Implementing a case management intervention for frequent users of the emergency department (I-CaM): an effectiveness-implementation hybrid trial study protocol

Health mediation does not reduce the readmission rate of frequent users of emergency departments living in precarious conditions: what lessons can be learned from this randomised controlled trial?

BACKGROUND

Severe overcrowding of emergency departments (EDs) affects the quality of healthcare. One factor of overcrowding is precariousness, but it has rarely been considered a key factor in designing interventions to improve ED care. Health mediation (HM) aims to facilitate access to rights, prevention, and care for the most vulnerable persons and to raise awareness among healthcare providers about obstacles in accessing healthcare. The primary aim was to determine whether HM intervention for frequent users of EDs (FUED) living in precarious conditions could reduce the readmission rate at 90 days.

METHODS

Between February 2019 and May 2022, we enrolled and interviewed 726 FUED in four EDs of southeastern France in this randomised controlled trial. The HM intervention started in the ED and lasted 90 days. In addition to the primary endpoint (first readmission at 90 days), secondary endpoints (readmission at 30 and 180 days, number of hospitalisations at 30, 90, 180 days, admissions for the same reasons as the first admission) were also studied. The outcomes were measured in the ED information systems. Statistical methods included an intention-to-treat analysis and a per-protocol analysis. Comparisons were adjusted for gender, age, ED, and health mediator.

RESULTS

46% of patients reported attending the ED because they felt their life was in danger, and 42% had been referred to the ED by the emergency medical dispatch centre or their GP; 40% of patients were considered to be in a serious condition by ED physicians. The proportion of patients who were readmitted at 90 days was high but did not differ between the control and the HM intervention groups (31.7% vs. 36.3%, p = 0.23). There was no significant difference in any of the secondary outcome measures between the control and HM intervention groups. Per-protocol analysis also showed no significant difference for the primary and secondary endpoints.

CONCLUSIONS

This randomised controlled trial did not show that our health mediation intervention was effective in reducing the use of emergency services by FUED living in precarious conditions. Some limitations are discussed: the duration of the intervention (90 days), the long-term effects (> 6 months), the involvement of the ED staff.

TRIAL REGISTRATION

Registered on clinicaltrials.gov as NCT03660215 on 4th September 2018.

Health mediation: an intervention mode for improving emergency department care and support for patients living in precarious conditions

BACKGROUND

Severe overcrowding of emergency departments (EDs) impacts the quality of healthcare. One factor of this overcrowding is precariousness, but it has rarely been considered a key factor in designing interventions to improve ED care. Health mediation (HM) aims to facilitate access to rights, prevention, and care for the most vulnerable persons and to raise awareness among healthcare providers about obstacles in accessing healthcare. We here present the results of an ancillary qualitative study to explore the prospects regarding a health mediation intervention implemented in EDs for deprived persons who are frequent ED users, from professionals' and patients' perspectives.

METHODS

Design, data collection, and data analysis were done according to a psychosocial approach, based on thematic content analysis and semi-structured interviews of 16 frequent ED users and deprived patients exposed to HM and of 14 professionals in 4 EDs of South-eastern France.

RESULTS

All patients reported multifactorial distress. Most of them expressed experiencing isolation and powerlessness, and lacking personal resources to cope with healthcare. They mentioned the use of ED as a way of quickly meeting a professional to respond to their suffering, and recognized the trustworthy alliance with health mediators (HMrs) as a means to put them back in a healthcare pathway. The presence of HMrs in EDs was appreciated by ED professionals because HMrs responded to requests they were not able to access and were perceived as an efficient support for caring for deprived persons in emergency contexts.

CONCLUSIONS

Our results are in favour of health mediation in EDs as a promising solution, requested by patients and ED professionals, to cope with frequent ED users and deprived patients. Our results could also be used to adapt other strategies for the most vulnerable populations to reduce the frequency of ED readmissions. At the interface of the patients' health experience and the medico-social sector, HM could complete the immediate responses to medical needs given in EDs and contribute in alleviating the social inequalities of health.

Experiences of Frequent Users of Emergency Departments in Health Care Setting in French-Speaking Switzerland: A Qualitative Study

AIMS

Frequent users of the emergency department (FUED; five ED visits or more per year) often have negative experiences in health care settings, potentially aggravating their health problems. Scarce research has explored FUED experiences in health care in Europe, none in Switzerland. Thus, this study aimed to conduct an in-depth exploration of FUED experiences in health care settings in Switzerland.

METHODS

Semi-structured interviews were conducted among 20 FUED (75% female; mean age = 40.6, SD = 12.8). Qualitative data were subject to inductive content analysis.

