Mobile emergency department care to nursing home residents: a novel outreach service

Knowledge, Attitude, and Practice of Chinese Medical Staff for Common Resident Emergencies in Elder Care Facilities: A Structural Equation Model-Based Survey

Aims/Background Increasing population longevity poses challenges to health care for the elderly. Facility-based care is a primary approach to elder care, and medical staff in these settings must be skilled in managing emergencies, as the elderly are more likely to experience emergencies than those living in the community. To aid in developing first aid training, procedures, and regulations for medical staff in elder care facilities, we evaluated the knowledge, attitude, and practice (KAP) levels concerning commonly reported emergencies, as well as the correlations between these factors. Methods The questionnaires were distributed among 1493 doctors and nurses within 258 residential facilities in Shanghai between 1 May 2023 and 31 October 2023. Of the 725 valid questionnaires, we obtained socio-demographic and KAP-related data. Structural equation modeling (SEM) was applied to determine associations between KAP elements. Results Chinese medical staff in elder care facilities had relatively suboptimal knowledge regarding first aid for common resident emergencies, with only 41.7% rated as good. Their levels of attitude and practice were optimistic. The proportion of medical staff demonstrating a positive attitude and appropriate practice in first aid was 79.31% and 68.00%, respectively. Age, gender, educational level, experience with witnessing and dealing with emergencies were identified as factors influencing knowledge, attitude, and practice. Structural equation modeling revealed that attitude and knowledge could directly or indirectly affect management approaches for common elderly emergencies, with a correlation coefficient of 0.11 between knowledge and attitude and 0.66 between attitude and practice. The "first aid for nine preventions" and "cardiac arrest and cardiopulmonary resuscitation" substantially influenced knowledge acquisition, with correlation coefficients of 0.66 and 0.48, respectively. "Attitude toward emergency management" had a significant impact on the attitude of the medical staff, with correlation coefficients of 0.90. Conclusion Knowledge, attitude, and practice are interconnected, with knowledge indirectly influencing behavior by shaping attitude. The medical staff in elder care facilities in Shanghai had a limited understanding of first aid for common resident emergencies. Targeted training and education are urgently required to enhance their knowledge and skills in managing common emergencies among elderly patients, while fostering a strong sense of responsibility. Such initiatives can ensure prompt and appropriate first aid actions, boosting their confidence and promoting a positive and harmonious environment for medical staff and elderly residents.

Potential interactions of community-based acute care teams on the frequency of acute contacts with health-care systems: an interrupted time series analysis

BACKGROUND

Ageing populations necessitate innovative approaches to health-care services. In 2018, Denmark introduced statutory municipal acute nursing care as part of community-based health care to improve care for adults with complex health needs. We evaluated the potential interactions of the acute care team Odense (ATO) on (1) acute hospital contacts; (2) acute hospital contacts caused by specific infection diagnoses, hypernatraemia, delirium, or confusion; and (3) acute ambulance transports.

METHODS

In this retrospective, population-based, longitudinal study, we employed interrupted time series analysis to evaluate the association of ATO on adults in Odense Municipality from Jan 1, 2015, to Feb 28, 2019. Subgroup analyses were used to examine the data of people aged 80 years or older, nursing home residents, and people living at home with home or nursing care.

FINDINGS

The people treated by ATO were older, had more comorbidities, and were more dependent on municipal health care than the average population. The implementation of ATO was not statistically significantly associated with the monthly rate of acute hospital contacts but associated with a substantial reduction of the monthly rates of acute hospital contacts caused by specific infection diagnoses, hypernatraemia, delirium, or confusion (-2·8 [95% CI -5·5 to -0·1]), and acute ambulance transports (-9·5 [-16·2 to -2·9]). For nursing home residents, the monthly rates decreased for acute hospital contacts caused by specific infection diagnoses, hypernatraemia, delirium, or confusion (-0·8 [-1·7 to 0·0]), and acute ambulance transports (-2·1 [-3·7 to -0·4]). Among those aged 80 years or older, acute ambulance transports decreased monthly (-3·8 [-6·6 to -0·9]).

