A physiotherapy-led transition to home intervention for older adults following emergency department discharge: protocol for a pilot feasibility randomised controlled trial

Background Older adults frequently attend the emergency department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. This paper reports a protocol designed to evaluate the feasibility of conducting a three arm randomised controlled trial (RCT) within the ED setting and in the patient’s home. The interventions are comprehensive geriatric assessment (CGA), ED PLUS and usual care. Methods The ED PLUS pilot trial is designed as a feasibility RCT conducted in the ED and Acute Medical Assessment Unit of a university teaching hospital in the mid-west region of Ireland. We aim to recruit 30 patients, aged 65 years and over presenting to the ED with undifferentiated medical complaints and discharged within 72 h of index visit. Patients will be randomised by a computer in a ratio of 1:1:1 to deliver usual care, CGA or ED PLUS during a 6-month study period. A randomised algorithm is used to perform randomization. CGA will include a medical assessment, medication review, nursing assessment, falls assessment, assessment of mobility and stairs, transfers, personal care, activities of daily living (ADLs), social supports and baseline cognition. ED PLUS, a physiotherapist led, multidisciplinary intervention, aims to bridge the transition of care between the index visit to the ED and the community by initiating a CGA intervention in the ED and implementing a 6-week follow-up self-management programme in the patient’s own home following discharge from the ED. The outcomes will be parameters of the feasibility of the intervention and trial methods and will be assessed quantitatively and qualitatively. Discussion Rising ED visits and an ageing population with chronic health issues render ED interventions to reduce adverse outcomes in older adults a research priority. This feasibility RCT will generate data and experience to inform the conduct and delivery of a definite RCT. Trial registration The trial was registered in Clinical Trials Protocols and Results System as of 21st July 2021, with registration number NCT049836020.

Lung Function and Dementia Risk in the Atherosclerosis Risk in Communities (ARIC) Study

Poor lung function has been linked with adverse neurocognitive outcomes including dementia, but evidence from well-designed prospective studies is limited. We therefore examined the association between lung function, as measured by forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC), and dementia risk in 12,688 participants of the ARIC study, a prospective study of adults aged 46-70 years (at index visit, mean age =57y, 45% male, 76% White) from four US communities. Lung function was assessed in 1991-1992 (index visit, 76% normal, 16% obstructive, and 8% restrictive lung function), and dementia was ascertained through 2019 via in-person assessments, telephone interviews, and medical record surveillance, with adjudication of dementia with all in-person exams. A total of 2452 developed dementia over 30 years of follow-up. We used Cox proportional hazards model to estimate hazard ratio (HR) and 95% confidence intervals (CI), adjusting for potential confounders (socio-demographics, behavioral factors, cardiovascular risk factors, APOE ε4). Higher FEV1 and FVC were associated with reduced dementia risk [(HR: 0.86, 95%CI: 0.78-0.98, per 1L increase in FEV1) and (HR: 0.86, 95%CI: 0.80-0.93 per 1L increase in FVC)]. Compared to normal lung function, restrictive disease was associated with elevated dementia risk [(HR: 1.19, 95%CI: 1.01-1.41), n=168 dementia cases]; HR for obstructive disease, though modestly elevated (1.09, 95%CI: 0.96-1.24, n=713 dementia cases), was not statistically significant. Our findings of decreased dementia risk with better lung function may have important implications in reducing burden of dementia that is attributable to environmental exposures and associated lung function impairment.

Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study

Background Resource utilization among emergency department (ED) patients with possible coronary chest pain is highly variable. Methods and Results Controlled cohort study amongst 21 EDs of an integrated healthcare system examining the implementation of a graded coronary risk stratification algorithm (RISTRA‐ACS [risk stratification for acute coronary syndrome]). Thirteen EDs had access to RISTRA‐ACS within the electronic health record (RISTRA sites) beginning in month 24 of a 48‐month study period (January 2016 to December 2019); the remaining 8 EDs served as contemporaneous controls. Study participants had a chief complaint of chest pain and serum troponin measurement in the ED. The primary outcome was index visit resource utilization (observation unit or hospital admission, or 7‐day objective cardiac testing). Secondary outcomes were 30‐day objective cardiac testing, 60‐day major adverse cardiac events (MACE), and 60‐day MACE‐CR (MACE excluding coronary revascularization). Difference‐in‐differences analyses controlled for secular trends with stratification by estimated risk and adjustment for risk factors, ED physician and facility. A total of 154 914 encounters were included. Relative to control sites, 30‐day objective cardiac testing decreased at RISTRA sites among patients with low (≤2%) estimated 60‐day MACE risk (−2.5%, 95% CI −3.7 to −1.2%, P <0.001) and increased among patients with non‐low (>2%) estimated risk (+2.8%, 95% CI +0.6 to +4.9%, P =0.014), without significant overall change (−1.0%, 95% CI −2.1 to 0.1%, P =0.079). There were no statistically significant differences in index visit resource utilization, 60‐day MACE or 60‐day MACE‐CR. Conclusions Implementation of RISTRA‐ACS was associated with better allocation of 30‐day objective cardiac testing and no change in index visit resource utilization or 60‐day MACE. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03286179.

