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Dennis B, Deane A, Lauzier F, Zytaruk N, Hardie M, Hammond N, Finfer S, Arabi Y, Marshall J, Saunders L, Heels-Ansdell D, Myburgh J, Knowles S, Muscedere J, Ostermann M, Rajbhandari D, English S, Matic K, Venkatesh B, Al Fares A, Guyatt G, Alhazzani W, Mumtaz H, Poole A, Xie F, Thabane L, Hall R, Cook D. Protocol implementation during the COVID-19 pandemic: experiences from a randomized trial of stress ulcer prophylaxis. BMC Med Res Methodol 2024; 24:109. [PMID: 38704520 PMCID: PMC11069460 DOI: 10.1186/s12874-024-02233-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 04/23/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND During the COVID-19 pandemic, many intensive care units (ICUs) halted research to focus on COVID-19-specific studies. OBJECTIVE To describe the conduct of an international randomized trial of stress ulcer prophylaxis (Re-Evaluating the Inhibition of Stress Erosions in the ICU [REVISE]) during the pandemic, addressing enrolment patterns, center engagement, informed consent processes, data collection, a COVID-specific substudy, patient transfers, and data monitoring. METHODS REVISE is a randomized trial among mechanically ventilated patients, comparing pantoprazole 40 mg IV to placebo on the primary efficacy outcome of clinically important upper gastrointestinal bleeding and the primary safety outcome of 90-day mortality. We documented protocol implementation status from March 11th 2020-August 30th 2022. RESULTS The Steering Committee did not change the scientific protocol. From the first enrolment on July 9th 2019 to March 10th 2020 (8 months preceding the pandemic), 267 patients were enrolled in 18 centers. From March 11th 2020-August 30th 2022 (30 months thereafter), 41 new centers joined; 59 were participating by August 30th 2022 which enrolled 2961 patients. During a total of 1235 enrolment-months in the pandemic phase, enrolment paused for 106 (8.6%) months in aggregate (median 3 months, interquartile range 2;6). Protocol implementation involved a shift from the a priori consent model pre-pandemic (188, 58.8%) to the consent to continue model (1615, 54.1%, p < 0.01). In one new center, an opt-out model was approved. The informed consent rate increased slightly (80.7% to 85.0%, p = 0.05). Telephone consent encounters increased (16.6% to 68.2%, p < 0.001). Surge capacity necessitated intra-institutional transfers; receiving centers continued protocol implementation whenever possible. We developed a nested COVID-19 substudy. The Methods Centers continued central statistical monitoring of trial metrics. Site monitoring was initially remote, then in-person when restrictions lifted. CONCLUSION Protocol implementation adaptations during the pandemic included a shift in the consent model, a sustained high consent rate, and launch of a COVID-19 substudy. Recruitment increased as new centers joined, patient transfers were optimized, and monitoring methods were adapted.
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Affiliation(s)
- Brittany Dennis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Adam Deane
- Department of Critical Care Or Medicine, Department of Critical Care Medicine, Melbourne Medical School, University of Melbourne, Parkville, Victoria, Australia
| | - François Lauzier
- Departments of Anesthesiology, Medicine and Critical Care Medicine, Université Laval, Québec, Canada
| | - Nicole Zytaruk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Research Institute, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Miranda Hardie
- Critical Care Program, Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Naomi Hammond
- Critical Care Program, Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Simon Finfer
- Critical Care Program, Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Yaseen Arabi
- Intensive Care Department, Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - John Marshall
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Lois Saunders
- Division of Critical Care, Research Institute, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - John Myburgh
- Critical Care Program, Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Intensive Care Unit, St. George Hospital, Sydney, Australia
| | - Serena Knowles
- Critical Care Program, Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - John Muscedere
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Thomas' Hospital, Guy's & St, London, UK
| | - Dorrilyn Rajbhandari
- Critical Care Program, Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Shane English
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Karlo Matic
- Division of Critical Care, Research Institute, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Bala Venkatesh
- Critical Care Program, Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Abdulrahman Al Fares
- Departments of Anesthesia, Critical Care Medicine, and Pain Medicine, Al-Amiri Center for Respiratory and Cardiac Failure, Al-Amiri Hospital, Ministry of Health, Kuwait Extracorporeal Life Support Program, Ministry of Health, Kuwait City, Kuwait
| | - Gordon Guyatt
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Research Institute, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Hassan Mumtaz
- Department of Critical Care, Maroof Hospital, Islamabad, Pakistan
| | - Alexis Poole
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia
- Centre for Research Excellence in Translating Nutrition Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
| | - Feng Xie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Research Institute, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Biostatistics Unit, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Richard Hall
- Departments of Anesthesia, Critical Care and Pharmacology, Dalhousie University, Halifax, NS, Canada
| | - Deborah Cook
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
- Division of Critical Care, Research Institute, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada.
