81 Integrating A Front Door Frailty Service in the Emergency Department: Results of A Pilot Study

2021 ◽  
Vol 50 (Supplement_1) ◽  
pp. i12-i42
Author(s):  
L Dunnell ◽  
A Shrestha ◽  
E Li ◽  
Z Khan ◽  
N Hashemi
Keyword(s):  
Emergency Department ◽  
Hospital Admissions ◽  
Admission Rate ◽  
Community Services ◽  
Service Improvement ◽  
Specialist Nurse ◽  
Front Door ◽  
Medication Changes ◽  
Health Service Improvement

Abstract Introduction Increasing old age and frailty is putting pressure on health services with 5–10% of patients attending the emergency department (ED) and 30% of patients in acute medical units classified as older and frail. National Health Service improvement mandates that by 2020 hospital trusts with type one EDs provide at least 70 hours of acute frailty service each week. Methodology A two-week pilot (Monday–Friday 8 am-5 pm) was undertaken, with a “Front Door Frailty Team” comprising a consultant, junior doctor, specialist nurse and pharmacist, with therapy input from the existing ED team. They were based in the ED seeing patients on arrival, referrals from the ED team and patients in the ED observation ward—opposed to the usual pathway of referral from the ED team to medical team. Data was captured using “Cerner” electronic healthcare records. A plan, do, study, act methodology was used throughout with daily debrief and huddle sessions. Results 95 patients were seen over two weeks. In the over 65 s, average time to be seen was 50 minutes quicker than the ED team over the same period, with reduced admission rate (25.7% vs 46.5%). The wait between decision to admit and departure was shortened by 119 minutes. Overall, this led to patients spending on average 133 minutes less in the ED. 64 patients were discharged, of which 44 had community follow-up (including 37.5% of 64 referred to acute elderly clinic and 25% to rapid response). 47 medications were stopped across 25 patients. Conclusion The pilot shows that introduction of an early comprehensive geriatric assessment in the ED can lead to patients being seen sooner, with more timely decisions over their care and reduction in hospital admissions. It allowed for greater provision of acute clinics and community services as well as prompt medication review and real time medication changes.

scholarly journals Implementation of the acutely presenting older patient (APOP) screening program in routine emergency department care

2021 ◽  
Author(s):  
Laura C. Blomaard ◽  
Bas de Groot ◽  
Jacinta A. Lucke ◽  
Jelle de Gelder ◽  
Anja M. Booijen ◽  
...  
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Older Patients ◽  
Screening Program ◽  
Admission Rate ◽  
Older Patient ◽  
Hospital Admission Rate ◽  
High Risk Patients ◽  
Risk Patients

Abstract Objective The aim of this study was to evaluate the effects of implementation of the acutely presenting older patient (APOP) screening program for older patients in routine emergency department (ED) care shortly after implementation. Methods We conducted an implementation study with before-after design, using the plan-do-study-act (PDSA) model for quality improvement, in the ED of a Dutch academic hospital. All consecutive patients ≥ 70 years during 2 months before and after implementation were included. The APOP program comprises screening for risk of functional decline, mortality and cognitive impairment, targeted interventions for high-risk patients and education of professionals. Outcome measures were compliance with interventions and impact on ED process, length of stay (LOS) and hospital admission rate. Results Two comparable groups of patients (median age 77 years) were included before (n = 920) and after (n = 953) implementation. After implementation 560 (59%) patients were screened of which 190 (34%) were high-risk patients. Some of the program interventions for high-risk patients in the ED were adhered to, some were not. More hospitalized patients received comprehensive geriatric assessment (CGA) after implementation (21% before vs. 31% after; p = 0.002). In 89% of high-risk patients who were discharged to home, telephone follow-up was initiated. Implementation did not influence median ED LOS (202 min before vs. 196 min after; p = 0.152) or hospital admission rate (40% before vs. 39% after; p = 0.410). Conclusion Implementation of the APOP screening program in routine ED care did not negatively impact the ED process and resulted in an increase of CGA and telephone follow-up in older patients. Future studies should investigate whether sustainable changes in management and patient outcomes occur after more PDSA cycles.

scholarly journals LO14: Interdepartmental program to improve outcomes for acute heart failure patients seen in the emergency department

