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Chary AN, Bhananker AR, Brickhouse E, Torres B, Santangelo I, Godwin KM, Naik AD, Carpenter CR, Liu SW, Kennedy M. Implementation of delirium screening in the emergency department: A qualitative study with early adopters. J Am Geriatr Soc 2024. [PMID: 39264150 DOI: 10.1111/jgs.19188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/26/2024] [Accepted: 08/04/2024] [Indexed: 09/13/2024]
Abstract
INTRODUCTION Delirium affects 15% of older adults presenting to emergency departments (EDs) but is detected in only one-third of cases. Evidence-based guidelines for ED delirium screening exist, but are underutilized. Frontline staff perceptions about delirium and time and resource constraints are known barriers to ED delirium screening uptake. Early adopters of ED delirium screening can offer valuable lessons about successful implementation. METHODS We conducted semi-structured interviews with clinician-administrators leading ED delirium screening initiatives from 20 EDs in the United States and Canada. Interviews focused on experiences of planning and implementing ED delirium screening. Interviews lasted 15 to 50 minutes and were digitally recorded and transcribed. To identify factors that commonly impacted implementation of ED delirium screening, we used constructs from the Consolidated Framework for Implementation Research (CFIR), an Implementation Science framework widely used to evaluate healthcare improvement initiatives. RESULTS Overall, notable facilitators of successful implementation were having institutional and ED leadership support and designated clinical champions to longitudinally engage and educate frontline staff. We found specific examples of factors affecting implementation drawn from the following seven CFIR constructs: (1) intervention complexity, (2) intervention adaptability, (3) external policies and incentives, (4) peer pressure from other institutions, (5) the implementation climate of the ED, (6) staff knowledge and beliefs, and (7) engaging deliverers of intervention, that is, frontline ED staff. CONCLUSION Implementing ED delirium screening is complex and requires institutional resources as well as clinical champions to engage frontline staff in a sustained fashion.
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Affiliation(s)
- Anita N Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Annika R Bhananker
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Elise Brickhouse
- School of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Beatrice Torres
- University of Texas School of Public Health, UT Health Science Center, Houston, Texas, USA
| | - Ilianna Santangelo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kyler M Godwin
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Aanand D Naik
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- University of Texas School of Public Health, UT Health Science Center, Houston, Texas, USA
- Institute on Aging, University of Texas Health Science Center, Houston, Texas, USA
| | | | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Pepping RMC, Vos RC, Numans ME, Kroon I, Rappard K, Labots G, van Nieuwkoop C, van Aken MO. An emergency department transitional care team prevents unnecessary hospitalization of older adults: a mixed methods study. BMC Geriatr 2024; 24:668. [PMID: 39118014 PMCID: PMC11312197 DOI: 10.1186/s12877-024-05260-2] [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: 01/21/2024] [Accepted: 07/29/2024] [Indexed: 08/10/2024] Open
Abstract
INTRODUCTION Older adults with acute functional decline may visit emergency departments (EDs) for medical support despite a lack of strict medical urgency. The introduction of transitional care teams (TCT) at the ED has shown promise in reducing avoidable admittances. However, the optimal composition and implementation of TCTs are still poorly defined. We evaluated the effect of TCTs consisting of an elderly care physician (ECP) and transfer nurse versus a transfer nurse only on reducing hospital admissions, as well as the experience of patients and caregivers regarding quality of care. METHODS We assessed older adults (≥ 65 years) at the ED with acute functional decline but no medical indication for admission. Data were collected on type and post-ED care, and re-visits were evaluated over a 30-day follow-up period. Semi-structured interviews with stakeholders were based on the Consolidated-Framework-for-Implementation-Research, while patient and caregiver experiences were collected through open-ended interviews. RESULTS Among older adults (N = 821) evaluated by the TCT, ECP and transfer nurse prevented unnecessary hospitalization at the same rate (81.2%) versus a transfer nurse alone (79.5%). ED re-visits were 15.6% (ECP and transfer nurse) versus 13.5%. The interviews highlighted the added value of an ECP, which consisted of better staff awareness, knowledge transfer and networking with external organizations. The TCT intervention in general was broadly supported, but adaptability was regarded as an important prerequisite. CONCLUSION Regardless of composition, a TCT can prevent unnecessary hospitalization of older adults without increasing ED re-visiting rates, while the addition of an ECP has a favourable impact on patient and professional experiences.
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Affiliation(s)
- R M C Pepping
- Department of Public Health & Primary Care/Health Campus The Hague, Leiden University Medical Center, Eilersplein 275, Den Haag, 2545 AA, The Netherlands
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - R C Vos
- Department of Public Health & Primary Care/Health Campus The Hague, Leiden University Medical Center, Eilersplein 275, Den Haag, 2545 AA, The Netherlands
| | - M E Numans
- Department of Public Health & Primary Care/Health Campus The Hague, Leiden University Medical Center, Eilersplein 275, Den Haag, 2545 AA, The Netherlands
| | - I Kroon
- Elderly Care Medicine, Florence Health & Care, The Hague, The Netherlands
| | - K Rappard
- Emergency department, Haga Teaching Hospital, The Hague, The Netherlands
| | - G Labots
- Geriatric department, Haga Teaching Hospital, The Hague, The Netherlands
| | - C van Nieuwkoop
- Department of Public Health & Primary Care/Health Campus The Hague, Leiden University Medical Center, Eilersplein 275, Den Haag, 2545 AA, The Netherlands
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Maarten O van Aken
- Department of Public Health & Primary Care/Health Campus The Hague, Leiden University Medical Center, Eilersplein 275, Den Haag, 2545 AA, The Netherlands.
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands.
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Cohen I, Sangal RB, Taylor RA, Crawford A, Lai JM, Martin P, Palleschi S, Rothenberg C, Tomasino D, Hwang U. Impact of the geriatric emergency medicine specialist intervention on final emergency department disposition. J Am Geriatr Soc 2024; 72:2017-2026. [PMID: 38667266 DOI: 10.1111/jgs.18908] [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: 11/12/2023] [Revised: 02/28/2024] [Accepted: 03/14/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND The Geriatric Emergency Medicine Specialist (GEMS) pilot program is an innovative approach that utilizes geriatric-trained advanced practice providers to facilitate geriatric assessments and care planning for older adults in the emergency department (ED). The objective of this study was to explore the effect of GEMS on the use of observation status and final ED disposition. METHODS This was a retrospective study under a target trial emulation framework. Geriatric patients (65+ years old) who presented to two ED sites within a large regional healthcare system between December 2020 and December 2022 were included. The primary outcome was final ED disposition (discharge, hospital inpatient admission, or hospital observation admission). Secondary outcomes included ED observation and ED length of stay. Non-GEMS patients were propensity score matched 5:1 to GEMS patients. Doubly robust regression was used to estimate the odds ratios and 95% confidence intervals of inpatient admission, discharge, hospital observation admission, ED observation admission, and estimate the mean ED length of stay. RESULTS A total of 427 of 43,064 total patients (1.0%) received a GEMS intervention during the study period. Our analysis included 2,302 geriatric ED patients (410 GEMS, 1,892 non-GEMS) after propensity score matching. Hospital admission rates were 34.1% for GEMS compared to 56.4% for conventional treatment. GEMS patients had decreased odds of inpatient admission (OR: 0.41, 95 CI: 0.34-0.51, p < 0.001), increased odds of discharge (OR: 1.19 95 CI: 1.00-1.42, p = 0.047), hospital observation admission (OR: 2.97, 95 CI: 2.35-3.75, p < 0.001), ED observation admission (OR: 4.84 95 CI: 3.67-6.38, p < 0.001), and had a longer average ED length of stay (170 min, 95 CI: 84.6-256, p < 0.001) compared to non-GEMS patients. CONCLUSIONS Patients seen by GEMS during their ED visit were associated with higher rates of hospital discharge and lower rates of hospital admissions.
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Affiliation(s)
- Inessa Cohen
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Rohit B Sangal
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Richard Andrew Taylor
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- Section for Biomedical Informatics and Data Science, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Anna Crawford
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James M Lai
- Division of Geriatrics and Palliative Care, Department of Internal Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Pamela Martin
- Department of Internal Medicine and Geriatrics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sarah Palleschi
- Department of Internal Medicine and Geriatrics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Craig Rothenberg
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Debra Tomasino
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- Geriatric Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
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Hunold KM, Caterino JM, Carpenter CR, Mion LC, Southerland LT. Geriatric screening in the emergency department increases consultations to geriatric medicine and physical and occupational therapy: A pre/post cohort study. Acad Emerg Med 2024. [PMID: 38873870 DOI: 10.1111/acem.14964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 05/07/2024] [Accepted: 05/23/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND The Geriatric Emergency Department (ED) Guidelines recommend screening older patients for need for evaluation by geriatric medicine, physical therapy (PT), and occupational therapy (OT), but explicit evidence that geriatric screening changes care compared to physician gestalt is lacking. We assessed changes in multidisciplinary consultation after implementation of standardized geriatric screening in the ED. METHODS Retrospective single-site observational cohort of older adult ED patients from 2019 to 2023 with three time periods: (1) preimplementation, (2) implementation of geriatric screening, and (3) postimplementation. Geriatric, PT, and OT consultations/referrals were available during all time periods. Descriptive analysis was stratified by disposition: discharged, observation and discharged, observation and hospital admission, and hospital admission. The independent variable was completion of three geriatric screening tools by ED nurses. The dependent variable was consultation and/or referral to geriatrics, PT, and OT. Secondary outcomes were disposition, ED revisits, and 30-day rehospitalizations. RESULTS There were 57,775 qualifying ED visits of patients age ≥ 65 years during the time periods: implementation increased geriatric screening from 0.5% to 63.2%; postimplementation, discharge patients who received screening had more consultations/referrals to geriatrics (1.5% vs. 0.4%), PT (7.9% vs. 1.9%), and OT (6.5% vs. 1.2%) compared to unscreened patients. Patients observed and then discharged had more consultations/referrals to geriatrics (15.1% vs. 11.3%), PT (74.1% vs. 64.5%), and OT (65.7% vs. 56.5%). Admitted patients had no change in consultation rates. Geriatric screening was not associated with a change in 7-day ED revisits for discharged patients but was associated with decreased revisits for patients discharged from observation (11.6% vs. 42.9%, p < 0.001). CONCLUSION Geriatric screening was associated with increased consultations/referrals to geriatrics, PT, and OT in the ED and ED observation unit. This suggests that geriatric screening changes ED care for older adults.
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Affiliation(s)
- Katherine M Hunold
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | | | - Lorraine C Mion
- College of Nursing, The Ohio State University, Columbus, Ohio, USA
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
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Lee M, Briggs W, Gordon D, Hauser E, Hebbard C, Hunold KM, Southerland LT. Incorporation of geriatric screening into clinical practice: A quality improvement study in a geriatric emergency department. Am J Emerg Med 2024; 80:210-212. [PMID: 38677909 DOI: 10.1016/j.ajem.2024.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/15/2024] [Accepted: 04/15/2024] [Indexed: 04/29/2024] Open
Affiliation(s)
- Michelle Lee
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Whitney Briggs
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Darnell Gordon
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Eric Hauser
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Carleigh Hebbard
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Katherine M Hunold
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Chary AN, Hernandez N, Rivera AP, Santangelo I, Ritchie C, Ouchi K, Liu SW, Naik AD, Kennedy M. Emergency department communication with diverse caregivers and persons living with dementia: A qualitative study. J Am Geriatr Soc 2024; 72:1687-1696. [PMID: 38553011 DOI: 10.1111/jgs.18897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/24/2024] [Accepted: 03/07/2024] [Indexed: 06/19/2024]
Abstract
BACKGROUND Research to date has detailed numerous challenges in emergency department (ED) communication with persons living with dementia (PLWD) and their caregivers. However, little is known about communication experiences of individuals belonging to minoritized racial and ethnic groups, who are disproportionately impacted by dementia and less likely to be included in dementia research. METHODS We conducted semi-structured interviews with 29 caregivers of PLWD from two urban academic hospital EDs with distinct patient populations. The first site is an ED in the Northeast serving a majority White, English-speaking, and insured population. The second site is an ED in the South serving a majority Black and/or Hispanic, Spanish-speaking, and underinsured population. Interviews lasted an average of 25 min and were digitally recorded and transcribed. We used an inductive approach to analyze interview transcripts for dominant themes and compared themes between sites. RESULTS Our sample included caregivers of diverse racial and ethnic backgrounds. Caregivers cared for PLWD who spoke English, Spanish, Arabic, Chinese, and Vietnamese. We identified three themes. First, caregiver advocacy was central to experiences of ED communication, particularly when PLWD primarily spoke a non-English language. Second, routine care plans did not address what mattered most to participants and PLWD. Participants felt that care arose from protocols and did not address what mattered most to them. Third, White English-speaking caregivers in Site 1 more commonly expected ED staff to engage them in care decision-making than Black, Hispanic, Asian, and Middle Eastern caregivers in Site 2. CONCLUSION Language barriers amplify the higher intensity care needed by PLWD in the ED. Strategies should be developed for communicating with PLWD and caregivers about what matters most in their ED care.
