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Lee S, Skains RM, Magidson PD, Qadoura N, Liu SW, Southerland LT. Enhancing healthcare access for an older population: The age-friendly emergency department. J Am Coll Emerg Physicians Open 2024; 5:e13182. [PMID: 38726466 PMCID: PMC11079440 DOI: 10.1002/emp2.13182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/29/2023] [Accepted: 01/24/2024] [Indexed: 05/12/2024] Open
Abstract
Healthcare systems face significant challenges in meeting the unique needs of older adults, particularly in the acute setting. Age-friendly healthcare is a comprehensive approach using the 4Ms framework-what matters, medications, mentation, and mobility-to ensure that healthcare settings are responsive to the needs of older patients. The Age-Friendly Emergency Department (AFED) is a crucial component of a holistic age-friendly health system. Our objective is to provide an overview of the AFED model, its core principles, and the benefits to older adults and healthcare clinicians. The AFED optimizes the delivery of emergency care by integrating age-specific considerations into various aspects of (1) ED physical infrastructure, (2) clinical care policies, and (3) care transitions. Physical infrastructure incorporates environmental modifications to enhance patient safety, including adequate lighting, nonslip flooring, and devices for sensory and ambulatory impairment. Clinical care policies address the physiological, cognitive, and psychosocial needs of older adults while preserving focus on emergency issues. Care transitions include communication and involving community partners and case management services. The AFED prioritizes collaboration between interdisciplinary team members (ED clinicians, geriatric specialists, nurses, physical/occupational therapists, and social workers). By adopting an age-friendly approach, EDs have the potential to improve patient-centered outcomes, reduce adverse events and hospitalizations, and enhance functional recovery. Moreover, healthcare clinicians benefit from the AFED model through increased satisfaction, multidisciplinary support, and enhanced training in geriatric care. Policymakers, healthcare administrators, and clinicians must collaborate to standardize guidelines, address barriers to AFEDs, and promote the adoption of age-friendly practices in the ED.
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Affiliation(s)
- Sangil Lee
- Department of Emergency MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Rachel M. Skains
- University of Alabama at BirminghamBirminghamAlabamaUSA
- Geriatric Research, Education, and Clinical CenterBirmingham VA Medical CenterBirminghamAlabamaUSA
| | | | - Nadine Qadoura
- Department of Emergency MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Shan W. Liu
- Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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Pinardi E, Ornago AM, Bianchetti A, Morandi A, Mantovani S, Marengoni A, Colombo M, Arosio B, Okoye C, Cortellaro F, Bellelli G. Optimizing older patient care in emergency departments: a comprehensive survey of current practices and challenges in Northern Italy. BMC Emerg Med 2024; 24:86. [PMID: 38764046 PMCID: PMC11103964 DOI: 10.1186/s12873-024-01004-y] [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: 02/26/2024] [Accepted: 05/10/2024] [Indexed: 05/21/2024] Open
Abstract
BACKGROUND The progressive aging of the population and the increasing complexity of health issues contribute to a growing number of older individuals seeking emergency care. This study aims to assess the state of the art of care provided to older people in the Emergency Departments of Lombardy, the most populous region in Italy, counting over 2 million people aged 65 years and older. METHODS An online cross-sectional survey was developed and disseminated among emergency medicine physicians and physicians affiliated to the Lombardy section of the Italian Society of Geriatrics and Gerontology (SIGG), during June and July 2023. The questionnaire covered hospital profiles, geriatric consultation practices, risk assessment tools, discharge processes and perspectives on geriatric emergency care. RESULTS In this mixed method research, 219 structured interviews were collected. The majority of physicians were employed in hospitals, with 54.7% being geriatricians. Critical gaps in older patient's care were identified, including the absence of dedicated care pathways, insufficient awareness of screening tools, and a need for enhanced professional training. CONCLUSIONS Tailored protocols and geriatric educational programs are crucial for improving the quality of emergency care provided to older individuals. These measures might also help relieve the burden on the Emergency Departments, thereby potentially enhancing overall efficiency and ensuring better outcomes.
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Affiliation(s)
- Elena Pinardi
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
- Italian Society of Gerontology and Geriatrics (Società Italiana di Gerontologia e Geriatria - SIGG), Firenze, Italy.
| | - Alice Margherita Ornago
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Italian Society of Gerontology and Geriatrics (Società Italiana di Gerontologia e Geriatria - SIGG), Firenze, Italy
| | - Angelo Bianchetti
- Italian Society of Gerontology and Geriatrics (Società Italiana di Gerontologia e Geriatria - SIGG), Firenze, Italy
- Medicine and Rehabilitation Department, Istituto Clinico S.Anna Hospital, Gruppo San Donato, Brescia, Italy
| | - Alessandro Morandi
- Italian Society of Gerontology and Geriatrics (Società Italiana di Gerontologia e Geriatria - SIGG), Firenze, Italy
- Intermediate Care and Rehabilitation, Azienda Speciale "Cremona Solidale", Cremona, Italy
- Parc Sanitari Pere Virgili, Vall d'Hebrón Institute of Research, Barcelona, Spain
| | - Stefano Mantovani
- Italian Society of Gerontology and Geriatrics (Società Italiana di Gerontologia e Geriatria - SIGG), Firenze, Italy
- RSA Don Giuseppe Cuni, Magenta, Italy
| | - Alessandra Marengoni
- Italian Society of Gerontology and Geriatrics (Società Italiana di Gerontologia e Geriatria - SIGG), Firenze, Italy
- Department of Clinical and Experimental Sciences, Geriatric Unit, University of Brescia, Brescia, Italy
| | - Mauro Colombo
- Italian Society of Gerontology and Geriatrics (Società Italiana di Gerontologia e Geriatria - SIGG), Firenze, Italy
- Golgi Cenci Foundation, Abbiategrasso, Italy
| | - Beatrice Arosio
- Italian Society of Gerontology and Geriatrics (Società Italiana di Gerontologia e Geriatria - SIGG), Firenze, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Chukwuma Okoye
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Italian Society of Gerontology and Geriatrics (Società Italiana di Gerontologia e Geriatria - SIGG), Firenze, Italy
- Acute Geriatrics Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Francesca Cortellaro
- Integrazione Percorsi di Cura Ospedale Territorio, Urgency Emergency Regional Agency (Agenzia Regionale Emergenza Urgenza - AREU), Milan, Italy
| | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Italian Society of Gerontology and Geriatrics (Società Italiana di Gerontologia e Geriatria - SIGG), Firenze, Italy
- Acute Geriatrics Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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Aguirre NL, Gutiérrez SG, Miro O, Aguiló S, Jacob J, Alquézar-Arbé A, Burillo G, Fernandez C, Llorens P, Alonso CR, Lopez IT, Cañete M, Asensio PR, Díaz BP, Pizarro TP, Navarro RJDR, Viola NP, Hernández-Castells L, Soler AC, Sánchez Fernández-Linares E, Serrano JÁS, Ezponda P, Lorenzo AM, Liarte JVO, Ramón SS, Aranda AR, Martín-Sánchez FJ, del Castillo JG. Older Adult Patients in the Emergency Department: Which Patients should be Selected for a Different Approach? Ann Geriatr Med Res 2024; 28:9-19. [PMID: 37963716 PMCID: PMC10982447 DOI: 10.4235/agmr.23.0121] [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: 08/02/2023] [Revised: 10/05/2023] [Accepted: 11/08/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND While multidimensional and interdisciplinary assessment of older adult patients improves their short-term outcomes after evaluation in the emergency department (ED), this assessment is time-consuming and ill-suited for the busy environment. Thus, identifying patients who will benefit from this strategy is challenging. Therefore, this study aimed to identify older adult patients suitable for a different ED approach as well as independent variables associated with poor short-term clinical outcomes. METHODS We included all patients ≥65 years attending 52 EDs in Spain over 7 days. Sociodemographic, comorbidity, and baseline functional status data were collected. The outcomes were 30-day mortality, re-presentation, hospital readmission, and the composite of all outcomes. RESULTS During the study among 96,014 patients evaluated in the ED, we included 23,338 patients ≥65 years-mean age, 78.4±8.1 years; 12,626 (54.1%) women. During follow-up, 5,776 patients (24.75%) had poor outcomes after evaluation in the ED: 1,140 (4.88%) died, 4,640 (20.51) returned to the ED, and 1,739 (7.69%) were readmitted 30 days after discharge following the index visit. A model including male sex, age ≥75 years, arrival by ambulance, Charlson Comorbidity Index ≥3, and functional impairment had a C-index of 0.81 (95% confidence interval, 0.80-0.82) for 30-day mortality. CONCLUSION Male sex, age ≥75 years, arrival by ambulance, functional impairment, or severe comorbidity are features of patients who could benefit from approaches in the ED different from the common triage to improve the poor short-term outcomes of this population.
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Affiliation(s)
- Nere Larrea Aguirre
- Research Unit, Galdakao-Usansolo University Hospital, Vizcaya, Spain. Kronikgune Institute for Health Services Research, Barakaldo, Spain
| | - Susana García Gutiérrez
- Research Unit, Galdakao-Usansolo University Hospital, Vizcaya, Spain. Kronikgune Institute for Health Services Research, Barakaldo, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud (RICAPPS), Faculty of Health Sciences, Medicine Department, University of Deusto, Bilbo, Spain
| | - Oscar Miro
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Sira Aguiló
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Javier Jacob
- Emergency Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Catalonia, Spain
| | - Aitor Alquézar-Arbé
- Emergency Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Guillermo Burillo
- Emergency Department, Hospital Universitario de Canarias, University of La Laguna, Tenerife, Spain
| | - Cesáreo Fernandez
- Emergency Department, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Pere Llorens
- Emergency Department, Hospital General Universitario Dr. Balmis de Alicante, Alicante, Spain
| | | | | | - Mónica Cañete
- Emergency Department, Hospital Nuestra Señora del Prado de Talavera de la Reina, Toledo, Spain
| | | | | | | | | | | | | | | | | | | | - Patxi Ezponda
- Emergency Department, Hospital De Zumarraga, Guipuzcoa, Spain
| | | | | | | | | | | | | | - on behalf of the members of the SIESTA Network
- Research Unit, Galdakao-Usansolo University Hospital, Vizcaya, Spain. Kronikgune Institute for Health Services Research, Barakaldo, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud (RICAPPS), Faculty of Health Sciences, Medicine Department, University of Deusto, Bilbo, Spain
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
- Emergency Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Catalonia, Spain
- Emergency Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Catalonia, Spain
- Emergency Department, Hospital Universitario de Canarias, University of La Laguna, Tenerife, Spain
- Emergency Department, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
- Emergency Department, Hospital General Universitario Dr. Balmis de Alicante, Alicante, Spain
- Emergency Department, Hospital del Nalón, Langreo, Asturias, Spain
- Emergency Department, Hospital Virgen de Altagracia, Ciudad Real, Spain
- Emergency Department, Hospital Nuestra Señora del Prado de Talavera de la Reina, Toledo, Spain
- Emergency Department, Hospital Universitario Vinalopó, Alicante, Spain
- Emergency Department, Hospital Universitario de Móstoles, Madrid, Spain
- Emergency Department, Hospital Virgen del Rocio, Sevilla, Spain
- Emergency Department, Hospital General Universitario Dr. Peset, Valencia, Spain
- Emergency Department, Hospital Universitario Son Espases, Mallorca, Spain
- Emergency Department, Clinica Universitaria Navarra, Madrid, Spain
- Emergency Department, Clinico Universitario de Valencia, Valencia, Spain
- Emergency Department, Hospital Alvaro Cunqueiro, Pontevedra, Spain
- Emergency Department, Hospital Universitario de Salamanca, Salamanca, Spain
- Emergency Department, Hospital De Zumarraga, Guipuzcoa, Spain
- Emergency Department, Hospital Virxe Da Xunqueira, A Coruña, Spain
- Emergency Department, Hospital Universitario Los Arcos del Mar Menor, San Javier, Murcia, Spain
- Emergency Department, Hospital Universitario Río Ortega, Valladolid, Spain
- Emergency Department, Hospital Juan Ramón Jiménez, Huelva, Spain
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Liljas AE, Pulkki J, Jensen NK, Jämsen E, Burström B, Andersen I, Keskimäki I, Agerholm J. Opportunities for transitional care and care continuity following hospital discharge of older people in three Nordic cities: A comparative study. Scand J Public Health 2024; 52:5-9. [PMID: 36113132 PMCID: PMC10845833 DOI: 10.1177/14034948221122386] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/25/2022] [Indexed: 02/06/2024]
Abstract
AIM To outline and discuss care transitions and care continuity following hospital discharge of older people with complex care needs in three Nordic cities: Copenhagen, Tampere and Stockholm. METHODS Data on potential pathways following hospital discharge of older people were obtained from existing literature and expert consultations. The pathways for each system were outlined and presented in three figures. The hospital discharge process of the systems was then compared. RESULTS In all three care systems, the main care path from hospital is to home. Short-term intermediate healthcare can be provided in all three systems, possibly creating additional care transitions; however, once home, extensive home healthcare may prevent further care transitions. Opportunities for continuity of care include needs assessments (all cities) and meetings with the patient about care upon return home (Copenhagen, Stockholm). Yet this is challenged by lack of transfer of information (Tampere) and patients' having to apply for some services themselves (Tampere, Stockholm). CONCLUSIONS Comparisons of the discharge processes studied suggest that despite individual care planning and short- and long-term care options, transitional care and care continuity are challenged by limited access as some services need to be applied for by the older person themselves.