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S11-S12
Author(s):  
I. Stiell ◽  
M. Taljaard ◽  
A. Forster ◽  
L. Mielniczuk ◽  
G. Wells ◽  
...  
Keyword(s):  
Heart Failure ◽  
Emergency Department ◽  
Acute Heart Failure ◽  
Hospital Admissions ◽  
Tertiary Care ◽  
Control Period ◽  
Care Hospital ◽  
Index Visit ◽  
Rapid Access

Introduction: An important challenge physicians face when treating acute heart failure (AHF) patients in the emergency department (ED) is deciding whether to admit or discharge, with or without early follow-up. The overall goal of our project was to improve care for AHF patients seen in the ED while avoiding unnecessary hospital admissions. The specific goal was to introduce hospital rapid referral clinics to ensure AHF patients were seen within 7 days of ED discharge. Methods: This prospective before-after study was conducted at two campuses of a large tertiary care hospital, including the EDs and specialty outpatient clinics. We enrolled AHF patients ≥50 years who presented to the ED with shortness of breath (<7 days). The 12-month before (control) period was separated from the 12-month after (intervention) period by a 3-month implementation period. Implementation included creation of rapid access AHF clinics staffed by cardiology and internal medicine, and development of referral procedures. There was extensive in-servicing of all ED staff. The primary outcome measure was hospital admission at the index visit or within 30 days. Secondary outcomes included mortality and actual access to rapid follow-up. We used segmented autoregression analysis of the monthly proportions to determine whether there was a change in admissions coinciding with the introduction of the intervention and estimated a sample size of 700 patients. Results: The patients in the before period (N = 355) and the after period (N = 374) were similar for age (77.8 vs. 78.1 years), arrival by ambulance (48.7% vs 51.1%), comorbidities, current medications, and need for non-invasive ventilation (10.4% vs. 6.7%). Comparing the before to the after periods, we observed a decrease in hospital admissions on index visit (from 57.7% to 42.0%; P <0.01), as well as all admissions within 30 days (from 65.1% to 53.5% (P < 0.01). The autoregression analysis, however, demonstrated a pre-existing trend to fewer admissions and could not attribute this to the intervention (P = 0.91). Attendance at a specialty clinic, amongst those discharged increased from 17.8% to 42.1% (P < 0.01) and the median days to clinic decreased from 13 to 6 days (P < 0.01). 30-day mortality did not change (4.5% vs. 4.0%; P = 0.76). Conclusion: Implementation of rapid-access dedicated AHF clinics led to considerably increased access to specialist care, much reduced follow-up times, and possible reduction in hospital admissions. Widespread use of this approach can improve AHF care in Canada.

Improving cancer pain management in the emergency department: An EMR-based solution.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 12110-12110
Author(s):  
Christopher John Coyne ◽  
Ellen Kettler ◽  
Kelly Dong ◽  
James Killeen
Keyword(s):  
Emergency Department ◽  
Cancer Pain ◽  
Cancer Patients ◽  
Hospital Admissions ◽  
Admission Rate ◽  
Chief Complaint ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Opioid Dose ◽  
Patients With Cancer

12110 Background: Pain is common reason for patients with cancer to seek care in the emergency department (ED). Unfortunately, these patients frequently receive inadequate doses of pain medication, partially due to opioid reduction efforts in the ED, as well as opioid tolerance among those with chronic cancer pain. The purpose of this study was to investigate the effectiveness of an electronic medical record (EMR) based best practice advisory (BPA) at improving analgesic dosing for cancer patients in the ED. Methods: We performed a retrospective cohort study on cancer pain at two academic medical centers from 05/18/20 to 10/27/20. The BPA algorithm identified ED patients with cancer that were taking prescription opioids with a morphine equivalent daily dose (MEDD) of at least 100, as calculated by the EMR. If the ED provider ordered opioids for these patients, a BPA alert appeared with a recommended opioid dose based on the patient’s individual MEDD. This alert also included pre-set safety orders for O2 and end tidal CO2 monitoring as well as naloxone. We compared outcomes based on whether an ED provider accepted or cancelled the BPA recommendation. These outcomes included the change in opioid dose and ED disposition. Continuous variables were compared using the students t-test, while categorical variables were compared with the chi-squared test with an alpha of 0.05. Results: Our BPA identified 92 patients that met our criteria, representing 143 BPA alerts. The mean age was 52, 43.5% were female, 54.3% had metastatic disease, and 56.5% presented with a painful chief complaint. Of the ED providers that accepted the BPA, 57.5% increased their dose of opioid medication. BPA usage led to a 33.3% mean increase in medication dosage (p <.001). Patients that presented with a painful chief complaint, whose providers utilized the BPA were admitted at a rate of 60.5%, verses a 77.8% admission rate among those whose providers did not utilize the BPA (p <.01). No patients required an opioid reversal agent. Conclusions: Among cancer patients on chronic opioids presenting to the ED, use of an EMR-based BPA led to more appropriate opioid dosing without the need for opioid reversal agents, and was associated with an overall decrease in hospital admissions.

