Unplanned readmission prevention by a geriatric emergency network for transitional care (URGENT): a prospective before-after study

The impact of discharge letter content on unplanned hospital readmissions within 30 and 90 days in older adults with chronic illness - a mixed methods study

BACKGROUND

Care transitions are high-risk processes, especially for people with complex or chronic illness. Discharge letters are an opportunity to provide written information to improve patients' self-management after discharge. The aim of this study is to determine the impact of discharge letter content on unplanned hospital readmissions and self-rated quality of care transitions among patients 60 years of age or older with chronic illness.

METHODS

The study had a convergent mixed methods design. Patients with chronic obstructive pulmonary disease or congestive heart failure were recruited from two hospitals in Region Stockholm if they were living at home and Swedish-speaking. Patients with dementia or cognitive impairment, or a "do not resuscitate" statement in their medical record were excluded. Discharge letters from 136 patients recruited to a randomised controlled trial were coded using an assessment matrix and deductive content analysis. The assessment matrix was based on a literature review performed to identify key elements in discharge letters that facilitate a safe care transition to home. The coded key elements were transformed into a quantitative variable of "SAFE-D score". Bivariate correlations between SAFE-D score and quality of care transition as well as unplanned readmissions within 30 and 90 days were calculated. Lastly, a multivariable Cox proportional hazards model was used to investigate associations between SAFE-D score and time to readmission.

RESULTS

All discharge letters contained at least five of eleven key elements. In less than two per cent of the discharge letters, all eleven key elements were present. Neither SAFE-D score, nor single key elements correlated with 30-day or 90-day readmission rate. SAFE-D score was not associated with time to readmission when adjusted for a range of patient characteristics and self-rated quality of care transitions.

CONCLUSIONS

While written summaries play a role, they may not be sufficient on their own to ensure safe care transitions and effective self-care management post-discharge.

TRIAL REGISTRATION

Clinical Trials. giv, NCT02823795, 01/09/2016.

Impact of the geriatric emergency medicine specialist intervention on final emergency department disposition

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.

Older Adult Patients in the Emergency Department: Which Patients should be Selected for a Different Approach?

BACKGROUND

While multidimensional and interdisciplinary assessment of older adult patients improves their short-term outcomes after evaluation in the emergency department (ED), this assessment is time-consuming and ill-suited for the busy environment. Thus, identifying patients who will benefit from this strategy is challenging. Therefore, this study aimed to identify older adult patients suitable for a different ED approach as well as independent variables associated with poor short-term clinical outcomes.

METHODS

We included all patients ≥65 years attending 52 EDs in Spain over 7 days. Sociodemographic, comorbidity, and baseline functional status data were collected. The outcomes were 30-day mortality, re-presentation, hospital readmission, and the composite of all outcomes.

RESULTS

During the study among 96,014 patients evaluated in the ED, we included 23,338 patients ≥65 years-mean age, 78.4±8.1 years; 12,626 (54.1%) women. During follow-up, 5,776 patients (24.75%) had poor outcomes after evaluation in the ED: 1,140 (4.88%) died, 4,640 (20.51) returned to the ED, and 1,739 (7.69%) were readmitted 30 days after discharge following the index visit. A model including male sex, age ≥75 years, arrival by ambulance, Charlson Comorbidity Index ≥3, and functional impairment had a C-index of 0.81 (95% confidence interval, 0.80-0.82) for 30-day mortality.

CONCLUSION

Male sex, age ≥75 years, arrival by ambulance, functional impairment, or severe comorbidity are features of patients who could benefit from approaches in the ED different from the common triage to improve the poor short-term outcomes of this population.

Strategies to improve care for older adults who present to the emergency department: a systematic review

BACKGROUND

The aim of this systematic review was to examine the relationship between strategies to improve care delivery for older adults in ED and evaluation measures of patient outcomes, patient experience, staff experience, and system performance.

METHODS

A systematic review of English language studies published since inception to December 2022, available from CINAHL, Embase, Medline, and Scopus was conducted. Studies were reviewed by pairs of independent reviewers and included if they met the following criteria: participant mean age of ≥ 65 years; ED setting or directly influenced provision of care in the ED; reported on improvement interventions and strategies; reported patient outcomes, patient experience, staff experience, or system performance. The methodological quality of the studies was assessed by pairs of independent reviewers using The Joanna Briggs Institute critical appraisal tools. Data were synthesised using a hermeneutic approach.