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Affiliation(s)
- Ann E.M. Liljas
- Department of Global Public Health, Karolinska Institutet, Sweden
| | - Jutta Pulkki
- Faculty of Social Sciences, Tampere University, Finland
| | | | - Esa Jämsen
- Gerontology Research Centre (GEREC), Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Finland
- Centre of Geriatrics, Tampere University Hospital, Finland
| | - Bo Burström
- Department of Global Public Health, Karolinska Institutet, Sweden
| | | | - Ilmo Keskimäki
- Faculty of Social Sciences, Tampere University, Finland
- Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Janne Agerholm
- Department of Global Public Health, Karolinska Institutet, Sweden
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Memedovich A, Asante B, Khan M, Eze N, Holroyd BR, Lang E, Kashuba S, Clement F. Strategies for improving ED-related outcomes of older adults who seek care in emergency departments: a systematic review. Int J Emerg Med 2024; 17:16. [PMID: 38302890 PMCID: PMC10835906 DOI: 10.1186/s12245-024-00584-7] [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: 10/05/2023] [Accepted: 01/12/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Despite constituting 14% of the general population, older adults make up almost a quarter of all emergency department (ED) visits. These visits often do not adequately address patient needs, with nearly 80% of older patients discharged from the ED carrying at least one unattended health concern. Many interventions have been implemented and tested in the ED to care for older adults, which have not been recently synthesized. METHODS A systematic review was conducted to identify interventions initiated in the ED to address the needs of older adults. Embase, MEDLINE, CINAHL, Cochrane CENTRAL, the Cochrane Database of Systematic Reviews, and grey literature were searched from January 2013 to January 18, 2023. Comparative studies assessing interventions for older adults in the ED were included. The quality of controlled trials was assessed with the Cochrane risk-of-bias tool for randomized trials, and the quality of observational studies was assessed with the risk of bias in non-randomized studies of interventions tool. Due to heterogeneity, meta-analysis was not possible. RESULTS Sixteen studies were included, assessing 12 different types of interventions. Overall study quality was low to moderate: 10 studies had a high risk of bias, 5 had a moderate risk of bias, and only 1 had a low risk of bias. Follow-up telephone calls, referrals, geriatric assessment, pharmacist-led interventions, physical therapy services, care plans, education, case management, home visits, care transition interventions, a geriatric ED, and care coordination were assessed, many of which were combined to create multi-faceted interventions. Care coordination with additional support and early assessment and intervention were the only two interventions that consistently reported improved outcomes. Most studies did not report significant improvements in ED revisits, hospitalization, time spent in the ED, costs, or outpatient utilization. Two studies reported on patient perspectives. CONCLUSION Few interventions demonstrate promise in reducing ED revisits for older adults, and this review identified significant gaps in understanding other outcomes, patient perspectives, and the effectiveness in addressing underlying health needs. This could suggest, therefore, that most revisits in this population are unavoidable manifestations of frailty and disease trajectory. Efforts to improve older patients' needs should focus on interventions initiated outside the ED.
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Affiliation(s)
- Ally Memedovich
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Benedicta Asante
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Maha Khan
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Nkiruka Eze
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Brian R Holroyd
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
- Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Eddy Lang
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
- Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada
| | - Sherri Kashuba
- Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Fiona Clement
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada.
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Gettel CJ, Hastings SN, Biese KJ, Goldberg EM. Emergency Department-to-Community Transitions of Care: Best Practices for the Older Adult Population. Clin Geriatr Med 2023; 39:659-672. [PMID: 37798071 PMCID: PMC10716862 DOI: 10.1016/j.cger.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
This article describes emergency department (ED)-to-community care transitions for older adults and associated challenges, measurement, proven efficacious and effective interventions, and policy considerations. Older adults experiencing social isolation and impairments in functional status or cognition represent unique populations that are particularly at risk during ED-to-community transitions of care and may benefit from targeted intervention implementation. Future efforts should target optimizing screening techniques to identify those at risk, developing and validating patient-centered outcome measures, and using policy and reimbursement levers to include transitional care management services for older adults within the ED setting.
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Affiliation(s)
- Cameron J Gettel
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Avenue, Suite 260, New Haven, CT 06519, USA; Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT 06519, USA.
| | - Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Box 3003, Durham, NC 27710, USA; Geriatric Research, Education, Clinical Center, Durham VA Health Care System, Durham, NC, USA; Center for the Study of Human Aging and Development, Duke University School of Medicine, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Kevin J Biese
- Department of Emergency Medicine, University of North Carolina, 170 Manning Drive, CB #7594, Chapel Hill, NC 27599, USA; Department of Medicine, Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Elizabeth M Goldberg
- Department of Emergency Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, 13001 East 17th Place, CB #C290, Aurora, CO 80045, USA
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Balu SR, Khoo A, Hunter CL, Ní Chróinín D. Does Case-Finding for Admission to Aged Care Rapid Investigation and Assessment Unit for Older Patients Improve Hospital Length of Stay? Evaluation of ARIA Unit. Int J Integr Care 2023; 23:3. [PMID: 37867578 PMCID: PMC10588540 DOI: 10.5334/ijic.7038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 09/26/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Many older people present to emergency departments annually, often with complex geriatric syndromes, yet current acute care models and traditional admissions process may under-serve their needs. The multidisciplinary Aged Care Rapid Investigation and Assessment (ARIA) Unit seeks to bridge this gap, by actively identifying and assessing patients. Methods A prospective case-control study was undertaken at a single-centre tertiary referral institution. Patients were eligible for inclusion in ARIA group if admitted to ARIA via case-finding by the geriatrician or Aged Care Services Emergency Team, whilst standard geriatric admissions formed the control group. This study evaluates whether ARIA reduced hospital length-of-stay (LOS) and representation rates. Results 370 patients were included (185 each arm) with similar baseline demographics, frailty scores, and Charlson Comorbidity Indices. Patients admitted to ARIA had significantly shorter hospital LOS than those via standard pathway (3.3 days [IQR2.2-5.8] vs 7.5 days [IQR4.2-13.7], p < 0.00001). There were no significant differences in 90-day representation rates (n = 66 [35.7%] vs n = 64 [34.6%], p = 0.82). Discussion/Conclusion Introduction of an ARIA unit with a targeted approach to frontline geriatric services and case-finding is associated with improved LOS of older acute hospital patients. An economical cost analysis of this study would be beneficial in exploring potential financial savings.
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Affiliation(s)
- Sundhar R. Balu
- Department of Geriatric Medicine, Liverpool Hospital, Liverpool, AU
- Department of Geriatric Medicine, Shoalhaven District Memorial Hospital, Nowra, AU
| | - Angela Khoo
- Department of Geriatric Medicine, Liverpool Hospital, Liverpool, AU
| | - Carol Lu Hunter
- Department of Geriatric Medicine, Liverpool Hospital, Liverpool, AU
- South Western Sydney Clinical School, UNSW Sydney, Liverpool, AU
| | - Danielle Ní Chróinín
- Department of Geriatric Medicine, Liverpool Hospital, Liverpool, AU
- South Western Sydney Clinical School, UNSW Sydney, Liverpool, AU
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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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10
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Balzaretti PL, Reano A, Canonico S, Aurucci ML, Ricotti A, Pili FG, Monacelli F, Vallino D. A geriatric re-evaluation clinic is associated with fewer unplanned returns in the Emergency Department: an observational case-control study. Eur Geriatr Med 2023; 14:123-129. [PMID: 36471122 PMCID: PMC9734542 DOI: 10.1007/s41999-022-00726-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE The increasing share of older adults is associated with heavier Emergency Health Services utilization. In this context, a significant problem is the rate of unplanned revisits of geriatric patients after discharge from the Emergency Department (ED). We aimed to evaluate whether the referral to a dedicated Geriatric Revaluation Clinic (GRC) after discharge from the ED is associated with fewer early unplanned returns. METHODS We conducted an observational, retrospective, case-control study comparing patients 65 years or older evaluated in a GRC after an ED visit and a control group of same age subjects accessing the ED during the study period and discharged with one of the ICD-9-CM diagnoses used for the cases, for whom defined post-ED assessment was not arranged. The intervention at the GRC consisted of a comprehensive geriatric evaluation. We calculated unadjusted and adjusted OR for unplanned ED revisits within 30 days from ED discharge using two logistic regression models including the variables with statistically significant differences among study groups at univariate analysis. RESULTS During the study period, 121 eligible patients were evaluated at the GRC and were matched to 242 subjects included in the control group. The median age of the study population was 85 years. The adjusted OR for unplanned return after ED discharge and unplanned hospital admission after ED discharge were 0.44 (CI 0.20-0.89) and 0.52 (CI 95% 0.18-1.74), respectively. CONCLUSIONS In a population of older patients discharged from the ED, the referral to a GRC is associated with fewer early unplanned revisits.
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Affiliation(s)
- P L Balzaretti
- Emergency Department, Azienda Ospedaliera "Ordine Mauriziano", Turin, Italy.
| | - A Reano
- Emergency Department, Azienda Ospedaliera "Ordine Mauriziano", Turin, Italy
| | - S Canonico
- Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, Genoa, Italy
| | - M L Aurucci
- Emergency Department, Azienda Ospedaliera "Ordine Mauriziano", Turin, Italy
| | - A Ricotti
- Emergency Department, Azienda Ospedaliera "Ordine Mauriziano", Turin, Italy
| | - F G Pili
- Emergency Department, Azienda Ospedaliera "Ordine Mauriziano", Turin, Italy
| | - F Monacelli
- Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, Genoa, Italy
| | - D Vallino
- Emergency Department, Azienda Ospedaliera "Ordine Mauriziano", Turin, Italy
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11
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McQuown CM, Snell KT, Abbate LM, Jetter EM, Blatnik JK, Ragsdale LC. Telehealth for geriatric post-emergency department visits to promote age-friendly care. Health Serv Res 2023; 58 Suppl 1:16-25. [PMID: 36054025 PMCID: PMC9843080 DOI: 10.1111/1475-6773.14058] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To describe a feasibility pilot study for older adults that addresses the digital divide, unmet health care needs, and the 4Ms of Age-Friendly Health Systems via the emergency department (ED) follow-up home visits supported by telehealth. DATA SOURCES AND STUDY SETTING Data sources were a pre-implementation site survey and pilot phase individual-level patient data from six US Department of Veterans Affairs (VA) EDs. STUDY DESIGN A pre-implementation survey assessed existing geriatric ED processes. In the pilot called SCOUTS (Supporting Community Outpatient, Urgent care & Telehealth Services), sites identified high-risk patients during an ED visit. After ED discharge, Intermediate Care Technicians (ICTs, former military medics), performed follow-up telephone, or home visits. During the follow-up visit, ICTs identified "what matters," performed geriatric screens aligned with Age-Friendly Health Systems, observed home safety risks, assisted with video telehealth check-ins with ED providers, and provided care coordination. SCOUTS visit data were recorded in the patient's electronic medical record using a standardized template. DATA COLLECTION/EXTRACTION METHODS Sites were surveyed via electronic form. Administrative pilot data extracted from VA Corporate Data Warehouse, May-October 2021. PRINCIPLE FINDINGS Site surveys showed none of the EDs had a formalized way of identifying the 4 M "what matters." During the pilot, ICT performed 56 telephone and 247 home visits. All home visits included a telehealth visit with an ED provider (n = 244) or geriatrician (n = 3). ICTs identified 44 modifiable home fall risks and 99 unmet care needs, recommended 80 pieces of medical equipment, placed 36 specialty care consults, and connected 180 patients to a Patient Aligned Care Team member for follow-up. CONCLUSIONS A post-ED follow-up program in which former military medics perform geriatric screens and care coordination is feasible. Combining telehealth and home visits allows providers to address what matters and unmet care needs.
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Affiliation(s)
- Colleen M. McQuown
- Geriatric Research Education and Clinical CenterLouis Stokes Cleveland VA Medical CenterClevelandOhioUSA
| | - Kristina T. Snell
- U.S. Department of Veterans AffairsOffice of Primary CareWashingtonDistrict of ColumbiaUSA
| | - Lauren M. Abbate
- Eastern Colorado Geriatric Research Education and Clinical CenterRocky Mountain Regional VA Medical CenterAuroraColoradoUSA
| | - Ethan M. Jetter
- University of Florida College of MedicineU.S. Department of Veterans Affairs, Office of Emergency MedicineWashingtonDistrict of ColumbiaUSA
| | - Jennifer K. Blatnik
- Ambulatory Care DepartmentLouis Stokes Cleveland VA Medical CenterClevelandOhioUSA
| | - Luna C. Ragsdale
- Duke UniversityDepartment of Surgery, Division of Emergency Medicine, Emergency Medicine Department, Durham VA Health Care SystemDurhamNorth CarolinaUSA
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12
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England T, Brailsford S, Evenden D, Street A, Maynou L, Mason SM, Preston L, Burton C, Van Oppen J, Conroy S. Examining the effect of interventions in emergency care for older people using a system dynamics decision support tool. Age Ageing 2023; 52:afac336. [PMID: 36702512 PMCID: PMC9879714 DOI: 10.1093/ageing/afac336] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Rising demand for Emergency and Urgent Care is a major international issue and outcomes for older people remain sub-optimal. Embarking upon large-scale service development is costly in terms of time, energy and resources with no guarantee of improved outcomes; computer simulation modelling offers an alternative, low risk and lower cost approach to explore possible interventions. METHOD A system dynamics computer simulation model was developed as a decision support tool for service planners. The model represents patient flow through the emergency care process from the point of calling for help through ED attendance, possible admission, and discharge or death. The model was validated against five different evidence-based interventions (geriatric emergency medicine, front door frailty, hospital at home, proactive care and acute frailty units) on patient outcomes such as hospital-related mortality, readmission and length of stay. RESULTS The model output estimations are consistent with empirical evidence. Each intervention has different levels of effect on patient outcomes. Most of the interventions show potential reductions in hospital admissions, readmissions and hospital-related deaths. CONCLUSIONS System dynamics modelling can be used to support decisions on which emergency care interventions to implement to improve outcomes for older people.
