-discharge community component. Paradoxically 3 ED initiated interventions showed an increase in ED re-attendance. Six studies (1 RCT) set in acute care settings were effective in reducing: hospital admission, ED re-attendance or re-admission (two in an observation ward, one in an ED assessment unit and three in which the intervention was conducted within 72 h of admission). Conclusions There is no clear evidence that specific interventions along the patient journey from ED arrival to 72 h after admission benefit ED re-attendance or readmission. Interventions targeted at high-risk patients, particularly the elderly, may reduce ED utilization and warrant future research. Some interventions showing effectiveness in reducing unplanned ED attendances and admissions are delivered by appropriately trained personnel in an environment that allows sufficient time to assess and manage patients.
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Affiliation(s)
- Sarah H Credé
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, England. .,School of Health and Related Research (ScHARR), The University of Sheffield, Regent Court, Regent Street, Sheffield, S1 4DA, UK.
| | - Colin O'Keeffe
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, England
| | - Suzanne Mason
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, England
| | - Anthea Sutton
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, England
| | - Emma Howe
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, England
| | - Susan J Croft
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England
| | - Mike Whiteside
- Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Doncaster, England
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McCusker J, Vadeboncoeur A, Cossette S, Veillette N, Ducharme F, Minh Vu TT, Ciampi A, Cetin‐Sahin D, Belzile E. Changes in Emergency Department Geriatric Services in Quebec and Correlates of These Changes. J Am Geriatr Soc 2017; 65:1448-1454. [DOI: 10.1111/jgs.14818] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 11/21/2016] [Accepted: 12/06/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Jane McCusker
- St. Mary's Research Centre Montreal Canada
- McGill University Montreal Canada
| | - Alain Vadeboncoeur
- Université de Montréal Montreal Canada
- Emergency Medicine Services Montreal Heart Institute Montreal Canada
| | - Sylvie Cossette
- Université de Montréal Montreal Canada
- Montreal Heart Institute Research Center Montreal Canada
| | - Nathalie Veillette
- Université de Montréal Montreal Canada
- Centre de recherche de l'Institut universitaire de gériatrie de Montréal Montreal Canada
| | - Francine Ducharme
- Université de Montréal Montreal Canada
- Centre de recherche de l'Institut universitaire de gériatrie de Montréal Montreal Canada
| | - Thien Tuong Minh Vu
- Université de Montréal Montreal Canada
- Centre de recherche de l'Institut universitaire de gériatrie de Montréal Montreal Canada
- Centre hospitalier de l'Université de Montréal Montreal Canada
| | - Antonio Ciampi
- St. Mary's Research Centre Montreal Canada
- McGill University Montreal Canada
| | - Deniz Cetin‐Sahin
- St. Mary's Research Centre Montreal Canada
- Center for Research in Aging Donald Berman Maimonides Geriatric Centre Montreal Canada
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Galvin R, Gilleit Y, Wallace E, Cousins G, Bolmer M, Rainer T, Smith SM, Fahey T. Adverse outcomes in older adults attending emergency departments: a systematic review and meta-analysis of the Identification of Seniors At Risk (ISAR) screening tool. Age Ageing 2017; 46:179-186. [PMID: 27989992 DOI: 10.1093/ageing/afw233] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Indexed: 11/12/2022] Open
Abstract
Background older adults are frequent users of emergency services and demonstrate high rates of adverse outcomes following emergency care. Objective to perform a systematic review and meta-analysis of the Identification of Seniors At Risk (ISAR) screening tool, to determine its predictive value in identifying adults ≥65 years at risk of functional decline, unplanned emergency department (ED) readmission, emergency hospitalisation or death within 180 days after index ED visit/hospitalisation. Methods a systematic literature search was conducted in PubMed, EMBASE, CINAHL, EBSCO and the Cochrane Library to identify validation and impact analysis studies of the ISAR tool. A pre-specified ISAR score of ≥2 (maximum score 6 points) was used to identify patients at high risk of adverse outcomes. A bivariate random effects model generated pooled estimates of sensitivity and specificity. Statistical heterogeneity was explored and methodological quality was assessed using validated criteria. Results thirty-two validation studies (n = 12,939) are included. At ≥2, the pooled sensitivity of the ISAR for predicting ED return, emergency hospitalisation and mortality at 6 months is 0.80 (95% confidence interval (CI) 0.70-0.87), 0.82 (95% CI 0.74-0.88) and 0.87 (95% CI 0.75-0.94), respectively, with a pooled specificity of 0.31 (95% CI 0.24-0.38), 0.32 (95% CI 0.24-0.41) and 0.35 (95% CI 0.26-0.44). Similar values are demonstrated at 30 and 90 days. Three heterogeneous impact analysis studies examined the clinical implementation of the ISAR and reported mixed findings across patient and process outcomes. Conclusion the ISAR has modest predictive accuracy and may serve as a decision-making adjunct when determining which older adults can be safely discharged.