RESULTS

Seventy-six studies were included in the review, incorporating strategies for comprehensive assessment and multi-faceted care (n = 32), targeted care such as management of falls risk, functional decline, or pain management (n = 27), medication safety (n = 5), and trauma care (n = 12). We found a misalignment between comprehensive care delivered in ED for older adults and ED performance measures oriented to rapid assessment and referral. Eight (10.4%) studies reported patient experience and five (6.5%) reported staff experience.

CONCLUSION

It is crucial that future strategies to improve care delivery in ED align the needs of older adults with the purpose of the ED system to ensure sustainable improvement effort and critical functioning of the ED as an interdependent component of the health system. Staff and patient input at the design stage may advance prioritisation of higher-impact interventions aligned with the pace of change and illuminate experience measures. More consistent reporting of interventions would inform important contextual factors and allow for replication.

Strategies for improving ED-related outcomes of older adults who seek care in emergency departments: a systematic review

BACKGROUND

Despite constituting 14% of the general population, older adults make up almost a quarter of all emergency department (ED) visits. These visits often do not adequately address patient needs, with nearly 80% of older patients discharged from the ED carrying at least one unattended health concern. Many interventions have been implemented and tested in the ED to care for older adults, which have not been recently synthesized.

METHODS

A systematic review was conducted to identify interventions initiated in the ED to address the needs of older adults. Embase, MEDLINE, CINAHL, Cochrane CENTRAL, the Cochrane Database of Systematic Reviews, and grey literature were searched from January 2013 to January 18, 2023. Comparative studies assessing interventions for older adults in the ED were included. The quality of controlled trials was assessed with the Cochrane risk-of-bias tool for randomized trials, and the quality of observational studies was assessed with the risk of bias in non-randomized studies of interventions tool. Due to heterogeneity, meta-analysis was not possible.

RESULTS

Sixteen studies were included, assessing 12 different types of interventions. Overall study quality was low to moderate: 10 studies had a high risk of bias, 5 had a moderate risk of bias, and only 1 had a low risk of bias. Follow-up telephone calls, referrals, geriatric assessment, pharmacist-led interventions, physical therapy services, care plans, education, case management, home visits, care transition interventions, a geriatric ED, and care coordination were assessed, many of which were combined to create multi-faceted interventions. Care coordination with additional support and early assessment and intervention were the only two interventions that consistently reported improved outcomes. Most studies did not report significant improvements in ED revisits, hospitalization, time spent in the ED, costs, or outpatient utilization. Two studies reported on patient perspectives.

CONCLUSION

Few interventions demonstrate promise in reducing ED revisits for older adults, and this review identified significant gaps in understanding other outcomes, patient perspectives, and the effectiveness in addressing underlying health needs. This could suggest, therefore, that most revisits in this population are unavoidable manifestations of frailty and disease trajectory. Efforts to improve older patients' needs should focus on interventions initiated outside the ED.

Impact of Geriatric Consult Evaluations on Hospital Admission Rates for Older Adults

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.

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

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.

Models of care for frail older persons who present to the emergency department: A scoping review of the literature

BACKGROUND

People aged ≥65 years comprise approximately 20 % of all emergency department (ED) presentations. Frailty amongst this cohort is common yet can go undetected.

OBJECTIVE

To summarise the evidence regarding models of care for frail older people in the ED.

METHODS

The Joanna Briggs Institute scoping review framework was used. Literature searches were conducted in five electronic databases published from 2009 to 2022. Original research that met the criteria: frail older people aged ≥65 years, models of care and ED were included.

RESULTS

A total of thirteen articles met the criteria for inclusion in this review. These comprised four studies of frailty care models and nine studies of care models using different assessment tools to identify frail older people. Care models were comprised of various specialist team members (e.g., geriatrician/ED physician and nurse). Processes underpinning these models included tools to support clinicians in the assessment of frail older adults, particularly around functional status, comorbidities, symptom distress, quality of life, cognition/delirium, and social aspects. Outcomes of care models for frail older people included: shorter ED length of stay, lower hospital admission rates, cost savings and increased patient satisfaction rates.

CONCLUSION

A variety of models, supported by a variety of assessment tools, exist to identify and guide care delivery for frail older people in the ED. Careful consideration of existing policies, guidelines and models is required before implementing new service models.

