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Goldberg EM, Marks SJ, Resnik LJ, Long S, Mellott H, Merchant RC. Can an Emergency Department-Initiated Intervention Prevent Subsequent Falls and Health Care Use in Older Adults? A Randomized Controlled Trial. Ann Emerg Med 2020; 76:739-750. [PMID: 32854965 PMCID: PMC7686139 DOI: 10.1016/j.annemergmed.2020.07.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 12/28/2022]
Abstract
STUDY OBJECTIVE We determine whether an emergency department (ED)-initiated fall-prevention intervention can reduce subsequent fall-related and all-cause ED visits and hospitalizations in older adults. METHODS The Geriatric Acute and Post-acute Fall Prevention intervention was a randomized controlled trial conducted from January 2018 to October 2019. Participants at 2 urban academic EDs were randomly assigned (1:1) to an intervention or usual care arm. Intervention participants received a brief, tailored, structured, pharmacy and physical therapy consultation in the ED, with automated communication of the recommendations to their primary care physicians. RESULTS Of 284 study-eligible participants, 110 noninstitutionalized older adults (≥65 years) with a recent fall consented to participate; median age was 81 years, 67% were women, 94% were white, and 16.3% had cognitive impairment. Compared with usual care participants (n=55), intervention participants (n=55) were half as likely to experience a subsequent ED visit (adjusted incidence rate ratio 0.47 [95% CI 0.29 to 0.74]) and one third as likely to have fall-related ED visits (adjusted incidence rate ratio 0.34 [95% CI 0.15 to 0.76]) within 6 months. Intervention participants experienced half the rate of all hospitalizations (adjusted incidence rate ratio 0.57 [95% CI 0.31 to 1.04]), but confidence intervals were wide. There was no difference in fall-related hospitalizations between groups (adjusted incidence rate ratio 0.99 [95% CI 0.31 to 3.27]). Self-reported adherence to pharmacy and physical therapy recommendations was moderate; 73% of pharmacy recommendations were adhered to and 68% of physical therapy recommendations were followed. CONCLUSION Geriatric Acute and Post-acute Fall Prevention, a postfall, in-ED, multidisciplinary intervention with pharmacists and physical therapists, reduced 6-month ED encounters in 2 urban EDs. The intervention could provide a model of care to other health care systems aiming to reduce costly and burdensome fall-related events in older adults.
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Affiliation(s)
- Elizabeth M Goldberg
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI; Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI.
| | - Sarah J Marks
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, MA
| | - Linda J Resnik
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI; Providence VA Medical Center, Providence, RI
| | - Sokunvichet Long
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Hannah Mellott
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Roland C Merchant
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, MA
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Gurley KL, Blodgett MS, Burke R, Shapiro NI, Edlow JA, Grossman SA. The utility of emergency department physical therapy and case management consultation in reducing hospital admissions. J Am Coll Emerg Physicians Open 2020; 1:880-886. [PMID: 33145536 PMCID: PMC7593441 DOI: 10.1002/emp2.12075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 04/02/2020] [Accepted: 04/03/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND A significant number of patients who present to the emergency department (ED) following a fall or with other injuries require evaluation by a physical therapist. Traditionally, once emergent conditions are excluded in the ED, these patients are admitted to the hospital for evaluation by a physical therapist to determine whether they should be transferred to a sub-acute rehabilitation facility, discharged, require services at home, or require further inpatient care. Case management is typically used in conjunction with a physical therapist to determine eligibility for recommended services and to aid in placement. OBJECTIVE To evaluate the benefit of using ED-based physical therapist and case management services in lieu of routine hospital admission. METHODS Retrospective, observational study of consecutive patients presenting to an urban, tertiary care academic medical center ED between December 1, 2017, and November 30, 2018, who had a physical therapist consult placed in the ED. We additionally evaluated which of these patients were placed into ED observation for physical therapist consultation, how many required case management, and ED disposition: discharged home from the ED or ED observation with or without services, placed in a rehabilitation facility, or admitted to the hospital. RESULTS During the 12-month study period, 1296 patients (2.4% of the total seen in the ED) were assessed by a physical therapist. The mean age was 75.5 ± 15.2 and 832 (64.2%) were female. Case management was involved in 91.8% of these cases. The final patient disposition was as follows: admission 24.3% (95% CI = 22.1-26.7%), home discharge with or without services 47.8% (95% CI = 45.1-50.5%), rehabilitation (rehab) setting 27.9% (95% CI = 25.6%-30.4). The median (interquartile range) time in observation was 13.1 (6.0-20.3), 9.9 (1.8-15.8), and 18.4 (14.1-24.8) hours for patients admitted, discharged home, or sent to rehabilitation (P < 0.001). Among the 979 patients discharged home or sent to rehabilitation, 17 (1.7%) returned to the ED within 72 hours and were ultimately admitted. CONCLUSION Given that the standard of care would otherwise be an admission to the hospital for 1 day or more for all patients requiring physical therapist consultation, an ED-based physical therapy and case management system serves as a viable method to substantially decrease hospital admissions and potentially reduce resource use, length of hospital stay, and cost both to patients and the health care system.
