Implementation and impact analysis of a transitional care pathway for patients presenting to the emergency department with cardiac-related complaints

Internationally, the implementation of care pathways is a common strategy for making transitional care for older people more effective and patient-centered. Previous research highlights inherent tensions in care pathways, particularly in relation to their patient-centered aspects, which may cause dilemmas for health care providers. Health care providers’ understandings and experiences of this, however, remain unclear. Our aim was to explore health care providers’ experiences and understandings of implementing a care pathway to improve transitional care for older people. We conducted semistructured interviews with 20 health care providers and three key persons, along with participant observations of 22 meetings, in a Norwegian quality improvement collaborative. Through a thematic analysis, we identified an understanding of the care pathway as both patient flow and the patient’s journey and a dilemma between the two, and we discuss how the negotiation of conflicting institutional logics is a central part of care pathway implementation.

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Transitional care models for chronic patients: preliminary results from an umbrella review

European Journal of Public Health ◽

10.1093/eurpub/ckz185.277 ◽

2019 ◽

Vol 29 (Supplement_4) ◽

Author(s):

M T Riccardi ◽

M Cicconi ◽

W Ricciardi ◽

M M Gianino ◽

G Damiani

Keyword(s):

Emergency Department ◽

Usual Care ◽

Hospital Readmission ◽

Readmission Rate ◽

Care Setting ◽

Transitional Care ◽

Emergency Department Visits ◽

Current Evidence ◽

Chronic Patients ◽

Care Models

Abstract Worldwide, chronic diseases are burdening and the health systems need to be rethought to better manage this epidemiologic shift. One of the critical points in the care pathway of chronic patients is the transition from one care setting to another. Aim of this study is to provide an overview of the current evidence on the impact of transitional care programs on health and economic outcomes for chronic patients Medline, Web of Science and EMBASE were queried for relevant reviews using the Population-Intervention-Context-Outcome (PICO) model. The quality of the included articles was determined using A MeaSurement Tool to Assess systematic Reviews (AMSTAR 2). Data were analyzed using descriptive statistic, and comparison among studies carried out in European Union (EU) versus non-EU was performed (Chi-square test was used and a p < 0.05 was deemed as statistically significant) 124 reviews were assessed for eligibility and 14 were eventually included (for a total of 167 primary articles). Quality appraisal was critically low in 60% of the reviews. Both hospital readmission rate and Emergency Department (ED) visit rate were lower than those in usual care group, but this difference was significant in 40% of articles. In EU studies readmission rate was lower in 65% of cases while in non-EU ones the percentage was 51.0%, but the difference was not significant (p = 0.23). Six reviews (43%) investigated the economic impact of the transitional care: most reported an initial increase in cost due to investment in staff training and creation of organizational networks, followed by a sharp decrease in costs due to a better utilization of health services, thus leading to a reduction in overall costs. Compared with usual care, transitional care shows an overall cost reduction, even if with limited effects on re-hospitalization or ED visit rates. These findings should encourage decision makers to invest in the development of this kind of programs in order to identify models that best perform. Key messages The patient transfer supervision from one care setting to another is necessary for continuity of care, but there is no robust evidence about the better performance of transitional care models. Systematically reviewed transitional care models has been shown be more cost saving, with a moderate impact on hospital readmission or emergency department visits rates.

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The Waiting Room Assessment to Virtual Emergency Department pathway: Initiating video-based telemedicine in the pediatric emergency department

Journal of Telemedicine and Telecare ◽

10.1177/1357633x211044038 ◽

2021 ◽

pp. 1357633X2110440

Author(s):

Esli Osmanlliu ◽

Isabelle Gagnon ◽

Saskia Weber ◽

Chi Quan Bach ◽

Jennifer Turnbull ◽

...

Keyword(s):

Emergency Department ◽

Care Delivery ◽

Care Pathway ◽

Clinical Pathways ◽

A Priori ◽

Pediatric Emergency ◽

Pediatric Emergency Department ◽

Pilot Phase ◽

Waiting Room ◽

Hospital Pediatric

The COVID-19 pandemic has presented pediatric emergency departments with unique challenges, resulting in a heightened demand for adapted clinical pathways. In response to this need, the Montreal Children's Hospital pediatric emergency department introduced the WAVE (Waiting Room Assessment to Virtual Emergency Department) pathway, a video-based telemedicine pathway for selected non-critical patients, aiming to reduce safety issues related to emergency department overcrowding, while providing timely care to all children presenting and registering at our emergency department. The objective of the WAVE pilot phase was to evaluate the feasibility and acceptability of telemedicine in our pediatric emergency department, which was previously unfamiliar with this mode of care delivery. During the six-week, three-evening per week deployment, we conducted 18 five-hour telemedicine shifts. In total, 27 patients participated in the WAVE pathway. Results from this pilot phase met four of five a priori feasibility and acceptability criteria. Overall, participating families were satisfied with this novel care pathway and reported no disruptive technological barriers.