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Affiliation(s)
- Rose Galvin
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
- Discipline of Physiotherapy, Department of Clinical Therapies, Faculty of Education and Health Sciences, Health Research Institute, University of Limerick, Limerick, Republic of Ireland
| | - Yannick Gilleit
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
- Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Emma Wallace
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - Gráinne Cousins
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - Manon Bolmer
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
- Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Timothy Rainer
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, Hong Kong
- Institute of Molecular and Experimental Medicine, Cardiff University, Cardiff, UK
| | - Susan M Smith
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
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Orrell M, Hoe J, Charlesworth G, Russell I, Challis D, Moniz-Cook E, Knapp M, Woods B, Hoare Z, Aguirre E, Toot S, Streater A, Crellin N, Whitaker C, d’Amico F, Rehill A. Support at Home: Interventions to Enhance Life in Dementia (SHIELD) – evidence, development and evaluation of complex interventions. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BackgroundDementia is a national priority and this research addresses the Prime Minister’s commitment to dementia research as demonstrated by his 2020 challenge and the new UK Dementia Research Institute. In the UK > 800,000 older people have dementia. It has a major impact on the lives of people with dementia themselves, on the lives of their family carers and on services, and costs the nation £26B per year. Pharmacological cures for dementias such as Alzheimer’s disease are not expected before 2025. If no cure can be found, the ageing demographic will result in 2 million people living with dementia by 2050. People with dementia lose much more than just their memory and their daily living skills; they can also lose their independence, their dignity and status, their confidence and morale, and their roles both within the family and beyond. They can be seen as a burden by society, by their families and even by themselves, and may feel unable to contribute to society. This programme of research aims to find useful interventions to improve the quality of life of people with dementia and their carers, and to better understand how people with dementia can be supported at home and avoid being admitted to hospital.Objectives(1) To develop and evaluate the maintenance cognitive stimulation therapy (MCST) for people with dementia; (2) to develop the Carer Supporter Programme (CSP), and to evaluate the CSP and Remembering Yesterday, Caring Today (RYCT) for people with dementia both separately and together in comparison with usual care; and (3) to develop a home treatment package (HTP) for dementia, to field test the HTP in practice and to conduct an exploratory trial.Methods(1) The MCST programme was developed for people with dementia based on evidence and qualitative work. A randomised controlled trial (RCT) [with a pilot study of MCST plus acetylcholinesterase inhibitors (AChEIs)] compared MCST with cognitive stimulation therapy (CST) only. The MCST implementation study conducted a trial of outreach compared with usual care, and assessed implementation in practice. (2) The CSP was developed based on existing evidence and the engagement of carers of people with dementia. The RCT (with internal pilot) compared the CSP and reminiscence (RYCT), both separately and in combination, with usual care. (3) A HTP for dementia, including the most promising interventions and components, was developed by systematically reviewing the literature and qualitative studies including consensus approaches. The HTP for dementia was evaluated in practice by conducting in-depth field testing.Results(1) Continuing MCST improved quality of life and improved cognition for those taking AChEIs. It was also cost-effective. The CST implementation studies indicated that many staff will run CST groups following a 1-day training course, but that outreach support helps staff go on to run maintenance groups and may also improve staff sense of competence in dementia care. The study of CST in practice found no change in cognition or quality of life at 8-month follow-up. (2) The CSP/RYCT study found no benefits for family carers but improved quality of life for people with dementia. RYCT appeared beneficial for the quality of life of people with dementia but at an excessively high cost. (3) Case management for people with dementia reduces admissions to long-term care and reduces behavioural problems. In terms of managing crises, staff suggested more costly interventions, carers liked education and support, and people with dementia wanted family