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Sunner C, Giles M, Ball J, Barker R, Hullick C, Oldmeadow C, Foureur M. Implementation and evaluation of a nurse-led intervention to augment an existing residential aged care facility outreach service with a visual telehealth consultation: stepped-wedge cluster randomised controlled trial. BMC Health Serv Res 2023; 23:1429. [PMID: 38110923 PMCID: PMC10726593 DOI: 10.1186/s12913-023-10384-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 11/27/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND Up to 75% of residents from residential aged care facilities (RACF) are transferred to emergency departments (ED) annually to access assessment and care for unplanned or acute health events. Emergency department presentations of RACF residents can be both expensive and risky, and many are unnecessary and preventable. Processes or triage systems to assess residents with a health event, prior to transfer, may reduce unnecessary ED transfer. The Aged Care Emergency (ACE) service is a nurse-led ED outreach service that provides telephone support to RACF nurses regarding residents' health events. This service is available Monday to Friday, 8am to 4 pm (ED ACE hours). The primary objective of this study was to assess whether the augmentation of the phone-based ED ACE service with the addition of a visual telehealth consultation (VTC) would reduce RACF rate of ED presentations compared to usual care. The secondary objectives were to 1) monitor presentations to ED within 48 h post VTC to detect any adverse events and 2) measure RACF staff perceptions of VTC useability and acceptability. METHODS This implementation study used a stepped wedge cluster randomised controlled trial design. Study settings were four public hospital EDs and 16 RACFs in two Local Health Districts. Each ED was linked to 4 RACFs with approximately 350 RACF beds, totalling 1435 beds across 16 participating RACFs. Facilities were randomised into eight clusters with each cluster comprising one ED and two RACFs. RESULTS A negative binomial regression demonstrated a 29% post-implementation reduction in the rate of ED presentations (per 100 RACF beds), within ED ACE hours (IRR [95% CI]: 0.71 [0.46, 1. 09]; p = 0.122). A 29% reduction, whilst not statistically significant, is still clinically important and impactful for residents and EDs. A post-hoc logistic regression demonstrated a statistically significant 69% reduction in the probability that an episode of care resulted in an ED presentation within ED ACE hours post-implementation compared to pre-implementation (OR [95% CI]: 0.31 [0.11, 0.87]; p = 0.025). CONCLUSION Findings have shown the positive impact of augmenting ACE with a VTC. Any reduction of resident presentations to a busy ED is beneficial to healthcare overall, but more so to the individual older person who can recover safely and comfortably in their own RACF. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ID ACTR N12619001692123) (02/12/2019) https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378629andisReview=true.
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Affiliation(s)
- Carla Sunner
- Hunter New England Local Health District, Newcastle, 2300, Australia.
- University of Newcastle, Callaghan, 2308, Australia.