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Affiliation(s)
- Kiersten L. Gurley
- Emergency Medicine, Harvard Medical School, Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusetts
- Mount Auburn HospitalCambridgeMassachusetts
| | - Maxwell S. Blodgett
- Emergency Medicine, Harvard Affiliated Emergency Medicine Residency, Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusetts
| | - Ryan Burke
- Beth Israel Deaconess Medical CenterBostonMassachusetts
| | - Nathan I. Shapiro
- Emergency Medicine, Harvard Medical School, Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusetts
| | - Jonathan A. Edlow
- Emergency Medicine, Harvard Medical School, Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusetts
| | - Shamai A Grossman
- Emergency Medicine, Harvard Medical School, Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusetts
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Magel J, Kim J, Fritz JM, Freburger JK. Time Between an Emergency Department Visit and Initiation of Physical Therapist Intervention: Health Care Utilization and Costs. Phys Ther 2020; 100:1782-1792. [PMID: 32478851 PMCID: PMC7530572 DOI: 10.1093/ptj/pzaa100] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 05/26/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The aim of this study was to examine the association between the length of time between an emergency department (ED) visit and the subsequent initiation of physical therapist intervention for low back pain (LBP) on 1-year LBP-related health care utilization (ie, surgery, advanced imaging, injections, long-term opioid use, ED visits) and costs. METHODS This retrospective cohort study focused on individuals who consulted the ED for an initial visit for LBP. Claims from a single statewide, all-payers database were used. LBP-related health care use and costs for the 12 months after the ED visit were extracted. Poisson and general linear models weighted with inverse probability treatment weights were used to compare the outcomes of patients who attended physical therapy early or delayed after the ED visit. RESULTS Compared with the delayed physical therapy group (n = 94), the early physical therapy group (n = 171) had a lower risk of receiving lumbar surgery (relative risk [RR] = 0.47, 95% CI = 0.26-0.86) and advanced imaging (RR = 0.72, 95% CI = 0.55-0.95), and they were less likely to have long-term opioid use (RR = 0.45, 95% CI = 0.28-0.76). The early physical therapy group incurred lower costs (mean = $3,806, 95% CI = $1,998-$4,184) than those in the delayed physical therapy group (mean = $8,689, 95% CI = $4,653-$12,727). CONCLUSION Early physical therapy following an ED visit was associated with a reduced risk of using some types of health care and reduced health care costs in the 12 months following the ED visit. IMPACT STATEMENT The ED is an entry point into the health care system for patients with LBP. Until now, the impact of the length of time between an ED visit and physical therapy for LBP has not been well understood. This study shows that swift initiation of physical therapy following an ED visit for LBP is associated with lower LBP-related health utilization for some important outcomes and lower LBP-related health care costs.