support, home adaptations and technology. The easy-to-use home treatment manual was feasible in practice to help staff working in crisis teams to prevent hospital admissions for people with dementia.LimitationsGiven constraints on time and funding, we were unable to compete the exploratory trial of the HTP package or to conduct an economic evaluation.Future researchTo improve the care of people with dementia experiencing crises, a large-scale clinical trial of the home treatment manual is needed.ConclusionThere is an urgent need for effective psychosocial interventions for dementia. MCST improved quality of life and was cost-effective, with benefits to cognition for those on AChEIs. MCST was feasible in practice. Both CSP and RYCT improved the quality of life of people with dementia, but the overall costs may be too high. The HTP was useful in practice but requires evaluation in a full trial. Dementia care research may improve the lives of millions of people across the world.Trial registrationsCurrent Controlled Trials ISRCTN26286067 (MCST), ISRCTN28793457 (MCST implementation) and ISRCTN37956201 (CSP/RYCT).FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin Orrell
- Department of Mental Health Sciences, University College London, London, UK
| | - Juanita Hoe
- Department of Mental Health Sciences, University College London, London, UK
| | | | - Ian Russell
- Clinical Trials Unit, Swansea University, Swansea, UK
| | - David Challis
- Personal Social Services Research Unit, University of Manchester, Manchester, UK
| | - Esme Moniz-Cook
- Centre of Dementia Research and Practice, University of Hull, Hull, UK
| | - Martin Knapp
- Health and Social Care Department, London School of Economics and Political Science, London, UK
| | - Bob Woods
- North Wales Organisation for Randomised Trials in Health (NWORTH) Clinical Trials Unit, Bangor University, Bangor, UK
| | - Zoe Hoare
- North Wales Organisation for Randomised Trials in Health (NWORTH) Clinical Trials Unit, Bangor University, Bangor, UK
| | - Elisa Aguirre
- Department of Mental Health Sciences, University College London, London, UK
| | - Sandeep Toot
- Research and Development Department, North East London NHS Foundation Trust, London, UK
| | - Amy Streater
- Research and Development Department, North East London NHS Foundation Trust, London, UK
| | - Nadia Crellin
- Research and Development Department, North East London NHS Foundation Trust, London, UK
| | - Chris Whitaker
- North Wales Organisation for Randomised Trials in Health (NWORTH) Clinical Trials Unit, Bangor University, Bangor, UK
| | - Francesco d’Amico
- Health and Social Care Department, London School of Economics and Political Science, London, UK
| | - Amritpal Rehill
- Health and Social Care Department, London School of Economics and Political Science, London, UK
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Barnard A, Hou XY, Lukin B. Director of nursing experiences of a hospital in the nursing home program in South East Queensland. Collegian 2016. [DOI: 10.1016/j.colegn.2016.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Craswell A, Marsden E, Taylor A, Wallis M. Emergency Department presentation of frail older people and interventions for management: Geriatric Emergency Department Intervention. ACTA ACUST UNITED AC 2016. [DOI: 10.1186/s40886-016-0049-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Brennan-Cook J, Molloy MA. Utilizing Trigger Films to Enhance Communication Skills of Home Care Clinicians. Home Healthc Now 2016; 34:376-380. [PMID: 27348031 DOI: 10.1097/nhh.0000000000000409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The purpose of this article is to describe an innovative method to help home care clinicians better communicate with older adults experiencing normal physiologic changes that impact their ability to communicate effectively. Developmental changes such as hearing, speech, vision, and cognition profoundly impede an older adult's ability to communicate with others, potentially undermining the quality of care delivered. The use of trigger films as an educational intervention can assist home care clinicians to improve communication with their patients. Trigger films are 2- to 4-minute video clips that end abruptly, encouraging learners to analyze clinical situations in a safe environment, such as a staff conference room. Trigger films are easy to make with the use of a smart phone and two staff members portraying the role of home care clinician and patient. Allowing discussion after viewing the trigger film places clinicians in an active learning role, thus fostering the sharing of ideas and best practice. Addressing age-related barriers to communication with this modality serves to improve patient interaction and healthcare outcomes. The use of trigger films is another tool that empowers the clinician to provide improved care for patients with communication deficits.