Abstract P1: Limitations of Self-Reported Readmission Data After Acute Myocardial Infarction: Insights from the TRIUMPH Registry

2011 ◽  
Vol 4 (suppl_2) ◽  
Author(s):  
Philip G Jones ◽  
Adam C Salisbury ◽  
Carole Decker ◽  
Harlan M Krumholz ◽  
John A Spertus
Keyword(s):  
Emergency Department ◽  
Hospital Admissions ◽  
Coronary Intervention ◽  
Self Report ◽  
Readmission Rates ◽  
Hospital Records ◽  
Outpatient Visits ◽  
Patient Reported ◽  
Reason For Admission

Background: Self-reported readmission rates are frequently reported in the medical literature, yet the validity of these data is controversial. Few studies describe the accuracy of self-report of readmission following an AMI in comparison with physician-adjudicated data. Methods: We studied 4,340 AMI patients enrolled in the 24-US center TRIUMPH registry. Patients were interviewed at 1, 6 and 12 months after their AMI, and were asked to report all hospitalizations since their last contact, including the hospital name, date and reason. After obtaining consent from the patient and each hospital, all hospitalization records within the first year after the patient's index MI were requested and adjudicated by a physician panel. Accuracy of patients’ report of hospitalization and reason for admission (sensitivity, specificity) were assessed. Results: Of 4,340 patients, 3,633 (84%) completed follow-up interviews, reporting a total of 2,016 readmissions. Of these, hospital records were successfully obtained on 1,373. Record review revealed that 501 (36%) were not actual rehospitalizations (e.g., emergency department only, outpatient visits, admissions prior to study enrollment). Interestingly, when obtaining hospital records, we identified another 394 readmissions that were not reported by patients. Sensitivity of self-reported reason for admission was modest to poor for cardiac-cause rehospitalization, AMI and percutaneous coronary intervention (Table). Conclusions: We identified several limitations of self-reported readmission rates in this multi-center AMI cohort. Emergency department and outpatient visits were frequently reported as hospital admissions, nearly 400 hospitalizations were not reported to study personnel at the time of the follow-up interview, and accuracy of patient-reported reason for admission was modest at best. These data underscore the importance of verifying self-reported follow-up outcomes data. Accuracy of Patient Self-Reported Reason for Admission Adjudicated Reason for Admission Sensitivity Specificity Any cardiac 37% 88% AMI 43% 94% PCI 66% 93%

scholarly journals 2481 A collaborative neurology-emergency medicine rapid outpatient clinic for the management of TIA and minor stroke in the emergency department

2018 ◽  
Vol 2 (S1) ◽  
pp. 37-37
Author(s):  
Bernard P. Chang ◽  
Rachel Mehendale ◽  
Eliza Miller ◽  
Benjamin Kummer ◽  
Joshua Willey ◽  
...  
Keyword(s):  
Emergency Department ◽  
Hospital Admissions ◽  
Tertiary Care ◽  
Low Risk ◽  
Minor Stroke ◽  
Decision Tool ◽  
Inpatient Hospitalization ◽  
Rapid Access ◽  
Rapid Access Clinic