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Affiliation(s)
- Tracey England
- Southampton Business School, University of Southampton, Highfield, Southampton, UK
| | - Sally Brailsford
- Southampton Business School, University of Southampton, Highfield, Southampton, UK
| | - Dave Evenden
- Southampton Business School, University of Southampton, Highfield, Southampton, UK
| | - Andrew Street
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Laia Maynou
- Department of Health Policy, London School of Economics and Political Science, London, UK
- Department of Economics, Econometrics and Applied Economics, Universitat de Barcelona, Barcelona, Spain
- Center for Research in Health and Economics is a research unit within the Universitat Pompeu Fabra, Barcelona, Spain
| | - Suzanne M Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Louise Preston
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Christopher Burton
- Academic Unit of Primary Medical Care, University of Sheffield, Samuel Fox House, Northern General Hospital, Sheffield, UK
| | - James Van Oppen
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Simon Conroy
- MRC Unit for Lifelong Health and Ageing at University College London, London, UK
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13
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Pulido I, Nunes C, Botelho A, Lopes M, Martins S, Tomé L, Dinis F, Boto P. Comprehensive geriatric assessment of older patients and associated factors of admission to Emergency Departments in pre-covid 19 Era - A Portuguese study. Rev Esp Geriatr Gerontol 2022; 57:250-256. [PMID: 36115748 PMCID: PMC9444501 DOI: 10.1016/j.regg.2022.08.005] [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] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/21/2022] [Accepted: 08/29/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Identifying frequent users' (≥3admissions/year) associated factors in an emergency department (ED), using a comprehensive geriatric assessment (CGA), describing the characteristics of patients over 65 years of age. METHODS A cross-sectional study was performed between August 2017 and June 2018 in an ED in Lisbon, Portugal. CGA was applied and completed with clinical records. Clinical, functional, mental and social scores were created based in Portuguese Society of Internal Medicine, and a statistical model was developed. RESULTS CGA was applied to 426 patients over 64 years old in an ED. The mean age was 79.3, 84.7% had multimorbidity. 51.2%, 75.6%, and 40% had dependence on basic, instrumental, and walking activities, respectively. 52% had depressive symptoms, 65.7% had cognitive impairment, 63% were undernourished/at risk for malnutrition. 33.1% were socially at risk. Polypharmacy was present with a use on average of 6.5 drugs daily. Social, clinical, functional, and mental scores were unfavourable in 48.6%, 79.6%, 54.9% and 83.1% of the population, respectively. There were 2.7 hospital admissions/year and 39.9% were frequent ED users (≥3/year). The logistic regression model was weak, but showed that patients with polypharmacy, elevated Charlson Comorbidity index and an impairment nutritional status presented higher risk of being frequent users. CONCLUSIONS This study showed that 97.1% of patients had needs that would justify an interventional care plan. This intervention should be extended to primary care and nursing homes. While not providing a robust model, our study has indicated nutritional problems, polypharmacy, and an elevated Charlson index as the features with more weight in frequent users' admissions.
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Affiliation(s)
- Isabel Pulido
- Consultant Physician in Internal Medicine, Emergency Department, Hospital Santa Maria, Portugal; Public Health Research Centre, NOVA National School of Public Health, Universidade NOVA de Lisboa, Portugal.
| | - Carla Nunes
- Public Health Research Centre, NOVA National School of Public Health, Universidade NOVA de Lisboa, Portugal; Associate Professor of Statistics and Member of the Public Health Research Centre (CISP/UNL), Portugal
| | - Amália Botelho
- Assistant Professor of Clinical Medicine, Researcher in the Comprehensive Health Research Centre (CHRC), Nova Medical School/Faculdade de Ciências Médicas (NMS/FCM), Portugal
| | - Manuel Lopes
- Coordinating Professor, Department of Nursing, University of Évora, Researcher in the Comprehensive Health Research Centre (CHRC), Portugal
| | - Sónia Martins
- Integrated Researcher in the Centre for Health Technology and Services Research (CINTESIS) and the Department of Clinical Neurosciences and Mental Health of the Faculty of Medicine, University of Porto (FMUP), Portugal
| | - Luis Tomé
- Registered Nurse, Masters in Critical Care, Charge Nurse in CHULN Central Emergency Department, Portugal
| | - Francisco Dinis
- Emergency Department Social Worker, Hospital Santa Maria, Portugal
| | - Paulo Boto
- Public Health Research Centre, NOVA National School of Public Health, Universidade NOVA de Lisboa, Portugal; Assistant Professor, Department of Health Systems Policy and Management and Member of the Public Health Research Centre (CISP/UNL), Portugal
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14
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Afilalo M, Xue X, Colacone A, Jourdenais E, Boivin JF, Grad R. Association between access to primary care and unplanned emergency department return visits among patients 75 years and older. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2022; 68:599-606. [PMID: 35961725 PMCID: PMC9374085 DOI: 10.46747/cfp.6808599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To identify factors associated with unplanned return visits to the emergency department (ED) among the population aged 75 years and older. Moreover, it aims to determine the association between patients' access to primary care and unplanned return visits. DESIGN Data were collected from structured interviews, administrative databases, and medical charts at the index visits, and follow-up telephone calls were made at 3 months. SETTING Emergency departments of the 3 tertiary care hospitals in Montréal, Que. PARTICIPANTS Community-dwelling patients aged 75 years and older. MAIN OUTCOME MEASURES Zero-inflated negative binomial regression analysis was conducted of unplanned return visits within 3 months. Rate ratios (RRs) and odds ratios (ORs) with 95% CIs are presented. RESULTS During the study period, 4577 patients were identified, 2303 were recruited, and 1998 were retained for the analysis. Among the analysis sample, 33% were 85 and older, 34% lived alone, and 91% had a family physician. Before their ED visits, 16% of patients attempted to contact their family physicians. More than half of the patients reported having difficulty seeing their physicians for urgent problems, more than 40% had difficulty speaking with their family physicians by telephone, and more than one-third had difficulty booking appointments for new health problems. Within 3 months, 562 patients (28%) had made 894 return visits. Factors associated with a lower return visit rate included age 85 years and older (RR=0.80; 95% CI 0.67 to 0.96), less severe triage score (RR=0.83; 95% CI 0.74 to 0.92), and hospitalization at the index visit (RR=0.76; 95% CI 0.64 to 0.90). Factors that resulted in a higher return visit rate were difficulty booking appointments for new problems with their family physicians (RR=1.19; 95% CI 1.01 to 1.41), having had ED visits within the previous 6 months (RR=1.47; 95% CI 1.28 to 1.68), and higher Charlson comorbidity index scores (RR=1.06; 95% CI 1.01 to 1.11). Having had ED visits within the previous 6 months (OR=2.11; 95% CI 1.27 to 3.49), having a higher Charlson comorbidity index score (OR=1.41; 95% CI 1.19 to 1.68), and having received community care services (OR=3.00; 95% CI 0.95 to 9.53) also increased the odds of return visits. CONCLUSION Although most people 75 years and older have a family physician, problems still exist in terms of timely access. Unplanned return visits to the ED are associated with having more comorbidities, having had previous ED visits, having already received community services, and having difficulty booking appointments with family physicians for new problems.
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Affiliation(s)
- Marc Afilalo
- Director of the Emergency Department at Jewish General Hospital in Montréal, Que, and Chair of the Department of Emergency Medicine at McGill University
| | - Xiaoqing Xue
- Biostatistician and Research Coordinator in the Emergency Department at Jewish General Hospital.
| | - Antoinette Colacone
- Former Research Manager in the Emergency Department at Jewish General Hospital
| | | | - Jean-François Boivin
- Senior Investigator in the Lady Davis Institute for Medical Research at Jewish General Hospital and Professor in the Department of Epidemiology and Biostatistics at McGill University
| | - Roland Grad
- Associate Professor in the Department of Family Medicine in the Jewish General Hospital at McGill University
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15
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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: 12] [Impact Index Per Article: 6.0] [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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16
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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: 16] [Impact Index Per Article: 8.0] [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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Gettel CJ, Voils CI, Bristol AA, Richardson LD, Hogan TM, Brody AA, Gladney MN, Suyama J, Ragsdale LC, Binkley CL, Morano CL, Seidenfeld J, Hammouda N, Ko KJ, Hwang U, Hastings SN. Care transitions and social needs: A Geriatric Emergency care Applied Research (GEAR) Network scoping review and consensus statement. Acad Emerg Med 2021; 28:1430-1439. [PMID: 34328674 PMCID: PMC8725618 DOI: 10.1111/acem.14360] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/05/2021] [Accepted: 07/20/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Individual-level social needs have been shown to substantially impact emergency department (ED) care transitions of older adults. The Geriatric Emergency care Applied Research (GEAR) Network aimed to identify care transition interventions, particularly addressing social needs, and prioritize future research questions. METHODS GEAR engaged 49 interdisciplinary stakeholders, derived clinical questions, and conducted searches of electronic databases to identify ED discharge care transition interventions in older adult populations. Informed by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) framework, data extraction and synthesis of included studies included the degree that intervention components addressed social needs and their association with patient outcomes. GEAR convened a consensus conference to identify topics of highest priority for future care transitions research. RESULTS Our search identified 248 unique articles addressing care transition interventions in older adult populations. Of these, 17 individual care transition intervention studies were included in the current literature synthesis. Overall, common care transition interventions included coordination efforts, comprehensive geriatric assessments, discharge planning, and telephone or in-person follow-up. Fourteen of the 17 care transition intervention studies in older adults specifically addressed at least one social need within the PRAPARE framework, most commonly related to access to food, medicine, or health care. No care transition intervention addressing social needs in older adult populations consistently reduced subsequent health care utilization or other patient-centered outcomes. GEAR stakeholders identified that determining optimal outcome measures for ED-home transition interventions was the highest priority area for future care transitions research. CONCLUSIONS ED care transition intervention studies in older adults frequently address at least one social need component and exhibit variation in the degree of success on a wide array of health care utilization outcomes.
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Affiliation(s)
- Cameron J. Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- National Clinician Scholars Program, Department of internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Corrine I. Voils
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | - Lynne D. Richardson
- Department of Emergency Medicine, icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Population Health Science & Policy, icahn School of Medicine at Mount Sinai, New York, New York, USA
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Teresita M. Hogan
- Department of Medicine, Section of Emergency Medicine, The University of Chicago School of Medicine, Chicago, Illinois, USA
| | - Abraham A. Brody
- Hartford Institute for Geriatric Nursing, New York University Rory Meyers College of Nursing, New York, New York, USA
| | - Micaela N. Gladney
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Joe Suyama
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Luna C. Ragsdale
- Department of Surgery, Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Emergency Medicine, Durham VA Health Care System, Durham, North Carolina, USA
| | - Christine L. Binkley
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Carmen L. Morano
- School of Social Welfare, University at Albany, State University of New York, Albany, New York, USA
| | - Justine Seidenfeld
- Department of Surgery, Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nada Hammouda
- Department of Emergency Medicine, icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kelly J. Ko
- West Health Institute, La Jolla, California, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Geriatrics Research, Education, and Clinical Center, James J. Peters VAMC, Bronx, New York, USA
| | - Susan N. Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, North Carolina, USA
- Center for the Study of Human Aging and Development, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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Gill S, Mills PD, Watts BV, Paull DE, Tomolo A. A Review of Adverse Event Reports From Emergency Departments in the Veterans Health Administration. J Patient Saf 2021; 17:e898-e903. [PMID: 32084094 DOI: 10.1097/pts.0000000000000636] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous work assessing the frequency of adverse events in emergency medicine has been limited. The emergency department (ED) provides an initial point of care for millions of patients. Given the volume of patient encounters and the complexity of medical conditions treated in the ED, it is necessary to determine the system-based issues and associated contributing factors impacting patient safety. OBJECTIVES The aim of this retrospective study were to use root cause analysis reports of adverse events occurring in Veterans Health Administration EDs to understand the range of events that were happening and to determine the primary causes of these events as well as actions to prevent them. METHODS Retrospective safety reports from EDs from Veterans Health Administration medical centers across the nation for a 2-year period (2015-2016) were coded by event type, root cause, and recommended actions. RESULTS One hundred forty-four cases were included for analysis. The most common adverse events were as follows: delays in care (n = 38, 26.4%), elopements (n = 21, 14.6%), suicide attempts and deaths by suicide (n = 15, 10.4%), inappropriate discharges (n = 15, 10.4%), and errors in following procedures (n = 14, 9.7%). Overall, the most common root cause categories leading to adverse events were knowledge/educational deficits (11.4%), policies/procedures needing improvement (11.1%), and lack of standardized policies/procedures (9.4%). DISCUSSION Root cause analysis reports are a useful tool to determine the primary systems-based factors of common adverse events in the ED. Recommendations made in this article for addressing these root causes and potentially ameliorating these events will be useful to EDs and related health systems.
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Affiliation(s)
| | - Peter D Mills
- Veterans Affairs National Center for Patient Safety Field Office, VA Medical Center, White River Junction, Vermont
| | | | | | - Anne Tomolo
- Atlanta VA Healthcare System, Decatur, Georgia
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Schouten B, Driesen BEJM, Merten H, Burger BHCM, Hartjes MG, Nanayakkara PWB, Wagner C. Experiences and perspectives of older patients with a return visit to the emergency department within 30 days: patient journey mapping. Eur Geriatr Med 2021; 13:339-350. [PMID: 34761369 PMCID: PMC9018642 DOI: 10.1007/s41999-021-00581-6] [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: 06/22/2021] [Accepted: 10/26/2021] [Indexed: 12/30/2022]
Abstract
Aim To achieve patient-centered care for older patients at the emergency department (ED) it is important to include their perspective and experience, and this can be done through the patient journey method. Findings By mapping the patient journey, we found that waiting times and suboptimal discharge communication are almost always related to a negative experience for older patients. Message The novelty of this study lies within the qualitative patient journey method, which allowed us to include the voice of the patient in issues that have been previously described (i.e. waiting times and discharge communication). We believe this can guide towards patient-centered improvement initiatives that can contribute to a positive ED experience in the future, for example a time-out at the ED and a discharge check list Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00581-6. Purpose Up to 22% of older patients who visit the emergency department (ED) have a return visit within 30 days. To achieve patient-centered care for this group at the ED it is important to involve the patient perspective and strive to provide the best possible experience. The aim of this study was to gain insight into the experiences and perspectives of older patients from initial to return ED visit by mapping their patient journey. Methods We performed a qualitative patient journey study with 13 patients of 70 years and older with a return ED visit within 30 days who presented at the Amsterdam UMC, a Dutch academic hospital. We used semi-structured interviews focusing on the patient experience during their journey and developed a conceptual framework for coding. Results Our sample consisted of 13 older patients with an average age of 80 years, and 62% of them were males. The framework contained a timeline of the patient journey with five chronological main themes, complemented with an ‘experience’ theme, these were divided into 34 subthemes. Health status, social system, contact with the general practitioner, aftercare, discharge and expectations were the five main themes. The experiences regarding these themes differed greatly between patients. The two most prominent subthemes were waiting time and discharge communication, which were mostly related to a negative experience. Conclusions This study provides insight into the experiences and perspectives of older patients from initial to return ED visit. The two major findings were that lack of clarity regarding waiting times and suboptimal discharge communication contributed to negative experiences. Recommendations regarding waiting time (i.e. a two-hour time out at the ED), and discharge communication (i.e. checklist for discharge) could contribute to a positive ED experience and thereby potentially improve patient-centered care. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00581-6.