| | - Michelle Giles
- Hunter New England Local Health District, Newcastle, 2300, Australia
- University of Newcastle, Callaghan, 2308, Australia
| | - Jean Ball
- Hunter New England Local Health District, Newcastle, 2300, Australia
| | - Roslyn Barker
- Hunter New England Local Health District, Newcastle, 2300, Australia
| | - Carolyn Hullick
- Hunter New England Local Health District, Newcastle, 2300, Australia
- University of Newcastle, Callaghan, 2308, Australia
| | | | - Maralyn Foureur
- Hunter New England Local Health District, Newcastle, 2300, Australia
- University of Newcastle, Callaghan, 2308, Australia
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Dennis BB, Thabane L, Heels-Ansdell D, Dionne JC, Binnie A, Tsang J, Guyatt G, Ahmed A, Lauzier F, Deane A, Arabi Y, Marshall J, Zytaruk N, Saunders L, Finfer S, Myburgh J, Muscedere J, English S, Ostermann M, Hardie M, Knowles S, Cook D. Proton pump inhibitors in critically ill mechanically ventilated patients with COVID-19: protocol for a substudy of the Re-EValuating the Inhibition of Stress Erosions (REVISE) Trial. Trials 2023; 24:561. [PMID: 37644556 PMCID: PMC10466724 DOI: 10.1186/s13063-023-07589-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Critically ill patients commonly receive proton pump inhibitors (PPIs) to prevent gastrointestinal (GI) bleeding from stress-induced ulceration. Despite widespread use in the intensive care unit (ICU), observational data suggest that PPIs may be associated with adverse outcomes in patients with COVID-19 infection. This preplanned study is nested within a large randomized trial evaluating pantoprazole versus placebo in invasively ventilated patients. The 3 objectives are as follows: (1) to describe the characteristics of patients with COVID-19 in terms of demographics, biomarkers, venous thromboembolism, tracheostomy incidence and timing, and other clinical outcomes; (2) to evaluate the impact of COVID-19 infection on clinically important GI bleeding, 90-day mortality, and other outcomes compared to a propensity-matched non-infected cohort; and (3) to explore whether pantoprazole has a differential treatment effect on clinically important GI bleeding, 90-day mortality, and other outcomes in patients with and without COVID-19 infection. METHODS The ongoing trial Re-EValuating the Inhibition of Stress Erosions (REVISE) compares pantoprazole 40 mg IV to placebo on the primary efficacy outcome of clinically important GI bleeding and the primary safety outcome of 90-day mortality. The protocol described in this report is for a substudy focused on patients with COVID-19 infection that was not in the original pre-pandemic trial protocol. We developed a one-page case report form to characterize these patients including data related to biomarkers, venous thromboembolism, COVID-19 therapies, tracheostomy incidence and timing, duration of mechanical ventilation, and ICU and hospital stay. Our analysis will describe the trajectory of patients with COVID-19 infection, a propensity-matched analysis of infected and non-infected patients, and an extended subgroup analysis comparing the effect of PPI among patients with and without COVID-19 infection. DISCUSSION Prophylactic acid suppression in invasively ventilated critically ill patients with COVID-19 infection has unknown consequences. The results of these investigations will inform practice, guidelines, and future research. TRIAL REGISTRATION REVISE Trial [NCT03374800 December 15, 2017], COVID-19 Cohort Study [NCT05715567 February 8, 2023].
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Affiliation(s)
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada
- Biostatistics Unit, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
- Division of Critical Care, Research Institute, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada
| | - Joanna C. Dionne
- Departments of Medicine and Health Research Methods, Evidence, and Impact, McMaster University, McMaster University Health Sciences Center, Room 2C11, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
| | - Alexandra Binnie
- Department of Critical Care Medicine, Niagara Health System, St. Catharines, ON Canada
| | - Jennifer Tsang
- Department of Medicine, McMaster University, Hamilton, ON Canada
- Department of Critical Care Medicine, Niagara Health System, St. Catharines, ON Canada
| | - Gordon Guyatt
- Departments of Medicine and Health Research Methods, Evidence, and Impact, McMaster University, McMaster University Health Sciences Center, Room 2C11, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
| | - Aijaz Ahmed
- Department of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA USA
| | - François Lauzier
- Departments of Anesthesiology and Medicine and Critical Care Medicine, Université Laval, Québec, Québec Canada
| | - Adam Deane
- Department of Critical Care Medicine, University of Melbourne, Melbourne Medical School, Parkville, VIC Australia
| | - Yaseen Arabi
- Intensive Care Department, Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - John Marshall
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON Canada
| | - Nicole Zytaruk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada
- Division of Critical Care, Research Institute, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Lois Saunders