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Affiliation(s)
- Jill Brennan-Cook
- Jill Brennan-Cook, DNP, RN, CNE, is an Assistant Professor of Nursing, School of Nursing, Duke University, Durham, North Carolina. Margory A. Molloy, DNP, RN, CNE, CHSE, is the Director, Center for Nursing Discovery, School of Nursing, Duke University, Durham, North Carolina
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Schraeder C, Fraser CW, Clark I, Long B, Shelton P, Waldschmidt V, Kucera CL, Lanker WK. Evaluation of a primary care nurse case management intervention for chronically ill community dwelling older people. J Clin Nurs 2016; 17:407-17. [PMID: 26327423 DOI: 10.1111/j.1365-2702.2008.02578.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM The purpose of this study was to test the effectiveness of a collaborative primary care nurse case management intervention emphasising collaboration between physicians, nurses and patients, risk identification, comprehensive assessment, collaborative planning, health monitoring, patient education and transitional care on healthcare utilisation and cost for community dwelling chronically ill older persons. BACKGROUND Primary care teams comprised of nurses and primary care physicians have been suggested as a model for providing quality care to the chronically ill, but this type of intervention has not been systematically evaluated. DESIGN A non-randomised, 36 month comparison of two geographically distinct primary care populations was conducted. METHODS Six hundred and seventy-seven persons aged 65 and older were determined to be at high-risk for mortality, functional decline, or increased health service use. The treatment group (n = 400) received the intervention and the comparison group (n = 277) received usual care. Health plan claims files provided data on number of hospitalisations and bed days, emergency department (ED) visits, physician visits and total cost of care. RESULTS After adjustment for baseline variables, there were no significant differences between the treatment and comparison group in the percentage of patients hospitalised or ED visits. However, among those hospitalised in the treatment group, the likelihood of being re-hospitalised was significantly reduced by 34% (p = 0·032). After adjusting for the cost of the intervention, although not statistically significant, the reduced hospital use resulted in cost savings of $106 per patient per month in the treatment group. CONCLUSIONS The results indicate that a collaborative primary care nurse case management intervention has the potential to be an effective alternative to current primary care delivery system practice. RELEVANCE TO CLINICAL PRACTICE The study suggests that a chronic care intervention emphasising collaboration between physicians, nurses and patients, may be more effective when implemented in integrated provider networks.
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Affiliation(s)
- Cheryl Schraeder
- Director of Policy & Practice Initiatives, Institute for Healthcare Innovation, UIC College of Nursing, Urbana, IL, USADirector of Operations, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAClinical Nurse Partner Specialist, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USANurse Partner, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAOutcomes Analyst, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAOutcomes Analyst, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USASystems Developer, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USACarle Clinic Association, Monticello Family Medicine, Monticello, IL, USA
| | - Cynthia W Fraser
- Director of Policy & Practice Initiatives, Institute for Healthcare Innovation, UIC College of Nursing, Urbana, IL, USADirector of Operations, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAClinical Nurse Partner Specialist, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USANurse Partner, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAOutcomes Analyst, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAOutcomes Analyst, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USASystems Developer, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USACarle Clinic Association, Monticello Family Medicine, Monticello, IL, USA
| | - Ida Clark
- Director of Policy & Practice Initiatives, Institute for Healthcare Innovation, UIC College of Nursing, Urbana, IL, USADirector of Operations, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAClinical Nurse Partner Specialist, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USANurse Partner, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAOutcomes Analyst, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAOutcomes Analyst, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USASystems Developer, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USACarle Clinic Association, Monticello Family Medicine, Monticello, IL, USA
| | - Barbara Long
- Director of Policy & Practice Initiatives, Institute for Healthcare Innovation, UIC College of Nursing, Urbana, IL, USADirector of Operations, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAClinical Nurse Partner Specialist, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USANurse Partner, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAOutcomes Analyst, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAOutcomes Analyst, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USASystems Developer, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USACarle Clinic Association, Monticello Family Medicine, Monticello, IL, USA