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Affiliation(s)
- Anita N Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Norvin Hernandez
- School of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Ilianna Santangelo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kei Ouchi
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Aanand D Naik
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Consortium on Aging, University of Texas Health Science Center, Houston, Texas, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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McKnight MA, Sheber MK, Liebzeit DJ, Seaman AT, Husser EK, Buck HG, Reisinger HS, Lee S. Usability of the 4Ms Worksheet in the Emergency Department for Older Patients: A Qualitative Study. West J Emerg Med 2024; 25:230-236. [PMID: 38596924 PMCID: PMC11000547 DOI: 10.5811/westjem.18088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 10/30/2023] [Accepted: 11/21/2023] [Indexed: 04/11/2024] Open
Abstract
Introduction Older adults often have multiple comorbidities; therefore, they are at high risk for adverse events after discharge. The 4Ms framework-what matters, medications, mentation, mobility-has been used in acute and ambulatory care settings to identify risk factors for adverse events in older adults, although it has not been used in the emergency department (ED). We aimed to determine whether 1) use of the 4Ms worksheet would help emergency clinicians understand older adult patients' goals of care and 2) use of the worksheet was feasible in the ED. Methods We conducted a qualitative, descriptive study among patients aged ≥60 years and emergency clinicians from January-June 2022. Patients were asked to fill out a 4Ms worksheet; following this, semi-structured interviews were conducted with patients and clinicians separately. We analysed data to create codes, which were divided into categories and sub-categories. Results A total of 20 older patients and 19 emergency clinicians were interviewed. We identified two categories based on our aims: understanding patient goals of care (sub-categories: clinician/ patient concordance; understanding underlying goals of care; underlying goals of care discrepancy) and use of 4Ms Worksheet (sub-categories: worksheet to discussion discrepancy; challenges using worksheet; challenge completing worksheet before discharge). Rates of concordance between patient and clinician on main concern/goal of care and underlying goals of care were 82.4% and 15.4%, respectively. Conclusion We found that most patients and emergency clinicians agreed on the main goal of care, although clinicians often failed to elicit patients' underlying goal(s) of care. Additionally, many patients preferred to have the interviewer fill out the worksheet for them. There was often discrepancy between what was written and what was discussed with the interviewer. More research is needed to determine the best way to integrate the 4Ms framework within emergency care.
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Affiliation(s)
- Mackenzie A. McKnight
- University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa
| | - Melissa K. Sheber
- University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa
| | | | - Aaron T. Seaman
- University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Department of Internal Medicine, Iowa City, Iowa
| | - Erica K. Husser
- Penn State University, Ross and Carol Nese College of Nursing, University Park, Pennsylvania
| | | | - Heather S. Reisinger
- University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Department of Internal Medicine, Iowa City, Iowa
| | - Sangil Lee
- University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Department of Internal Medicine, Iowa City, Iowa
- Department of Epidemiology, University of Iowa College of Public Health, Department of Emergency Medicine, Iowa City, Iowa
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Adeyemi O, Walker L, Bermudez E, Cuthel AM, Zhao N, Siman N, Goldfeld K, Brody AA, Bouillon-Minois JB, DiMaggio C, Chodosh J, Grudzen CR. Emergency Nurses' Perceived Barriers and Solutions to Engaging Patients With Life-Limiting Illnesses in Serious Illness Conversations: A United States Multicenter Mixed-Method Analysis. J Emerg Nurs 2024; 50:225-242. [PMID: 37966418 PMCID: PMC10939973 DOI: 10.1016/j.jen.2023.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 07/27/2023] [Accepted: 09/06/2023] [Indexed: 11/16/2023]
Abstract
INTRODUCTION This study aimed to assess emergency nurses' perceived barriers toward engaging patients in serious illness conversations. METHODS Using a mixed-method (quant + QUAL) convergent design, we pooled data on the emergency nurses who underwent the End-of-Life Nursing Education Consortium training across 33 emergency departments. Data were extracted from the End-of-Life Nursing Education Consortium post-training questionnaire, comprising a 5-item survey and 1 open-ended question. Our quantitative analysis employed a cross-sectional design to assess the proportion of emergency nurses who report that they will encounter barriers in engaging seriously ill patients in serious illness conversations in the emergency department. Our qualitative analysis used conceptual content analysis to generate themes and meaning units of the perceived barriers and possible solutions toward having serious illness conversations in the emergency department. RESULTS A total of 2176 emergency nurses responded to the survey. Results from the quantitative analysis showed that 1473 (67.7%) emergency nurses reported that they will encounter barriers while engaging in serious illness conversations. Three thematic barriers-human factors, time constraints, and challenges in the emergency department work environment-emerged from the content analysis. Some of the subthemes included the perceived difficulty of serious illness conversations, delay in daily throughput, and lack of privacy in the emergency department. The potential solutions extracted included the need for continued training, the provision of dedicated emergency nurses to handle serious illness conversations, and the creation of dedicated spaces for serious illness conversations. DISCUSSION Emergency nurses may encounter barriers while engaging in serious illness conversations. Institutional-level policies may be required in creating a palliative care-friendly emergency department work environment.
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Affiliation(s)
- Oluwaseun Adeyemi
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
| | | | | | - Allison M. Cuthel
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
| | - Nicole Zhao
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
- Renaissance School of Medicine, Stony Brook University, Stony Brook NY
| | - Nina Siman
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
| | - Keith Goldfeld
- New York University Grossman School of Medicine, Department of Population Health, New York, New York, USA
| | - Abraham A. Brody
- New York University Rory Meyers College of Nursing, New York, NY, USA; Hartford Institute for Geriatric Nursing, New York, NY, USA; Division of Geriatric Medicine and Palliative Care, Department of Internal Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Jean-Baptiste Bouillon-Minois
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
- Emergency Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Charles DiMaggio
- New York University Grossman School of Medicine, Department of Surgery, New York, New York, USA
| | - Joshua Chodosh
- New York University Grossman School of Medicine, Department of Population Health, New York, New York, USA
- New York University Grossman School of Medicine, Department of Medicine, New York, New York, USA
| | - Corita R. Grudzen
- New York University Grossman School of Medicine, Department of Surgery, New York, New York, USA
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Wolf LA, Lo AX, Serina P, Chary A, Sri‐On J, Shankar K, Sano E, Liu SW. Frailty assessment tools in the emergency department: A geriatric emergency department guidelines 2.0 scoping review. J Am Coll Emerg Physicians Open 2024; 5:e13084. [PMID: 38162531 PMCID: PMC10755799 DOI: 10.1002/emp2.13084] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 01/03/2024] Open
Abstract
Objective Given the aging population and growing burden of frailty, we conducted this scoping review to describe the available literature regarding the use and impact of frailty assessment tools in the assessment and care of emergency department (ED) patients older than 60 years. Methods A search was made of the available literature using the Covidence system using various search terms. Inclusion criteria comprised peer-reviewed literature focusing on frailty screening tools used for a geriatric population (60+ years of age) presenting to EDs. An additional search of PubMed, EBSCO, and CINAHL for articles published in the last 5 years was conducted toward the end of the review process (January 2023) to search specifically for literature describing interventions for frailty, yielding additional articles for review. Exclusion criteria comprised articles focusing on an age category other than geriatric and care environments outside the emergency care setting. Results A total of 135 articles were screened for inclusion and 48 duplicates were removed. Of the 87 remaining articles, 20 were deemed irrelevant, leaving 67 articles for full-text review. Twenty-eight were excluded for not meeting inclusion criteria, leaving 39 full-text studies. Use of frailty screening tools were reported in the triage, care, and discharge decision-making phases of the ED care trajectory, with varying reports of usefulness for clinical decision-making. Conclusion The literature reports tools, scales, and instruments for identifying frailty in older patients at ED triage; multiple frailty scores or tools exist with varying levels of utilization. Interventions for frailty directed at the ED environment were scant. Further research is needed to determine the usefulness of frailty identification in the context of emergency care, the effects of care delivery interventions or educational initiatives for front-line medical professionals on patient-oriented outcomes, and to ensure these initiatives are acceptable for patients.
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Affiliation(s)
- Lisa A. Wolf
- Emergency Nurses AssociationSchaumburgIllinoisUSA
| | - Alexander X. Lo
- Department of Emergency MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Peter Serina
- Department of Emergency MedicineBrown UniversityProvidenceRhode IslandUSA
| | - Anita Chary
- Department of Emergency MedicineBaylor College of MedicineHoustonTexasUSA
| | - Jiraporn Sri‐On
- Department of Emergency MedicineVajira HospitalBangkokThailand
| | - Kalpana Shankar
- Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA
| | - Ellen Sano
- Department of Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Shan W. Liu
- Department of Emergency MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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Meldon S, Saxena S, Hashmi A, Masciarelli McFarland A, Muir M, Delgado F, Briskin I. Impact of Geriatric Consult Evaluations on Hospital Admission Rates for Older Adults. West J Emerg Med 2024; 25:86-93. [PMID: 38205989 PMCID: PMC10777177 DOI: 10.5811/westjem.60664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 09/08/2023] [Accepted: 11/15/2023] [Indexed: 01/12/2024] Open
Abstract
Introduction We examined the impact of a geriatric consult program in the emergency department (ED) and an ED observation geriatric care unit (GCU) setting on hospital admission rates for older ED patients. Methods We performed a retrospective case control study from June 1-August 31, 2019 (pre-program) to September 24, 2019-January 31, 2020 (post-program). Post-program geriatric consults were readily available in the ED and required in the GCU setting. Hospital admission rates (outcome) are reported for patients who received a geriatric consult evaluation (intervention). We analyzed probability of admission using a mixed-effects logistic regression model that included age, gender, recent ED visit, Charlson Comorbidity Index, referral to ED observation, and geriatric consult evaluation as predictor variables. Results A total of 9,663 geriatric ED encounters occurred, 4,042 pre-program and 5,621 post-program. Overall, ED admission rates for geriatric patients were similar pre- and post-program (44.8% vs 43.9%, P = 0.39). Of 243 geriatric consults, 149 (61.3%) occurred in the GCU. Overall admission rates post-program for patients receiving geriatric intervention were significantly lower compared to pre-program (23.4% vs 44.9%, P < 0.001). Post-program GCU hospital admission rates were significantly lower than pre-program ED observation unit admission rates (14/149, 9.4%, vs 111/477, 23.3%, P < 0.001). In the logistic regression model, admissions post-program were lower when a geriatric consult evaluation occurred (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.41-0.83). Hospital admissions for older ED observation patients were also significantly decreased when a geriatric consult was obtained (GCU vs pre-program ED observation unit; OR 0.27, 95% CI 0.14-0.50). Conclusion Geriatric consult evaluations were associated with significantly lower rates of hospital admission and persisted when controlled for age, gender, comorbidities, and ED observation unit placement. This model may allow healthcare systems to decrease potentially avoidable hospital admission rates in older ED patients.