- Division of Critical Care, Research Institute, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Simon Finfer
- Critical Care Program, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW Australia
| | - John Myburgh
- Critical Care Program, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW Australia
- Intensive Care Unit, St. George Hospital, Sydney, Australia
| | - John Muscedere
- Department of Critical Care Medicine, Queen’s University, Kingston, ON Canada
| | - Shane English
- Department of Medicine, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Marlies Ostermann
- Department of Critical Care, King’s College London, Guy’s & St Thomas’ Hospital, London, UK
| | - Miranda Hardie
- Critical Care Program, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW Australia
| | - Serena Knowles
- Critical Care Program, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW Australia
| | - Deborah Cook
- Division of Critical Care, Research Institute, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
- Departments of Medicine and Health Research Methods, Evidence, and Impact, McMaster University, McMaster University Health Sciences Center, Room 2C11, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
| | - For the REVISE Investigators the Canadian Critical Care Trials Group
- Department of Medicine, McMaster University, Hamilton, ON Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada
- Biostatistics Unit, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
- Division of Critical Care, Research Institute, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
- Departments of Medicine and Health Research Methods, Evidence, and Impact, McMaster University, McMaster University Health Sciences Center, Room 2C11, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
- Department of Critical Care Medicine, Niagara Health System, St. Catharines, ON Canada
- Department of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA USA
- Departments of Anesthesiology and Medicine and Critical Care Medicine, Université Laval, Québec, Québec Canada
- Department of Critical Care Medicine, University of Melbourne, Melbourne Medical School, Parkville, VIC Australia
- Intensive Care Department, Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON Canada
- Critical Care Program, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW Australia
- Intensive Care Unit, St. George Hospital, Sydney, Australia
- Department of Critical Care Medicine, Queen’s University, Kingston, ON Canada
- Department of Medicine, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Department of Critical Care, King’s College London, Guy’s & St Thomas’ Hospital, London, UK
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Vogelsmeier A, Popejoy L, Fritz E, Canada K, Ge B, Brandt L, Rantz M. Repeat hospital transfers among long stay nursing home residents: a mixed methods analysis of age, race, code status and clinical complexity. BMC Health Serv Res 2022; 22:626. [PMID: 35538575 PMCID: PMC9087933 DOI: 10.1186/s12913-022-08036-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background Nursing home residents are at increased risk for hospital transfers resulting in emergency department visits, observation stays, and hospital admissions; transfers that can also result in adverse resident outcomes. Many nursing home to hospital transfers are potentially avoidable. Residents who experience repeat transfers are particularly vulnerable to adverse outcomes, yet characteristics of nursing home residents who experience repeat transfers are poorly understood. Understanding these characteristics more fully will help identify appropriate intervention efforts needed to reduce repeat transfers. Methods This is a mixed-methods study using hospital transfer data, collected between 2017 and 2019, from long-stay nursing home residents residing in 16 Midwestern nursing homes who transferred four or more times within a 12-month timeframe. Data were obtained from an acute care transfer tool used in the Missouri Quality Initiative containing closed- and open-ended questions regarding hospital transfers. The Missouri Quality Initiative was a Centers for Medicare and Medicaid demonstration project focused on reducing avoidable hospital transfers for long stay nursing home residents. The purpose of the analysis presented here is to describe characteristics of residents from that project who experienced repeat transfers including resident age, race, and code status. Clinical, resident/family, and organizational factors that influenced transfers were also described. Results Findings indicate that younger residents (less than 65 years of age), those who were full-code status, and those who were Black were statistically more likely to experience repeat transfers. Clinical complexity, resident/family requests to transfer, and lack of nursing home resources to manage complex clinical conditions underlie repeat transfers, many of which were considered potentially avoidable. Conclusions Improved nursing home resources are needed to manage complex conditions in the NH and to help residents and families set realistic goals of care and plan for end of life thus reducing potentially avoidable transfers.