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Affiliation(s)
- John Magel
- Address all correspondence to Dr Magel at:
| | - Jaewhan Kim
- Department of Physical Therapy and Athletic Training, University of Utah
| | | | - Janet K Freburger
- Department of Physical Therapy, School of Health & Rehabilitation Sciences, University of Pittsburg, Pittsburgh, Pennsylvania
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Southerland LT, Stephens JA, Carpenter CR, Mion LC, Moffatt-Bruce SD, Zachman A, Hill M, Caterino JM. Study protocol for IMAGE: implementing multidisciplinary assessments for geriatric patients in an emergency department observation unit, a hybrid effectiveness/implementation study using the Consolidated Framework for Implementation Research. Implement Sci Commun 2020; 1:28. [PMID: 32885187 PMCID: PMC7427917 DOI: 10.1186/s43058-020-00015-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 01/27/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Older adults in the emergency department (ED) are at high risk for functional decline, unrecognized delirium, falls, and medication interactions. Holistic assessment by a multidisciplinary team in the ED decreases these adverse outcomes and decreases admissions, but there are many barriers to incorporating this type of care during the ED visit. METHODS This is a hybrid type II effectiveness-implementation study using a pre-/post-cohort design (n = 380) at a tertiary care academic ED with an ED observation unit (Obs Unit). The intervention is a two-step protocol of (step 1) ED nurses screening adult patients ≥ 65 years old for geriatric needs using the Delirium Triage Screen, 4-Stage Balance Test, and the Identifying Seniors at Risk score. Patients who have geriatric needs identified by this screening but who do not meet hospital admission criteria will (step 2) be placed in the Obs Unit for multidisciplinary geriatric assessment by the hospital's geriatric consultation team, physical therapists, occupational therapists, pharmacists, and/or case managers. Not all patients may require all elements of the multidisciplinary geriatric assessment. The Consolidated Framework for Implementation Research: Care Transitions Framework was used to identify barriers to implementation. Lean Six Sigma processes will be used to overcome these identified barriers with the goal of achieving geriatric screening rates of > 80%. Implementation success and associated factors will be reported. For the effectiveness aim, pre-/post-cohorts of adults ≥ 65 years old cared for in the Obs Unit will be followed for 90 days post-ED visit (n = 150 pre and 230 post). The primary outcome is the prevention of functional decline. Secondary outcomes include health-related quality of life, new geriatric syndromes identified, new services provided, and Obs Unit metrics such as length of stay and admission rates. DISCUSSION A protocol for implementing integrated multidisciplinary geriatric assessment into the ED setting has the potential to improve patient functional status by identifying and addressing geriatric issues and needs prior to discharge from the ED. Using validated frameworks and implementation strategies will increase our understanding of how to improve the quality of ED care for older adults in the acute care setting. TRIAL REGISTRATION ClinicalTrials.gov Identifier, NCT04068311, registered 28 August 2019.
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Affiliation(s)
- Lauren T. Southerland
- Department of Emergency Medicine, The Ohio State Wexner Medical Center, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210 USA
| | - Julie A. Stephens
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State College of Medicine, Columbus, OH USA
| | | | - Lorraine C. Mion
- College of Nursing, The Ohio State Wexner Medical Center, Columbus, OH USA
| | | | - Angela Zachman
- Department of Emergency Medicine, The Ohio State Wexner Medical Center, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210 USA
| | - Michael Hill
- Department of Emergency Medicine, The Ohio State Wexner Medical Center, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210 USA
| | - Jeffrey M. Caterino
- Department of Emergency Medicine, The Ohio State Wexner Medical Center, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210 USA
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Juneja H, Platon R, Soerensen UM, Praestegaard J. The Emergency Physiotherapy Practitioner (EPP) – a descriptive case study of development and implementation in two Danish hospitals. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2019. [DOI: 10.1080/21679169.2019.1578825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Hemant Juneja
- Faculty of Physiotherapy, Center of Nutrition and Rehabilitation, University College Absalon, Naestved, Denmark
| | - Ruxandra Platon
- Department of Physiotherapy and Occupational Therapy, Naestved-Slagelse-Ringsted Hospitals, Naestved, Denmark
| | | | - Jeanette Praestegaard
- Faculty of Physiotherapy, Center of Nutrition and Rehabilitation, University College Absalon, Naestved, Denmark
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Southerland LT, Hunold KM, Carpenter CR, Caterino JM, Mion LC. A National Dataset Analysis of older adults in emergency department observation units. Am J Emerg Med 2018; 37:1686-1690. [PMID: 30563716 DOI: 10.1016/j.ajem.2018.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/03/2018] [Accepted: 12/06/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Emergency Department (ED) Observation Units (Obs Units) are prevalent in the US, but little is known regarding older adults in observation. Our objective was to describe the Obs Units nationally and observation patients with specific attention to differences in care with increasing age. DESIGN This is an analysis of 2010-2013 data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a national observational cohort study including ED patients. Weighted means are presented for continuous data and weighted percent for categorical data. Multivariable logistic regression was used to identify variables associated with placement in and admission from observation. RESULTS The number of adult ED visits varied from 100 million to 107 million per year and 2.3% of patients were placed in observation. Adults ≥65 years old made up a disproportionate number of Obs Unit patients, 30.6%, compared to only 19.7% of total ED visits (odds ratio 1.5 (95% CI 1.5-1.6), adjusting for sex, race, month, day of week, payer source, and hospital region). The overall admission rate from observation was 35.6%, ranging from 31.3% for ages 18-64 years to 47.5% for adults ≥85 years old (p < 0.001). General symptoms (e.g., nausea, dizziness) and hypertensive disease were the most common diagnoses overall. Older adults varied from younger adults in that they were frequently observed for diseases of the urinary system (ICD-9 590-599) and metabolic disorders (ICD-9 270-279). CONCLUSIONS Older adults are more likely to be cared for in Obs Units. Older adults are treated for different medical conditions than younger adults.