Is Recent Exposure to Antibiotics a Risk Factor for Hospitalisation in Korean Children with Acute Non-Bacterial Gastroenteritis? A Nationwide Population-Based Study

The purpose of this study was to evaluate the effect of recent antibiotic therapy and probiotics on hospitalisation in children with acute gastroenteritis. Using a retrospective study design, data from the population aged up to 18 years were collected from the Korean National Health Insurance Service-National Sample Cohort. The duration of antibiotic therapy within 14 days of the index visit, prescription of probiotics at initial presentation, the effect size of antibiotic exposure on hospitalisation, and its modification by probiotics were assessed. Of 275,395 patients with acute gastroenteritis, 51,008 (18.5%) had prior exposure to antibiotics. Hospitalisation within 7 days of the index visit was positively associated with exposure to antibiotics (p-trend < 0.001). The prescription of probiotics (as a main effect; odds ratio, 0.80; 95% confidence interval 0.72–0.87) was associated with a decreased risk of hospitalisation. Prior exposure to antibiotics might be a significant risk factor for hospitalisation in children presenting with acute gastroenteritis. This may be favourably modified by administering probiotics at the initial presentation.

Cancer-related Emergency Department Visits: Comparing Characteristics and Outcomes

Introduction: There is increasing appreciation of the challenges of providing safe and appropriate care to cancer patients in the emergency department (ED). Our goal here was to assess which patient characteristics are associated with more frequent ED revisits. Methods: This was a retrospective cohort study of all ED visits in California during the 2016 calendar year using data from the California Office of Statewide Health Planning and Development. We defined revisits as a return visit to an ED within seven days of the index visit. For both index and return visits, we assessed various patient characteristics, including age, cancer type, medical comorbidities, and ED disposition. Results: Among 12.9 million ED visits, we identified 73,465 adult cancer patients comprising 103,523 visits that met our inclusion criteria. Cancer patients had a 7-day revisit rate of 17.9% vs 13.2% for non-cancer patients. Cancer patients had a higher rate of admission upon 7-day revisit (36.7% vs 15.6%). Patients with cancers of the small intestine, stomach, and pancreas had the highest rate of 7-day revisits (22-24%). Cancer patients younger than 65 had a higher 7-day revisit rate than the elderly (20.0% vs 16.2%). Conclusion: In a review of all cancer-related ED visits in the state of California, we found a variety of characteristics associated with a higher rate of 7-day ED revisits. Our goal in this study was to inform future research to identify interventions on the index visit that may improve patient outcomes.

Time to put it out – nurse-facilitated tobacco treatment in a comprehensive cancer center

Few cancer patients receive guideline-concordant care for treatment of tobacco dependence. The purpose of this pilot trial was to obtain preliminary estimates of effectiveness of an evidence-based practice intervention on the delivery of tobacco treatment and cessation outcomes in cancer patients. We conducted a pragmatic implementation trial with a before-after design in 119 current or recently quit adult smokers with cancer who met with a clinician at a single National Cancer Institute designated comprehensive cancer center (CCC) (n = 61 pre-implementation, n = 58 post-implementation). We used a multi-component strategy based on the Chronic Care Model to implement National Comprehensive Cancer Network (NCCN) guidelines for smoking cessation. Smoking cessation counseling during the index visit was assessed by exit interview and patients were interviewed by phone to assess cessation outcomes at 3-month follow-up. Performance of cessation counseling and 7-day point prevalence abstinence (PPA) were compared across the pre- and post-implementation periods using log-logistic regression, accounting for clustering by nursing staff. More patients had received assistance in quitting at the index visit during the post-implementation period compared to the pre-implementation period (30 vs. 10%, p &lt; .01). At 3-month follow-up, 38 and 14% of participants had discussed smoking cessation medication with a CCC healthcare professional and 57 and 27% of participants had used pharmacotherapy, respectively (p &lt; .01 for both comparisons). Seven-day PPA at 3-month follow-up was similar in both periods, however (14 vs. 12%, respectively). A multi-component tobacco treatment intervention increased the proportion of smokers who received assistance in quitting smoking during usual cancer care but did not improve cessation outcomes.

