Predictors and outcomes of patients that return unplanned to the Emergency Department and require critical care admission: A multicenter study

OBJECTIVE

To determine the incidence, characteristics (including timeframe) and predictors of patients discharged from the Emergency Department (ED) that later return and require admission.

METHODS

A retrospective cross-sectional study examining all return visits to three EDs in Sydney, Australia, over a 12-month period. Patients returning within 28 days from ED discharge with the same or similar complaint were classified as a return visit to ensure capture of all return visits. Descriptive and inferential statistics were used to analyse the data and logistic regression was performed to predict factors associated with return visits with general admission, and return visits admitted to critical care.

RESULTS

There were 1,798 (30%) return visits which resulted in admission, mostly to a non-critical care area (1,679, 93%). The current NSW 48 -h time frame used to define a return visit in NSW captured half of all admitted returns (49.5%) and just over half (59.2%) of critical care admissions. Variables associated with an admission to critical care were age (OR 1.02, 95% CI 1.01, 1.03), initial presentation (index visit) made to a lower level ED (OR 3.76 95% CI 2.06, 6.86), Triage Category 2 (OR 3.67 95% CI 2.04, 6.60) and a cardiac diagnosis (OR 5.76, 95% CI 3.01, 11.01). This model had adequate discriminant ability with AUROC = 0.825.

CONCLUSION

A small number of return visits result in admission, especially to critical care. These patients are at risk of poor outcomes. As such, clinicians should have increased index of suspicion for patients who return that are older, present with cardiac problems, or have previously presented to a lower level ED. Revision of the current timeframe that defines a return visit ought to be considered by policy makers to improve the accuracy of this widely used key performance indicator.

Connecting With Trauma Patients After Discharge: A Phone Call Follow-Up Study

BACKGROUND

Traumatic injury is sudden and unexpected. It may lead to long-standing physical and physiological consequences. Approximately 10% of the world's disease burden is attributable to traumatic injuries. At the commencement of the study, there was limited information regarding civilian trauma patients' recovery following discharge from the hospital. There are several reasons for this including lack of available resources for follow-up by clinical staff and often trauma patients have multiple injuries, which can result in fragmented care. This limits the ability to assess a patient's recovery following discharge from the hospital.

OBJECTIVE

This phone call follow-up study was conducted to assess the number of trauma patients who may be showing symptoms of physical and psychological distress after traumatic injury.

METHODS

The study was carried out in New South Wales (Australia) Metropolitan major (Level 1) trauma center. Consented patients were contacted at 72 hr, 1 month, and 3 months after discharge from the hospital.

RESULTS

Many patients at all time points had difficulty coping with activities of daily living from pain (183 patients [64%], 121 patients [43%], and 58 patients [23%]), fatigue and sleep disturbance (110 patients [38%], 79 patients [28%], and 49 patients [20%]), as well as anxiety and frustration (38 patients [13%], 79 patients [28%], and 98 patients [39%]) regarding their recovery and returning to their preinjury activities.

CONCLUSION

The research indicates that some trauma patients do not recover quickly physically or emotionally. These patients require identification and appropriate management of the consequences of trauma to enable them to return to their preinjury quality of life.

Assessing unmet rehabilitation needs and the feasibility of a telehealth rehabilitation consultation service for road trauma survivors recently discharged from hospital

PURPOSE

Persistent activity limitations are common among road trauma survivors, yet access to rehabilitation in hospital and in the community remains variable. This study aimed to identify unmet rehabilitation needs following road trauma and assess the feasibility of a novel rehabilitation consultation service delivered via telehealth following hospitalization.

METHODS

A pilot cohort study was conducted with survivors of road trauma who were hospitalized but did not receive formal inpatient rehabilitation. All participants received a multidisciplinary rehabilitation consultation via telehealth 1-3 weeks post-discharge, to assess rehabilitation needs and initiate treatment referrals as required. Functional and qualitative outcomes were assessed at baseline (1-7 days); one month and three months post-discharge.

