Use of Community Services by Seniors Before and After an Emergency Visit

Eadem Sed Aliter. Validating an emergency department work domain analysis across three hospital configurations

Work Domain Analysis (WDA), the foundational phase in the Cognitive Work Analysis Framework (CWA), provides a platform for understanding and designing complex systems. Though it has been used extensively, there are few applications in healthcare, and model validation for different contexts is not always undertaken. The current study aimed to validate an Emergency Department (ED) WDA across three metropolitan hospitals that differ in the type and nature of services they provide, including the ED in which the original ED WDA was developed. A facilitated workshop was conducted at the first ED and interviews at two subsequent EDs to refine and validate the ED WDA. ED subject matter experts (SMEs) including nurses, doctors, administration, and allied health personnel provided feedback on the model. SME feedback resulted in modifications to the original ED WDA model including combining nodes to reduce duplication and amending five labels for clarity. The resulting WDA provides a valid representation of the EDs found in metropolitan districts within an Australian state and can be used by roles such as frontline ED clinicians, hospital managers, and policy developers to facilitate the design, testing, and sharing of solutions to local and shared problems. The findings also demonstrate the importance of validating WDA models across different contexts.

Exercise Interventions for Community-Dwelling Older Adults Following an Emergency Department Consultation for a Minor Injury

This study compared effects of exercise-based interventions with usual care on functional decline, physical performance, and health-related quality of life (12-item Short-Form health survey) at 3 and 6 months after minor injuries, in older adults discharged from emergency departments. Participants were randomized either to the intervention or control groups. The interventions consisted of 12-week exercise programs available in their communities. Groups were compared on cumulative incidences of functional decline, physical performances, and 12-item Short-Form health survey scores at all time points. Functional decline incidences were: intervention, 4.8% versus control, 15.4% (p = .11) at 3 months, and 5.3% versus 17.0% (p = .06) at 6 months. While the control group remained stable, the intervention group improved in Five Times Sit-To-Stand Test (3.0 ± 4.5 s, p < .01). The 12-item Short-Form health survey role physical score improvement was twice as high following intervention compared with control. Early exercises improved leg strength and reduced self-perceived limitations following a minor injury.

Unplanned Readmission within 28 Days of Hospital Discharge in a Longitudinal Population-Based Cohort of Older Australian Women

This study aimed to estimate the incidence of 28-day unplanned readmission among older women, and associated factors. Data were used from the 1921–1926 birth cohort of the Australian Longitudinal Study on Women’s Health. Linkage of self-reported survey data with the Admitted Patient Data Collection allowed the identification of hospital admissions for each woman and the corresponding baseline characteristics. The Cox proportional-hazards model was used to identify factors associated with time to unplanned readmission, using SAS software V 9.4. (SAS Institute, Cary, NC, USA). Of 2056 women with index unplanned admission, 363 (17.5%) were readmitted within 28 days of discharge, and of these 229 (11.14%) had unplanned readmission. Among women with unplanned readmission, 24% were for the same condition as for the index hospitalisation. Cardiovascular diseases were the main diagnoses for the index admission and readmission. Unplanned readmission risk was higher if not partnered (hazard ratio (HR) = 1.43, 95% confidence interval (CI): 1.05–1.95), of non-English speaking background (HR = 1.62%, 95% CI: 1.07–2.47), more than three days length of stay on index admission (HR = 1.41%, 95% CI: 1.04–1.90) and one or two of the assessed chronic diseases (HR = 1.68, 95% CI: 1.19–2.36). At least one in ten women had unplanned readmission at some time between ages 75–95 years. Women who are not partnered, not of English-speaking background, with longer hospital stay and those with multi-morbidity, may need further efforts during their stay and on discharge to mitigate unplanned readmission.

Re-structuring the negotiated order of the hospital

Researchers continue to lament the lack of organisational focus in the sociology of health and illness. Although studies have increasingly focused on boundaries between organizations, little such research has focused on the formal boundaries within the hospital itself. Given its dramatic compartmentalisation, and continuing prevalence in health systems, the lack of organisational perspective in hospital research limits insights into the effects (as well as the construction) of the order of health work and care. With a greater emphasis on 'ordering' in the concept of negotiated order, the aim of this study is to examine the manifestation and consequences of the formal boundaries of hospital departments. Fieldwork featured 12 months of ethnography, including formal and informal observations, 80 audio-recorded, semi-structured interviews, and 56 field interviews, in the Emergency Departments (EDs) of two tertiary referral hospitals. Compared with in-patient hospital departments, the ED has limited legitimacy claims of organ-specific knowledge to transfer patients out of the ED. The manifestation of specialised knowledge hierarchies in organisational structures disadvantages patients who are older and who have chronic conditions, underpinning the argument that effects as well as the negotiation of stable organisational orders deserve increased attention in the sociology of health and illness.