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Affiliation(s)
- Bo Schouten
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1117, P/O Box 7057, 1007 MB, Amsterdam, The Netherlands.
| | - Babiche E J M Driesen
- Department of Emergency Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Hanneke Merten
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1117, P/O Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Brigitte H C M Burger
- Section General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Mariëlle G Hartjes
- Section General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Prabath W B Nanayakkara
- Section General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Cordula Wagner
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1117, P/O Box 7057, 1007 MB, Amsterdam, The Netherlands.,Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
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Kolk D, Kruiswijk AF, MacNeil-Vroomen JL, Ridderikhof ML, Buurman BM. Older patients' perspectives on factors contributing to frequent visits to the emergency department: a qualitative interview study. BMC Public Health 2021; 21:1709. [PMID: 34544405 PMCID: PMC8454044 DOI: 10.1186/s12889-021-11755-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 09/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Older patients are at high risk of unplanned revisits to the emergency department (ED) because of their medical complexity. To reduce the number of ED visits, we need more knowledge about the patient-level, environmental, and healthcare factors involved. The aim of this study was to describe older patients' perspectives and experiences before and after an ED visit, and to identify factors that possibly contribute to frequent ED revisits. METHODS This was a qualitative description study. We performed semi-structured individual interviews with older patients who frequently visited the ED and were discharged home after an acute visit. Patients were enrolled in the ED of a university medical centre using purposive sampling. Interviews were recorded, transcribed, and coded independently by two researchers. Theoretical analysis was used to identify recurring patterns and themes in the data. Interviews were conducted until thematic saturation was reached. RESULTS In-depth interviews were completed with 13 older patients. Three main themes emerged: 1) medical events leading to feelings of crisis, 2) patients' untreated health problems, and 3) persistent problems in health and daily functioning post discharge. Participants identified problems before and after their ED visit that possibly contributed to further ED visits. These problems included increasing symptoms leading to feelings of crisis, the relationship with the general practitioner, incomplete discharge information at the ED, and inadequate follow-up and lack of recovery after an ED visit. CONCLUSIONS This qualitative study identified multiple factors that may contribute to frequent ED visits among older patients. Older patients in need of acute care might benefit from hospital-at-home interventions, or acute care provided by geriatric emergency teams in the primary care setting. Identifying frailty in the ED is needed to improve discharge communication and adequate follow-up is needed to improve recovery after an acute ED visit.
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Affiliation(s)
- Daisy Kolk
- Amsterdam UMC, University of Amsterdam, Emergency Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, Netherlands. .,Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health, Meibergdreef 9, Amsterdam, Netherlands.
| | - Anton F Kruiswijk
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health, Meibergdreef 9, Amsterdam, Netherlands.,OLVG Hospital, Department of Geriatric Medicine, Amsterdam, the Netherlands
| | - Janet L MacNeil-Vroomen
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health, Meibergdreef 9, Amsterdam, Netherlands
| | - Milan L Ridderikhof
- Amsterdam UMC, University of Amsterdam, Emergency Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, Netherlands
| | - Bianca M Buurman
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health, Meibergdreef 9, Amsterdam, Netherlands.,ACHIEVE - Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
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21
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De Brauwer I, Cornette P, D'Hoore W, Lorant V, Verschuren F, Thys F, Aujoulat I. Factors to improve quality for older patients in the emergency department: a qualitative study of patient trajectory. BMC Health Serv Res 2021; 21:965. [PMID: 34521415 PMCID: PMC8442337 DOI: 10.1186/s12913-021-06960-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 08/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Managing older people in the emergency department remains a challenge. We aimed to identify the factors influencing the care quality of older patients in the emergency department, to fine-tune future interventions for older people, considering the naturalistic context of the ED. METHODS This is a qualitative study of some 450 h of observations performed in three emergency departments selected for their diverse contexts. We performed seventy observations of older patient trajectories admitted to the emergency department. Themes were extracted from the material using an inductive reasoning approach, to highlight factors positively or negatively influencing management of patient's trajectories, in particular those presenting with typically geriatric syndromes. RESULTS Four themes were developed: no geriatric flow routine; risk of discontinuity of care; unmet basic needs and patient-centered care; complex older patients are unwelcome in EDs. CONCLUSIONS The overall process of care was based on an organ- and flow-centered paradigm, which ignored older people's specific needs and exposed them to discontinuity of care. Their basic needs were neglected and, when their management slowed the emergency department flow, older people were perceived as unwelcome. Findings of our study can inform the development of interventions about the influence of context and organizational factors.
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Affiliation(s)
- Isabelle De Brauwer
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium.
| | - Pascale Cornette
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium
| | - William D'Hoore
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium
| | - Vincent Lorant
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium
| | - Franck Verschuren
- Institute of Experimental and Clinical Research (IREC), Université catholique de Louvain, Brussels, Belgium
| | - Frédéric Thys
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium.,Institute of Experimental and Clinical Research (IREC), Université catholique de Louvain, Brussels, Belgium
| | - Isabelle Aujoulat
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium
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Conneely M, Robinson K, Leahy S, Trépel D, Jordan F, Galvin R. Effectiveness of interventions to reduce adverse outcomes among older adults following emergency department discharge: Protocol for an overview of systematic reviews. HRB Open Res 2021; 3:27. [PMID: 33969262 PMCID: PMC8078215 DOI: 10.12688/hrbopenres.13027.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 11/13/2023] Open
Abstract
Background: Older adults are frequent users of Emergency departments (ED) and this trend will continue due to population ageing and the associated increase in healthcare needs. Older adults are vulnerable to adverse outcomes following ED discharge. A number of heterogeneous interventions have been developed and implemented to improve clinical outcomes among this cohort. A growing number of systematic reviews have synthesised evidence regarding ED interventions using varying methodologies. This overview aims to synthesise the totality of evidence in order to evaluate the effectiveness of interventions to reduce adverse outcomes in older adults discharged from the ED. Methods: To identify relevant reviews, the following databases will be searched: Cochrane Database of Systematic reviews, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Databases of Abstracts of Reviews of Effects, PubMed, MEDLINE, Epistemonikos, Ageline, Embase, PEDro, Scopus, CINAHL and the PROSPERO register. The search for grey literature will include Open Grey and Grey Literature Reports. Systematic reviews of randomised controlled trials will be analysed to assess the effect of ED interventions on clinical and process outcomes in older adults. Methodological quality of the reviews will be assessed using the Assessment of Multiple Systematic Reviews 2 tool. The review will be reported in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Summary of findings will include a hierarchical rank of interventions based on estimates of effects and the quality of evidence. Discussion: This overview is required given the number of systematic reviews published regarding the effectiveness of various ED interventions for older adults at risk of adverse outcomes following discharge from the ED. There is a need to examine the totality of evidence using rigorous analytic techniques to inform best care and potentially develop a hierarchy of treatment options. PROSPERO registration: CRD42020145315 (28/04/2020).
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Affiliation(s)
- Mairéad Conneely
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland, V94 TPPX, Ireland
| | - Katie Robinson
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland, V94 TPPX, Ireland
| | - Siobhán Leahy
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland, V94 TPPX, Ireland
| | - Dominic Trépel
- Trinity Institute of Neurosciences, School of Medicine, Trinity College Dublin, Dublin, Ireland, DO2 PN40, Ireland
| | - Fionnuala Jordan
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland, H91 TK33, Ireland
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland, V94 TPPX, Ireland
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23
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Conneely M, Robinson K, Leahy S, Trépel D, Jordan F, Galvin R. Effectiveness of interventions to reduce adverse outcomes among older adults following emergency department discharge: Protocol for an overview of systematic reviews. HRB Open Res 2021; 3:27. [PMID: 33969262 PMCID: PMC8078215 DOI: 10.12688/hrbopenres.13027.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Older adults are frequent users of Emergency departments (ED) and this trend will continue due to population ageing and the associated increase in healthcare needs. Older adults are vulnerable to adverse outcomes following ED discharge. A number of heterogeneous interventions have been developed and implemented to improve clinical outcomes among this cohort. A growing number of systematic reviews have synthesised evidence regarding ED interventions using varying methodologies. This overview aims to synthesise the totality of evidence in order to evaluate the effectiveness of interventions to reduce adverse outcomes in older adults discharged from the ED. Methods: To identify relevant reviews, the following databases will be searched: Cochrane Database of Systematic reviews, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Databases of Abstracts of Reviews of Effects, PubMed, MEDLINE, Epistemonikos, Ageline, Embase, PEDro, Scopus, CINAHL and the PROSPERO register. The search for grey literature will include Open Grey and Grey Literature Reports. Systematic reviews of randomised controlled trials will be analysed to assess the effect of ED interventions on clinical and process outcomes in older adults. Methodological quality of the reviews will be assessed using the Assessment of Multiple Systematic Reviews 2 tool. The review will be reported in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Summary of findings will include a hierarchical rank of interventions based on estimates of effects and the quality of evidence. Discussion: This overview is required given the number of systematic reviews published regarding the effectiveness of various ED interventions for older adults at risk of adverse outcomes following discharge from the ED. There is a need to examine the totality of evidence using rigorous analytic techniques to inform best care and potentially develop a hierarchy of treatment options. PROSPERO registration: CRD42020145315 (28/04/2020).
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Affiliation(s)
- Mairéad Conneely
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland, V94 TPPX, Ireland
| | - Katie Robinson
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland, V94 TPPX, Ireland
| | - Siobhán Leahy
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland, V94 TPPX, Ireland
| | - Dominic Trépel
- Trinity Institute of Neurosciences, School of Medicine, Trinity College Dublin, Dublin, Ireland, DO2 PN40, Ireland
| | - Fionnuala Jordan
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland, H91 TK33, Ireland
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland, V94 TPPX, Ireland
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24
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Blomaard LC, de Groot B, Lucke JA, de Gelder J, Booijen AM, Gussekloo J, Mooijaart SP. Implementation of the acutely presenting older patient (APOP) screening program in routine emergency department care : A before-after study. Z Gerontol Geriatr 2021; 54:113-121. [PMID: 33471176 PMCID: PMC7946672 DOI: 10.1007/s00391-020-01837-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/16/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the effects of implementation of the acutely presenting older patient (APOP) screening program for older patients in routine emergency department (ED) care shortly after implementation. METHODS We conducted an implementation study with before-after design, using the plan-do-study-act (PDSA) model for quality improvement, in the ED of a Dutch academic hospital. All consecutive patients ≥ 70 years during 2 months before and after implementation were included. The APOP program comprises screening for risk of functional decline, mortality and cognitive impairment, targeted interventions for high-risk patients and education of professionals. Outcome measures were compliance with interventions and impact on ED process, length of stay (LOS) and hospital admission rate. RESULTS Two comparable groups of patients (median age 77 years) were included before (n = 920) and after (n = 953) implementation. After implementation 560 (59%) patients were screened of which 190 (34%) were high-risk patients. Some of the program interventions for high-risk patients in the ED were adhered to, some were not. More hospitalized patients received comprehensive geriatric assessment (CGA) after implementation (21% before vs. 31% after; p = 0.002). In 89% of high-risk patients who were discharged to home, telephone follow-up was initiated. Implementation did not influence median ED LOS (202 min before vs. 196 min after; p = 0.152) or hospital admission rate (40% before vs. 39% after; p = 0.410). CONCLUSION Implementation of the APOP screening program in routine ED care did not negatively impact the ED process and resulted in an increase of CGA and telephone follow-up in older patients. Future studies should investigate whether sustainable changes in management and patient outcomes occur after more PDSA cycles.
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Affiliation(s)
- Laura C Blomaard
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, 9600, 2300 RC, Leiden, The Netherlands.
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacinta A Lucke
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Emergency Medicine, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Jelle de Gelder
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, 9600, 2300 RC, Leiden, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Anja M Booijen
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, 9600, 2300 RC, Leiden, The Netherlands
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacobijn Gussekloo
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, 9600, 2300 RC, Leiden, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Simon P Mooijaart
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, 9600, 2300 RC, Leiden, The Netherlands
- Institute of Evidence-Based Medicine in Old Age | IEMO, Leiden, The Netherlands
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25
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Baughman DJ, Waheed A, Khan MN, Nicholson JM. Enhancing Value-Based Care With a Walk-in Clinic: A Primary Care Provider Intervention to Decrease Low Acuity Emergency Department Overutilization. Cureus 2021; 13:e13284. [PMID: 33728217 PMCID: PMC7955766 DOI: 10.7759/cureus.13284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 11/15/2022] Open
Abstract
Background Emergency department overutilization is a known contributor to the high per-capita healthcare cost in the United States. There is a knowledge gap regarding the substitution effect of walk-in clinic availability in primary care provider (PCP) offices and emergency department utilization (EDU). This study evaluates associations between PCP availability and EDU and analyzes the potential cost savings for health systems. Methods A retrospective cohort analysis compared low acuity EDU rates in established patients at a family medicine residency's PCP office before and after walk-in clinic implementation. The practice had 12 providers, 12 residents, and a patient panel of approximately 7,000-8,000. Inclusion criteria were met if patients were: (1) established with the PCP office, (2) had a low acuity emergency department (ED) visit (emergency index score level 4 or 5) OR had a walk-in clinic visit at the family practice. ED visits were tracked from January 2018 to January 2020 and encounters were compared numbers to pre and post-implementation of a walk-in clinic. Cost savings for comparable management was estimated with average price differences for low acuity encounters in the ED versus clinic. Results Over the two-year timeframe, there were 10,962 total visits to the ED by family practice patients, 4,250 of these visits were low acuity. Despite gross monthly increases of EDU from 2018-2020, after implementation of a walk-in clinic in 2019, rates of total EDU decreased by 1.5% and low acuity utilization rates also decreased. The average annual patient census nearly doubled from 5,763 to 8,042. T-tests confirmed statistical significance with p-values <0.05. Average low acuity ED visits ($437) cost 4.9 times more than comparable PCP office visits ($91). Managing 2,387 patients in the walk-in clinic resulted in an estimated annual cost savings of $825,902. Conclusion Extended walk-in availability in primary care offices provides non-ED capacity for low acuity management and might mitigate low acuity ED utilization while providing more cost-effective care. This study supports similarly described pre-hospital diversions in reducing ED over-utilization by increasing access to care. Higher levels of evidence are needed to establish causality.