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Affiliation(s)
- Stephen Meldon
- Cleveland Clinic Emergency Services Institute, Cleveland, Ohio
| | - Saket Saxena
- Cleveland Clinic Center for Geriatric Medicine, Cleveland, Ohio
| | - Ardeshir Hashmi
- Cleveland Clinic Center for Geriatric Medicine, Cleveland, Ohio
| | | | - McKinsey Muir
- Cleveland Clinic Emergency Services Institute, Cleveland, Ohio
| | | | - Isaac Briskin
- Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, Ohio
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11
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Knight T, Kamwa V, Atkin C, Green C, Ragunathan J, Lasserson D, Sapey E. Acute care models for older people living with frailty: a systematic review and taxonomy. BMC Geriatr 2023; 23:809. [PMID: 38053044 PMCID: PMC10699071 DOI: 10.1186/s12877-023-04373-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 10/03/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND The need to improve the acute care pathway to meet the care needs of older people living with frailty is a strategic priority for many healthcare systems. The optimal care model for this patient group is unclear. METHODS A systematic review was conducted to derive a taxonomy of acute care models for older people with acute medical illness and describe the outcomes used to assess their effectiveness. Care models providing time-limited episodes of care (up to 14 days) within 48 h of presentation to patients over the age of 65 with acute medical illness were included. Care models based in hospital and community settings were eligible. Searches were undertaken in Medline, Embase, CINAHL and Cochrane databases. Interventions were described and classified in detail using a modified version of the TIDIeR checklist for complex interventions. Outcomes were described and classified using the Core Outcome Measures in Effectiveness Trials (COMET) taxonomy. Risk of bias was assessed using RoB2 and ROBINS-I. RESULTS The inclusion criteria were met by 103 articles. Four classes of acute care model were identified, acute-bed based care, hospital at home, emergency department in-reach and care home models. The field is dominated by small single centre randomised and non-randomised studies. Most studies were judged to be at risk of bias. A range of outcome measures were reported with little consistency between studies. Evidence of effectiveness was limited. CONCLUSION Acute care models for older people living with frailty are heterogenous. The clinical effectiveness of these models cannot be conclusively established from the available evidence. TRIAL REGISTRATION PROSPERO registration (CRD42021279131).
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Affiliation(s)
- Thomas Knight
- Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK.
| | - Vicky Kamwa
- Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Catherine Atkin
- Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Catherine Green
- Department of Geriatric Medicine, Whiston Hospital, Mersey and West Lancashire Teaching Hospital NHS Trust, Prescot, L35 5DR, UK
| | - Janahan Ragunathan
- Department of Geriatric Medicine, Royal Bolton NHS Foundation Trust, Bolton, BL4 0JR, UK
| | - Daniel Lasserson
- Warwick Medical School, Professor of Acute and Ambulatory Care, University of Warwick, Coventry, CV4 7AL, UK
| | - Elizabeth Sapey
- Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
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12
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Kennedy M, Biese K. Comparing Geriatric and Nongeriatric Emergency Departments: A First Step on a Critical Avenue of Research. Ann Emerg Med 2023; 82:690-693. [PMID: 37725018 DOI: 10.1016/j.annemergmed.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 09/21/2023]
Affiliation(s)
- Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Kevin Biese
- West Health Institute, La Jolla, CA; Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC.
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13
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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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14
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McQuown CM, Tsivitse EK. Nonspecific Complaints in Older Emergency Department Patients. Clin Geriatr Med 2023; 39:491-501. [PMID: 37798061 DOI: 10.1016/j.cger.2023.04.007] [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] [Indexed: 10/07/2023]
Abstract
Nonspecific complaints such as generalized weakness and fatigue are common in older adults presenting to an emergency department. These complaints may be caused by acute or chronic medical problems, or they may be exacerbated or caused by socioeconomic risks factors. Acute causes may be related to serious medical conditions requiring prompt treatment. A thorough history and physical examination in conjunction with an interdisciplinary approach allows emergency departments to identify acute conditions as well as geriatric syndromes and unmet home needs, such as food insecurity and caregiver burden. A whole-health system approach should be used for safe transitions of care.
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Affiliation(s)
- Colleen M McQuown
- Louis Stokes Veterans Affairs Medical Center, 10701 East Boulevard. Cleveland, OH 44106, USA.
| | - Emily K Tsivitse
- Louis Stokes Veterans Affairs Medical Center, 10701 East Boulevard. Cleveland, OH 44106, USA
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15
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Southerland LT, Biese K, Hwang U. Geriatric assessment in the emergency department reduces healthcare costs-So when will CMS pay for it? J Am Geriatr Soc 2023; 71:2698-2700. [PMID: 37435831 DOI: 10.1111/jgs.18473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/20/2023] [Indexed: 07/13/2023]
Abstract
This editorial comments on the article by Haynesworth et al. in this issue.
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Affiliation(s)
- Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Kevin Biese
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
- Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New York, USA
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16
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Haynesworth A, Gilmer TP, Brennan JJ, Weaver EH, Tolia VM, Chan TC, Killeen JP, Castillo EM. Clinical and financial outcome impacts of comprehensive geriatric assessment in a level 1 geriatric emergency department. J Am Geriatr Soc 2023; 71:2704-2714. [PMID: 37435746 DOI: 10.1111/jgs.18468] [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: 11/04/2022] [Revised: 03/10/2023] [Accepted: 04/05/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND The aging population has led to an increase in emergency department (ED) visits by older adults who have complex medical conditions and high social needs. The purpose of this study was to assess if comprehensive geriatric evaluation and management impacted service utilization and cost by older adults admitted to the ED. METHODS This is a retrospective matched case-control study at a level 1 geriatric ED (GED) from January 1, 2018-March 31, 2020. Geriatric nurse specialists (GENIEs) provided comprehensive evaluations and management for GED patients. Propensity score matching was used to match patients receiving GENIE consultations to ED patients who did not receive a GENIE consult. Regression was used to assess the impact of the GENIE services on inpatient admissions, ED revisits and cost of inpatient and ED care from the payor perspective. RESULTS GENIE consults were associated with a 13.0% reduction in absolute risk of admission through the ED at index (95% confidence interval [CI] -17.0%, -9.0%, p < 0.001) and a reduction in risk for total admissions at 30 and 90-days post discharge (-11.3%, 95% CI -15.6%, -7.1%, p-value < 0.001; and -10.0, 95% CI -13.8%, -6.0%; p < 0.001 respectively), both driven by reduced risk of admission at the index visit. GENIE consults were associated with a 4% increase in absolute risk of revisits to the ED within 30 days (95% CI 0.6%, 7.3%; p = 0.001). GENIE consults were associated with a decrease in cost of inpatient and ED care, with savings of $2344 within 30 days (95% CI $2247, $2441, p < 0.001) and savings of $2004 USD within 90 days (95% CI $1895, $2114, p < 0.001), driven by reduced costs at the index visit. CONCLUSIONS GENIE consults were associated with decreased inpatient admissions through the ED, modestly increased ED revisits, and decreased cost of inpatient and ED care. The results of this study can be useful for EDs considering approaches to better serve older adults. They can also be of interest to payers as an area of potential cost savings.
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Affiliation(s)
- Austin Haynesworth
- School of Medicine, University of California San Diego, San Diego, California, USA
| | - Todd P Gilmer
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, San Diego, California, USA
| | - Jesse J Brennan
- Department of Emergency Medicine, University of California San Diego, San Diego, California, USA
| | - Emily H Weaver
- Clinical Research Department, West Health Institute, San Diego, California, USA
| | - Vaishal M Tolia
- Department of Emergency Medicine, University of California San Diego, San Diego, California, USA
| | - Theodore C Chan
- Department of Emergency Medicine, University of California San Diego, San Diego, California, USA
| | - James P Killeen
- Department of Emergency Medicine, University of California San Diego, San Diego, California, USA
| | - Edward M Castillo
- Department of Emergency Medicine, University of California San Diego, San Diego, California, USA
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17
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Fakha A, de Boer B, Hamers JP, Verbeek H, van Achterberg T. Systematic development of a set of implementation strategies for transitional care innovations in long-term care. Implement Sci Commun 2023; 4:103. [PMID: 37641112 PMCID: PMC10463528 DOI: 10.1186/s43058-023-00487-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 08/09/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Numerous transitional care innovations (TCIs) are being developed and implemented to optimize care continuity for older persons when transferring between multiple care settings, help meet their care needs, and ultimately improve their quality of life. Although the implementation of TCIs is influenced by contextual factors, the use of effective implementation strategies is largely lacking. Thus, to improve the implementation of TCIs targeting older persons receiving long-term care services, we systematically developed a set of viable strategies selected to address the influencing factors. METHODS As part of the TRANS-SENIOR research network, a stepwise approach following Implementation Mapping (steps 1 to 3) was applied to select implementation strategies. Building on the findings of previous studies, existing TCIs and factors influencing their implementation were identified. A combination of four taxonomies and overviews of change methods as well as relevant evidence on their effectiveness were used to select the implementation strategies targeting each of the relevant factors. Subsequently, individual consultations with scientific experts were performed for further validation of the process of mapping strategies to implementation factors and for capturing alternative ideas on relevant implementation strategies. RESULTS Twenty TCIs were identified and 12 influencing factors (mapped to the Consolidated Framework for Implementation Research) were designated as priority factors to be addressed with implementation strategies. A total of 40 strategies were selected. The majority of these target factors at the organizational level, e.g., by using structural redesign, public commitment, changing staffing models, conducting local consensus discussions, and organizational diagnosis and feedback. Strategies at the level of individuals included active learning, belief selection, and guided practice. Each strategy was operationalized into practical applications. CONCLUSIONS This project developed a set of theory and evidence-based implementation strategies to address the influencing factors, along further tailoring for each context, and enhance the implementation of TCIs in daily practice settings. Such work is critical to advance the use of implementation science methods to implement innovations in long-term care successfully.
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Affiliation(s)
- Amal Fakha
- Department of Health Services Research, Maastricht University, CAPHRI Care and Public Health Research Institute, Maastricht, the Netherlands.
- Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands.
- KU Leuven, Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, Leuven, Belgium.
| | - Bram de Boer
- Department of Health Services Research, Maastricht University, CAPHRI Care and Public Health Research Institute, Maastricht, the Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
| | - Jan P Hamers
- Department of Health Services Research, Maastricht University, CAPHRI Care and Public Health Research Institute, Maastricht, the Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
| | - Hilde Verbeek
- Department of Health Services Research, Maastricht University, CAPHRI Care and Public Health Research Institute, Maastricht, the Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
| | - Theo van Achterberg
- KU Leuven, Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, Leuven, Belgium
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18
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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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19
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van den Broek S, Westert GP, Hesselink G, Schoon Y. Effect of ED-based transitional care interventions by healthcare professionals providing transitional care in the emergency department on clinical, process and service use outcomes: a systematic review. BMJ Open 2023; 13:e066030. [PMID: 36918249 PMCID: PMC10016244 DOI: 10.1136/bmjopen-2022-066030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
OBJECTIVE Suboptimal transitional care (ie, needs assessment and coordination of follow-up care) in the emergency department (ED) is an important cause of ED revisits and hospital admissions and may potentially harm patients, especially frail older adults. We aimed to systematically review the effect of ED-based interventions by health professionals who are dedicated to providing transitional care to older adults. DESIGN Systematic review. MEASUREMENTS We searched five biomedical databases for published (quasi)experimental studies evaluating the effects of health professionals in the ED dedicated to providing transitional care to older ED patients on clinical, process and/or service use outcomes. Reviewers screened studies for relevance and assessed methodological quality with published criteria (Robins-1 and the Cochrane risk of bias tool). Data were synthesised around study and intervention characteristics and outcomes of interest. RESULTS From the 6561 references initially extracted from the databases, 12 studies were eligible for inclusion. Two types of interventions were identified, namely, individual needs assessment of ED patients (8 studies; 75%) and discharge planning and coordination of services (4 studies; 25%). Structured individual needs assessment was associated with a significant decrease in hospital admissions, hospital readmissions and ED revisits. Individualised discharge plans from the ED were associated with a significant decrease in ED revisits and hospital readmission. The overall methodological quality of the included studies was relatively low. CONCLUSIONS Comprehensive assessment of patient needs and ED discharge planning and coordination of services by health professionals interested in transitional care can help optimise the transition of care for older ED patients and reduce the risk of costly and potentially harmful (re)admissions for this population. However, more robust research is needed on the effectiveness of these interventions aiming to improve clinical, process and service use outcomes. PROSPERO REGISTRATION NUMBER CRD42021237345.