Factors influencing satisfaction with emergency department medical service: Patients' and their companions' perspectives

AIMS

To examine the individual determinants that influence satisfaction with medical services at the emergency department and to compare the factors that influence satisfaction for the patients, compared with their companions.

METHODS

Using data from the 2009 Korea Health Panel Survey, Andersen's behavioral model was used to examine the factors that affect satisfaction with service. A logistic regression analysis was conducted with the data.

RESULTS

Patients who were older, female, and employed were more satisfied with the service, as were patients who visited more frequently and those who had non-surgical treatment. Companions who had less education, were accompanying non-Medicaid-holders, and spent a longer time in the emergency department were less likely to be satisfied. This was in contrast to those who spent a shorter amount of time in the emergency department and who visited due to illness, rather than injury; these companions were more satisfied with the service. When all the factors were analyzed simultaneously, they differed significantly between the two groups of patients and companions.

CONCLUSIONS

Different factors contributed to the satisfaction with the services for the patients and their companions. In order to increase the satisfaction levels and improve the quality of care in emergency departments, it is necessary to consider more specific approaches that reflect the different perspectives of the visitors to the emergency department.

The emergency department "carousel": an ethnographically-derived model of the dynamics of patient flow

Emergency department (ED) overcrowding reduces efficiency and increases the risk of medical error leading to adverse events. Technical solutions and models have done little to redress this. A full year's worth of ethnographic observations of patient flow were undertaken, which involved making hand-written field-notes of the communication and activities of emergency clinicians (doctors and nurses), in two EDs in Sydney, Australia. Observations were complemented by semi-structured interviews. We applied thematic analysis to account for the verbal communication and activity of emergency clinicians in moving patients through the ED. The theoretical model that emerged from the data analysis is the ED "carousel". Emergency clinicians co-construct a moving carousel which we conceptualise visually, and which accounts for the collective agency of ED staff, identified in the findings. The carousel model uniquely integrates diagnosis, treatment and transfer of individual patients with the intellectual labour of leading and coordinating the department. The latter involves managing staff skill mix and the allocation of patients to particular ED sub-departments. The model extends traditional patient flow representations and underlines the importance of valuing ethnographic methods in health services research, in order to foster organisational learning, and generate creative practical and policy alternatives that may, for example, reduce or ameliorate access block and ED overcrowding.

Use of adult day care centers: do they offset utilization of health care services?

PURPOSE

Based on the medical offset effect, the goal of the study was to examine the extent to which users and nonusers of adult day care centers (ADCC) differ in frequency of use of out-patient health services (visits to specialists) and in-patient health services (number of hospital admissions, length of hospitalizations, and visits to emergency departments).

DESIGN AND METHODS

A case-control study was used with a sample of 800 respondents, of whom 400 were users of 13 day care centers in the southern region of Israel and 400 were nonusers, matched by age, gender, and active family physician. Data collection included face-to-face interviews using a structured questionnaire. Data on health care service utilization were drawn from the central computerized data of one of the health care organizations in Israel.

RESULTS

Although users of ADCC significantly differed from nonusers in socioeconomic characteristics, they did not significantly differ from nonusers in the magnitude of health care services' utilization. Utilization of health care services was rather connected with morbidity rather than with use of ADCC. Therefore, no offset effect was found.

IMPLICATIONS

The current form of ADCC in Israel focuses mainly on meeting social needs of the participants and therefore do not meet the their actual health needs. Therefore, inclusion of health services within ADCC may have an offset effect, but this necessitates further examination.

Standardized Screening and Assessment of Older Emergency Department Patients: A Survey of Implementation in Quebec

Cost-effective methods have been developed to help busy emergency department (ED) staff cope with the growing number of older patients, including quick screening and assessment tools to identify those at high risk and note their specific needs. This survey, from a sample of key informants from all EDs (n=111) in the province of Quebec (participation rate of 88.2%), investigated the implementation of these tools and barriers to implementation. Questionnaires (administered either by telephone or by self-completion) included characteristics of the ED, characteristics of the respondent, use of tools, and method of implementation. Barriers to the implementation of these tools included lack of resources for screening and follow-up, misunderstandings of the difference between screening and assessment tools, and need for adaptation of the tools to the local context. Education of staff and pre-implementation adaptation and testing are needed for successful implementation.