| | - Paul Shelton
- Director of Policy & Practice Initiatives, Institute for Healthcare Innovation, UIC College of Nursing, Urbana, IL, USADirector of Operations, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAClinical Nurse Partner Specialist, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USANurse Partner, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAOutcomes Analyst, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAOutcomes Analyst, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USASystems Developer, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USACarle Clinic Association, Monticello Family Medicine, Monticello, IL, USA
| | - Valerie Waldschmidt
- Director of Policy & Practice Initiatives, Institute for Healthcare Innovation, UIC College of Nursing, Urbana, IL, USADirector of Operations, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAClinical Nurse Partner Specialist, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USANurse Partner, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAOutcomes Analyst, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAOutcomes Analyst, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USASystems Developer, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USACarle Clinic Association, Monticello Family Medicine, Monticello, IL, USA
| | - Christine L Kucera
- Director of Policy & Practice Initiatives, Institute for Healthcare Innovation, UIC College of Nursing, Urbana, IL, USADirector of Operations, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAClinical Nurse Partner Specialist, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USANurse Partner, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAOutcomes Analyst, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAOutcomes Analyst, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USASystems Developer, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USACarle Clinic Association, Monticello Family Medicine, Monticello, IL, USA
| | - William K Lanker
- Director of Policy & Practice Initiatives, Institute for Healthcare Innovation, UIC College of Nursing, Urbana, IL, USADirector of Operations, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAClinical Nurse Partner Specialist, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USANurse Partner, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAOutcomes Analyst, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USAOutcomes Analyst, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USASystems Developer, Health Systems Research Center, Carle Foundation Hospital, Urbana, IL, USACarle Clinic Association, Monticello Family Medicine, Monticello, IL, USA
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Shaw PB, Delate T, Lyman A, Adams J, Kreutz H, Sanchez JK, Dowd MB, Gozansky W. Impact of a Clinical Pharmacy Specialist in an Emergency Department for Seniors. Ann Emerg Med 2015. [PMID: 26211427 DOI: 10.1016/j.annemergmed.2015.06.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE This study assesses outcomes associated with the implementation of an emergency department (ED) for seniors in which a clinical pharmacy specialist, with specialized geriatric training that included medication management training, is a key member of the ED care team. METHODS This was a retrospective cohort analysis of patients aged 65 years or older who presented at an ED between November 1, 2012, and May 31, 2013. Three groups of seniors were assessed: treated by the clinical pharmacy specialist in the ED for seniors, treated in the ED for seniors but not by the clinical pharmacy specialist, and not treated in the ED for seniors. Outcomes included rates of an ED return visit, mortality and hospital admissions, and follow-up total health care costs. Multivariable regression modeling was used to adjust for any potential confounders in the associations between groups and outcomes. RESULTS A total of 4,103 patients were included, with 872 (21%) treated in the ED for seniors and 342 (39%) of these treated by the clinical pharmacy specialist. Groups were well matched overall in patient characteristics. Patients who received medication review and management by the clinical pharmacy specialist did not experience a reduction in ED return visits, mortality, cost of follow-up care, or hospital admissions compared with the other groups. Of the patients treated by the clinical pharmacy specialist, 154 (45.0%) were identified as having at least 1 medication-related problem. CONCLUSION Although at least 1 medication-related problem was identified in almost half of patients treated by the clinical pharmacy specialist in the ED for seniors, incorporation of a clinical pharmacy specialist into the ED staff did not improve clinical outcomes.
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Affiliation(s)
- Paul B Shaw
- Pharmacy Department, Kaiser Permanente Colorado, Lafayette, CO.
| | - Thomas Delate
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO
| | - Alfred Lyman
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO
| | - Jody Adams
- Pharmacy Department, Lutheran Medical Center, Wheat Ridge, CO
| | - Heather Kreutz
- Pharmacy Department, Kaiser Permanente Colorado, Denver, CO
| | - Julia K Sanchez
- Pharmacy Department, Kaiser Permanente Colorado, Englewood, CO
| | - Mary Beth Dowd
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO
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