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Affiliation(s)
- Amy Vogelsmeier
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA.
| | - Lori Popejoy
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
| | - Elizabeth Fritz
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
| | - Kelli Canada
- School of Social Work, University of Missouri, Columbia, MO, USA
| | - Bin Ge
- School of Medicine, University of Missouri, Columbia, MO, USA
| | - Lea Brandt
- School of Medicine, University of Missouri, Columbia, MO, USA
| | - Marilyn Rantz
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
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Webb HT, Lieb KM, Stump TE, Unroe KT, Carnahan JL. Describing Transfers Originating Out-of-Facility for Nursing Home Residents. J Am Med Dir Assoc 2022; 23:105-110. [PMID: 34181908 PMCID: PMC8709881 DOI: 10.1016/j.jamda.2021.05.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 05/06/2021] [Accepted: 05/29/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Potentially avoidable hospitalizations are harmful to nursing home residents. Despite extensive care transitions research, no studies have described transfers originating outside the nursing home (eg, visiting family members or at a dialysis center). This article describes 82 out-of-facility (community) transfers and compares them to transfers originating within the nursing home (direct transfers). DESIGN Secondary data analysis with multivariable model for community transfer risk factors. SETTING AND PARTICIPANTS Eighty-two community transfers and 1362 transfers originating in the nursing home, involving 870 residents enrolled in the OPTIMISTIC demonstration project between January 1, 2015, and June 30, 2016. METHODS Transfers were compared using data from the Minimum Data Set and root cause analyses performed at time of transfer. Multivariable associations were assessed at the transfer level to define risk factors for community transfers. Project nurses collected data on community transfers to inform a root cause analysis. RESULTS Residents with community transfers were younger (74.4 years vs 78.2 years), with lower prevalence of cognitive impairment (44.8% vs 70.3%) and higher rates of heart failure (38.7% vs 23.3%) than residents with direct transfers. Community transfers were more likely due to cardiovascular illness (31.2% vs 8.7%), whereas less likely to be for cognitive, behavioral, and psychiatric concerns (11.7% vs 22.7%). Nearly half (46%) of community transfers originated at dialysis centers. Residents transferred outside the nursing home were less likely to have documented limitations to care such as a do not resuscitate code status. Communication during community transfers was identified on root cause analyses as a potential area for improvement. CONCLUSIONS AND IMPLICATIONS Community transfers were more likely to occur in younger residents with higher rates of cardiovascular disease and lower rates of cognitive impairment. Improved communication between nursing home staff and outside providers as well as more extensive advance care planning for residents with cardiovascular disease may reduce community transfers.
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Affiliation(s)
- Hanna T Webb
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kristi M Lieb
- Indiana University School of Medicine, Indianapolis, IN, USA; Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Timothy E Stump
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kathleen T Unroe
- Indiana University School of Medicine, Indianapolis, IN, USA; Regenstrief Institute, IU Center for Aging Research, Indianapolis, IN, USA
| | - Jennifer L Carnahan
- Indiana University School of Medicine, Indianapolis, IN, USA; Regenstrief Institute, IU Center for Aging Research, Indianapolis, IN, USA; Roudebush VA Medical Center, Indianapolis, IN, USA.
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Heinold S, Fassmer AM, Schmiemann G, Hoffmann F. Characteristics of outpatient emergency department visits of nursing home residents: an analysis of discharge letters. Aging Clin Exp Res 2021; 33:3343-51. [PMID: 33939126 DOI: 10.1007/s40520-021-01863-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/13/2021] [Indexed: 10/30/2022]
Abstract
BACKGROUND Unplanned emergency department (ED) visits of nursing home residents (NHR) are common, with many transfers not leading to hospitalization. However, there is little research on what diagnostic and therapeutic measures are performed during visits. AIMS We analyzed underlying diagnoses, characteristics and performed medical procedures of unplanned outpatient ED visits by NHR. METHODS We conducted a multi-center study of 14 nursing homes (NHs) in northwestern Germany in 03/2018-07/2019. Hospital transfers were documented by nursing staff using a standardized questionnaire for 12 months. In addition, discharge letters were used to collect information about the respective transfer, its reasons and the extend of the medical services performed in the ED. RESULTS A total of 161 unplanned ED visits were included (mean age: 84.2 years; 68.3% females). The main transfer reasons were trauma (59.0%), urinary catheter and nutritional probe problems (overall 10.6%; male NHR 25.5%) and altered mental state (9.9%). 32.9% where discharged without imaging or blood test prior. 67.4% of injured NHR (n = 95) required no or only basic wound care. Catheter-related problems (n = 17) were mainly treated by changing an existing suprapubic catheter (35.3%) and by flushing the pre-existing catheter (29.4%). DISCUSSION Our data suggest that the diagnostic and therapeutic interventions performed in ED, often do not exceed general practitioner (GP) care and many ED visits seem to be unnecessary. CONCLUSION Better coordination and consultation with GPs as well as better training of nursing staff in handling catheter problems could help to reduce the number of ED visits.