OBJECTIVES/SPECIFIC AIMS: Current practice frequently dictates hospitalization for TIA and minor stroke (TIAMS) in order to obtain comprehensive evaluation of stroke risk factors and mechanism. Inpatient hospitalization is often done to expedite workup and to coordinate care although may be associated with nosocomial risks and increased healthcare cost. However, a subset of these patients who do not have debilitating deficits may not require inpatient hospitalization. We conducted a pilot study to assess the feasibility of conducting rapid outpatient stroke evaluations in low risk patients with TIAMS without disabling deficits. METHODS/STUDY POPULATION: The rapid access clinic was initiated at a single-site urban tertiary care facility for outpatient evaluation of TIAMS within 24 hours of emergency department (ED) evaluation. Patients were selected using a decision tool identifying presumed low-risk TIAMS seen in the ED. Criteria included medical (e.g., no disabling deficit, no thrombolytic agent given, negative CT for hemorrhagic stroke) as well as social criteria (e.g., patient ability to follow-up as an outpatient). We evaluated rates of noncompliance with post-ED follow-up, need for hospitalization from clinic, and 90 day stroke and health outcome data. RESULTS/ANTICIPATED RESULTS: Between December 2016 and December 2017 a total of 93 TIAMS patients seen in the ED were recommended for the rapid access clinic utilizing the decision tool. Of these patients, 94.5% (86) were evaluated within 24 hours of ED discharge. Only 2 patients (2.4%) who received outpatient evaluation required hospitalization; 61 (71.8%) patients had TIAMS on final evaluation in clinic. DISCUSSION/SIGNIFICANCE OF IMPACT: Our pilot data suggests that for a subset of patients, rapid outpatient evaluation may be a feasible and safe strategy for TIAMS management. Future work exploring such strategies may help improve TIAMS outcomes and reduce ED crowding and unnecessary hospital admissions.

scholarly journals Pharmacist-Driven Culture and Sexually Transmitted Infection Testing Follow-Up Program in the Emergency Department

Pharmacy ◽  
2020 ◽  
Vol 8 (2) ◽  
pp. 72
Author(s):  
Stephanie C. Shealy ◽  
Christine Alexander ◽  
Tina Grof Hardison ◽  
Joseph Magagnoli ◽  
Julie Ann Justo ◽  
...  
Keyword(s):  
Emergency Department ◽  
Hospital Admissions ◽  
Rank Test ◽  
Transmitted Infection ◽  
Sexually Transmitted ◽  
Signed Rank ◽  
Outpatient Intervention ◽  
Signed Rank Test ◽  
The Impact

Expanding pharmacist-driven antimicrobial stewardship efforts in the emergency department (ED) can improve antibiotic management for both admitted and discharged patients. We piloted a pharmacist-driven culture and rapid diagnostic technology (RDT) follow-up program in patients discharged from the ED. This was a single-center, pre- and post-implementation, cohort study examining the impact of a pharmacist-driven culture/RDT follow-up program in the ED. Adult patients discharged from the ED with subsequent positive cultures and/or RDT during the pre- (21 August 2018–18 November 2018) and post-implementation (19 November 2018–15 February 2019) periods were screened for inclusion. The primary endpoints were time from ED discharge to culture/RDT review and completion of follow-up. Secondary endpoints included antimicrobial agent prescribed during outpatient follow-up, repeat ED encounters within 30 days, and hospital admissions within 30 days. Baseline characteristics were analyzed using descriptive statistics. Time-to-event data were analyzed using the Wilcoxon signed-rank test. One-hundred-and-twenty-seven patients were included, 64 in the pre-implementation group and 63 in the post-implementation group. There was a 36.3% reduction in the meantime to culture/RDT data review in the post-implementation group (75.2 h vs. 47.9 h, p < 0.001). There was a significant reduction in fluoroquinolone prescribing in the post-implementation group (18.1% vs. 5.4%, p = 0.036). The proportion of patients who had a repeat ED encounter or hospital admission within 30 days was not significantly different between the pre- and post-implementation groups (15.6 vs. 19.1%, p = 0.78 and 9.4% vs. 7.9%, p = 1.0, respectively). Introduction of a pharmacist culture and RDT follow-up program in the ED reduced time to data review, time to outpatient intervention and outpatient follow-up of fluoroquinolone prescribing.

scholarly journals Substance-related problems in patients visiting an urban Canadian emergency department

CJEM ◽  
2008 ◽  
Vol 10 (03) ◽  
pp. 198-204 ◽  
Author(s):  
Jeffrey R. Brubacher ◽  
Amy Mabie ◽  
Michelle Ngo ◽  
Riyad B. Abu-Laban ◽  
Jan Buchanan ◽  
...  
Keyword(s):  
Emergency Department ◽  
Substance Use ◽  
Intervention Program ◽  
Hospital Admissions ◽  
Screening Program ◽  
Tertiary Care ◽  
Admission Rate ◽  
Problematic Substance Use ◽  
Problematic Substance ◽  
Ed Visits