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Affiliation(s)
| | - Gert P Westert
- IQ Healtcare, Radboudumc, Nijmegen, Gelderland, Netherlands
| | - Gijs Hesselink
- Intensive Care Department, Radboudumc, Nijmegen, Gelderland, Netherlands
| | - Yvonne Schoon
- Geriatrics Department, Radboudumc, Nijmegen, Gelderland, Netherlands
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20
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Simpson M, Sergi C, Malsch A, Ryer S, Rubach C, Singh M. Association of Geriatric Emergency Department post-discharge referral order and follow-up with healthcare utilization. J Am Geriatr Soc 2023; 71:821-831. [PMID: 36455283 DOI: 10.1111/jgs.18137] [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: 06/29/2022] [Revised: 10/13/2022] [Accepted: 11/03/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Compared with younger adults who receive care in the emergency department (ED), older patients who are discharged home have greater risk of adverse health outcomes. Connecting older adults with outpatient care following ED discharge are among the guidelines of the Geriatric Emergency Department (GED). The objective of this study was to examine the association between referral order placed during the ED visit for older adults and post-discharge follow-up to the outcomes of 72-h ED revisit, 30-day ED revisit, and 30-day all cause and unplanned hospital admission. METHODS We conducted a retrospective cohort study. Ten accredited GEDs within one midwestern health system and all ED encounters of older adults aged 65 years and older who were discharged home from the ED between July 2019 and December 2020 were included. Predictor variables included age, sex, race, ISAR©, ED Length of Stay, post-ED referral order, and follow-up. RESULTS Among the older adults discharged home from the ED, 17% of older adult encounters had an outpatient referral ordered in the ED, 48.4% attended a follow-up appointment. Referrals were ordered for 69 referral order types with orthopedic, family practice, and urology referrals as the top 3. In mixed-effect regression models, compared with older adults with follow-up, those with a referral order but no follow-up had 19% higher odds of having a 30-day ED revisit (OR = 1.19; 95% CI = 1.07-1.31) and 11% higher odds of having 30-day unplanned hospital admission (OR = 1.11; 95% CI = 0.98-1.26). CONCLUSIONS Older adults who had an outpatient referral ordered prior to ED discharge and followed up had lower odds of a 30-day ED revisit and 30-day subsequent unplanned hospital admission. However, less than half of patients with a referral order attended a follow-up appointment. Designing interventions for older adults aimed at improving follow-up after an ED visit is needed.
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Affiliation(s)
- Michelle Simpson
- Advocate Aurora Health, Advocate Aurora Research Institute, Milwaukee, Wisconsin, USA
| | - Clinton Sergi
- Advocate Aurora Health, Advocate Aurora Research Institute, Milwaukee, Wisconsin, USA
| | - Aaron Malsch
- Department of Senior Services, Advocate Aurora Health, Milwaukee, Wisconsin, USA
| | - Suzanne Ryer
- Department of Senior Services, Advocate Aurora Health, Milwaukee, Wisconsin, USA
| | - Christopher Rubach
- Department of Senior Services, Advocate Aurora Health, Milwaukee, Wisconsin, USA
| | - Maharaj Singh
- Advocate Aurora Health, Advocate Aurora Research Institute, Milwaukee, Wisconsin, USA
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21
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Bunney G, Tran S, Han S, Gu C, Wang H, Luo Y, Dresden S. Using Machine Learning to Predict Hospital Disposition With Geriatric Emergency Department Innovation Intervention. Ann Emerg Med 2023; 81:353-363. [PMID: 36253298 DOI: 10.1016/j.annemergmed.2022.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/27/2022] [Accepted: 07/19/2022] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE The Geriatric Emergency Department Innovations (GEDI) program is a nurse-based geriatric assessment and care coordination program that reduces preventable admissions for older adults. Unfortunately, only 5% of older adults receive GEDI care because of resource limitations. The objective of this study was to predict the likelihood of hospitalization accurately and consistently with and without GEDI care using machine learning models to better target patients for the GEDI program. METHODS We performed a cross-sectional observational study of emergency department (ED) patients between 2010 and 2018. Using propensity-score matching, GEDI patients were matched to other older adult patients. Multiple models, including random forest, were used to predict hospital admission. Multiple second-layer models, including random forest, were then used to predict whether GEDI assessment would change predicted hospital admission. Final model performance was reported as the area under the curve using receiver operating characteristic models. RESULTS We included 128,050 patients aged over 65 years. The random forest ED disposition model had an area under the curve of 0.774 (95% confidence interval [CI] 0.741 to 0.806). In the random forest GEDI change-in-disposition model, 24,876 (97.3%) ED visits were predicted to have no change in disposition with GEDI assessment, and 695 (2.7%) ED visits were predicted to have a change in disposition with GEDI assessment. CONCLUSION Our machine learning models could predict who will likely be discharged with GEDI assessment with good accuracy and thus select a cohort appropriate for GEDI care. In addition, future implementation through integration into the electronic health record may assist in selecting patients to be prioritized for GEDI care.
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Affiliation(s)
- Gabrielle Bunney
- Department of Emergency Medicine, Northwestern University, Chicago, IL.
| | - Steven Tran
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Sae Han
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Carol Gu
- Applied Health Sciences, University of Illinois, Chicago, IL
| | - Hanyin Wang
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Yuan Luo
- Department of Preventative Medicine, Northwestern University, Chicago, IL
| | - Scott Dresden
- Department of Emergency Medicine, Northwestern University, Chicago, IL
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Hwang U, Runels T, Han L, Gruber E, McQuown CM, Ragsdale L, Jetter E, Rossomano N, Javier D. Dissemination and implementation of age-friendly care and geriatric emergency department accreditation at Veterans Affairs hospitals. Acad Emerg Med 2023; 30:270-277. [PMID: 36653961 DOI: 10.1111/acem.14665] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/08/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023]
Abstract
OBJECTIVES In 2018, the U.S. Department of Veterans Affairs (VA) National Office of Geriatrics and Extended Care (GEC) and the National Emergency Medicine (EM) Program partnered to improve emergency care for older Veterans. A core team disseminated age-friendly models of care via education and standardization of practice with the goal of multisite geriatric emergency department (GED) accreditation. We compare rates of GED screening at VAs with GED implementation to those without. METHODS Observational evaluation of GED screening of older Veterans (≥65 years) at VA Emergency Departments (ED) from January 2018 to March 2022, during peak pandemic years. Data were extracted from the VA Corporate Data Warehouse of Veteran ED visit encounters to track documented GED screens and Veteran demographic data. Generalized estimating equation models were used to compare screening completion across different levels of GED accreditation, adjusting for potential confounding. RESULTS During this period, over 1.07 million Veterans ≥ 65 years of age made 4.07 million VA ED visits. Mean (±SD) age was 73.4 (±7.2) years, 96.5% were male, 68% were White, and 89.9% made their index ED visit at a non-GED VA ED. As of early 2022, a total of 50 of 111 VA EDs have achieved or applied for GED accreditation. During early 2022, 8.3% of all visits by older Veterans had at least one GED screen documented; 15% were screened at Levels 1-3 GED versus 2.2% at non-GED facilities. Screens identifying older adults at risk for poor outcomes, for delirium, and for falls had the highest usage rates within VA GEDs. Veterans seen at Level 1 GEDs had a 76-fold greater odds of having a GED screen than at Level 3 GEDs (odds ratio 75.8, 95% confidence interval 72.8-79.0). CONCLUSIONS Through VA National Office of GEC and EM Program partnership, the VA has created, standardized, and disseminated a GED Model of Care, despite the pandemic. GED accreditation was associated with GED screen implementation, with Level 1 having the highest screening prevalence.
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Affiliation(s)
- Ula Hwang
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA.,Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Tessa Runels
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Ling Han
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Erica Gruber
- Department of Emergency Medicine, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Colleen M McQuown
- Geriatric Research Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
| | - Luna Ragsdale
- Department of Emergency Medicine, Durham VA Health Care System, Durham, North Carolina, USA.,Department of Surgery, Division of Emergency Medicine, Duke University Hospital, Durham, North Carolina, USA
| | - Ethan Jetter
- Veteran Affairs National Emergency Medicine Office, Washington, DC, USA
| | - Nicole Rossomano
- Veteran Affairs National Emergency Medicine Office, Washington, DC, USA
| | - Denise Javier
- Veteran Affairs National Emergency Medicine Office, Washington, DC, USA
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23
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Stoltenberg MJ, Kennedy M, Rico J, Russell M, Petrillo LA, Engel KG, Kamdar M, Ouchi K, Wang DH, Bernacki RH, Biese K, Aaronson E. Developing a novel integrated geriatric palliative care consultation program for the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12860. [PMID: 36518882 PMCID: PMC9742608 DOI: 10.1002/emp2.12860] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 10/27/2022] [Accepted: 11/01/2022] [Indexed: 12/14/2022] Open
Abstract
With the aging of our population, older adults are living longer with multiple chronic conditions, frailty, and life-limiting illnesses, which creates specific challenges for emergency departments (EDs). Older adults and those with serious illnesses have high rates of ED use and hospitalization, and the emergency care they receive may be discordant with their goals and values. In response, new models of care delivery have begun to emerge to address both geriatric and palliative care needs in the ED. However, these programs are typically siloed from one another despite significant overlap. To develop a new combined model, we assembled stakeholders and thought leaders at the intersection of emergency medicine, palliative care, and geriatrics and used a consensus process to define elements of an ideal model of a combined palliative care and geriatric intervention in the ED. This article provides a brief history of geriatric and palliative care integration in EDs and presents the integrated geriatric and palliative care model developed.
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Affiliation(s)
- Mark J. Stoltenberg
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Maura Kennedy
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Janet Rico
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Matthew Russell
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Laura A. Petrillo
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Kirsten G. Engel
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Mihir Kamdar
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Kei Ouchi
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Department of Psychosocial Oncology and Palliative CareDana‐Farber Cancer InstituteBostonMassachusettsUSA
| | - David H. Wang
- Division of Palliative MedicineScripps HealthSan DiegoCaliforniaUSA
| | - Rachelle H. Bernacki
- Harvard Medical SchoolBostonMassachusettsUSA
- Ariadne LabsBrigham and Women's Hospital & Harvard T. H. Chan School of Public HealthBostonMassachusettsUSA
- Department of Psychosocial Oncology and Palliative CareDana‐Farber Cancer InstituteBostonMassachusettsUSA
| | - Kevin Biese
- West Health InstituteLa JollaCaliforniaUSA
- Department of Emergency MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Emily Aaronson
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
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24
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Schmutte T, Olfson M, Xie M, Marcus SC. Factors Associated With 7-Day Follow-Up Outpatient Mental Healthcare in Older Adults Hospitalized for Suicidal Ideation, Suicide Attempt, and Self-Harm. Am J Geriatr Psychiatry 2022; 30:478-491. [PMID: 34563430 PMCID: PMC10563141 DOI: 10.1016/j.jagp.2021.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Older adults are one of the fastest growing age groups seeking emergency care for suicidal ideation and self-harm. Timely follow-up outpatient mental healthcare is important to suicide prevention, yet little is known about predictors of care continuity following hospital discharge. This study identified patient-, hospital-, and regional-level factors associated with 7-day follow-up outpatient mental healthcare in suicidal older adults. METHODS Retrospective cohort analysis using 2015 Medicare data for adults aged ≥65 years hospitalized for suicidal ideation, suicide attempt, or deliberate self-harm (n = 27,257) linked with the American Hospital Association survey and Area Health Resource File. Rates and adjusted risk ratios stratified by patient, hospital, and regional variables were assessed for 7-day follow-up outpatient mental healthcare. RESULTS Overall, 30.3% of patients received follow-up mental healthcare within 7 days of discharge. However, follow-up rates were higher for patients with any mental healthcare within 30 days prehospitalization (43.7%) compared to patients with no recent mental healthcare (15.7%). Longer length of stay and care in psychiatric hospitals were associated with higher odds of follow-up. For patients with no mental healthcare in the 30 days prehospitalization, discharge from hospitals that were large, system-affiliated, academic medical centers, or provided hospitalist-based care were associated with lower odds of follow-up. Females were more likely to receive 7-day follow-up, whereas non-white patients were less likely to receive follow-up care. CONCLUSION Timely follow-up is influenced by multiple patient, hospital, and community characteristics. Findings highlight the need for quality improvement to promote successful transitions from inpatient to outpatient care.