Transitional care interventions to reduce emergency department visits in older adults: A systematic review

Background

Preventable illnesses cause many emergency department visits in older adults, which can be minimized by implementing appropriate transitional care interventions. However, the most effective transitional care strategies for older adults are unknown.

Objective

To discover and consolidate transitional care interventions that can help older people avoid going to the emergency department.

Methods

From January 2011 to August 2021, PubMed, The Cochrane Library, CINAHL, Web of Science, ProQuest, and The JAMA Network were used to search. Two authors independently screened and selected papers, assessed the risk of bias, and extracted data into a standardized form in accordance with Cochrane guidelines. For the risk of bias in studies, the RevMan 5.4.1 program was utilized.

Results

Six randomized controlled trials, four non-randomized controlled trials, and three retrospective investigations were among the 13 studies examined. All studies evaluated emergency department visits but in different periods (ranging from 1-12 months after discharge) and with varying groups of baselines (pre-post intervention and between groups). The multi-component strategies, either pre or postdischarge phase using high-intensity care delivered within six months of discharge, were implemented in transitional care that had been shown to reduce emergency department visits in older adults.

Conclusion

To prevent emergency department visits by older patients, nurses should arrange for a high-intensity transitional care intervention that involves both pre-and postdischarge interventions. The effectiveness of the intervention in reducing emergency department visits in older adults is difficult to determine due to inter-study heterogeneity and poor methodological quality. There is a need for more evidence-based research with consistent and trustworthy effect assessments.

PROSPERO registration number

CRD42021261326.

Hospital-associated deconditioning: Not only physical, but also cognitive

INTRODUCTION

Hospital-associated deconditioning (HAD) or post-hospital syndrome is well recognized as reduced functional performance after an acute hospitalization. Recommendations for the management of HAD are still lacking, partly due to a poor understanding of the underlying processes. We aimed to review existing data on risk factors, pathophysiology, measurement tools, and potential interventions.

MATERIALS AND METHODS

We conducted a systematic review from bibliographical databases in English, Spanish and French with keywords such as 'post-hospitalization syndrome' or 'deconditioning'. We selected studies that included people aged 60 years or older. Three researchers independently selected articles and assessed their quality.

RESULTS

From 4421 articles initially retrieved, we included 94 studies. Most were related to risk factors, trajectories and measures, and focused on the physical aspects of deconditioning. Risk factors for HAD included age, nutritional status, mobility, and pre-admission functional status, but also cognitive impairment and depression. Regarding interventions, almost all studies were devoted to physical rehabilitation and environmental modifications. Only one study focused on cognitive stimulation.

DISCUSSION

In the last decade, studies on HAD have mostly focused on the physical domain. However, neurological changes may also play a role in the pathophysiology of HAD. Beyond physical interventions, cognitive rehabilitation and neurological interventions should also be evaluated to improve deconditioning prevention and treatment in the hospital setting.

[Nursing roles and competencies in emergency care - focusing on geriatric emergency care: A scoping review]

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.

Interventions for the discharge of older people to their home from the emergency department: a systematic review

BACKGROUND

Clinicians have limited evidence on which to base their practice to effectively discharge older people from emergency. The aim of the review was to assess the effectiveness of interventions used for the discharge of older people from the emergency department to their home in the community by emergency clinicians.

METHODS

The PRISMA guidelines were followed. The search comprised seven databases including CINAHL Complete, Medline and EMBASE, and additionally unpublished literature sources including trial registries and theses databases. The results were presented for three outcomes: mortality; emergency department representation after the index visit; and physical function. A narrative analysis was performed.

RESULTS

Twenty-five studies met the inclusion criteria; 13 RCTs and 12 quasi-experimental. Risk of bias was moderate to high. There was a trend towards reduced probability of representing to the emergency department within 3 months of the index visit for individualised focussed elder discharge health interventions. Results were equivocal for other outcomes.

CONCLUSIONS

Greater clarity and consensus is needed to determine the most appropriate discharge measures, screening tools, information sources and discharge roles for the emergency setting. Rigorous multicentre trials to improve the evidence on which to base this aspect of emergency care are required.

Effects of perioperative comprehensive nursing based on risk prevention for patients with intracranial aneurysm

OBJECTIVE

To explore the effect of comprehensive nursing based on risk prevention in perioperative nursing of intracranial aneurysm.