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Affiliation(s)
| | - Abdul Waheed
- Family Medicine, Wellspan Good Samaritan Hospital, Lebanon, USA
- Family and Community Medicine, Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, USA
| | - Muhammad N Khan
- Family Medicine, WellSpan Good Samaritan Hospital, Lebanon, USA
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Schumacher JR, Lutz BJ, Hall AG, Harman JS, Turner K, Brumback BA, Hendry P, Carden DL. Impact of an Emergency Department-to-Home Transitional Care Intervention on Health Service Use in Medicare Beneficiaries: A Mixed Methods Study. Med Care 2021; 59:29-37. [PMID: 33298706 PMCID: PMC8689563 DOI: 10.1097/mlr.0000000000001452] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hospital-based acute care [emergency department (ED) visits and hospitalizations] that is preventable with high-quality outpatient care contributes to health care system waste and patient harm. OBJECTIVE To test the hypothesis that an ED-to-home transitional care intervention reduces hospital-based acute care in chronically ill, older ED visitors. RESEARCH DESIGN Convergent, parallel, mixed-methods design including a randomized controlled trial. SETTING Two diverse Florida EDs. SUBJECTS Medicare fee-for-service beneficiaries with chronic illness presenting to the ED. INTERVENTION The Coleman Care Transition Intervention adapted for ED visitors. MEASURES The main outcome was hospital-based acute care within 60 days of index ED visit. We also assessed office-based outpatient visits during the same period. RESULTS The Intervention did not significantly reduce return ED visits or hospitalizations or increase outpatient visits. In those with return ED visits, the Intervention Group was less likely to be hospitalized than the Usual Care Group. Interview themes describe a cycle of hospital-based acute care largely outside patients' control that may be difficult to interrupt with a coaching intervention. CONCLUSIONS AND RELEVANCE Structural features of the health care system, including lack of access to timely outpatient care, funnel patients into the ED and hospital admission. Reducing hospital-based acute care requires increased focus on the health care system rather than patients' care-seeking decisions.
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Affiliation(s)
- Jessica R. Schumacher
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison WI
| | - Barbara J. Lutz
- School of Nursing, College of Health and Human Services, University of North Carolina-Wilmington, Wilmington NC
| | - Allyson G. Hall
- Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL
| | - Jeffrey S. Harman
- Department of Behavioral Sciences and Social Medicine, College of Medicine, Florida State University, Tallahassee FL
| | | | - Babette A. Brumback
- Department of Biostatistics, College of Public Health and Health Professions & College of Medicine, University of Florida-Gainesville, Gainesville FL
| | - Phyllis Hendry
- Department of Emergency Medicine, College of Medicine, University of Florida-Jacksonville, Jacksonville FL
| | - Donna L. Carden
- Department of Emergency Medicine, College of Medicine, University of Florida-Gainesville, Gainesville FL
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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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Oliveira J E Silva L, Jeffery MM, Campbell RL, Mullan AF, Takahashi PY, Bellolio F. Predictors of return visits to the emergency department among different age groups of older adults. Am J Emerg Med 2020; 46:241-246. [PMID: 33071094 DOI: 10.1016/j.ajem.2020.07.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/24/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE To identify predictors of 30-day emergency department (ED) return visits in patients age 65-79 years and age ≥ 80 years. METHODS This was a cohort study of older adults who presented to the ED over a 1-year period. A mixed-effects logistic regression model was used to identify predictors for returning to the ED within 30 days. We stratified the cohort into those aged 65-79 years and aged ≥80 years. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) were reported. This study adhered to the STROBE reporting guidelines. RESULTS A total of 21,460 ED visits representing 14,528 unique patients were included. The overall return rate was 15% (1998/13,300 visits) for age 65-79 years, and 16% (1306/8160 visits) for age ≥ 80 years. A history of congestive heart failure (CHF), dementia, or prior hospitalization within 2 years were associated with increased odds of returning in both age groups (for age 65-79: CHF aOR 1.36 [CI 1.16-1.59], dementia aOR 1.27 [CI 1.07-1.49], prior hospitalization aOR 1.36 [CI 1.19-1.56]; for age ≥ 80: CHF aOR 1.32 [CI 1.13-1.55], dementia aOR 1.22 [CI 1.04-1.42], and prior hospitalization aOR 1.27 [CI 1.09-1.47]). Being admitted from the ED was associated with decreased odds of returning to the ED within 30 days (aOR 0.72 [CI 0.64-0.80] for age 65-79 years and 0.72 [CI 0.63-0.82] for age ≥ 80). CONCLUSION Age alone was not an independent predictor of return visits. Prior hospitalization, dementia and CHF were predictors of 30-day ED return. The identification of predictors of return visits may help to optimize care transition in the ED.
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Affiliation(s)
| | - Molly M Jeffery
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - Aidan F Mullan
- Department of Biostatistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Paul Y Takahashi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.
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Ooi M, Lewis ET, Brisbane J, Tubb E, McClean T, Assareh H, Hillman K, Achat H, Cardona M. Feasibility of Using a Risk Assessment Tool to Predict Hospital Transfers or Death for Older People in Australian Residential Aged Care. A Retrospective Cohort Study. Healthcare (Basel) 2020; 8:E284. [PMID: 32825603 PMCID: PMC7551645 DOI: 10.3390/healthcare8030284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/18/2020] [Accepted: 08/18/2020] [Indexed: 12/19/2022] Open
Abstract
Residents of Aged Care Facilities (RACF) experience burdensome hospital transfers in the last year of life, which may lead to aggressive and potentially inappropriate hospital treatments. Anticipating these transfers by identifying risk factors could encourage end-of-life discussions that may change decisions to transfer. The aim was to examine the feasibility of identifying an end-of-life risk profile among RACF residents using a predictive tool to better anticipate predictors of hospital transfers, death or poor composite outcome of hospitalisation and/or death after initial assessment. A retrospective cohort study of 373 permanent residents aged 65+ years was conducted using objective clinical factors from records in nine RACFs in metropolitan Sydney, Australia. In total, 26.8% died and 34.3% experienced a composite outcome. Cox proportional hazard regression models confirmed the feasibility of estimating the level of risk for death or a poor composite outcome. Knowing this should provide opportunities to initiate advance care planning in RACFs, facilitating decision making near the end of life. We conclude that the current structure of electronic RACF databases could be enhanced to enable comprehensive assessment of the risk of hospital re-attendance without admission. Automation tools to facilitate the risk score calculation may encourage the adoption of prediction checklists and evaluation of their association with hospital transfers.
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Affiliation(s)
- Meidelynn Ooi
- Medical School, The University of New South Wales, Kensington 2052, Australia;
| | - Ebony T Lewis
- School of Population Health, Faculty of Medicine, University of New South Wales, Kensington 2052, Australia;
- School of Psychology, Faculty of Science, University of New South Wales, Kensington 2052, Australia
| | - Julianne Brisbane
- Uniting (Aged Care Services), Sydney 2067, Australia; (J.B.); (E.T.); (T.M.)
| | - Evalynne Tubb
- Uniting (Aged Care Services), Sydney 2067, Australia; (J.B.); (E.T.); (T.M.)
| | - Tom McClean
- Uniting (Aged Care Services), Sydney 2067, Australia; (J.B.); (E.T.); (T.M.)
| | - Hassan Assareh
- Agency for Clinical Innovation, St Leonards 2065, Australia;
| | - Ken Hillman
- Intensive Care Unit, Liverpool Hospital, Liverpool 2170, Australia;
| | - Helen Achat
- Western Sydney Local Health District, North Parramatta 2151, Australia;
| | - Magnolia Cardona
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast 4226, Australia
- EBP Professorial Unit, Gold Coast University Hospital, Southport 4215, Australia
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Dawson S, Kunonga P, Beyer F, Spiers G, Booker M, McDonald R, Cameron A, Craig D, Hanratty B, Salisbury C, Huntley A. Does health and social care provision for the community dwelling older population help to reduce unplanned secondary care, support timely discharge and improve patient well-being? A mixed method meta-review of systematic reviews. F1000Res 2020; 9:857. [PMID: 34621521 PMCID: PMC8482050 DOI: 10.12688/f1000research.25277.1] [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] [Accepted: 07/23/2020] [Indexed: 11/20/2022] Open
Abstract
Background: This study aimed to identify and examine systematic review evidence of health and social care interventions for the community-dwelling older population regarding unplanned hospital admissions, timely hospital discharge and patient well-being. Methods: A meta-review was conducted using Joanna Briggs and PRISMA guidance. A search strategy was developed: eight bibliographic medical and social science databases were searched, and references of included studies checked. Searches were restricted to OECD countries and to systematic reviews published between January 2013-March 2018. Data extraction and quality appraisal was undertaken by one reviewer with a random sample screened independently by two others. Results: Searches retrieved 21,233 records; using data mining techniques, we identified 8,720 reviews. Following title and abstract and full-paper screening, 71 systematic reviews were included: 62 quantitative, seven qualitative and two mixed methods reviews. There were 52 reviews concerned with healthcare interventions and 19 reviews concerned with social care interventions. This meta-review summarises the evidence and evidence gaps of nine broad types of health and social care interventions. It scrutinises the presence of research in combined health and social care provision, finding it lacking in both definition and detail given. This meta-review debates the overlap of some of the person-centred support provided by community health and social care provision. Research recommendations have been generated by this process for both primary and secondary research. Finally, it proposes that research recommendations can be delivered on an ongoing basis if meta-reviews are conducted as living systematic reviews. Conclusions: This meta-review provides evidence of the effect of health and social care interventions for the community-dwelling older population and identification of evidence gaps. It highlights the lack of evidence for combined health and social care interventions and for the impact of social care interventions on health care outcomes. Registration: PROSPERO ID CRD42018087534; registered on 15 March 2018.
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Affiliation(s)
- Shoba Dawson
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Patience Kunonga
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, UK, Newcastle, UK
| | - Fiona Beyer
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, UK, Newcastle, UK
| | - Gemma Spiers
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, UK, Newcastle, UK
| | - Matthew Booker
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Ruth McDonald
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Ailsa Cameron
- School for Policy Studies, University of Bristol, Bristol, UK
| | - Dawn Craig
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, UK, Newcastle, UK
| | - Barbara Hanratty
- Population Health Sciences Institute, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle University, UK, Newcastle, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Alyson Huntley
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
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Nielsen LM, Maribo T, Kirkegaard H, Bjerregaard MK, Oestergaard LG. Identifying elderly patients at risk of readmission after discharge from a short-stay unit in the emergency department using performance-based tests of daily activities. BMC Geriatr 2020; 20:217. [PMID: 32571229 PMCID: PMC7310017 DOI: 10.1186/s12877-020-01591-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 05/21/2020] [Indexed: 11/21/2022] Open
Abstract
Background Readmission is a serious and adverse event for elderly patients. Despite efforts, predicting the risk of readmission remains imprecise. The objective of this study is to examine if performance-based tests of daily activities can identify elderly patients at risk of readmission within 26 weeks after discharge from a short-stay unit in the emergency department. Methods The current study is an observational study based on data from 144 elderly patients included in a previous non-randomised controlled trial. Before discharge, patients were assessed for limitations in performing daily activities using three performance-based tests with predetermined cut-off values: the Assessment of Motor and Process Skills, Timed Up and Go and the 30s-Chair Stand Test. Outcome was risk of readmission within 26 weeks after discharge. Results Limitations in performing daily activities were associated with risk of readmission as measured by the Assessment of Motor and Process Skills motor scale (Crude OR = 4.38 [1.36; 14.12]), (Adjusted OR = 4.17 [1.18; 14.75]) and the 30s-Chair Stand Test (Adjusted OR = 3.36 [1.42; 7.93]). No significant associations were found in regards to other measures. Conclusion The Assessment of Motor and Process Skills motor scale and the age, gender and comorbidity adjusted 30s-Chair Stand Test can identify elderly patients at increased risk of readmission after discharge from the emergency department. The results were limited by one-third of the patients did not perform the Assessment of Motor and Process Skills and the association between 30s-Chair Stand Test and risk of readmission were only positive when adjusted for age, gender and comorbidity.
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Affiliation(s)
- Louise Moeldrup Nielsen
- Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Arhus, Denmark. .,Department of Occupational Therapy, VIA University College, Aarhus, Denmark.
| | - Thomas Maribo
- Department of Public Health, Aarhus University, Aarhus, Denmark.,DEFACTUM, Central Denmark Region, Aarhus, Denmark
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | | | - Lisa Gregersen Oestergaard
- Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Arhus, Denmark.,Department of Public Health, Aarhus University, Aarhus, Denmark.,DEFACTUM, Central Denmark Region, Aarhus, Denmark.,The Research Initiative for Activity Studies and Occupational Therapy, General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Gerhard T, Mayer K, Braisch U, Dallmeier D, Jamour M, Klaus J, Seufferlein T, Denkinger M. [Validation of the geriatrie-check for identification of geriatric patients in emergency departments]. Z Gerontol Geriatr 2020; 54:106-112. [PMID: 32112273 PMCID: PMC7946687 DOI: 10.1007/s00391-020-01699-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/16/2020] [Indexed: 11/12/2022]
Abstract
Hintergrund Der Geriatrie-Check wurde im Rahmen des Geriatriekonzept Baden-Württemberg zur Identifikation geriatrischer Patienten in der Notaufnahme entwickelt. Ziel Bestimmung der konvergenten und prädiktiven Validität des Geriatrie-Checks zu Identifikation und Verlaufsprädiktion geriatrischer Patienten in der Notaufnahme. Material und Methoden Prospektive Kohortenstudie zwischen November 2015 und April 2016 mit 146 Patienten, älter als 70 Jahre, der internistischen Notaufnahme der Uniklinik Ulm. Getrennte Erhebung durch Ärzte und Pflegende: Identification of Seniors at Risk (ISAR), Geriatrie-Check, weitere kognitive und funktionelle Assessments und als Endpunkte: Veränderung von Pflegestufe, Barthel-Index, Wohnform. Ergebnisse Der ISAR klassifizierte n =117 Patienten als geriatrisch, der Geriatrie-Check n =107. Die Übereinstimmung betrug 78,1 %. Mit dem ISAR als Goldstandard zeigte der Geriatrie-Check eine Sensitivität von 82,0 % und eine Spezifität von 62,1 %. Der positiv- bzw. negativ-prädiktive Wert lag bei 89,7 % bzw. 46,1 %. Mit dem ISAR als Goldstandard war die Einschätzung der Pflege präziser als die der Ärzte überlegen (Sensitivität 70,5 % vs. 58 %; Spezifität 88,9 % vs. 83,3 %). Die prädiktive Validität 5 Monate nach Aufnahme bezüglich oben genannter Endpunkte war am besten für die Einschätzung durch Pflege und Ärzte (insbesondere die Spezifität). Beide Tests waren sehr sensitiv, aber wenig spezifisch. Diskussion Der Geriatrie-Check ist dem ISAR vergleichbar. Die konvergente Validität unterscheidet sich nur wenig. Beide, ISAR und Geriatrie-Check, sind etwas sensitiver als Ärzte und Pflege. Bezüglich der prädiktiven Validität sind Ärzte und Pflege den Scores überlegen. Ein Algorithmus aus ISAR oder Geriatrie-Check mit nachfolgender Einschätzung durch Arzt oder Pflege könnte sich für eine bedarfsgerechte Ressourcenallokation am besten eignen.