RESULTS

38 participants were enrolled. All (100%) reported functional limitations at baseline; 86.5% were found to have unmet rehabilitation needs, and 75.7% were recommended rehabilitation interventions. Functional ability improved over time, but more than half the cohort continued to report activity limitations (67.6%), pain (64.7%) and/or altered mood (41.2%) for up to three months. Participants found the telehealth service to be acceptable, convenient, and helpful for recovery.

CONCLUSIONS

A high proportion of mild-moderate trauma survivors report unmet rehabilitation needs following hospital discharge. Telehealth appears to be a feasible, convenient and acceptable mode of assessing these needs.Implications for rehabilitationSurvivors of road-related injuries often experience ongoing impairments and activity limitations.Among those who don't receive rehabilitation in hospital, we found a high proportion (86.5%) had unmet rehabilitation needs after discharge.A telehealth rehabilitation service was feasible to deliver and could successfully identify unmet rehabilitation needs.The piloted telehealth intervention was viewed as acceptable, convenient and beneficial by patients.

Post-discharge adjustment of medication in geriatric patients : A prospective cohort study

BACKGROUND

Little is known to what extent general practitioners (GP) change hospital discharge medications in older patients.

OBJECTIVE

This prospective cohort study aimed to analyze medication changes at the interface between hospital and community in terms of quality, quantity and type of drugs.

METHODS

A total of 121 out of 248 consecutively enrolled patients admitted to an acute geriatric hospital unit participated in the study. Medication regimens were recorded at admission and discharge and 4 weeks after hospital discharge the general practitioners in charge were contacted to provide the current medication charts. Changes in the extent of polypharmacy, in the type of drugs using anatomical therapeutic chemical classification (ATC) codes and potentially inappropriate medications (PIM) were analyzed.

RESULTS

Medication charts could be obtained for 98 participants in primary care. Only 21% of these patients remained on the original discharge medication. Overall, the average number of medications rose from hospital admission (6.58 SD ± 3.45) to discharge (6.96 SD ± 3.49) and again post-discharge in general practice (7.22 SD ± 3.68). The rates of patients on excessive polypharmacy (≥10 drugs) and on PIM were only temporarily reduced during hospital stay. The GPs stopped anti-infective drugs (ATC-J) and prescribed more antirheumatic drugs (ATC-M). Although no significant net changes occurred in other ATC groups, a substantial number of drugs were interchanged regarding the subgroups.

CONCLUSION

The study found that GPs extensively adjusted geriatric discharge medications. Whereas some changes may be necessary due to alterations in patients' state of health, a thorough communication between hospital doctors and GPs may level off different prescribing cultures and contribute to consistency in medication across sectors.

The experience and understanding of pain management in recently discharged adult trauma patients: A qualitative study

INTRODUCTION

Pain following injury is often intense, prolonged and debilitating. If poorly managed, this acute pain has the potential to delay rehabilitation and lead to chronic pain. Recent quantitative Australian research recommends implementing further information and interventions to improve trauma patient outcomes, however, to ensure effectiveness, exploration of the patient perspective is imperative to ensure the success of future pain management strategies. This study aimed to gain understanding about the experience of pain management using prescribed analgesic regimens of recently discharged adult trauma patients.

METHOD

Semi-structured interviews were used to explore the experiences and understandings of trauma patients in managing pain using prescribed analgesic regimens during the initial post-hospital discharge period. Twelve participants were purposively selected over a 6-month period at a level one trauma outpatient clinic based on questionnaire responses indicating pain related concerns. Qualitative data were thematically analysed.

RESULTS

The overarching finding was that injuries and inadequate pain management incapacitate the patient at home. Four main themes were developed: injury pain is unique and debilitating; patients are uninformed at hospital discharge; patients have low confidence with pain management at home; and patients make independent decisions about pain management. Patients felt they were not given adequate information at hospital discharge to support them to make effective decisions about their pain management practices at home.

CONCLUSION

There is a need for more inclusive and improved hospital discharge processes that includes patient and family education around pain management following injury. To achieve this, clinician education, support and training is essential.