RESULTS

Five main themes emerged from the analysis. The main findings documented that FUED experiences in health care were mostly negative, leading to negative emotions, dissatisfaction and a loss of confidence in the system, although some positive experiences were reported as well. The relationship with health care workers was perceived as playing a key role in FUED experiences.

CONCLUSION

The findings indicate that FUED often have negative experiences in the health care system in Switzerland. The relationship with the health care staff is reported as a decisive ingredient of the experience in health care. Future research is needed to develop awareness-raising interventions for health care staff to improve FUED experiences in health care.

Understanding the experience in the healthcare system of non-migrant and migrant frequent users of the emergency department in French-speaking Switzerland: a comparative qualitative study

BACKGROUND

Previous research revealed the vulnerability of frequent users of emergency department (FUED) because of concomitant medical, psychological and social issues. Case management (CM) provides FUED with effective medical and social support, however, the heterogeneity of this population has highlighted the need to explore the specific needs of FUED subpopulations. In response, this study aimed to explore qualitatively the lived experience of migrant and non-migrant FUED in the healthcare system to identify unmet needs.

METHODS

Adult migrant and non-migrant FUED (≥ 5 visits in the ED in the past 12 months) were recruited in a Swiss university hospital to collect qualitative data on their experience within the Swiss health system. Participants were selected based on predefined quotas for gender and age. Researchers conducted one-on-one semistructured interviews until reaching data saturation. Inductive conventional content analysis was used to analyse qualitative data.

RESULTS

In total, 23 semistructured interviews were conducted (11 migrant FUED and 12 non-migrant FUED). Four main themes emerged from the qualitative analysis: (1) self-evaluation of the Swiss healthcare system; (2) orientation within the healthcare system; (3) relationship with caregivers and (4) perception of own health. While both groups were overall satisfied with the healthcare system and care provided, migrant FUED reported language and financial barriers to access it. Both groups expressed overall satisfaction over their relationship with healthcare professionals, although migrant FUED reported a feeling of illegitimacy to consult the ED based on social status, whereas non-migrant FUED felt more often the need to justify their use of the ED. Finally, migrant FUED perceived their own health to be affected by their status.

CONCLUSION

This study highlighted difficulties specific to subpopulations of FUED. For migrant FUED, these included access to care and impact of migrant status on own health. Adapting CM to the specific needs of migrant FUED could help reduce their vulnerability.

Perspectives of Frequent Users of Emergency Departments on a Case Management Intervention: A Qualitative Study

BACKGROUND

Effective management of frequent users of emergency departments (FUED) remains challenging. Case management (CM) has shown to improve patient quality of life while reducing ED visits and associated costs. However, little data is available on FUED's perception of CM outside of North America to further improve CM implementation.

OBJECTIVES

Explore the FUED's perspectives about CM in Switzerland.

DESIGN, SETTING & PARTICIPANTS

Semi-structured qualitative interviews eliciting FUED's experiences of CM were conducted among 20 participants (75% female; mean age = 40.6, SD = 12.8) across 6 hospital ED.

OUTCOMES MEASURES & ANALYSIS

Inductive content analysis.

MAIN RESULTS

Most participants were satisfied with the CM program. In particular, FUEDs identified the working relationship with the case manager (cm) as key for positive outcomes, and also valued the holistic evaluation of their needs and resources. Overall, patients reported increased motivation and health literacy, as well as facilitated interactions within the healthcare system. Conversely, a small number of participants reported negative views on CM (ie, stigmatization, lack of concrete outcomes). Barriers identified were cm's lack of time, COVID-19's negative impact on CM organization, as well as lack of clarity on the objectives of CM. FUED perceived CM as useful, in particular establishing a working relationship with the cm. Our results suggest that CM can be further improved by (1) professionals remaining non-judgmental toward FUED, (2) making sure the aims and objectives of the CM are understood by the participants, and (3) allowing more time for the cm to carry out their work.

Methodological approaches to study context in intervention implementation studies: an evidence gap map

BACKGROUND

Within implementation science studies, contextual analysis is increasingly recognized as foundational to interventions' successful and sustainable implementation. However, inconsistencies between methodological approaches currently limit progress in studying context and guidance to standardize the use of those approaches is scant. Therefore, this study's objective was to systematically review and map current methodological approaches to contextual analysis in intervention implementation studies. The results would help us both to systematize the process of contextual analysis and identify gaps in the current evidence.

METHODS

We conducted an evidence gap map (EGM) based on literature data via a stepwise approach. First, using an empirically developed search string, we randomly sampled 20% of all intervention implementation studies available from PubMed per year (2015-2020). Second, we assessed included studies that conducted a contextual analysis. Data extraction and evaluation followed the Basel Approach for CoNtextual ANAlysis (BANANA), using a color-coded rating scheme. Also based on BANANA and on the Context and Implementation of Complex Interventions (CICI) framework-an implementation framework that pays ample attention to context- we created visual maps of various approaches to contextual analysis.