ABSTRACTObjective:For many patients with addiction and other substance problems, the emergency department (ED) is the sole provider of medical care. This study sought to determine the prevalence and characteristics of substance-related medical problems in ED patients, as defined by documentation in the medical record. We also sought to compare the ED resource use (length of ED stay and number of revisits) of patients with and without substance problems.Methods:Trained evaluators using explicit criteria reviewed all ED charts during a 6-week period at a Canadian tertiary care teaching centre. Data was collected on demographics, documentation of problematic substance use and whether the ED visit was due to substance problems. Using a computerized database, we determined how many patients with and without substance problems had 1 or more subsequent ED visits during the 1-year period from Sept. 1, 2002, to Aug. 31, 2003.Results:Of 6064 visits made by 5194 patients, 6026 visits (99.4%) representing 5188 patients (99.9%) were captured for review. Of those visits, 674 (11.2%, 95% confidence interval [CI] 10.4%–12.0%), made by 600 patients, had documentation of problematic substance use and 521 visits (8.6%, 95% CI 7.9%–9.4%) by 469 patients were caused by substance problems. The mean age of patients with a visit due to a substance problem was 39.2 years, compared with 48.5 years for those with other visits (p&lt; 0.001). The admission rate for substance-related visits was 25.3%, compared with 17.6% for other visits (p&lt; 0.001). For discharged patients, the median length of the ED visit owing to substance-related problems lasted 232 minutes (IQR [interquartile range] 267 min), compared with 164 minutes (IQR 167 min) for other visits (p&lt; 0.001). In 1 year of follow-up, 161 of 600 patients (26.8%) with a substance problem made 466 revisits (mean 0.78 revisits/patient), compared with 975 of 4588 patients (21.3%) without a substance problem who made a total of 2150 revisits (mean 0.47 revisits/patient,p&lt; 0.001).Conclusion:Substance problems contribute significantly to ED visits, hospital admissions and duration of ED stay at a tertiary centre. It is likely that our methodology underestimates the scope of the problem and that a universal screening program would find a higher prevalence. The magnitude of this problem supports the need for an interdisciplinary identification and intervention program for ED patients with substance-related issues.

A preliminary study of the relationship between general practice care and hospitalisation using a diabetes register, CARDIAB

2013 ◽  
Vol 37 (2) ◽  
pp. 210 ◽  
Author(s):  
Elizabeth J. Comino ◽  
Duong Thuy Tran ◽  
Jane R. Taggart ◽  
Siaw-Teng Liaw ◽  
Warwick Ruscoe ◽  
...  
Keyword(s):  
Risk Factors ◽  
Primary Care ◽  
Emergency Department ◽  
General Practice ◽  
Data Collection ◽  
Hospital Admissions ◽  
Processes Of Care ◽  
Control Of Diabetes ◽  
Diabetes Register

Background. Diabetes can be effectively managed in general practice (GP). This study used record linkage to explore associations between diabetes care in GP and hospitalisation. Methods. Data on patients with type 2 diabetes were extracted from a Division of GP diabetes register (CARDIAB) for 2002–05 and were linked to the New South Wales Admitted Patient and Emergency Department (ED) Data Collection to create a unit record data collection containing demographic, clinical and health service records. Rates of admission and ED presentation per patient-year of follow up were calculated for the year following CARDIAB record. Results. The study included 1178 diabetic patients with 2959 patient-years of follow up. Their mean age was 65.7 years and duration of diabetes was 5.9 years. All-cause admission and ED presentation rates were 0.7 and 0.2 per patient-year of follow up respectively and length of admission 3.2 days (s.d. 11.7 days). Admission was associated with age, duration of diabetes and prior admission. The number of processes of care recorded for each patient-year was associated with admission. Admission and length of stay were not associated with achievement of clinical targets. Conclusions. These data suggest that receipt of processes of care, rather than clinical targets, will prevent admission. One explanation may be that continuity of care in GP provides opportunity for early intervention and treatment. What is known about the topic? Diabetes is a serious public health problem that is largely managed in primary care. Health care planners use health service use (hospital admissions) for diabetes as an indicator of primary care. Guidelines for diabetes care are known to be effective in reducing diabetes-related complications. What does this paper add? This paper created a linked data collection comprising demographic and clinical data from general practice and administrative health records of hospital admissions and emergency department presentations. The paper explores the associations between processes of primary care and control of diabetes and cardiovascular risk factors, and use of health services for a general practice population with diabetes. What are the implications for practitioners? The study suggests that processes of care and not technical control of diabetes and cardiovascular risk factors are important in preventing hospital admission. Continuity of care in general practice that ensures implementation of processes of care provides opportunity for early intervention and treatment.

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