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Affiliation(s)
- Lauren T Southerland
- 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
| | | | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lorraine C Mion
- College of Nursing, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Ferreira GE, Traeger AC, Maher CG. Review article: A scoping review of physiotherapists in the adult emergency department. Emerg Med Australas 2018; 31:43-57. [DOI: 10.1111/1742-6723.12987] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 03/02/2018] [Accepted: 03/13/2018] [Indexed: 12/29/2022]
Affiliation(s)
- Giovanni E Ferreira
- School of Public Health, Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
| | - Adrian C Traeger
- School of Public Health, Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
| | - Chris G Maher
- School of Public Health, Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
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Southerland LT, Vargas AJ, Nagaraj L, Gure TR, Caterino JM. An Emergency Department Observation Unit Is a Feasible Setting for Multidisciplinary Geriatric Assessments in Compliance With the Geriatric Emergency Department Guidelines. Acad Emerg Med 2018; 25:76-82. [PMID: 28975679 DOI: 10.1111/acem.13328] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/22/2017] [Accepted: 09/24/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Geriatric Emergency Department (ED) Guidelines recommend providing multidisciplinary geriatric assessment in the ED, but these assessments can be difficult to coordinate and may prolong length of stay. Patients who need longer than a typical ED stay can be placed in an ED observation unit (Obs Unit). We investigated the effects of offering multidisciplinary assessments for ED patients in an Obs Unit. METHODS Evaluation by a geriatric hospital consultation team, physical therapist, case manager, and/or pharmacist was made available to all Obs Unit patients. Use of any or all of these ancillary consult services could be requested by the Obs Unit physician. A retrospective chart review of random older adult Obs Unit patients was done to assess rates of consult use and interventions by these consulting teams. All patients ≥ 65 years old in our institutional review board-approved, monthly Obs Unit quality database from October 2015 through March 2017 were included. RESULTS Our quality database included 221 older patients over 18 months. The mean (±SD) age was 73.3 (±6.8) years (range = 65-96 years) and 55.2% were women. The mean (±SD) observation length of stay was 14.7 (±6.5) hours. The majority (74.3%) were discharged from the Obs Unit and 72-hour ED recidivism was 3.6%. Overall, at least one of the multidisciplinary consultant services were requested in 40.3% of patients (n = 89). Additional interventions or services were recommended in 80.0% of patients evaluated by physical therapy (32 of 40 patients), 100% of those evaluated by a pharmacist (five of five patients), 38% of those evaluated by case management (27 of 71 patients), and 100% of those evaluated by a geriatrician (eight of eight patients). Only 5.4% (n = 12) of patients were placed in observation specifically for multidisciplinary assessment; these patients had a mean (±SD) length of stay of 12.2 (±5) hours and an admission rate of 41.7%. CONCLUSIONS Incorporating elements of multidisciplinary geriatric assessment for older patients is feasible within an observation time frame and resulted in targeted interventions. An Obs Unit is a reasonable setting to offer services in compliance with the Geriatric ED Guidelines.
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Affiliation(s)
| | | | - Lalitha Nagaraj
- Department of Emergency Medicine The Ohio State University Columbus OH
| | - Tanya R. Gure
- Department of Internal Medicine Division of General Internal Medicine and Geriatrics The Ohio State University Columbus OH
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Caspers CG. Care of Traumatic Conditions in an Observation Unit. Emerg Med Clin North Am 2017; 35:673-683. [PMID: 28711130 DOI: 10.1016/j.emc.2017.03.010] [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: 10/19/2022]
Abstract
Patients presenting to the emergency department with certain traumatic conditions can be managed in observation units. The evidence base supporting the use of observation units to manage injured patients is smaller than the evidence base supporting the management of medical conditions in observation units. The conditions that are eligible for management in an observation unit are not limited to those described in this article, and investigators should continue to identify types of conditions that may benefit from this type of health care delivery.
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Affiliation(s)
- Christopher G Caspers
- Ronald O. Perelman Department of Emergency Medicine, New York University Langone Medical Center, 560 First Avenue, New York, NY 10016, USA.
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