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Affiliation(s)
- Timothy Schmutte
- Department of Psychiatry, Program for Recovery and Community Health, Yale University, New Haven, Connecticut.
| | - Mark Olfson
- Department of Psychiatry and the New York State Psychiatric Institute, Columbia University, New York, New York
| | - Ming Xie
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven C Marcus
- School of Social Policy & Practice, University of Pennsylvania, Philadelphia, Pennsylvania
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25
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Fakha A, de Boer B, van Achterberg T, Hamers J, Verbeek H. Fostering the implementation of transitional care innovations for older persons: prioritizing the influencing key factors using a modified Delphi technique. BMC Geriatr 2022; 22:131. [PMID: 35172760 PMCID: PMC8848680 DOI: 10.1186/s12877-021-02672-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/26/2021] [Indexed: 12/03/2022] Open
Abstract
Background Transitions in care for older persons requiring long-term care are common and often problematic. Therefore, the implementation of transitional care innovations (TCIs) aims to improve necessary or avert avoidable care transitions. Various factors were recognized as influencers to the implementation of TCIs. This study aims to gain consensus on the relative importance level and the feasibility of addressing these factors with implementation strategies from the perspectives of experts. This work is within TRANS-SENIOR, an innovative research network focusing on care transitions. Methods A modified Delphi study was conducted with international scientific and practice-based experts, recruited using purposive and snowballing methods, from multiple disciplinary backgrounds, including implementation science, transitional care, long-term care, and healthcare innovations. This study was built on the findings of a previously conducted scoping review, whereby 25 factors (barriers, facilitators) influencing the implementation of TCIs were selected for the first Delphi round. Two sequential rounds of anonymous online surveys using an a priori consensus level of > 70% and a final expert consultation session were performed to determine the implementation factors’: i) direction of influence, ii) importance, and iii) feasibility to address with implementation strategies. The survey design was guided by the Consolidated Framework for Implementation Research (CFIR). Data were collected using Qualtrics software and analyzed with descriptive statistics and thematic analysis. Results Twenty-nine experts from 10 countries participated in the study. Eleven factors were ranked as of the highest importance among those that reached consensus. Notably, organizational and process-related factors, including engagement of leadership and key stakeholders, availability of resources, sense of urgency, and relative priority, showed to be imperative for the implementation of TCIs. Nineteen factors reached consensus for feasibility of addressing them with implementation strategies; however, the majority were rated as difficult to address. Experts indicated that it was hard to rate the direction of influence for all factors. Conclusions Priority factors influencing the implementation of TCIs were mostly at the organizational and process levels. The feasibility to address these factors remains difficult. Alternative strategies considering the interaction between the organizational context and the outer setting holds a potential for enhancing the implementation of TCIs. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02672-2.
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Affiliation(s)
- Amal Fakha
- CAPHRI Care and Public Health Research Institute, Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands. .,Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands. .,KU Leuven, Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, Kapucijnenvoer 35, 3000, Leuven, Belgium.
| | - Bram de Boer
- CAPHRI Care and Public Health Research Institute, Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.,Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
| | - Theo van Achterberg
- KU Leuven, Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, Kapucijnenvoer 35, 3000, Leuven, Belgium
| | - Jan Hamers
- CAPHRI Care and Public Health Research Institute, Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.,Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
| | - Hilde Verbeek
- CAPHRI Care and Public Health Research Institute, Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.,Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
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26
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Keene SE, Cameron-Comasco L. Implementation of a geriatric emergency medicine assessment team decreases hospital length of stay. Am J Emerg Med 2022; 55:45-50. [DOI: 10.1016/j.ajem.2022.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/31/2022] [Accepted: 02/17/2022] [Indexed: 10/19/2022] Open
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27
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Markgraf M, Telschow J. [Nursing roles and competencies in emergency care - focusing on geriatric emergency care: A scoping review]. Pflege 2022; 35:143-153. [PMID: 35012370 DOI: 10.1024/1012-5302/a000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Nursing roles and competencies in emergency care - focusing on geriatric emergency care: A scoping review Abstract. Background: Older patients make up an increasing number of emergency admissions in Germany. Their complex needs require advanced nursing competencies. Aim: The aim of this scoping review was to identify extended nursing roles in the emergency care of geriatric patients, to describe the training or educational programs that enable nurses to fill these roles and to compare these to the task catalog of German nurses with standard three-year training. Methods: The literature search was conducted in the databases MEDLINE and CINAHL. In addition, forward and backward citation tracking was performed. To describe the situation in Germany a snowballing literature search was carried out using Google and experts were contacted. A sheet created for this review was used for data extraction. Results: A total of 13 publications were included and seven extended competencies were extracted: Collection of information, initial assessment, coordination, medical / nursing care, treatment planning, follow-up, and education. Training qualifying nurses to take on these competencies were academic and / or specialized training measures, partially with the requirement of subject-specific working experience. In Germany advanced training courses are offered, while academic specializations are the exception. A comparison with the German task catalog was not possible. Conclusions: Internationally there are varying nursing roles, which often require both professional experience and academic training. No specific German nursing role profile could be identified. Specific qualification pathways do not exist.
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Affiliation(s)
- Miriam Markgraf
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg
| | - Josephine Telschow
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg
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28
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Conneely M, Leahy A, O'Connor M, Barry L, Corey G, Griffin A, O'Shaughnessy Í, O'Carroll I, Leahy S, Trépel D, Ryan D, Robinson K, Galvin R. A physiotherapy-led transition to home intervention for older adults following emergency department discharge: protocol for a pilot feasibility randomised controlled trial. Pilot Feasibility Stud 2022; 8:3. [PMID: 34980285 PMCID: PMC8720939 DOI: 10.1186/s40814-021-00954-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/28/2021] [Indexed: 12/12/2022] Open
Abstract
Background Older adults frequently attend the emergency department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. This paper reports a protocol designed to evaluate the feasibility of conducting a three arm randomised controlled trial (RCT) within the ED setting and in the patient’s home. The interventions are comprehensive geriatric assessment (CGA), ED PLUS and usual care. Methods The ED PLUS pilot trial is designed as a feasibility RCT conducted in the ED and Acute Medical Assessment Unit of a university teaching hospital in the mid-west region of Ireland. We aim to recruit 30 patients, aged 65 years and over presenting to the ED with undifferentiated medical complaints and discharged within 72 h of index visit. Patients will be randomised by a computer in a ratio of 1:1:1 to deliver usual care, CGA or ED PLUS during a 6-month study period. A randomised algorithm is used to perform randomization. CGA will include a medical assessment, medication review, nursing assessment, falls assessment, assessment of mobility and stairs, transfers, personal care, activities of daily living (ADLs), social supports and baseline cognition. ED PLUS, a physiotherapist led, multidisciplinary intervention, aims to bridge the transition of care between the index visit to the ED and the community by initiating a CGA intervention in the ED and implementing a 6-week follow-up self-management programme in the patient’s own home following discharge from the ED. The outcomes will be parameters of the feasibility of the intervention and trial methods and will be assessed quantitatively and qualitatively. Discussion Rising ED visits and an ageing population with chronic health issues render ED interventions to reduce adverse outcomes in older adults a research priority. This feasibility RCT will generate data and experience to inform the conduct and delivery of a definite RCT. Trial registration The trial was registered in Clinical Trials Protocols and Results System as of 21st July 2021, with registration number NCT049836020. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-021-00954-5.
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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.
| | - Aoife Leahy
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland.,Department of Ageing and Therapeutics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Margaret O'Connor
- Department of Ageing and Therapeutics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Louise Barry
- School of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Gillian Corey
- School of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Anne Griffin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Íde O'Shaughnessy
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland.,Department of Ageing and Therapeutics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Ida O'Carroll
- Department of Ageing and Therapeutics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Siobhán Leahy
- Department of Sport, Exercise & Nutrition, School of Science & Computing, Galway-Mayo Institute of Technology, Dublin Road, Galway, Ireland
| | - Dominic Trépel
- Trinity Institute of Neurosciences, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Damian Ryan
- Limerick EM Education Research Training (ALERT), Emergency Department, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Katie Robinson
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
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29
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Jacobsohn GC, Jones CMC, Green RK, Cochran AL, Caprio TV, Cushman JT, Kind AJH, Lohmeier M, Mi R, Shah MN. Effectiveness of a care transitions intervention for older adults discharged home from the emergency department: A randomized controlled trial. Acad Emerg Med 2022; 29:51-63. [PMID: 34310796 PMCID: PMC8766871 DOI: 10.1111/acem.14357] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/06/2021] [Accepted: 07/20/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Improving care transitions following emergency department (ED) visits may reduce post-ED adverse events among older adults (e.g., ED revisits, decreased function). The Care Transitions Intervention (CTI) improves hospital-to-home transitions; however, its effectiveness at improving post-ED outcomes is unknown. We tested the effectiveness of the CTI with community-dwelling older adult ED patients, hypothesizing that it would reduce revisits and increase performance of self-management behaviors during the 30 days following discharge. METHODS We conducted a randomized controlled trial among patients age ≥ 60 discharged home from one of three EDs in two states. Intervention participants received a minimally modified CTI, with a home visit 24 to 72 h postdischarge and one to three phone calls over 28 days. We collected demographic, health status, and psychosocial data at the initial ED visit. Medication adherence and knowledge of red flag symptoms were assessed via phone survey. Care use and comorbidities were abstracted from medical records. We performed multivariate regressions for intention-to-treat and per-protocol (PP) analyses. RESULTS Participant characteristics (N = 1,756) were similar across groups: mean age 72.4 ± 8.6 years and 53% female. Of those randomized to the intervention, 84% completed the home visit. Overall, 12.4% of participants returned to the ED within 30 days. The CTI did not significantly affect odds of 30-day ED revisits (adjusted odds ratio [AOR] = 0.97, 95% confidence interval [CI] = 0.72 to 1.30) or medication adherence (AOR = 0.89, 95% CI = 0.60 to 1.32). Participants receiving the CTI (PP) had increased odds of in-person follow-up with outpatient clinicians during the week following discharge (AOR = 1.24, 95% CI = 1.01 to 1.51) and recalling at least one red flag from ED discharge instructions (AOR = 1.34 95% CI = 1.05 to 1.71). CONCLUSIONS The CTI did not reduce 30-day ED revisits but did significantly increase key care transition behaviors (outpatient follow-up, red flag knowledge). Additional research is needed to explore if patients with different conditions benefit more from the CTI and whether decreasing ED revisits is the most appropriate outcome for all older adults.
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Affiliation(s)
- Gwen C Jacobsohn
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Courtney M C Jones
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Rebecca K Green
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Amy L Cochran
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Thomas V Caprio
- Division of Geriatrics, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Jeremy T Cushman
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Amy J H Kind
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
- William S. Middleton Veterans Affairs Geriatrics Research, Education, and Clinical Center, Madison, Wisconsin, USA
| | - Michael Lohmeier
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Ranran Mi
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
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30
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Huded JM, Lee A, Song S, McQuown CM, Wilson BM, Smith TI, Bonomo RA. Association of a geriatric emergency department program with healthcare outcomes among veterans. J Am Geriatr Soc 2021; 70:601-608. [PMID: 34820827 DOI: 10.1111/jgs.17572] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/03/2021] [Accepted: 11/03/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND We aim to describe the outcomes of Geriatric Emergency Room Innovations for Veterans (GERI-VET), the first comprehensive Veterans Affairs Geriatric ED program. METHODS In this prospective observational cohort study at an urban Veterans Affairs Medical Center ED, participants included Veterans aged 65 years and older treated in the ED from January 7, 2017 to February 29, 2020. Veterans with an Identification of Seniors At Risk (ISAR) score >2 were considered eligible for GERI-VET, receiving geriatric screens and care coordination in addition to standard ED treatment. The control group included GERI-VET eligible Veterans who did not receive GERI-VET care. Propensity score matching was used to compare outcomes in the GERI-VET group (N = 725) and a matched control group (n = 725). Key measures included ED resource utilization, outpatient referrals, ED admission, and 30-day admission. RESULTS In the ED, the GERI-VET group received more consults to pharmacy (315 [43.4%] vs. 195 [26.9%], p < 0.001) and social work (399 [55.0%] vs. 132 [18.2%], p < 0.001). The GERI-VET group had higher referral rates to Geriatrics (64 [17.7%] vs. 18 [5.8%], p < 0.001) and Home Based Primary Care (110 [30.4%] vs. 24 [7.8%], p < 0.001). Key outcome measures included lower rates of ED admission (363 [50.1%] vs. 417 [n = 57.5%], p = 0.003) and 30-day hospital admission (412 [56.8%] vs. 464 [64.0%], p = 0.004) without increasing ED length of stay (5.4 ± 2.2 vs. 5.4 ± 2.6 h, p = 0.85) or 72-h ED revisits (23 [3.2%] vs. 16 [2.2%], p = 0.25) in the GERI-VET group. CONCLUSIONS A program designed to screen for geriatric syndromes and coordinate care among at-risk older Veterans was associated with increased multidisciplinary resource utilization and reduced ED and 30-day admissions without increasing ED length of stay or re-visitation.