A clinical prediction model to identify children at risk for revisits with serious illness to the emergency department: A prospective multicentre observational study

Background To develop a clinical prediction model to identify children at risk for revisits with serious illness to the emergency department. Methods and findings A secondary analysis of a prospective multicentre observational study in five European EDs (the TRIAGE study), including consecutive children aged <16 years who were discharged following their initial ED visit (‘index’ visit), in 2012–2015. Standardised data on patient characteristics, Manchester Triage System urgency classification, vital signs, clinical interventions and procedures were collected. The outcome measure was serious illness defined as hospital admission or PICU admission or death in ED after an unplanned revisit within 7 days of the index visit. Prediction models were developed using multivariable logistic regression using characteristics of the index visit to predict the likelihood of a revisit with a serious illness. The clinical model included day and time of presentation, season, age, gender, presenting problem, triage urgency, and vital signs. An extended model added laboratory investigations, imaging, and intravenous medications. Cross validation between the five sites was performed, and discrimination and calibration were assessed using random effects models. A digital calculator was constructed for clinical implementation. 7,891 children out of 98,561 children had a revisit to the ED (8.0%), of whom 1,026 children (1.0%) returned to the ED with a serious illness. Rates of revisits with serious illness varied between the hospitals (range 0.7–2.2%). The clinical model had a summary Area under the operating curve (AUC) of 0.70 (95% CI 0.65–0.74) and summary calibration slope of 0.83 (95% CI 0.67–0.99). 4,433 children (5%) had a risk of > = 3%, which was useful for ruling in a revisit with serious illness, with positive likelihood ratio 4.41 (95% CI 3.87–5.01) and specificity 0.96 (95% CI 0.95–0.96). 37,546 (39%) had a risk <0.5%, which was useful for ruling out a revisit with serious illness (negative likelihood ratio 0.30 (95% CI 0.25–0.35), sensitivity 0.88 (95% CI 0.86–0.90)). The extended model had an improved summary AUC of 0.71 (95% CI 0.68–0.75) and summary calibration slope of 0.84 (95% CI 0.71–0.97). As study limitations, variables on ethnicity and social deprivation could not be included, and only return visits to the original hospital and not to those of surrounding hospitals were recorded. Conclusion We developed a prediction model and a digital calculator which can aid physicians identifying those children at highest and lowest risks for developing a serious illness after initial discharge from the ED, allowing for more targeted safety netting advice and follow-up.

Diagnostic accuracy of the HEART Pathway and EDACS-ADP when combined with a 0-hour/1-hour hs-cTnT protocol for assessment of acute chest pain patients

Background/aimIn ED chest pain patients, a 0-hour/1-hour protocol based on high sensitivity cardiac troponin T (hs-cTnT) tests combined with clinical risk stratification in diagnosing acute coronary syndrome is recommended. Two of the most promising risk stratification tools are the History, ECG, Age, Risk Factors and Troponin (HEART) and Emergency Department Assessment of Chest Pain (EDAC) scores. Few studies have assessed the diagnostic accuracy of the 0-hour/1-hour hs-cTnT protocol when combined with HEART score, and none with EDACS. In ED chest pain patients, we aimed to evaluate the diagnostic accuracy of a 0-hour/1-hour hs-cTnT protocol combined the HEART Pathway, or the EDACS accelerated diagnostic pathway (EDACS-ADP).MethodsThis was a secondary analysis of data from a prospective observational study enrolling 1167 ED chest pain patients who visited the ED at Skåne University Hospital in Lund, Sweden in the period between February 2013 and April 2014. HEART and EDAC scores were assessed together with hs-cTnT at 0 and 1 hour and compared with HEART score alone. Sensitivity, specificity, negative predictive value (NPV) and likelihood ratios were evaluated. The primary outcome was major adverse cardiac events (MACE) including unstable angina within 30 days. The secondary outcome was index visit acute myocardial infarction (AMI).ResultsA total of 939 patients were included in the final analysis. When combined with 0-hour/1-hour hs-cTnT testing, the HEART Pathway and EDACS-ADP identified 49.8% and 49.6% of the patients for rule-out, with NPVs for 30-day MACE of 99.8% and 99.1%, compared with the HEART score alone that identified 53.4% of the patients for rule-out with NPV of 99.2%. The NPV for index visit AMI were 100%, 99.8% and 99.2%, respectively.ConclusionThe combination of the HEART Pathway or the EDACS-ADP with a 0-hour/1-hour hs-cTnT protocol allows safe and early rule-out in a large proportion of ED chest pain patients.