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Affiliation(s)
- Tobias Gerhard
- Geriatrische Forschung der Universität Ulm, AGAPLESION Bethesda Ulm, Zollernring 26, 89073, Ulm, Deutschland.,Geriatrisches Zentrum Ulm/Alb-Donau, Universitätsklinikum Ulm, Ulm, Deutschland
| | - Kristina Mayer
- Geriatrische Forschung der Universität Ulm, AGAPLESION Bethesda Ulm, Zollernring 26, 89073, Ulm, Deutschland.,Geriatrisches Zentrum Ulm/Alb-Donau, Universitätsklinikum Ulm, Ulm, Deutschland
| | - Ulrike Braisch
- Geriatrische Forschung der Universität Ulm, AGAPLESION Bethesda Ulm, Zollernring 26, 89073, Ulm, Deutschland.,Geriatrisches Zentrum Ulm/Alb-Donau, Universitätsklinikum Ulm, Ulm, Deutschland.,Institut für Epidemiologie und Medizinische Biometrie, Universität Ulm, Ulm, Deutschland
| | - Dhayana Dallmeier
- Geriatrische Forschung der Universität Ulm, AGAPLESION Bethesda Ulm, Zollernring 26, 89073, Ulm, Deutschland.,Geriatrisches Zentrum Ulm/Alb-Donau, Universitätsklinikum Ulm, Ulm, Deutschland
| | - Michael Jamour
- Geriatrische Rehabilitationsklinik Ehingen, Ehingen, Deutschland
| | - Jochen Klaus
- Klinik für Innere Medizin I, Universitätsklinikum Ulm, Ulm, Deutschland
| | | | - Michael Denkinger
- Geriatrische Forschung der Universität Ulm, AGAPLESION Bethesda Ulm, Zollernring 26, 89073, Ulm, Deutschland. .,Geriatrisches Zentrum Ulm/Alb-Donau, Universitätsklinikum Ulm, Ulm, Deutschland.
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Shrapnel S, Dent E, Nicholson C. A nurse-led model of care within an emergency department reduces representation rates for frail aged care residents. Aging Clin Exp Res 2019; 31:1695-1698. [PMID: 30617858 DOI: 10.1007/s40520-018-1101-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 12/13/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hospital Emergency Departments (EDs) experience high presentation rates from older adults residing in Aged Care Facilities (ACFs), yet very few intervention studies have addressed the care needs of this population group. We designed and implemented a nurse-led model of care for older adults from ACFs, and determined its impact on patient outcomes. METHODS This 12-month pre-post intervention study was conducted during 2013-2014, with follow-up during 2015-2016. Participants included all older adults presenting from ACFs to the ED of Mater Hospital Brisbane (MHB), Australia. Frailty status was determined using the Clinical Frailty Scale (CFS). RESULTS All participants were frail (n = 1130), with 19% severely frail, 55% very-severely frail, and 26% terminally ill. The intervention resulted in several improvements in patient outcomes, including significant reductions in ward admissions and 28-day representation rates. CONCLUSION Significant improvements can be achieved by integration of an acute frail older person service into an ED.
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Affiliation(s)
- Sophie Shrapnel
- Mater/UQ Centre for Integrated Care and Innovation, Mater Health Services, Level 2 Aubigny Place, Raymond Tce, South Brisbane, QLD, 4101, Australia.
- Mater Research Institute, University of Queensland, Brisbane, QLD, Australia.
| | - Elsa Dent
- Mater/UQ Centre for Integrated Care and Innovation, Mater Health Services, Level 2 Aubigny Place, Raymond Tce, South Brisbane, QLD, 4101, Australia
- Mater Research Institute, University of Queensland, Brisbane, QLD, Australia
- Torrens University of Australia, Brisbane, QLD, Australia
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Caroline Nicholson
- Mater/UQ Centre for Integrated Care and Innovation, Mater Health Services, Level 2 Aubigny Place, Raymond Tce, South Brisbane, QLD, 4101, Australia
- Mater Research Institute, University of Queensland, Brisbane, QLD, Australia
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Wu Z, Kim MS, Broad JB, Zhang X, Bloomfield K, Connolly MJ. Association between post-discharge secondary care and risk of repeated hospital presentation, entry into long-term care and mortality in older people after acute hospitalization. Geriatr Gerontol Int 2019; 19:1048-1053. [PMID: 31475414 DOI: 10.1111/ggi.13766] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 07/30/2019] [Accepted: 08/05/2019] [Indexed: 11/26/2022]
Abstract
AIM Hospitalizations are frequent among acutely ill older people, and might be reduced by post-discharge secondary care (PDSC). We aimed to determine the proportion of older patients planned to receive or attending PDSC after acute hospitalization and the association with undesirable outcomes. METHODS A retrospective observational study was carried out using an electronic health record system in two hospitals in New Zealand. Patients were aged ≥75 years, initially presented at an emergency department (ED) and were discharged from medical, surgical, geriatrics or orthopedics wards in three 2-week periods. Planned PDSC at discharge, attended PDSC, ED presentation, long-term care (LTC) admission and death in 90 days after discharge were obtained through the health record system. Proportional hazards regression assessed the associations of planned or attended PDSC with undesirable outcomes (ED presentation, LTC admission and death) within 90 days of discharge. RESULTS Clinical records for 1085 patients were extracted, 963 were eligible. Of these, 413 (42.9%) had planned PDSC in discharge summaries, and 573 (59.5%) actually attended in 90 days. Patients planned for PDSC had a similarly adjusted hazard of ED presentation (HR 0.99, P = 0.92), LTC admission (HR 0.73, P = 0.25) and death (HR 0.80, P = 0.34) within 90 days of discharge, compared with those not planned. Similar non-significant associations were observed between attended PDSC and undesirable outcomes. CONCLUSIONS In patients aged ≥75 years in New Zealand, we did not find "planned PDSC" at discharge or "attended PDSC" after an acute hospitalization to be associated with ED presentation, LTC admission and death within 90 days after discharge. Other potential benefits of planned or attended PDSC require further investigation. Geriatr Gerontol Int 2019; 19: 1048-1053.
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Affiliation(s)
- Zhenqiang Wu
- Department of Geriatric Medicine, The University of Auckland, Auckland, New Zealand
| | - Min Soo Kim
- Auckland District Health Board, Auckland, New Zealand
| | - Joanna B Broad
- Department of Geriatric Medicine, The University of Auckland, Auckland, New Zealand
| | - Xian Zhang
- Department of Geriatric Medicine, The University of Auckland, Auckland, New Zealand
| | - Katherine Bloomfield
- Department of Geriatric Medicine, The University of Auckland, Auckland, New Zealand.,Waitemata District Health Board, Auckland, New Zealand
| | - Martin J Connolly
- Department of Geriatric Medicine, The University of Auckland, Auckland, New Zealand.,Waitemata District Health Board, Auckland, New Zealand
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Lisby M, Klingenberg M, Ahrensberg JM, Hoeyem PH, Kirkegaard H. Clinical impact of a comprehensive nurse-led discharge intervention on patients being discharged home from an acute medical unit: Randomised controlled trial. Int J Nurs Stud 2019; 100:103411. [PMID: 31629207 DOI: 10.1016/j.ijnurstu.2019.103411] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 08/20/2019] [Accepted: 08/23/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Acute medical units have increasingly been implemented in modern healthcare to ensure a fast track for treatment and care, thus increasing the number of patients being discharged. To avoid early readmissions, new approaches to discharging patients from these settings are needed. OBJECTIVE To investigate the clinical impact of a comprehensive nurse-led discharge intervention on patients being discharged home from an acute medical unit. OUTCOMES The primary outcome was 30-days hospital readmission. Secondary outcomes were utilisation of healthcare, including contacting emergency departments, the general practitioner or after-hours physicians; patient experience; and health-related quality of life. DESIGN This study was a non-blinded randomised clinical controlled trial with a 1 year enrolment period from November 2014 to 2015. Group assignment was performed by computer generated codes. SETTING The setting was a 34-bed acute medical unit at a Danish University Hospital. PARTICIPANTS Non-surgical patients aged 18+ with more than one contact to hospitals during the last 12 months were eligible for inclusion. Furthermore, patients had to have been discharged home and had a follow-up appointment after discharge. METHODS The intervention consisted of (1) an assessment of the patient's overall situation, (2) an assessment of their comprehension of discharge recommendations, (3) a simple discharge letter targeting the individual patient's health literacy and (4) a follow-up telephone call 2 days post-discharge. The study was carried out by a research nurse and the 1st author. Data was collected from medical records, registers and questionnaires. Intention-to-treat and per protocol analysis were performed. RESULTS In all, 200 participants were enrolled (101 intervention; 99 control). Of these, 17 were excluded due to transfer to another hospital department and 4 did not receive the full intervention, resulting in 86 in the intervention group and 93 in the control group. At 30 days post-discharge, 22/101 (22%) in the intervention group had at least one readmission vs. 19/99 (19%) in the control group. The total number of all-cause readmissions in the follow-up period was 0.28 (SD: 0.67) in the intervention group vs. 0.26 (SD: 0.63) in the control group. There were no statistically significant differences in baseline characteristics or any of the primary and secondary outcomes. CONCLUSION A comprehensive nurse-led discharge model focusing on the individual patient's situation and needs was not capable of reducing readmissions and healthcare utilisation. No statistically significant effects on quality of life or patients' experiences of the discharge from the acute medical unit were observed.
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Affiliation(s)
- M Lisby
- Research Centre for Emergency Medicine, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark; The Emergency Department, Aarhus University Hospital, Denmark.
| | - M Klingenberg
- The Emergency Department, Amager Hvidovre Hospital, Denmark; The Department of Endocrinology, Aarhus University Hospital, Denmark
| | - J M Ahrensberg
- The Emergency Department, Aarhus University Hospital, Denmark
| | - P H Hoeyem
- The Department of Endocrinology, Aarhus University Hospital, Denmark; The Emergency Department, The Regional Hospital in Horsens, Denmark
| | - H Kirkegaard
- Research Centre for Emergency Medicine, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark; The Emergency Department, Aarhus University Hospital, Denmark
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36
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Nielsen LM, Gregersen Østergaard L, Maribo T, Kirkegaard H, Petersen KS. Returning to everyday life after discharge from a short-stay unit at the Emergency Department-a qualitative study of elderly patients' experiences. Int J Qual Stud Health Well-being 2019; 14:1563428. [PMID: 30693847 PMCID: PMC6352949 DOI: 10.1080/17482631.2018.1563428] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: Elderly patients often receive care and rehabilitation from different providers across healthcare settings. Collaboration between hospital and primary care providers is therefore essential to ensure that the discharge and transition of rehabilitation is coherent. However, research that focuses on elderly patients’ experiences of the discharge, and their everyday lives after, has attracted little attention. Purpose: This study explores elderly patients’ experiences of being discharged and returning to everyday lives after discharge from a short-stay unit at the Emergency Department. Methods: Eleven qualitative interviews with elderly patients were conducted two weeks after their discharge. The transcribed interviews were analysed using systematic text condensation. Results: The study identified four themes related to the participants experiences. In the participants perspective it was difficult, due to fatigue and pain, to perform daily activities after discharge. Participants who experienced not being prepared and clarified in relation to their discharge continued to have concerns for the future. They also experienced some challenges related to lack of being involved and lack of receiving the information needed. Conclusion: The findings contribute with impotant knowledge about elderly patients' experiences and concerns which should be taken into consideration in the discharge planning process .