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Affiliation(s)
- Jill M Huded
- Department of Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Albert Lee
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Sunah Song
- Cleveland Geriatric Research Education and Clinical Centers, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA.,Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Colleen M McQuown
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Brigid M Wilson
- Cleveland Geriatric Research Education and Clinical Centers, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
| | - Todd I Smith
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA.,Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Robert A Bonomo
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA.,Cleveland Geriatric Research Education and Clinical Centers, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA.,Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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31
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Batista J, Pinheiro CM, Madeira C, Gomes P, Ferreira ÓR, Baixinho CL. Transitional Care Management from Emergency Services to Communities: An Action Research Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182212052. [PMID: 34831807 PMCID: PMC8624079 DOI: 10.3390/ijerph182212052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 11/16/2022]
Abstract
In recent years, nurses have developed projects in the area of hospital to community transition. The objective of the present study was to analyze the transitional care offered to elderly people after they used emergency services and were discharged to return to the community. The action research method was chosen. The participants were nurses, elderly people 70 years old or older, and their caregivers. The study was carried out from October 2018 to August 2019. The data were collected by means of semi-structured interviews with the nurses, analysis of medical records, participatory observation, phone calls to the elderly people and caregivers, and team meetings. The qualitative data were submitted to Bardin’s content analysis. Statistical treatment was carried out by applying SPSS version 23.0. The institution’s research ethics committee approved the research. Only 31.4% of the sample experienced care continuity after discharge, and the rate of readmission to emergency services during the first 30 days after discharge was 33.4%. The referral letters lacked data on information provided to patients or caregivers, and nurses mentioned difficulties in communication between care levels, as well as obstacles to teamwork; they also mentioned that the lack of health policies and clinical rules to formalize transitional care between the hospital and the community perpetuated non-coordination of care between the two contexts. The low level of literacy of patients and their relatives are mentioned as a cause for not understanding the information regarding seeking primary health care services and handing the discharge letter. It was concluded that there is an urgent need to mobilize health teams toward action in the patients’ process of returning home, and this factor must be taken into account in care planning.
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Affiliation(s)
- José Batista
- Vila Franca de Xira Hospital, 2600-009 Vila Franca de Xira, Portugal;
- Correspondence: ; Tel.: +351-917102953
| | | | - Carla Madeira
- Vila Franca de Xira Hospital, 2600-009 Vila Franca de Xira, Portugal;
| | - Pedro Gomes
- Portuguese Institute of Oncology, Nursing Research, Innovation and Development Centre of Lisbon, 1900-160 Lisbon, Portugal;
| | - Óscar Ramos Ferreira
- Nursing School of Lisbon, Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), 1900-160 Lisbon, Portugal; (Ó.R.F.); (C.L.B.)
| | - Cristina Lavareda Baixinho
- Nursing School of Lisbon, Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), 1900-160 Lisbon, Portugal; (Ó.R.F.); (C.L.B.)
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, 2411-901 Leiria, Portugal
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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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Silva CFT, Pedreira LC, Amaral JBD, Mussi FC, Martorell-Poveda MA, Souza MLD. The care offered by nurses to elders with coronary artery disease from the perspective of Transitions Theory. Rev Bras Enferm 2021; 74Suppl 2:e202000992. [PMID: 34287500 DOI: 10.1590/0034-7167-2020-0992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 01/26/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To analyze the planning and implementation of the care offered by nurses to elders with coronary disease during the hospital-house transition. METHODS Qualitative research that used the Transitions Theory as a theoretical reference. The participants were 12 nurses who work in a hospital that specializes in cardiology, in the city of Salvador-BA. A semistructured interview was carried out from January to February 2018, and the data was analyzed using the Content Analysis technique. RESULTS Transition care takes place on the day of discharge. The presence of the family was found to be a facilitator; low adherence, poor financial situations, the low educational levels inhibited its implementation. The rehospitalization is an indicator of the results of the transition of care. FINAL CONSIDERATIONS The planning and implementation of transition care is not effective. It must provide safety in the management of self-care in the home of elders with coronary disease and their families.
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Shadyab AH, Castillo EM, Chan TC, Tolia VM. Developing and Implementing a Geriatric Emergency Department (GED): Overview and Characteristics of GED Visits. J Emerg Med 2021; 61:131-139. [PMID: 34006420 DOI: 10.1016/j.jemermed.2021.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/22/2021] [Accepted: 02/21/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The traditional model of emergency care may not be sufficient to address the complex care needs of older adults, who present to the emergency department with multiple comorbidities, geriatric syndromes, and social determinants of health, complicating diagnosis and management. Geriatric emergency departments (GEDs) have emerged throughout the last decade to address these concerns and improve the emergency care of older adults. OBJECTIVE Our aim was to describe the policies, procedures, and workflow of our GEDs, and to provide data on patient outcomes and discuss challenges and recommendations in the development and implementation of a GED. DISCUSSION Our GED includes interdisciplinary staff trained in geriatric emergency medicine, evidence-based protocols for geriatric care, physical modifications to accommodate older adults' functional limitations, administration of geriatric assessments, care coordination with case managers and social workers, and referrals to care. Assessments screen for geriatric syndromes and social determinants of health. Quality improvement is a critical component and includes a robust medication safety plan to reduce use of potentially inappropriate medications. Hospital administrators considering developing a GED should create a care planning team, conduct an institutional needs assessment, and identify the GED model that will most efficiently help them achieve an age-friendly health system. CONCLUSIONS The GED will play an important role in addressing the diverse health care needs of older adults in the coming decades. Future research studies of health outcomes among older adults receiving care at GEDs compared with traditional EDs will be critical in informing future improvements and innovations in geriatric emergency care.
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Affiliation(s)
- Aladdin H Shadyab
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, California
| | - Edward M Castillo
- Department of Emergency Medicine, University of California, San Diego, La Jolla, California
| | - Theodore C Chan
- Department of Emergency Medicine, University of California, San Diego, La Jolla, California
| | - Vaishal M Tolia
- Department of Emergency Medicine, University of California, San Diego, La Jolla, California
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Shadyab AH, Tolia VM, Brennan JJ, Chan TC, Castillo EM. Ethnic Disparities in COVID-19 Among Older Adults Presenting to the Geriatric Emergency Department. J Emerg Med 2021; 61:437-444. [PMID: 34172334 PMCID: PMC8106891 DOI: 10.1016/j.jemermed.2021.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/27/2021] [Accepted: 04/26/2021] [Indexed: 01/15/2023]
Abstract
Background There is a dearth of epidemiological data on ethnic disparities among older patients with COVID-19. The objective of this study was to characterize ethnic differences in clinical presentation and outcomes from COVID-19 among older U.S. adults. Methods This was a retrospective cohort study within two geriatric emergency departments (GEDs) at a large academic health system. One hundred patients 65 years or older who visited a GED between March 10, 2020 and August 9, 2020 and tested positive for COVID-19 were examined. Electronic medical records were used to determine presenting COVID-19–related symptoms, comorbidities, and clinical outcomes. Descriptive statistics are reported with associated 95% confidence intervals (CIs). Results In the overall sample, mean age was 75.9 years; 18% were 85 years or older; 50% were male; and 46.0% were Hispanic. Relative to non-Hispanic patients with COVID-19, Hispanic patients with COVID-19 had a higher percentage of shortness of breath (78.3% vs. 51.9%; difference: 26.4%; 95% CI 7.6–42.5%), pneumonia (82.6% vs. 50.0%; difference: 32.6%; 95% CI 14.1–47.9%), acute respiratory distress syndrome (13.0% vs. 1.9%; difference: 11.1%; 95% CI 0.7–23.9%), and acute kidney failure (41.3% vs. 22.2%; difference: 19.1%; 95% CI 0.9–36.0%). Rates of other poor outcomes, including hospitalization, intensive care unit (ICU) admission, return visits to the GED within 30 days of discharge, or death, did not significantly differ between Hispanic and non-Hispanic patients with COVID-19. Conclusions These preliminary data show that older Hispanic patients relative to non-Hispanic patients with COVID-19 presenting to a GED did not experience worse outcomes, including hospitalization, ICU admission, 30-day return visits to the GED, or death.
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Affiliation(s)
- Aladdin H Shadyab
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, California
| | - Vaishal M Tolia
- Department of Emergency Medicine, University of California, San Diego, La Jolla, California
| | - Jesse J Brennan
- Department of Emergency Medicine, University of California, San Diego, La Jolla, California
| | - Theodore C Chan
- Department of Emergency Medicine, University of California, San Diego, La Jolla, California
| | - Edward M Castillo
- Department of Emergency Medicine, University of California, San Diego, La Jolla, California
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Hogervorst VM, Buurman BM, De Jonghe A, van Oppen JD, Nickel CH, Lucke J, Blomaard LC, Thaur A, Mooijaart SP, Banerjee J, Wallace J, de Groot B, Conroy SP. Emergency department management of older people living with frailty: a guide for emergency practitioners. Emerg Med J 2021; 38:724-729. [PMID: 33883216 DOI: 10.1136/emermed-2020-210014] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 03/09/2021] [Accepted: 03/31/2021] [Indexed: 11/04/2022]
Abstract
Emergency Departments (EDs) are increasingly seeing more seriously unwell older people living with frailty. In the context of limited resources and increasing demand it's the ED practitioner's challenge to unpick this constellation of physical, psychological, functional and social issues.To properly assess older people living with frailty at the ED it is crucial to use an holistic approach. This consists of triage with algorithms sensitive to the higher risk of older people living with frailty, a frailty assessment, and an assessment with the help of the principles of Comprehensive Geriatric Assessment. Multi-disciplinary care, a tailor-made treatment plan, based on what the person values most, will help the ED practitioner to deliver appropriate and valuable care during the ED stay, but also in transition from hospital to home.
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Affiliation(s)
- Vera M Hogervorst
- Department of Geriatric Medicine, Tergooi Hospital, Hilversum, The Netherlands .,Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Bianca M Buurman
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | | | - James David van Oppen
- Department of Health Sciences, University of Leicester, Leicester, UK.,Emergency & Specialist Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Jacinta Lucke
- Department of Emergency Medicine, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Laura C Blomaard
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjun Thaur
- Department of Emergency Medicine, Guy's and Saint Thomas' NHS Foundation Trust, London, London, UK
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jay Banerjee
- Department of Health Sciences, University of Leicester, Leicester, UK.,Department of Emergency Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - James Wallace
- Department of Emergency Medicine, Warrington and Halton Teaching Hospitals NHS Foundation Trust, Warrington, UK
| | - Bas de Groot
- Department of Emergency Medicine, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Simon Paul Conroy
- Department of Health Sciences, University of Leicester, Leicester, UK
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Affiliation(s)
- Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Kei Ouchi
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kevin Biese
- Department of Emergency Medicine, University of North Carolina at Chapel Hill
- West Health, La Jolla, California
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38
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Hwang U, Dresden SM, Vargas-Torres C, Kang R, Garrido MM, Loo G, Sze J, Cruz D, Richardson LD, Adams J, Aldeen A, Baumlin KM, Courtney DM, Gravenor S, Grudzen CR, Nimo G, Zhu CW. Association of a Geriatric Emergency Department Innovation Program With Cost Outcomes Among Medicare Beneficiaries. JAMA Netw Open 2021; 4:e2037334. [PMID: 33646311 PMCID: PMC7921898 DOI: 10.1001/jamanetworkopen.2020.37334] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
IMPORTANCE There has been a significant increase in the implementation and dissemination of geriatric emergency department (GED) programs. Understanding the costs associated with patient care would yield insight into the direct financial value for patients, hospitals, health systems, and payers. OBJECTIVE To evaluate the association of GED programs with Medicare costs per beneficiary. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included data on Medicare fee-for-service beneficiaries at 2 hospitals implementing Geriatric Emergency Department Innovations in Care Through Workforce, Informatics, and Structural Enhancement (GEDI WISE) (Mount Sinai Medical Center [MSMC] and Northwestern Memorial Hospital [NMH]) from January 1, 2013, to November 30, 2016. Analyses were conducted and refined from August 28, 2018, to November 20, 2020, using entropy balance to account for observed differences between the treatment and comparison groups. INTERVENTIONS Treatment included consultation with a transitional care nurse (TCN) or a social worker (SW) trained for the GEDI WISE program at a beneficiary's first ED visit (index ED visit). The comparison group included beneficiaries who were never seen by either a TCN or an SW during the study period. MAIN OUTCOMES AND MEASURES The main outcome evaluated was prorated total Medicare payer expenditures per beneficiary over 30 and 60 days after the index ED visit encounter. RESULTS Of the total 24 839 unique Medicare beneficiaries, 4041 were seen across the 2 EDs; 1947 (17.4%) at MSMC and 2094 (15.4%) at the NMH received treatment from either a GED TCN and/or a GED SW. The mean (SD) age of beneficiaries at MSMC was 78.8 (8.5) years and at NMH was 76.4 (7.7) years. Most patients at both hospitals were female (6821 [60.8%] at MSMC and 8023 [58.9%] at NMH) and White (7729 [68.9%] at MSMC and 9984 [73.3%] at NMH). Treatment was associated with statistically significant mean savings per beneficiary of $2436 (95% CI, $1760-$3111; P < .001) at one ED and $2905 (95% CI, $2378-$3431; P < .001) at the other ED in the 30 days after the index ED visit. The association between treatment and mean cumulative savings at 60 days after the index ED visit per beneficiary was also significant: $1200 (95% CI, $231-$2169; P = .02) at one ED and $3202 (95% CI, $2452-$3951; P < .001) at the other ED. CONCLUSIONS AND RELEVANCE Among Medicare fee-for-service beneficiaries, receipt of ED-based geriatric treatment by a TCN and/or an SW was associated with lower Medicare expenditures. These estimated cost savings may be used when calculating or considering the bundled value and potential reimbursement per patient for GED care programs.