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Appropriateness of cases presenting in the emergency department following ambulance service secondary telephone triage: a retrospective cohort study

BMJ Open ◽

10.1136/bmjopen-2017-016845 ◽

2017 ◽

Vol 7 (10) ◽

pp. e016845 ◽

Cited By ~ 8

Author(s):

Kathryn Eastwood ◽

Karen Smith ◽

Amee Morgans ◽

Johannes Stoelwinder

Keyword(s):

Emergency Department ◽

Hospital Admission ◽

Emergency Care ◽

Retrospective Cohort ◽

Care Pathway ◽

Cohort Analysis ◽

Care Pathways ◽

Telephone Triage ◽

Alternative Care ◽

Referral Service

ObjectiveTo investigate the appropriateness of cases presenting to the emergency department (ED) following ambulance-based secondary telephone triage.DesignA pragmatic retrospective cohort analysis of all the planned and unplanned ED presentations within 48 hours of a secondary telephone triage.SettingThe secondary telephone triage service, called the Referral Service, and the hospitals were located in metropolitan Melbourne, Australia and operated 24 hours a day, servicing 4.25 million people. The Referral Service provides an in-depth secondary triage of cases classified as low acuity when calling the Australian emergency telephone number.PopulationCases triaged by the Referral Service between September 2009 and June 2012 were linked to ED and hospital admission records (N=44,523). Planned ED presentations were cases referred to the ED following the secondary triage, unplanned ED presentations were cases that presented despite being referred to alternative care pathways.Main outcome measuresAppropriateness was measured using an ED suitability definition and hospital admission rates. These were compared with mean population data which consisted of all of the ED presentations for the state (termed the ‘average Victorian ED presentation’).ResultsPlanned ED presentations were more likely to be ED suitable than unplanned ED presentations (OR 1.62; 95% CI 1.5 to 1.7; p<0.001) and the average Victorian ED presentation (OR 1.85; 95% CI 1.01 to 3.4; p=0.046). They were also more likely to be admitted to the hospital than the unplanned ED presentation (OR 1.5; 95% CI 1.4 to 1.6; p<0.001) and the average Victorian ED presentation (OR 2.3, 95% CI 2.24 to 2.33; p<0.001). Just under 15% of cases diverted away from the emergency care pathways presented in the ED (unplanned ED attendances), and 9.5% of all the alternative care pathway cases were classified as ED suitable and 6.5% were admitted to hospital.ConclusionsSecondary telephone triage was able to appropriately identify many ED suitable cases, and while most cases referred to alternative care pathways did not present in the ED. Further research is required to establish that these were not inappropriately triaged away from the emergency care pathways.

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Planning Implementation Success of Syncope Clinical Practice Guidelines in the Emergency Department Using CFIR Framework

10.20944/preprints202103.0679.v1 ◽

2021 ◽

Author(s):

Jing Li ◽

Susan S. Smyth ◽

Jessica Miller Clouser ◽

Colleen A. McMullen ◽

Vedant Gupta ◽

...

Keyword(s):