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Affiliation(s)
- Louise Moeldrup Nielsen
- a Department of Physiotherapy and Occupational Therapy , Aarhus University Hospital , Aarhus , Denmark.,b Department of Occupational Therapy , VIA University College , Aarhus , Denmark.,c Research Centre for Emergency Medicine, Department of Clinical Medicine , Aarhus University Hospital , Aarhus , Denmark
| | - Lisa Gregersen Østergaard
- a Department of Physiotherapy and Occupational Therapy , Aarhus University Hospital , Aarhus , Denmark.,d Department of Public Health , Aarhus University , Aarhus , Denmark.,e Centre of Research in Rehabilitation (CORIR), Department of Clinical Medicine , Aarhus University and Aarhus University Hospital , Aarhus , Denmark
| | - Thomas Maribo
- d Department of Public Health , Aarhus University , Aarhus , Denmark.,f DEFACTUM , Aarhus , Denmark
| | - Hans Kirkegaard
- c Research Centre for Emergency Medicine, Department of Clinical Medicine , Aarhus University Hospital , Aarhus , Denmark
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Hughes JM, Freiermuth CE, Shepherd-Banigan M, Ragsdale L, Eucker SA, Goldstein K, Hastings SN, Rodriguez RL, Fulton J, Ramos K, Tabriz AA, Gordon AM, Gierisch JM, Kosinski A, Williams JW. Emergency Department Interventions for Older Adults: A Systematic Review. J Am Geriatr Soc 2019; 67:1516-1525. [PMID: 30875098 PMCID: PMC6677239 DOI: 10.1111/jgs.15854] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/21/2019] [Accepted: 02/02/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To evaluate the effect of emergency department (ED) interventions on clinical, utilization, and care experience outcomes for older adults. DESIGN A conceptual model informed, protocol-based systematic review. SETTING Emergency Department (ED). PARTICIPANTS Older adults 65 years of age and older. METHODS AND MEASUREMENT Medline, Embase, CINAHL, and PsycINFO were searched for English-language studies published through December 2017. Studies evaluating the use of one or more eligible intervention strategies (discharge planning, case management, medication safety or management, and geriatric EDs including those that cited the 2014 Geriatric ED Guidelines) with adults 65 years of age and older were included. Studies were classified by the number of intervention strategies used (ie, single strategy or multi-strategy) and key intervention components present (ie, assessment, referral plus follow-up, and contact both before and after ED discharge ["bridge"]). The effect of ED interventions on clinical (functional status, quality of life [QOL]), patient experience, and utilization (hospitalization, ED return visit) outcomes was evaluated. RESULTS A total of 2000 citations were identified; 17 articles describing 15 unique studies (9 randomized and 6 nonrandomized) met eligibility criteria and were included in analyses. ED interventions showed a mixed pattern of effects. Overall, there was a small positive effect of ED interventions on functional status but no effects on QOL, patient experience, hospitalization at or after the initial ED index visit, or ED return visit. CONCLUSION Studies using two or more intervention strategies may be associated with the greatest effects on clinical and utilization outcomes. More comprehensive interventions, defined as those with all three key intervention components present, may be associated with some positive outcomes.
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Affiliation(s)
- Jaime M. Hughes
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina
| | - Caroline E. Freiermuth
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Megan Shepherd-Banigan
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Luna Ragsdale
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Stephanie A. Eucker
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Karen Goldstein
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - S. Nicole Hastings
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, North Carolina
| | | | - Jessica Fulton
- Psychology Service, Durham VA Health Care System, Durham, North Carolina
| | - Katherine Ramos
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, North Carolina
| | - Amir Alishahi Tabriz
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Adelaide M. Gordon
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
| | - Jennifer M. Gierisch
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Andrzej Kosinski
- Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina
| | - John W. Williams
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
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Beauchet O, Fung S, Launay CP, Cooper-Brown LA, Afilalo J, Herbert P, Afilalo M, Chabot J. Screening for older inpatients at risk for long length of stay: which clinical tool to use? BMC Geriatr 2019; 19:156. [PMID: 31170929 PMCID: PMC6555010 DOI: 10.1186/s12877-019-1165-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 05/21/2019] [Indexed: 11/23/2022] Open
Abstract
Background Screening for inpatients at risk for long length of stay (LOS) is the first step of an effective hospital care plan for older inpatients. This study aims, in older adults admitted to a geriatric acute care ward, to examine and compare the 6-item brief geriatric assessment (BGA) and the “Programme de Recherche sur l’Intégration des Services pour le Maintien de l’Autonomie” (PRISMA-7) risk levels with long LOS, and to establish their performance criteria (i.e., sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios) for LOS. Methods Based on an observational, retrospective, cohort design, 166 inpatients aged ≥75 admitted to a geriatric acute care ward of a McGill University-affiliated hospital (Montreal, Quebec, Canada) were recruited. The risk levels of the 6-item BGA (low, moderate and high) and the PRISMA-7 (low versus high) were calculated from a baseline assessment. The LOS was subsequently calculated in number of days. Results Only the 6-item BGA high risk level was associated with a long LOS (Odds ratio = 1.1 with P = 0.028 and Hazard ratio = 2.1 with P = 0.004). Kaplan-Meier distributions showed that there was no significant difference in the delay of hospital discharge between the low and high-risk level reported by the PRISMA-7 (P = 0.381), whereas the 6-item BGA three risk levels differed significantly (P = 0.008), with individuals at high risk levels being discharged later when compared to those with low (P = 0.001) and moderate (P = 0.019) risk levels. Both tools’ performance criteria were poor (i.e., < 0.70), except for PRISMA-7’s sensitivity which was 100%. Conclusion The 6-item BGA risk levels were associated with LOS, low risk-level being associated with short LOS and high-risk level with long LOS, but no association was reported with the PRISMA-7 risk levels. Both tools had poor performance criteria for long LOS, suggesting that they cannot be used as prognostic tools with current scientific knowledge.
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Affiliation(s)
- Olivier Beauchet
- Department of Medicine, Division of Geriatric Medicine, Sir Mortimer B. Davis - Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, 3755 chemin de la Côte-Sainte-Catherine, Montréal, QC, H3T 1E2, Canada. .,Dr. Joseph Kaufmann Chair in Geriatric Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada. .,Centre of Excellence on longevity of McGill integrated University Health Network, Montreal, Quebec, Canada. .,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
| | - Shek Fung
- Department of Medicine, Division of Geriatric Medicine, St. Mary's Hospital Center, McGill University, Montreal, Quebec, Canada
| | - Cyrille P Launay
- Geriatric Medicine and Geriatric Rehabilitation ServiceDepartment of Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Liam Anders Cooper-Brown
- Centre of Excellence on longevity of McGill integrated University Health Network, Montreal, Quebec, Canada
| | - Jonathan Afilalo
- Division of Cardiology and Centre for Clinical Epidemiology, Jewish General Hospital and McGill University, Montreal, Quebec, Canada
| | - Paul Herbert
- Department of medicine, Montreal university Hospital and University of Montreal, Montreal, Quebec, Canada
| | - Marc Afilalo
- Emergency Department, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Julia Chabot
- Department of Medicine, Division of Geriatric Medicine, Sir Mortimer B. Davis - Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, 3755 chemin de la Côte-Sainte-Catherine, Montréal, QC, H3T 1E2, Canada.,Department of Medicine, Division of Geriatric Medicine, St. Mary's Hospital Center, McGill University, Montreal, Quebec, Canada
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Doheny M, Agerholm J, Orsini N, Schön P, Burström B. Socio-demographic differences in the frequent use of emergency department care by older persons: a population-based study in Stockholm County. BMC Health Serv Res 2019; 19:202. [PMID: 30922354 PMCID: PMC6440084 DOI: 10.1186/s12913-019-4029-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 03/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Sweden, the number of older people using emergency department (ED) care is rising. Among older persons an ED visit is a stressful event, which potentially could have been prevented or treated at other levels of care. Frequent ED use (> 4 visits a year) by older persons might reflect issues in the organisation of health care system to address their needs. We aimed to explore socio-demographic differences among older people seeking ED care in terms age and gender, and to investigate the association between income and frequent ED use. METHODS A population-based study analysing the utilisation of ED care by (N = 356,375) individuals aged 65+ years. We linked register data on socio-demographic characteristics from 2013 to health care utilisation data in 2014. Multivariable logistic regression was used to estimate the income differences in the frequent use of ED care, adjusting for living situation, country of birth, residential area, age in years, multi-morbidity and the use of other health care services. RESULTS Those 65+ years accounted for (27%) of all ED visits in Stockholm County in 2014. In the study population (2.5%) were identified as frequent ED users, who were predominantly in the lower income groups, living alone or in an institution, had more multi-morbidity, and utilised more of other health care services. The lowest income groups had a three-fold greater odds of being a frequent ED user than those in the highest income group. In the adjusted models, the odds were reduced by 12-44% for those in the lowest income groups. However, age and gender differences were observed with men 65-79 years (OR 1.75 CI: 1.51-2.03) and women 80+ years (OR 1.50, CI 1.19-1.87) in the lowest income groups having a higher odds of frequent ED use. CONCLUSION This study observed that ED visits by older persons are driven by a need of care, and those that frequently visit hospital-based EDs are a socially disadvantaged group, which suggests that the organisation of care for older people should be reviewed in order to better meet their needs in other levels of care.
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Affiliation(s)
- Megan Doheny
- Department of Public Health Sciences, Karolinska Institutet, Plan 6, Solnavägen 1 E, 113 65, Stockholm, Sweden.
| | - Janne Agerholm
- Aging Research Center, Karolinska Institutet, Stockholm, Sweden
| | - Nicola Orsini
- Department of Public Health Sciences, Karolinska Institutet, Plan 6, Solnavägen 1 E, 113 65, Stockholm, Sweden
| | - Pär Schön
- Aging Research Center, Karolinska Institutet, Stockholm, Sweden
| | - Bo Burström
- Department of Public Health Sciences, Karolinska Institutet, Plan 6, Solnavägen 1 E, 113 65, Stockholm, Sweden.,Center for epidemiology and community medicine, County Council, Stockholm, Sweden
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Morse L, Xiong L, Ramirez-Zohfeld V, Dresden S, Lindquist LA. Tele-Follow-Up of Older Adult Patients from the Geriatric Emergency Department Innovation (GEDI) Program. Geriatrics (Basel) 2019; 4:geriatrics4010018. [PMID: 31023986 PMCID: PMC6473232 DOI: 10.3390/geriatrics4010018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/22/2019] [Accepted: 01/24/2019] [Indexed: 11/24/2022] Open
Abstract
The objective of this study was to characterize the content and interventions performed during follow-up phone calls made to patients discharged from the Geriatrics Emergency Department Innovation (GEDI) Program and to demonstrate the benefit of these calls in the care of older adults discharged from the emergency department (ED). This study utilizes retrospective chart review with qualitative analysis. It was set in a large, urban, academic hospital emergency department utilizing the Geriatric Emergency Department Innovations (GEDI) Program. The subjects were adults aged 65 and over who visited the emergency department for acute care. Follow-up telephone calls were made by geriatric nurse liaisons (GNLs) at 24–72 h and 10–14 days post-discharge from the ED. The GNLs documented the content of the phone calls, and these notes were analyzed through a constant comparative method to identify emergent themes. The results showed that the most commonly arising themes in the patients’ questions and nurses’ responses across time-points included symptom management, medications, and care coordination (physician appointments, social services, therapy, and medical equipment). Early follow-up presented the opportunity for nurses to address needs in symptom management and care coordination that directly related to the ED admission; later follow-up presented a unique opportunity to resolve sub-acute issues that were not addressed by the initial discharge plan and to manage newly arising symptoms and patient needs. Thus, telephone follow-up after emergency department discharge presents an opportunity to better connect older adults with appropriate outpatient care and to address needs arising shortly after discharge that may not have otherwise been detected. By following up at two discrete time-points, this intervention identifies and addresses distinct patient needs.
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Affiliation(s)
- Lucy Morse
- Division of General Internal Medicine & Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
| | - Linda Xiong
- Division of General Internal Medicine & Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
| | - Vanessa Ramirez-Zohfeld
- Division of General Internal Medicine & Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
| | - Scott Dresden
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
| | - Lee A Lindquist
- Division of General Internal Medicine & Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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Teo DB, Wong HC, Yeo AW, Lai YW, Choo EL, Merchant RA. Characteristics of fall-related traumatic brain injury in older adults. Intern Med J 2019; 48:1048-1055. [PMID: 29573078 DOI: 10.1111/imj.13794] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 03/14/2018] [Accepted: 03/14/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Older adults admitted for falls and its complications, including traumatic brain injury (TBI), is increasing. Recent studies have shown that those with falls who presented to the emergency department (ED) had an increased frequency of ED revisits, especially those with head trauma. AIM To determine the characteristics and predictors of fall-related traumatic brain injury (FRTBI) in older adults. METHODS Retrospective medical chart review of 339 patients aged 65 years and older admitted for TBI in 2014 due to a fall. Characteristics analysed include demographics, fall circumstances, prior ED visits, polypharmacy, readmission, functional status and specialist outpatient clinic utilisation before and after FRTBI. RESULTS A total of 339 (37.4%) patients admitted due to FRTBI was 65 years old and older; 112 (33.0%) for subdural haemorrhage (SDH); 227 (67.0%) for head injury (HI), with a mean age of 80 years. A total of 46 (41.1%) patients with SDH and 107 (47.1%) with HI had a previous ED visit within the last year, while 22 (19.6%) of SDH and 49 (21.6%) of HI had hospitalisation 3 months prior to FRTBI. FRTBI was associated with significant decline in activities of daily living, polypharmacy and increased specialist outpatient clinic appointments (P < 0.001). Mortality was 11 (3.2%). Mild cognitive impairment or dementia was significantly associated with admissions for FRTBI, 3.31 (95% confidence interval 1.68-6.51, P = 0.001) using adjusted logistic regression. CONCLUSION FRTBI is associated with significant functional decline and increased resource utilisation with almost half of the patients having had prior ED visits or hospitalisation. Future studies should focus on falls risk assessment and interventions for high-risk older adults prior to discharge from ED and hospital, and its impact on readmissions due to FRTBI.
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Affiliation(s)
- Desmond B Teo
- Divisions of Advanced Internal Medicine, University Medicine Cluster, National University Hospital, National University Healthcare System, Singapore, Singapore
| | - Hung C Wong
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ai W Yeo
- Department of Nursing, National University Hospital, National University Healthcare System, Singapore, Singapore
| | - Yi W Lai
- Dean's Office, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ee L Choo
- Management Information, Corporate Planning and Development, National University Hospital, National University Healthcare System, Singapore, Singapore
| | - Reshma A Merchant
- Divisions of Geriatric Medicine, University Medicine Cluster, National University Hospital, National University Healthcare System, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Sheen JJ, Smith HA, Tu B, Liu Y, Sutton D, Bernstein PS. Risk Factors for Postpartum Emergency Department Visits in an Urban Population. Matern Child Health J 2019; 23:557-566. [DOI: 10.1007/s10995-018-2673-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Trivedi S, Roberts C, Karreman E, Lyster K. Characterizing the Long-term Care and Community-dwelling Elderly Patients' Use of the Emergency Department. Cureus 2018; 10:e3642. [PMID: 30705794 PMCID: PMC6349572 DOI: 10.7759/cureus.3642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction Elderly patients, particularly those in long-term care (LTC), are a growing proportion of patients who present to the emergency department (ED). This population is medically complex, with high burdens on ED resources and patient flow. This study sought to characterize how elderly LTC and community-dwelling (CD) patients use ED services. Materials and methods This was a retrospective cohort study that assessed approximately 200 senior (age>65) ED visits. These patients were either residing in LTC facilities or they were CD. All participants lived in the same, medium-sized Canadian city. Data indicating demographic information, acuity of presentation, and administrative parameters (such as disposition status or length of stay) were collected and analyzed. Results A few statistically significant differences between the populations were noted. This included mean age, which was 82.6 years in the LTC population and 77.3 for the CD group (p<0.001). There were 27 repeat visits among patients in the LTC group, compared to six from the CD patients (p<0.001). In the LTC population, 75 patients required transport from emergency medical services (EMS) compared to 41 from the control group (p<0.001). Conclusion LTC patients re-present to the ED and use EMS services more frequently than their CD counterparts. This difference indicates potential areas to target for future quality improvement work to help enhance care to this vulnerable population.