Differences in Accessibility, Affordability, and Availability (AAA) of Medical Specialists Among Three Age-Groups of Elderly People in Israel

Objectives: Older people use more health services due to health problems, but various reasons impede their ability to use health services. The purpose of this study is to examine difficulties in accessing and affording specialist services and to explore the factors that explain these difficulties among elderly people. Methods: The sample included 1,255 respondents in three age-groups: 65-75, 76-89, and 90+ years who were interviewed face-to-face in their homes. Results: The findings showed that between 21% and 41% of the respondents encountered difficulties in visiting specialists. Those aged 90+ encountered more accessibility problems and fewer affordability problems compared to their younger counterparts, and those aged 76-89 encountered more availability problems compared to the other two age-groups. Enabling and need factors were the most significant factors in explaining problems in accessing and affording specialist services. Discussion: Recommendations for policy and practice are discussed.

Consensus-based policy recommendations for geriatric emergency care

PURPOSE

The purpose of this paper is to establish policy recommendations to address service and care delivery challenges facing hospital emergency departments (EDs) responding to the needs of increasing numbers of older adults.

DESIGN/METHODOLOGY/APPROACH

The consensus development process used an international expert interdisciplinary panel, convened at an international conference. Following a round table discussion and think-tank session, a nominal group method with constant comparative analysis and coding techniques was used to identify policy recommendations. Two rounds of electronic input followed the face-to-face meeting to reach consensus on priority ranking of the policy recommendations. Findings underwent an external review by four independent experts.

FINDINGS

A total of seven categories of policy recommendations were developed: education, integration and coordination of care, resources, ED physical environment, evidence-based practice, research and evaluation, and advocacy.

RESEARCH LIMITATIONS/IMPLICATIONS

The consensus development process did not include a systematic literature review on the topic. However, participants included experts in their disciplines.

PRACTICAL IMPLICATIONS

The recommendations may assist administrators, policy makers, clinicians, and researchers on future directions for improving emergency care and service delivery for older adults.

ORIGINALITY/VALUE

The paper describes the process and results of a consensus development activity for ED care and services of older adults.

Helping family doctors detect vulnerable caregivers after an emergency department visit for an elderly relative: results of a longitudinal study

BACKGROUND

Family doctors have been ascribed a role in monitoring patients and their informal caregivers. Little is known about the factors that might alert physicians to changing circumstances or needs of the caregivers. The study objective was to examine changes in family caregivers' quality of life following an emergency department (ED) visit by an older community-dwelling relative that might cue doctors to subsequent caregiver distress.

METHODS

A longitudinal study with follow-up at 1- and 4-months was conducted in the EDs of 4 hospitals in Montreal, Canada. Caregivers reported on demographics and quality of life (SF-36). Patients reported on demographics and functional disability. Multiple linear regression for repeated measures was used to evaluate changes in caregiver quality of life and factors related to these changes.

RESULTS

159 caregivers (60.5 yrs +/- 15.8%; 73.0% female), including 68 (42.8%) spouses, 60 (37.7%) adult children, and 31 (19.5%) other relatives participated. Following an initial ED visit by older relatives, caregiver general health and physical functioning declined over time, while mental health status improved. Compared to the other relative caregiver group, spouses were at increased risk for decline in general health, mental health, and physical functioning at 1 month, while adult children were at increased risk for decline in physical health at 1 month.

CONCLUSION

Spouses were most at risk for decline in quality of life. Primary care physicians who become aware of an ED visit by an elderly person may be alerted to possible subsequent deterioration in family caregivers, especially spouses.

Do geriatric interventions reduce emergency department visits? A systematic review

BACKGROUND

Hospital emergency departments (EDs) serve an aging population with an increased burden on health resources. Few studies have examined the effects of comprehensive geriatric assessment interventions on ED use. This study aimed to systematically review the literature and compare the effects of these interventions on ED visits.

METHODS

Relevant articles were identified through electronic databases and a search of reference lists and personal files. Inclusion criteria included: original research (written in English or French) on interventions conducted in noninstitutionalized populations 60 years old or older, not restricted to a particular medical condition, in which ED visits were a study outcome. Data were abstracted and checked by the first author and a research assistant using a standard protocol.

RESULTS

Twenty-six relevant studies were identified, reported in 28 articles, with study samples obtained from EDs (9), hospitals (4), outpatient or primary care settings (10), home care (4), and community (1). The study designs included 17 randomized controlled trials, 3 trials with nonrandom allocation, 4 before-after studies, 1 quasi-experimental time-series study, and 1 cross-sectional study. Hospital-based interventions (mostly short-term assessment and/or liaison) had little overall effect on ED utilization, whereas many interventions in outpatient and/or primary care or home care settings (including geriatric assessment and management and case management) reduced ED utilization. Heterogeneity in study methods, measures of comorbidity, functional status, and ED utilization precluded meta-analysis of the results.

CONCLUSION

Further research, using improved methodologies and standardized measures, is needed to address the effects of innovative geriatric interventions on ED visits.