RESULTS

Of 15, 286 identified intervention implementation studies and study protocols, 3017 were screened for inclusion. Of those, 110 warranted close examination, revealing 22% that reported on contextual analysis. Only one study explicitly applied a framework for contextual analysis. Data were most commonly collected via surveys (n = 15) and individual interviews (n = 13). Ten studies reported mixed-methods analyses. Twenty-two assessed meso-level contextual and setting factors, with socio-cultural aspects most commonly studied. Eighteen described the use of contextual information for subsequent project phases (e.g., intervention development/adaption, selecting implementation strategies). Nine reported contextual factors' influences on implementation and/or effectiveness outcomes.

CONCLUSIONS

This study describes current approaches to contextual analysis in implementation science and provides a novel framework for evaluating and mapping it. By synthesizing our findings graphically in figures, we provide an initial evidence base framework that can incorporate new findings as necessary. We strongly recommend further development of methodological approaches both to conduct contextual analysis and to systematize the reporting of it. These actions will increase the quality and consistency of implementation science research.

Monthly Identification of High Frequency Emergency Presenters to Improve Care Delivery and Evaluation: A Unique Methodological Approach

Background: Frequent presenters to emergency departments (EDs) pose many challenges around care delivery and health service management. The aim of this study was to investigate the presentation patterns of people with 5 or more ED visits in any calendar month (5+ frequent presenter [FP5+]) to develop a useful methodological framework on which the real impact of interventions may be assessed. Methods: This study is a retrospective analysis of de-identified frequent ED presentation data using segmented regression analysis of an interrupted time series (ITS). Results: A total of 82 FP5+ to this single ED were identified in a year. Of these presenters, 77% had 10 or more presentations in a year. The total FP5+ presentations in the 12 months preceding and after each participant's ≥5 presentations in 1 month (the trigger month for inclusion in the study) accounted for 1,064 and 1,606 visits, respectively. ITS analysis of frequent ED presentations did not show a significant level change or trend change during the data collection period. Monthly review of people who frequently present to a single ED showed that presentations typically occurred in bouts that may span calendar years. Presentation bouts then typically slow, potentially distorting evaluation of the effects of interventions. Conclusion: Rolling monthly examination of presentation data may facilitate timely case review and care delivery, as well as provide a holistic picture of the impacts of interventions targeting patient care needs. This unique analysis demands a reconsideration of the typical before-and-after analysis of interventions for this vulnerable and high-cost group of patients.

Does Case Management Provide Support for Staff Facing Frequent Users of Emergency Departments? A Comparative Mixed-Method Evaluation of ED Staff Perception

Objective

Frequent users of emergency departments (FUED) account for a disproportionate number of emergency department (ED) visits and contribute to a wide range of challenges for ED staff. While several research has documented that case management (CM) tailored to FUED leads to a reduction in ED visits and a better quality of life (QoL) among FUED, whether there is added value for ED staff remains to be explored. This study aimed to compare, among staff in two academic EDs in Switzerland (one with and one without CM), the FUED-related knowledge, perceptions of the extent of the FUED issue, FUED-related work challenges and FUEDs’ legitimacy to use ED.

Method

Mixed methods were employed. First, ED physicians and nurses (N = 253) of the two EDs completed an online survey assessing their knowledge and perceptions of FUEDs. Results between healthcare providers working in an ED with CM to those working in an ED without CM were compared using independent two-sided T-tests. Next, a sample of participants (n = 16) took part in a qualitative assessment via one-to-one interviews (n = 6) or focus groups (n = 10).

Results

Both quantitative and qualitative results documented that the FUED-related knowledge, the extent FUED were perceived as an issue and perceived FUEDs’ legitimacy to use ED were not different between groups. The level of perceived FUED-related challenges was also similar between groups. Quantitative results showed that nurses with CM experienced more challenges related to FUED. Qualitative exploration revealed that lack of psychiatric staff within the emergency team and lack of communication between ED staff and CM team were some of the explanations behind these counterintuitive findings.

Conclusion

Despite promising results on FUEDs’ QoL and frequency of ED visits, these preliminary findings suggest that CM may provide limited support to ED staff in its current form. Given the high burden of FUED-related challenges encountered by ED staff, improved communication and FUED-related knowledge transfer between ED staff and the CM team should be prioritized to increase the value of a FUED CM intervention for ED staff.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00481-9.