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Richardson C, Abrol A, Cabrera CI, Goldstein J, Maronian N, Rodriguez K, D'Anza B. The power of a checklist: Decrease in emergency department epistaxis transfers after clinical care pathway implementation. Am J Otolaryngol 2021; 42:102941. [PMID: 33592555 DOI: 10.1016/j.amjoto.2021.102941] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Annually, epistaxis costs US hospitals over $100 million dollars. Many patients visit emergency departments (ED) with variable treatment, thus providing opportunity for improvement. OBJECTIVE To implement an epistaxis clinical care pathway (CCP) in the ED, and analyze its effects on treatment and ED transfers. METHODS An interdisciplinary team developed the CCP to be implemented at a tertiary hospital system with 11 satellite EDs. The analysis included matched eight-month periods prior to pathway implementation and after pathway implementation. Subjects included patients with ICD-10 code diagnosis of epistaxis. Patients under 18 years old, recent surgery or trauma, or bleeding disorders were excluded. There were 309 patients from the pre-implementation cohort, 53 of which were transferred and 37 met inclusion criteria; 322 from the post-implementation cohort, 37 of which were transferred, and 15 met inclusion criteria. Outcome measures included epistaxis intervention by ED providers and otolaryngologists before and after pathway implementation. RESULTS CCP implementation resulted in a 61% reduction in patient transfers (p < 0.001). ED providers showed a 51% increase in documentation of anterior rhinoscopy with proper equipment, 34% increased use of topical vasoconstrictors, 40% increased use of absorbable packing, 7% decrease in use of unilateral non-absorbable packing, and 17% decrease in use of bilateral non-absorbable packing. CONCLUSIONS Prior to CCP implementation, ED treatment of epistaxis varied significantly. CCP resulted in standardized treatment and significant reduction in transfers. A CCP checklist is an effective way to standardize care and prevent unnecessary hospital transfers.
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Richardson C, Abrol A, Hamill CS, Maronian N, Rodriguez K, D'Anza B. Improving efficiency in epistaxis transfers in a large health system: Analyzing emergency department treatment variability as pretext for a clinical care pathway. Am J Otolaryngol 2019; 40:530-535. [PMID: 31036416 DOI: 10.1016/j.amjoto.2019.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 04/16/2019] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Epistaxis is a common condition with an estimated $100 million in health care costs annually. A significant portion of this stems from Emergency Department (ED) management and hospital transfers. Currently there is no data in the literature clearly depicting the differences in treatment of epistaxis between Emergency Medicine (EM) physicians and Otolaryngologists. Clinical care pathways (CCP) are a way to standardize care and increase efficiency. Our goal was to evaluate the variability in epistaxis management between EM and Otolaryngology physicians in order to determine the potential impact of a system wide clinical care pathway. MATERIALS AND METHODS A retrospective case study was conducted of all patients transferred between emergency departments for epistaxis over an 18-month period. Exclusion criteria comprised patients under 18 years old, recent sinonasal surgery, bleeding disorders, and recent facial trauma. RESULTS 73 patients met inclusion criteria. EM physicians used nasal cautery in 8%, absorbable packing in 1% and non-absorbable packing in 92% (with 33% being bilateral). In comparison, Otolaryngologists used nasal cautery in 37%, absorbable packing in 34%, and non-absorbable packing in 23%. Eighty percent of patients treated by an Otolaryngology physician required less invasive intervention than previously performed by EM physicians prior to transfer. CONCLUSIONS Epistaxis management varied significantly between Emergency Medicine and Otolaryngology physicians. Numerous patients were treated immediately with non-absorbable packing. On post-transfer Otolaryngology evaluation, many of these patients required less invasive interventions. This study highlights the variability of epistaxis treatment within our hospital system and warrants the need for a standardized care pathway.
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