METHODS

A total of 156 patients who suffered from intracranial aneurysm were admitted in neurosurgery department from the hospital between January 2018 and January 2019. Patients were randomly divided into observation group (n = 78, patients were given comprehensive nursing based on risk prevention) and control group (n = 78, patients were given routine nursing). The following parameters, such as postoperative hospital stay, rescue success rate, Glasgow coma scale (GCS) after being awake, anxiety degree and nursing effect (incidence of complications, incidence of infection and patient satisfaction) were compared between the two groups.

RESULTS

The postoperative hospital stay, rescue success rate and GCS after intervention in the observation group were significantly better than those in the control group (P < .05). The degree of anxiety in the observation group after intervention was superior to that in the control group (P < .05), similar results were obtained in terms of the nursing effect in the observation group compared with the control group (P < .05).

CONCLUSION

Comprehensive nursing was associated with the shortness of hospitalisation time of patients, improved rescue rate, reduced occurrence of complications and infection, and improved satisfaction of patients. Thus, comprehensive nursing was regarded to exert protective effect with a promising future for clinical practice.

Comprehensive geriatric assessment in the emergency department

Completing comprehensive geriatric assessments (CGA) for frail patients admitted to acute hospitals has well-established benefits and is advocated by national guidelines. There is high-quality evidence demonstrating an association between inpatient CGAs and the patient being alive and community-dwelling at 12-month follow-up. However, less well-known is the effectiveness of CGAs conducted within the emergency department (ED), with the primary purpose of facilitating admission avoidance, on reducing 30-day reattendance or readmission. This commentary provides an overview of five studies that measure the impact of conducting an ED-CGA on subsequent secondary care attendance. Two randomised-controlled trials, one case-matched cohort study and two quasi-experimental pre- and post-intervention studies were reviewed. The studies reported variable success in preventing subsequent secondary care use. No studies meeting the criteria had been conducted within the UK, affecting generalisability of the findings. There is no clear evidence that conducting a CGA within ED reduced reattendances or admissions 30 days post-discharge. The existing evidence base is methodologically and clinically heterogeneous and is vulnerable to multiple sources of bias. Further research is needed to understand whether screening to identify target populations or whether increased intensity of interventions delivered improves outcomes. ED-CGA may not have a beneficial effect on cost improvement or service delivery metrics, but it may have positive outcomes that are of high importance to the patients. This warrants further study.

Errors in nurse-led triage: An observational study

BACKGROUND

Nurses play a crucial role in correctly prioritizing patients entering emergency departments. However, little is known of the accuracy of nurse-led triage systems.

OBJECTIVES

(1) To determine the frequency of nurse-led triage errors within the Manchester Triage System; (2) to explore patient, work environment and individual nurse factors associated with triage errors; and (3) to explore associations between triage errors and patient outcomes (i.e., length of emergency department stay, hospitalization, and 7- and 30-day mortality).

SETTING

This study was conducted in one emergency department in Northern Italy.

PARTICIPANTS

A random sample of 5% (n = 1,929) of all eligible patients accessing the emergency department over an 18-month period.

METHODS

For this retrospective observational study, electronic health record data on triage errors (i.e., incorrect presentational flowchart, specific discriminator and/or priority level) and triage nurses were combined with routine data on patient characteristics, outcomes and the work environment. To explore relationships between these variables, we performed univariate and multivariate logistic regression analyses.

RESULTS

We observed triage errors in 16.3% of patients (n = 314). These were significantly associated with patients' emergency department and hospital stays. Analyses revealed that when > one patient was triaged every 15 min (OR: 2.112;95%CI: 1.331-3.354), older patients (OR: 1.009; 95%CI: 1.003-1.015) with > than two chronic conditions (OR: 1.506; 95%CI: 1.091-2.081) and orange or red priority codes (OR: 1.314; 95%CI: 1.046-1.651,) whose triage nurse had previous experience with another triage system (OR: 3.189; 95%CI: 2.455-4.14) had higher odds of triage errors.

CONCLUSION

We provided primary evidence on triage errors. Confirming our findings on the prevalence, nature and consequences of such errors will require further prospective multicenter studies. Considering patient factors (e.g., age, polychronicity) as additional discriminators could make the nurse-led triage process using the Manchester Triage System more accurate. Investigating the roles of triage nurses' training and background and the emergency department work environment on their mental models regarding the triage process will require qualitative research.