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Affiliation(s)
- Sachin Trivedi
- Emergency Medicine, University of Saskatchewan, Saskatoon, CAN
| | | | - Erwin Karreman
- Miscellaneous, Regina Qu'appelle Health Region, Regina, CAN
| | - Kish Lyster
- Internal Medicine, Regina Qu'appelle Health Region, Regina, CAN
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Kandasamy D, Platts-Mills TF, Shah MN, Van Orden KA, Betz ME. Social Disconnection Among Older Adults Receiving Care in the Emergency Department. West J Emerg Med 2018; 19:919-925. [PMID: 30429922 PMCID: PMC6225945 DOI: 10.5811/westjem.2018.9.38784] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/15/2018] [Accepted: 09/04/2018] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Social disconnection is a public health problem in older adults, as it can lead to decreased quality of life for this population. This study describes the prevalence of social disconnection and patient interest in social resources to address social disconnection among older adults receiving emergency department (ED) care. METHODS We conducted a cross-sectional survey of community-dwelling older adults (≥65 years) receiving care at two U.S. EDs. We described participant characteristics (demographic, social, and health variables), social disconnection prevalence, and desire for social resources using percentages and 95% confidence intervals. Then, we performed Chi Square tests and logistic regression to determine factors associated with positive screens for social disconnection. RESULTS Of 289 participants, 51% were female and the median age was 72 (interquartile range: 69-78). Most (76%) engaged with the community regularly, and 68% reported driving. Regarding social disconnection, a substantial minority of participants reported feeling as if they were burdensome to others (37%); as if they didn't belong (27%); or that people would be better off if they were gone (15%); 52% reported at least one of these. In separate regression analyses, the perceptions of being a burden or better off if gone were each significantly associated with needing help with routine tasks (odds ratio [OR] [5.87, 5.90]); perceived burden was associated with hospitalization in the prior month (OR [2.09]); and low belonging was associated with not engaging in the community regularly (OR [2.50]), not seeing family regularly (OR [3.82]), and difficulty affording food (OR [2.50]). Regarding potential ED referrals, most participants were interested in transportation options (68%), food assistance (58%), and mental health resources (55%). Participants experiencing difficulties affording food were interested in food and housing assistance (p=.03; p=.01). CONCLUSION Over half of this sample of older ED patients reported feeling socially disconnected. Social and functional health problems are often related and both must be addressed to optimize older ED patient quality of life. Future research should consider the impact of social disconnection on older adults discharged from the ED and work to develop ED services that could refer this population to programs that may decrease social disconnection.
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Affiliation(s)
- Deepika Kandasamy
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Timothy F. Platts-Mills
- University of North Carolina of Chapel Hill School of Medicine, Department of Emergency Medicine, Chapel Hill, North Carolina
| | - Manish N. Shah
- University of Wisconsin School of Medicine and Public Health, Department of Emergency Medicine, Madison, Wisconsin
| | - Kim A. Van Orden
- University of Rochester School of Medicine and Dentistry, Department of Psychiatry, Rochester, New York
| | - Marian E. Betz
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
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Devriendt E, Heeren P, Fieuws S, Wellens NIH, Deschodt M, Flamaing J, Sabbe M, Milisen K. Unplanned Readmission prevention by Geriatric Emergency Network for Transitional care (URGENT): protocol of a prospective single centre quasi-experimental study. BMC Geriatr 2018; 18:244. [PMID: 30326860 PMCID: PMC6191899 DOI: 10.1186/s12877-018-0933-x] [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] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 10/01/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND International guidelines recommend adapting the classic emergency department (ED) management model to the needs of older adults in order to ameliorate post-ED outcomes among this vulnerable group. To improve the care for older ED patients and especially prevent unplanned ED readmissions, the URGENT care model was developed. METHODS The URGENT care model is a nurse-led, comprehensive geriatric assessment based care model in the ED with geriatric follow-up after ED discharge. A prospective single centre quasi-experimental study (sequential design with two cohorts) is used to evaluate its effectiveness on unplanned ED readmission compared to usual ED care. Secondary outcome measures are hospitalization rate, ED length of stay, in-hospital length of stay, higher level of care, functional decline and mortality. DISCUSSION URGENT builds on previous research with adaptations tailored to the local context and addresses the needs of older patients in the ED with a special focus on transition of care. Although the selected approaches have been tested in other settings, evidence on this type of innovative care models in the ED setting is inconclusive. TRIAL REGISTRATION The study protocol is registered retrospectively with ISRCTN ( ISRCTN91449949 ).
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Affiliation(s)
- Els Devriendt
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, B-3000 Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Pieter Heeren
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, B-3000 Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Research Foundation Flanders, Egmontstraat 5, 1000 Brussels, Belgium
| | - Steffen Fieuws
- I-Biostat Interuniversity Institute for Biostatistics and statistical Bioinformatics KU Leuven, Kapucijnenvoer 35/3, 3000 Leuven, Belgium
| | - Nathalie I. H. Wellens
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, B-3000 Leuven, Belgium
- Public Health and Social Affairs Department, Government Canton Vaud, Avenue des Casernes 2, 1014 Lausanne, Switzerland
| | - Mieke Deschodt
- Department of Chronic Diseases, Metabolism and Ageing, Gerontology and Geriatrics, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Public Health, Nursing Science, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
| | - Johan Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, Gerontology and Geriatrics, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Marc Sabbe
- Department of Emergency Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Public Health and Primary Care, Emergency Medicine, KU Leuven, Kapucijnenvoer 35/4, 3000 Leuven, Belgium
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, B-3000 Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
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Nielsen LM, Maribo T, Kirkegaard H, Petersen KS, Lisby M, Oestergaard LG. Effectiveness of the "Elderly Activity Performance Intervention" on elderly patients' discharge from a short-stay unit at the emergency department: a quasi-experimental trial. Clin Interv Aging 2018; 13:737-747. [PMID: 29731615 PMCID: PMC5927350 DOI: 10.2147/cia.s162623] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Purpose To examine the effectiveness of the Elderly Activity Performance Intervention on reducing the risk of readmission in elderly patients discharged from a short-stay unit at the emergency department. Patients and methods The study was conducted as a nonrandomized, quasi-experimental trial. Three hundred and seventy-five elderly patients were included and allocated to the Elderly Activity Performance Intervention (n=144) or usual practice (n=231). The intervention consisted of 1) assessment of the patients’ performance of daily activities, 2) referral to further rehabilitation, and 3) follow-up visit the day after discharge. Primary outcome was readmission (yes/no) within 26 weeks. The study was registered in ClinicalTrial.gov (NCT02078466). Results No between-group differences were found in readmission. Overall, 44% of the patients in the intervention group and 42% in the usual practice group were readmitted within 26 weeks (risk difference=0.02, 95% CI: [−0.08; 0.12] and risk ratio=1.05, 95% CI: [0.83; 1.33]). No between-group differences were found in any of the secondary outcomes. Conclusion The Elderly Activity Performance Intervention showed no effectiveness in reducing the risk of readmission in elderly patients discharged from a short-stay unit at the emergency department. The study revealed that 60% of the elderly patients had a need for further rehabilitation after discharge.
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Affiliation(s)
- Louise Moeldrup Nielsen
- Department of Occupational Therapy, VIA University College.,Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital
| | - Thomas Maribo
- Department of Public Health, Aarhus University, DEFACTUM
| | - Hans Kirkegaard
- Department of Clinical Medicine, Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus
| | | | - Marianne Lisby
- Department of Clinical Medicine, Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus
| | - Lisa Gregersen Oestergaard
- Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital.,Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
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Preston L, Chambers D, Campbell F, Cantrell A, Turner J, Goyder E. What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06160] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BackgroundEmergency departments (EDs) are facing unprecedented levels of demand. One of the causes of this increased demand is the ageing population. Older people represent a particular challenge to the ED as those older people who are frail will require management that considers their frailty alongside their presenting complaint. How to identify these older people as frail and how best to manage them in the ED is a major challenge for the health service to address.ObjectivesTo systematically map interventions to identify frail and high-risk older people in the ED and interventions to manage older people in the ED and to map the outcomes of these interventions and examine whether or not there is any evidence of the impact of these interventions on patient and health service outcomes.DesignA systematic mapping review.SettingEvidence from developed countries on interventions delivered in the ED.ParticipantsFrail and high-risk older people and general populations of older people (aged > 65 years).InterventionsInterventions to identify older people who are frail or who are at high risk of adverse outcomes and to manage (frail) older people within the ED.Main outcome measuresPatient outcomes (direct and indirect) and health service outcomes.Data sourcesEvidence from 103 peer-reviewed articles and conference abstracts and 17 systematic reviews published from 2005 to 2016.Review methodsA review protocol was drawn up and a systematic database search was undertaken for the years 2005–2016 (using MEDLINE, EMBASE, The Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium and PROSPERO). Studies were included according to predefined criteria. Following data extraction, evidence was classified into interventions relating to the identification of frail/high-risk older people in the ED and interventions relating to their management. A narrative synthesis of interventions/outcomes relating to these categories was undertaken. A quality assessment of individual studies was not undertaken; instead, an assessment of the overall evidence base in this area was made.ResultsOf the 90 included studies, 32 focused on a frail/high-risk population and 60 focused on an older population. These studies reported on interventions to identify (n = 57) and manage (n = 53) older people. The interventions to identify frail and at-risk older people, on admission and at discharge, utilised a number of different tools. There was extensive evidence on these question-based tools, but the evidence was inconclusive and contradictory. Service delivery innovations comprised changes to staffing, infrastructure and care delivery. There was a general trend towards improved outcomes in admissions avoidance, reduced ED reattendance and improved discharge outcomes.LimitationsThis review was a systematic mapping review. Some of the methods adopted differed from those used in a standard systematic review. Mapping the evidence base has led to the inclusion of a wide variety of evidence (in terms of study type and reporting quality). No recommendations on the effectiveness of specific interventions have been made as this was outside the scope of the review.ConclusionsA substantial body of evidence on interventions for frail and high-risk older people was identified and mapped.Future workFuture work in this area needs to determine why interventions work and whether or not they are feasible for the NHS and acceptable to patients.Study registrationThis study is registered as PROSPERO CRD42016043260.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Louise Preston
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Fiona Campbell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Janette Turner
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Kim MY, Subramaniam P, Flicker L. The Australian Aged Care and Its Implications for the Korean Aging Crisis. Ann Geriatr Med Res 2018; 22:9-19. [PMID: 32743238 PMCID: PMC7387634 DOI: 10.4235/agmr.2018.22.1.9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 12/22/2017] [Accepted: 12/25/2017] [Indexed: 11/01/2022] Open
Abstract
The Australian aged care system has evolved for >50 years to support frail older adults and allow them to make informed decisions about their care. Hospitals provide streamlined geriatric services from visits at the Emergency Department to discharges from acute and subacute geriatric care units. Moreover, nonhospital aged care services, including Transition Care Program, Commonwealth Home Support Program, Home Care Packages Program, and Residential Care (nursing home) are provided under the auspices of the Australian Government. These various specialized hospital and nonhospital services are integrated and coordinated by the multidisciplinary assessment team called ACAT (Aged Care Assessment Team). Korea does not have a similar amount of time to prepare a well-organized aged care system because of a rapidly increasing older population. The Korean government and aged care experts should exert vigorous efforts to improve the last journeys of the Korean older population.
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Affiliation(s)
- Moo-Young Kim
- Department of Family Medicine, Seoul Medical Center, Seoul, Korea
| | - Premala Subramaniam
- Department of General Medicine, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Leon Flicker
- Department of Geriatric Medicine, Royal Perth Hospital, University of Western Australia Medical School, Perth, Australia.,WA Centre for Health and Ageing, Centre for Medical Research, Perth, Australia
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49
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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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50
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Hall AG, Schumacher JR, Brumback B, Harman JS, Lutz BJ, Hendry P, Carden D. Health-related quality of life among older patients following an emergency department visit and emergency department-to-home coaching intervention: A randomized controlled trial. INTERNATIONAL JOURNAL OF CARE COORDINATION 2017. [DOI: 10.1177/2053434517733263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Many older patients experience repeated emergency department visits and hospitalizations and inadequate links to primary care. This fragmented care can result in anxiety, uncertainty, and poor health outcomes. This study compares the impact of an emergency department-to-home coaching intervention to usual, post-emergency department care on patient-reported health-related quality of life measures: information support, anxiety, and physical function. Methods This was a randomized controlled trial. Seven hundred and forty-nine chronically ill older adults presenting to emergency departments were randomized into Intervention (emergency department-to-home coaching) or Usual Care groups. Participants completed baseline, in-person and follow-up, telephone surveys. Within- and between-group differences in health-related quality of life were assessed using unweighted linear regression and propensity-weighted difference-in-difference analyses. Three Patient Reported Outcomes Measurement System measures were assessed: social health (informational support), mental health (anxiety/emotional distress), and physical health (physical functioning). Results Usual Care participants experienced statistically significant declines in informational support in unweighted (−3.13) and weighted (−2.84) analyses not observed in the Intervention group (−0.91 and −1.45, respectively). Self-reported anxiety was lowest and physical function highest at the time of emergency department visit. Patient-reported anxiety increased and physical function declined statistically significantly in Intervention participants. Conclusion Among older emergency department patients, health-related quality of life was highest at the emergency department visit and declined following the encounter. The emergency department visit per se appears to provide needed information, and in the short term, reassurance about patients’ medical conditions. The coaching intervention blunts the fall in informational support observed after usual, post-emergency department care but may heighten patients’ anxiety and awareness of chronic health conditions.
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