Emergency Department ◽

Clinical Practice ◽

Family Caregivers ◽

Implementation Strategy ◽

Care Pathway ◽

Implementation Strategies ◽

Mobile App ◽

Care Plan ◽

Local Context ◽

Successful Implementation

Background and Objectives: Overuse and inappropriate use of testing and hospital admission are common in syncope evaluation and management. Though guidelines are available to optimize syncope care, study suggested that the current clinical guidelines have not significantly impacted resource utilization surrounding emergency department (ED) evaluation of syncope. Matching implementation strategies to barriers and facilitators and tailoring strategies to local context hold significant promise for a successful implementation of clinical practice guideline (CPG). Our team applied implementation science principles to develop a stakeholder-based implementation strategy. Methods and Materials: We partnered with patients, family caregivers, frontline clinicians and staff, and health system administrators at four health systems to conduct quantitative surveys and qualitative interviews for context assessment. The identification of implementation strategies was done by applying the CFIR-ERIC Implementation Strategy Matching Tool and soliciting stakeholders’ inputs. We then co-designed with patients and frontline teams, developed and tested specific strategies. Results: 114 clinicians completed surveys and 32 clinicians and stake-holders participated in interviews. Results from the surveys and interview indicated low awareness of syncope guidelines, and communication challenges with patients, lack of CPG protocol integration into ED workflows, and organizational process to change were recognized as major barriers. Thirty-one patients and their family caregivers participated in interviews and ex-pressed their expectations: clarity regarding their diagnosis, context surrounding care plan and diagnostic testing, and a desire to feel cared about. After identifying change methods to address those barriers, the multilevel, multicomponent implementation strategy, MISSION, included pa-tient educational materials, mentored implementation, academic detailing, Syncope Optimal Care Pathway and corresponding Mobile App, and Lean quality improvement methods. The pilot of MISSION demonstrated feasibility, acceptability and initial success on appropriate testing. Con-clusions: Effect multifaceted implementation strategies that target individuals, teams, and healthcare systems can be employed to plan successful implementation and promote adherence to syncope CPGs.

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“There’s No Place Like Home”: Creating a Safe, Individualized, Transitional Care Pathway After a Skilled Nursing Facility Stay

The Permanente Journal ◽

10.7812/tpp/18-071-23 ◽

2018 ◽

Author(s):

Yvonne Rice

Keyword(s):

Transitional Care ◽

Care Pathway ◽

Skilled Nursing Facility ◽

Nursing Facility ◽

Skilled Nursing

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Su1508 The Impact of a Dedicated Acute Care Surgery Clinical Care Pathway for Suspected Appendicitis on Diagnostic Imaging and Flow Through the Emergency Department

Gastroenterology ◽

10.1016/s0016-5085(12)64077-3 ◽

2012 ◽

Vol 142 (5) ◽

pp. S-1051

Author(s):

Chad G. Ball ◽

Elijah Dixon ◽

Anthony R. MacLean ◽

May Lynn Quan ◽

Gilaad G. Kaplan ◽

...

Keyword(s):

Emergency Department ◽

Diagnostic Imaging ◽

Care Pathway ◽

Clinical Care ◽

Acute Care Surgery ◽

Suspected Appendicitis ◽

Flow Through ◽

Care Surgery ◽

Clinical Care Pathway ◽

The Impact

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Pharmacist-Led Transition of Care Pilot Targeting Older People After Emergency Department Discharge

The Senior Care Pharmacist ◽

10.4140/tcp.n.2020.273. ◽

2020 ◽

Vol 35 (6) ◽

pp. 273-282

Author(s):

Scott M. Pearson ◽

Anushka Tandon ◽

Danielle R. Fixen ◽

Sunny A. Linnebur ◽

Gretchen M. Orosz ◽

...

Keyword(s):

Emergency Department ◽

Older People ◽

Primary Outcome ◽

Transitional Care ◽

Intervention Group ◽

Chronic Obstructive ◽

P Value ◽

Historical Cohort ◽

Obstructive Pulmonary Disease ◽

The Impact

OBJECTIVE: To evaluate the impact of a pharmacist-led transitional care intervention targeting high-risk older people after an emergency department (ED) visit. DESIGN: Retrospective cohort study of older people with ED visits prior to and during a pharmacist-led intervention. SETTING: Patients receiving primary care from the University of Colorado Health Seniors Clinic. PARTICIPANTS: The intervention cohort comprised 170 patients with an ED visit between August 18, 2018, and February 19, 2019, and the historical cohort included 166 patients with an ED visit between August 18, 2017, and February 19, 2018. All included patients either had a historical diagnosis of heart failure or chronic obstructive pulmonary disease, or they had an additional ED visit in the previous six months. INTERVENTIONS: The pilot intervention involved postED discharge telephonic outreach and assessment by a clinical pharmacist, with triaging to other staff if necessary. MAIN OUTCOME MEASURE: The primary outcome was the proportion of patients with at least one repeat ED visit, hospitalization, or death within 30 days of ED discharge. Outcome rates were also assessed at 90 days postdischarge. RESULTS: The primary outcome occurred in 21% of the historical cohort and 25% of the intervention cohort (adjusted P-value = 0.48). The incidence of the composite outcome within 90 days of ED discharge was 43% in the historical group compared with 38% in the intervention group (adjusted P-value = 0.29). CONCLUSION: A pharmacist-led telephonic intervention pilot targeting older people did not appear to have a significant effect on the composite of repeat ED visit, hospitalization, or death within 30 or 90 days of ED discharge. A limited sample size may hinder the ability to make definitive conclusions based on these findings.

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