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Affiliation(s)
- Ula Hwang
- Department of Emergency Medicine, Yale University, New Haven, Connecticut
- Geriatric Research, Education Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Scott M. Dresden
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Carmen Vargas-Torres
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Raymond Kang
- Center for Healthcare Studies, Northwestern University, Chicago, Illinois
| | - Melissa M. Garrido
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
- Partnered Evidence-Based Policy Resource Center, Boston VA Healthcare Systems, Boston, Massachusetts
| | - George Loo
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeremy Sze
- Department of Emergency Medicine, New York University Grossman School of Medicine, New York
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Daniel Cruz
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lynne D. Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - James Adams
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Kevin M. Baumlin
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - D. Mark Courtney
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas
| | | | - Corita R. Grudzen
- Department of Emergency Medicine, New York University Grossman School of Medicine, New York
| | - Gloria Nimo
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carolyn W. Zhu
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Liu J, Palmgren T, Ponzer S, Masiello I, Farrokhnia N. Can dedicated emergency team and area for older people reduce the hospital admission rate? - An observational pre- and post-intervention study. BMC Geriatr 2021; 21:115. [PMID: 33568087 PMCID: PMC7877031 DOI: 10.1186/s12877-021-02044-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 01/20/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Emergency department (ED) care of older patients is often complex. Geriatric ED guidelines can help to meet this challenge. However, training requirements, the use of time-consuming tools for comprehensive geriatric assessment (CGA), a lack of golden standard to identify the frail patients, and the weak evidence of positive outcomes of using CGA in EDs pose barriers to introduce the guidelines. Dedicating an interprofessional team of regular ED medical and nursing staff and an older-friendly ED area can be another approach. Previous studies of geriatrician-led CGA in EDs have reported a reduced hospital admission rate. The aim of this study was to investigate whether a dedicated interprofessional emergency team also can reduce the hospital admission rate without the resources required by the formal use of CGA. METHODS An observational pre-post study at a large adult ED, where all patients 80 years or older arriving on weekdays in the intervention period from 2016.09.26 to 2016.11.28 and the corresponding weekdays in the previous year from 2015.09.28 to 2015.11.30 were included. In the intervention period, older patients either received care in the geriatric module by the dedicated team or in the regular team modules for patients of mixed ages. In 2015, all patients received care in regular team modules. The primary outcome measure was the total hospital admission rate and the ED length of stay was the secondary outcome measure. RESULTS We included 2377 arrivals in the intervention period, when 26.7% (N = 634) received care in the geriatric module, and 2207 arrivals in the 2015 period. The total hospital admission rate was 61.7% (N = 1466/2377) in the intervention period compared to 64.8% (N = 1431/2207) in 2015 (p = 0.03). The difference was larger for patients treated in the geriatric module, 51.1% compared to 62.1% (95% CI: 56.3 to 68.0%) for patients who would have been eligible in 2015. The ED length of stay was longer in the intervention period. CONCLUSIONS An interprofessional team and area dedicated to older patients was associated to a lower hospital admission rate. Further studies are needed to confirm the results.
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Affiliation(s)
- Jenny Liu
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden.
| | - Therese Palmgren
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden
| | - Sari Ponzer
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden
| | - Italo Masiello
- Department of Computer Science and Media Technology, Linnaeus University, Växjö, Sweden
| | - Nasim Farrokhnia
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden
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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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Lo AX, Heinemann AW, Gray E, Lindquist LA, Kocherginsky M, Post LA, Dresden SM. Inter-rater Reliability of Clinical Frailty Scores for Older Patients in the Emergency Department. Acad Emerg Med 2021; 28:110-113. [PMID: 32141671 DOI: 10.1111/acem.13953] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/31/2020] [Accepted: 03/01/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Alexander X. Lo
- From the Department of Emergency MedicineNorthwestern University ChicagoIL
- the Center for Health Services and Outcomes ResearchNorthwestern University ChicagoIL
| | - Allen W. Heinemann
- From the Department of Emergency MedicineNorthwestern University ChicagoIL
- the Center for Health Services and Outcomes ResearchNorthwestern University ChicagoIL
- the Department of Physical Medicine and RehabilitationNorthwestern University ChicagoIL
| | - Elizabeth Gray
- the Department of Preventive Medicine Division of BiostatisticsNorthwestern University ChicagoIL
| | - Lee A. Lindquist
- and the Division of General Internal Medicine and Geriatrics Department of Internal MedicineNorthwestern University ChicagoIL
| | - Masha Kocherginsky
- the Department of Preventive Medicine Division of BiostatisticsNorthwestern University ChicagoIL
| | - Lori A. Post
- From the Department of Emergency MedicineNorthwestern University ChicagoIL
- Department of Medical Social SciencesNorthwestern University ChicagoIL
- Buehler Center for Health Policy and Economics Northwestern University Chicago IL
| | - Scott M. Dresden
- From the Department of Emergency MedicineNorthwestern University ChicagoIL
- the Center for Health Services and Outcomes ResearchNorthwestern University ChicagoIL
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Gheno J, Weis AH. CARE TRANSTION IN HOSPITAL DISCHARGE FOR ADULT PATIENTS: INTEGRATIVE LITERATURE REVIEW. TEXTO & CONTEXTO ENFERMAGEM 2021. [DOI: 10.1590/1980-265x-tce-2021-0030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: to summarize and analyze the scientific production on care transition in the hospital discharge of adult patients. Method: integrative review, conducted from May to July 2020, in four relevant databases in the health area: Public Medline (PubMed); Scientific Electronic Library Online (SciELO); Scopus and Virtual Health Library (VHL). The analysis of the results occurred descriptively and was organized into thematic categories that emerged according to the similarity of the contents extracted from the articles. Results: 46 articles from national and international journals, with a predominance of descriptive/non-experimental studies or qualitative studies, met the inclusion criteria. Five categories were identified: discharge and post-discharge process; Continuity of post-discharge care; Benefits of care transition; Role of nurses in care transition and Experiences of patients on care transition. Hospital discharge and care transitions are interconnected processes as transitions qualify the dehospitalization process. Different strategies for continuity of care should be adopted, as they offer greater safety to the patient. Studies have shown that nurses play a fundamental role in transitions and, in Brazil, this activity still needs to gain more space. Reduced hospitalizations, mortality, hospital costs and patient satisfaction are benefits of transitions. Conclusion: care transition is an effective strategy for the care provided to the patient being discharged. It points out the need for integration between the care network and assists services in decision-making about the continuity of care on discharge.
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Affiliation(s)
- Jociele Gheno
- Grupo Hospitalar Conceição, Brasil; Universidade Federal de Ciências da Saúde de Porto Alegre, Brasil
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Nurses Training and Capacitation for Palliative Care in Emergency Units: A Systematic Review. ACTA ACUST UNITED AC 2020; 56:medicina56120648. [PMID: 33256039 PMCID: PMC7759785 DOI: 10.3390/medicina56120648] [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] [Received: 09/07/2020] [Revised: 11/13/2020] [Accepted: 11/24/2020] [Indexed: 12/15/2022]
Abstract
Background and objectives: Palliative care (PC) prevents and alleviates patients´ suffering to improve their quality of life in their last days. In recent years, there has been an increase in visits to the emergency services (ES) by patients who may need this type of care. The aims were to describe the training and capacitation of nurses from ES in PC. Accordingly, a systematic review was performed. Materials and Methods: Medline, Scopus, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were used. The search equation was “Palliative care and nursing care and emergency room”. A total of 12 studies were selected. Results: The studies agree on the need for training professionals in PC to provide a higher quality care, better identification of patient needs and to avoid unnecessary invasive processes. Similarly, the implementation of a collaborative model between ES and PC, the existence of a PC specialized team in the ES or proper palliative care at home correspond to a decrease in emergency visits, a lower number of hospitalizations or days admitted, and a decrease in hospital deaths. Conclusions: The development of PC in the different areas of patient care is necessary. Better palliative care leads to a lower frequency of ES by terminal patients, which has a positive impact on their quality of life. Access to PC from the emergency unit should be one of the priority health objectives due to increment in the aged population susceptible to this type of care.
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Implementation of a geriatric emergency department program using a novel workforce. Am J Emerg Med 2020; 46:703-707. [PMID: 33129647 DOI: 10.1016/j.ajem.2020.10.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/14/2020] [Accepted: 10/20/2020] [Indexed: 11/20/2022] Open
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Lo AX, Carpenter CR. Balancing Evidence and Economics While Adapting Emergency Medicine to the 21st Century's Geriatric Demographic Imperative. Acad Emerg Med 2020; 27:1070-1073. [PMID: 32335974 DOI: 10.1111/acem.13997] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Alexander X. Lo
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago IL USA
- Center for Health Services & Outcomes Research Northwestern University Feinberg School of Medicine Chicago IL USA
| | - Christopher R. Carpenter
- Department of Emergency Medicine and Emergency Care Research Core Washington University in St. Louis St. Louis MO USA
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Southerland LT, Savage EL, Muska Duff K, Caterino JM, Bergados TR, Hunold KM, Finnegan GI, Archual G. Hospital Costs and Reimbursement Model for a Geriatric Emergency Department. Acad Emerg Med 2020; 27:1051-1058. [PMID: 32338422 DOI: 10.1111/acem.13998] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/07/2020] [Accepted: 02/14/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVES The American College of Emergency Physicians' geriatric emergency department (GED) guidelines recommend additional staff and geriatric equipment, which may not be financially feasible for every ED. Data from an accredited Level 1 GED was used to report equipment costs and to develop a business model for financial sustainability of a GED. METHODS Staff salaries including the cost of fringe benefits were obtained from a Midwestern hospital with an academic ED of 80,000 annual visits. Reimbursement assumptions included 100% Medicare/Medicaid insurance payor and 8-hour workdays with 4.5 weeks of leave annually. Equipment costs from hospital invoices were collated. Operational and patient safety metrics were compared before and after the GED. RESULTS A geriatric nurse practitioner in the ED is financially self-sustaining at 7.1 consultations, a pharmacist is self-sustaining at 7.7 medication reconciliation consultations, and physical and occupational therapist evaluations are self-sustaining at 5.7 and 4.6 consults per workday, respectively. Total annual equipment costs for mobility aids, delirium aids, sensory aids, and personal care items for the GED was $4,513. Comparing the 2 years before and after, in regard to operational metrics the proportions of patients with lengths of stay > 8 hours and patients placed in observation did not change. In regard to patient safety, the rate of falls decreased from 0.60/1,000 patient visits to 0.42/1,000 in the ED observation unit and 0.42/1,000 to 0.36/1,000 in the ED. ED recidivism at 7 and 30 days did not change. Estimated cost savings from the reduction in falls was $80,328. CONCLUSION The additional equipment and personnel costs for comprehensive geriatric assessment in the ED are potentially financially justified by revenue generation and improvements in patient safety measures. A geriatric ED was associated with a decrease in patient falls in the ED but did not decrease admissions or ED recidivism.