Health care providers' perception of the frequent emergency department user issue and of targeted case management interventions: a cross-sectional national survey in Switzerland

Background

Frequent users of emergency departments (FUEDs) (≥5 ED visits/year) represent a vulnerable population with complex needs accounting for a significant number of emergency department (ED) consultations, thus contributing to EDs overcrowding. Research exploring ED staff perceptions of FUEDs is scarce.

Objectives

The current study aimed to evaluate in ED staff a) the extent to which FUEDs are perceived as an issue; b) their perceived levels of knowledge and understanding of FUEDs; c) levels of perceived usefulness of case management (CM) and interest in implementing this intervention in their ED service.

Methods

Head physicians of the EDs at all public hospitals in Switzerland (of various level of specialization) were sent a 19-item web-based survey, pilot tested prior to its dissemination. The head physicians were asked to forward the survey to ED staff members from different health professional backgrounds.

Results

The hospital response rate was 81% (85/106). The exploitable hospital response rate was 71% (75/106 hospitals) including 208 responding health professionals. Issues and difficulties around FUEDs were perceived as important by 64% of respondents. The perceived frequency of being confronted with FUEDs was higher among nurses in more specialized EDs. In total, 64% of respondents felt poorly informed about FUEDs, nurses feeling less informed than physicians. The understanding of FUEDs was lower in the French-Italian-speaking parts (FISP) of Switzerland than in the German-speaking part. Eighty-one percent of respondents had no precise knowledge of FUED-related interventions. The perceived usefulness of CM interventions after receiving explanations about it was high (92%). However, the overall level of interest for CM implementation was 59%. The interest in CM by physicians was low across all regions and ED categories. Nurses, on the other hand, showed more interest, especially those in EDs of high specialization.

Conclusions

The majority of ED staff reported being confronted with FUEDs on a regular basis. Staff perceived FUEDs as a vulnerable population, yet, they felt poorly informed about how to manage the issue. The majority of ED staff thought a CM intervention would be useful for FUEDs, however there appears to be a gap in their desire or willingness to implement such interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-020-00397-w.

Healthcare Providers' Perceptions of Challenges with Frequent Users of Emergency Department Care in Switzerland: A Qualitative Study

Frequent users of emergency departments (FUED; ≥ 5 ED visits/year) commonly cumulate medical, social, and substance use problems requiring complex and sustained care coordination often unavailable in ED. This study aimed to explore ED healthcare providers' challenges related to FUED care to gain insight into the support and resources required to address FUED complex needs. An online survey was sent to all general adult emergency services within Switzerland (N = 106). Participants were asked to indicate the extent to which they perceived that FUED represented a problem and to describe the main challenges encountered. In total, 208 physicians and nurses from 75 EDs (70.7%) completed the survey. Among the 208 participants, 134 (64%) reported that FUED represented a challenge and 133 described 1 to 5 challenges encountered. A conventional content analysis yielded 4 main categories of perceived challenges. Negative consequences in the ED secondary to FUED's presence (eg, ED overcrowding, staff helplessness, and fatigue) was the most frequently reported challenge, followed by challenges related to FUEDs' characteristics (eg, mental health and social problems) leading to healthcare complexity. The third most frequently encountered challenge was related to the ED inappropriateness and inefficiency to address FUEDs' needs. Finally, challenges related to the lack of FUED healthcare network were the least often mentioned. ED healthcare providers experience a wide range of challenges related to FUED care. These findings suggest that currently EDs nor their staff are equipped to address FUEDs' complex needs.

A conceptual model to guide research on the activities and effects of innovation champions

BACKGROUND

The importance of having a champion to promote implementation efforts has been discussed in the literature for more than five decades. However, the empirical literature on champions remains underdeveloped. As a result, health organizations commonly use champions in their implementation efforts without the benefit of evidence to guide decisions about how to identify, prepare, and evaluate their champions. The goal of this article is to present a model of champion impact that draws upon previous literature and is intended to inform future research on champions and serve as a guide for practitioners serving in a champion role.

METHODS

The proposed model is informed by existing literature, both conceptual and empirical. Prior studies and reviews of the literature have faced challenges in terms of operationalizing and reporting on champion characteristics, activities, and impacts. The proposed model addresses this challenge by delineating these constructs, which allows for consolidation of factors previously discussed about champions as well as new hypothesized relationships between constructs.

RESULTS

The model proposes that a combination of champion commitment and champion experience and self-efficacy influence champion performance, which influences peer engagement with the champion, which ultimately influences the champion's impact. Two additional constructs have indirect effects on champion impact. Champion beliefs about the innovation and organizational support for the champion affect champion commitment.

CONCLUSION

The proposed model is intended to support prospective studies of champions by hypothesizing relationships between constructs identified in the champion literature, specifically relationships between modifiable factors that influence a champion's potential impact. Over time, the model should be modified, as appropriate, based on new findings from champion-related research.