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Affiliation(s)
- Lauren T. Southerland
- From the Department of Emergency Medicine The Ohio State University Wexner Medical Center Columbus OH USA
| | - Elizabeth L. Savage
- From the Department of Emergency Medicine The Ohio State University Wexner Medical Center Columbus OH USA
| | - Katrina Muska Duff
- Human Resources College of Medicine The Ohio State University Wexner Medical Center Columbus OH USA
| | - Jeffrey M. Caterino
- From the Department of Emergency Medicine The Ohio State University Wexner Medical Center Columbus OH USA
| | - Tina R. Bergados
- and the James Cancer Hospital and Solove Research Institute Columbus OH USA
| | - Katherine M. Hunold
- From the Department of Emergency Medicine The Ohio State University Wexner Medical Center Columbus OH USA
| | | | - Gregory Archual
- From the Department of Emergency Medicine The Ohio State University Wexner Medical Center Columbus OH USA
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Ayton D, O'Donnell R, Vicary D, Bateman C, Moran C, Srikanth VK, Lustig J, Banaszak-Holl J, Hunter P, Pritchard E, Morris H, Savaglio M, Parikh S, Skouteris H. Psychosocial volunteer support for older adults with cognitive impairment: development of MyCare Ageing using a codesign approach via action research. BMJ Open 2020; 10:e036449. [PMID: 32994233 PMCID: PMC7526312 DOI: 10.1136/bmjopen-2019-036449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Older adults with cognitive impairment are vulnerable to frequent hospital admissions and emergency department presentations. The aim of this study was to use a codesign approach to develop MyCare Ageing, a programme that will train volunteers to provide psychosocial support to older people with dementia and/or delirium in hospital and at home when discharged from hospital. SETTING Melbourne, Victoria, Australia. RESEARCH DESIGN This study adopts an action research methodology. We report on two co-design workshops with keystakeholders: Workshop 1: identification of components from three existing programmes to inform the development of the MyCare Ageing program logic and, Workshop 2: identification of implementation strategies. PARTICIPANTS The key stakeholders and workshop participants included clinicians (geriatricians, nurses and allied health), hospital staff (volunteer coordinators and hospital executives), Baptcare staff, a consumer, researchers and implementation experts and project staff. RESULTS Workshop 1 identified the components from three existing programmes-the Volunteer Dementia and Delirium Care programme, Home-Start and MyCare for inclusion in MyCare Ageing. In workshop 2, the p implementation plan was developed taking into consideration hospital-specific processes, training and support needs of volunteers and safety and risk management processes. DISCUSSION AND CONCLUSION The codesign process was successfully applied to develop the MyCare Ageing programme to provide volunteer support to patients with dementia and/or delirium in hospital and their transition home. MyCare Ageing is an innovative programme that meets an identified need from hospitals and consumers to support patients with dementia and/or delirium to improve psychosocial outcomes on discharge from hospital.
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Affiliation(s)
- Darshini Ayton
- Monash Centre for Health Research and Implementation, Monash University, Melboune, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Renée O'Donnell
- Monash Centre for Health Research and Implementation, Monash University, Melboune, Victoria, Australia
| | - Dave Vicary
- Victoria Family & Community Services Service & Operations, Baptcare, Melbourne, Victoria, Australia
| | - Catherine Bateman
- Southern New South Wales Local Health District, Queanbeyan, New South Wales, Australia
| | - Chris Moran
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
| | - Velandai K Srikanth
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
| | - Julie Lustig
- Rehabilitation and Aged Care Services, Monash Health, Clayton, Victoria, Australia
| | - Jane Banaszak-Holl
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter Hunter
- Rehabilitation, Aged and Community Care, Alfred Health, Melbourne, Victoria, Australia
| | - Elizabeth Pritchard
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Heather Morris
- Monash Centre for Health Research and Implementation, Monash University, Melboune, Victoria, Australia
| | - Melissa Savaglio
- Monash Centre for Health Research and Implementation, Monash University, Melboune, Victoria, Australia
| | - Seema Parikh
- Department of Aged Care Services, Alfred Health, Melbourne, Victoria, Australia
| | - Helen Skouteris
- Monash Centre for Health Research and Implementation, Monash University, Melboune, Victoria, Australia
- University of Warwick, Coventry, West Midlands, UK
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Leaker H, Fox L, Holroyd-Leduc J. The Impact of Geriatric Emergency Management Nurses on the Care of Frail Older Patients in the Emergency Department: a Systematic Review. Can Geriatr J 2020; 23:250-256. [PMID: 32904804 PMCID: PMC7458600 DOI: 10.5770/cgj.23.408] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background Frail older adults are high users of emergency departments (EDs). Many Canadian EDs have hired Geriatric Emergency Management (GEM) nurses in an effort to improve care to older adults. Methods We conducted a systematic review to determine the impact of GEM nurses on care provided to frail older adults. We searched MEDLINE, Embase, CINAHL, and Cochrane databases. A grey literature search was also conducted. Inclusion criteria were English-language, evaluation of GEM nurse or geriatric-trained nurse assessments of older adults (age ≥ 65 years) within the ED, and reported clinical and/or health system outcomes. The PRISMA statement was followed, and article quality was assessed using GRADE. Results 5,115 citations and 191 full text articles were screened; 8 articles from 7 different studies were included. Study quality varied between very low to high. Five included studies analyzed the effect of GEM nurses on ED revisits, with most finding they decreased revisits. Four included studies analyzed the effect of GEM nurses on hospital admissions/readmissions, demonstrating variable impact. One study looked at the cost-effectiveness and found the cost to be negligible. The impact on patient-specific outcomes was less clear. Conclusions GEM nurses may be an effective option to help in the management of frail older adults in the ED.
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Affiliation(s)
- Hannah Leaker
- Faculty of Nursing, University of Calgary, Calgary, AB
| | - Loralee Fox
- Faculty of Nursing, University of Calgary, Calgary, AB
| | - Jayna Holroyd-Leduc
- Department of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB
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Dresden SM, Lo AX, Lindquist LA, Kocherginsky M, Post LA, French DD, Gray E, Heinemann AW. The impact of Geriatric Emergency Department Innovations (GEDI) on health services use, health related quality of life, and costs: Protocol for a randomized controlled trial. Contemp Clin Trials 2020; 97:106125. [PMID: 32858227 DOI: 10.1016/j.cct.2020.106125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/12/2020] [Accepted: 08/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Older adults (age 65 and older) use the emergency department (ED) at a rate of nearly 50 ED visits per 100 older adults, accounting for over 23 million ED visits in the US annually, up to 20% of all ED visits. These ED visits are sentinel health events as discharged patients often return to the ED, experience declines in health-related quality of life (HRQoL) and disability, or are later hospitalized. Those who are admitted incur increased costs and greater risk for poor outcomes including infections, delirium, and falls. The objective of this randomized controlled trial (RCT) is to evaluate the efficacy of the Geriatric Emergency Department Innovations (GEDI) program, an ED nurse-led geriatric assessment and care coordination program, in decreasing unnecessary health services use and improving Health-Related Quality-of-Life (HRQoL) for older adults in the ED. METHODS Community dwelling older adults aged 65 and older who are vulnerable or frail according to the Clinical Frailty Scale (CFS) during an ED visit will be randomized to either GEDI (n = 420) or to usual ED care (n = 420). Outcome variables will be assessed during the ED visit and at 7-11 days and 28-32 days post ED visit. PROJECTED OUTCOMES The primary outcome is hospitalization or death within 30 days of the ED visit. Secondary outcomes include health service use outcomes (ED visits and hospitalizations), healthcare costs, and HRQoL outcomes [Patient-Reported Outcomes Measurement Information System (PROMIS) scores: PROMIS-Preference, Physical Function, Ability to Participate in Social Roles and Activities, Anxiety, and Depression]. TRIAL REGISTRATION Clinicaltrials.Gov identifier NCT04115371.
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Affiliation(s)
- Scott M Dresden
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Buheler Center for Health Policy and Economics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Alexander X Lo
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Lee A Lindquist
- Department of Internal Medicine, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Masha Kocherginsky
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Lori Ann Post
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Buheler Center for Health Policy and Economics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Dustin D French
- Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, USA; Department of Veterans Affairs Health Services Research and Development Service, Edward Hines, Jr. VA Hospital, Hines, IL, USA
| | - Elizabeth Gray
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Allen W Heinemann
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University and Center for Rehabilitation Outcomes Research, Shirley Ryan AbilityLab, USA
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Casteli CPM, Mbemba GIC, Dumont S, Dallaire C, Juneau L, Martin E, Laferrière MC, Gagnon MP. Indicators of home-based hospitalization model and strategies for its implementation: a systematic review of reviews. Syst Rev 2020; 9:172. [PMID: 32771062 PMCID: PMC7415182 DOI: 10.1186/s13643-020-01423-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 07/10/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Home-based hospitalization (HBH) offers an alternative delivery model to hospital care. There has been a remarkable increase in pilot initiatives and deployment of this model to optimize services offered to a population with a variety of progressive and chronic diseases. Our objectives were to systematically summarize the indicators of HBH as well as the factors associated with the successful implementation and use of this model. METHODS We used a two-stage process. First, five databases were consulted, with no date delimitation. We included systematic reviews of quantitative, qualitative, and mixed studies published in English, French, Spanish, or Portuguese. We followed guidance from PRISMA and the Cochrane Collaboration. Second, we used the Nursing Care Performance Framework to categorize the indicators, a comprehensive grid of barriers and facilitators to map the factors affecting HBH implementation, and a thematic synthesis of the qualitative and quantitative findings. RESULTS Fifteen reviews were selected. We identified 26 indicators related to nursing care that are impacted by the use of HBH models and 13 factors related to their implementation. The most frequently documented indicators of HBH were cost of resources, problem and symptom management, comfort and quality of life, cognitive and psychosocial functional capacity, patient and caregiver satisfaction, hospital mortality, readmissions, and length of stay. Our review also highlighted new indicators, namely use of hospital beds, new emergency consultations, and use of healthcare services as indicators of resources of cost, and bowel complications, caregiver satisfaction, and survival time as indicators of change in the patient's condition. The main facilitators for HBH implementation were related to internal organizational factors (multidisciplinary collaboration and skill mix of professionals) whereas barriers were linked to the characteristics of the HBH, specifically eligibility criteria (complexity and social situation of the patient). CONCLUSION To the best of our knowledge, this is the first review that synthesizes both the types of indicators associated with HBH and the factors that influence its implementation. Considering both the processes and outcomes of HBH will help to identify strategies that could facilitate the implementation and evaluation of this innovative model of care delivery. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018103380.
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Affiliation(s)
- Christiane Pereira Martins Casteli
- Faculty of Nursing Sciences, Université Laval, Québec City, QC Canada
- University Health and Social Services Centre (IUHSSC) of Capitale-Nationale (CN), Québec City, QC Canada
| | | | - Serge Dumont
- School of Social Work, Université Laval, Québec City, QC Canada
- Primary Care and Services Research Center, Université Laval - Primary Health Care and Social Services University Institute, IUHSSC-CN, Québec City, QC Canada
| | - Clémence Dallaire
- Faculty of Nursing Sciences, Université Laval, Québec City, QC Canada
- Research Center of the CHU de Québec-Université Laval, 1050 Avenue de la Médecine. Pavillon Ferdinand-Vandry, Québec City, QC G1V0A6 Canada
| | - Lucille Juneau
- University Health and Social Services Centre (IUHSSC) of Capitale-Nationale (CN), Québec City, QC Canada
- Center of Excellence on Aging Quebec (CEVQ), IUHSSC-CN, Québec City, QC Canada
| | - Elisabeth Martin
- Faculty of Nursing Sciences, Université Laval, Québec City, QC Canada
- Primary Care and Services Research Center, Université Laval - Primary Health Care and Social Services University Institute, IUHSSC-CN, Québec City, QC Canada
| | | | - Marie-Pierre Gagnon
- Faculty of Nursing Sciences, Université Laval, Québec City, QC Canada
- Research Center of the CHU de Québec-Université Laval, 1050 Avenue de la Médecine. Pavillon Ferdinand-Vandry, Québec City, QC G1V0A6 Canada
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