INTERPRETATION

This framework shows potential in minimising transitions between sectors, particularly in the context of acute ambulance transports and acute hospital contacts caused by specific infection diagnoses, hypernatraemia, delirium, or confusion. These findings could offer valuable insights for policy makers on the role of municipal acute nursing care. According to acute hospital contacts, a proportion of numbers might fall beyond the scope of what this framework can prevent, making it valuable to focus on specific groups.

FUNDING

Østifterne, Region of Southern Denmark, Odense University Hospital, and Odense Municipality.

System-Level Effects of an Outreach Service Focusing on Continuity of Care in Nursing Homes: A 12-Month Before and After Cost-Benefit Analysis

AIM

An ageing population increases the demand for emergency department (ED) visits and hospitalisations, and people living in nursing homes in particular are impacted by burdensome transfers and hospitalisations. As such, several onsite-provided care services have been developed to reduce hospitalisations, but more evidence of their cost-effectiveness is needed. An outreach service (OS) was thus developed for nursing homes to increase the quality of care and to decrease avoidable transfers of patients to ED examinations and treatments in hospitals by promoting continuity of care. The model consists of a patient-centred care plan followed by a responsible doctor, an easy-to-use patient information system, 24/7 geriatric teleconsultation for acute problems and nurse training. Thus, this mixed-methods study evaluates the system-level effects of the service model.

METHODS

The study was conducted in 12 nursing homes, comprising 401 patients in total for both cohorts. The costs and benefits of the OS, including the use of health care services in other institutions, were analysed during the 12-month periods both before and after the implementation. An independent sample Mann-Whitney U-test was used at the patient level, and eight semi-structured interviews were conducted with the healthcare personnel concerning the benefits and challenges of the new model.

RESULTS

The system-level costs decreased in all 12 nursing homes and, in total, 21.7% after the implementation. The biggest monetary savings were accrued from inpatient stays, both in primary and secondary care, as the new OS patients needed remarkably less frequent care in hospital ward units. Ambulance transfers and acute visits at primary care decreased by more than 50%, and patient-level decreases in total costs and in the costs of inpatient care and acute visits were all statistically significant (p < 0.01). Nurses and municipality officials considered the OS to be invariably positive.

CONCLUSIONS

The OS was effective, as it led to remarkable decreases in system-level costs for society across nursing homes during the 12-month follow-up. Nurses appreciated the OS, as it improved their ability to maintain control over their work.

Hospitalizations, emergency medical care utilization, and contacts with the regional on-call medical services among nursing home residents in Germany: a cross-sectional study in 44 nursing homes

BACKGROUND

Nursing home residents frequently utilize medical care, but there lacks a complete picture of their acute medical care utilization. We quantified hospitalizations, emergency medical care utilization, and contacts with the regional on-call medical services among nursing home residents, and investigated individual characteristics that may be associated with the utilization of these medical care types.

METHODS

Cross-sectional data from the "Needs-based provision of medical care to nursing home residents" (MVP-STAT) study were analyzed, which were collected in 44 German nursing homes from 442 residents in 2018/2019. Proportions of residents with at least one hospitalization, emergency medical care utilization (via the nationwide phone number 112), and contact with an on-call medical service (nationwide via 116117) over the previous 12 months were determined. Associations between individual characteristics and the utilization of the three medical care types were examined using multivariable logistic regressions.

RESULTS

Of the analyzed residents, 45.8% were hospitalized, 23.2% utilized emergency medical care, and 12.1% had contact with an on-call medical service at least once in the previous 12 months. Hospitalizations were positively associated with male vs. female sex (adjusted odds ratio 1.99 [95% confidence interval 1.22-3.26]), age group 85 + vs. 60-74 years (2.15 [1.12-4.13]), long-term care grades 4/5 vs. 1/2 (2.78 [1.48-5.21]), 6 + vs. 0-1 Elixhauser diseases (2.58 [1.01-6.62]), and the risk or presence of vs. no malnutrition (3.10 [1.52-6.35] and 2.01 [1.26-3.21]); and not associated with years of residence in the respective nursing home. Emergency medical care utilization was positively associated with age group 85 + vs. 60-74 years (2.58 [1.14-5.84]) and long-term care grades 3 and 4/5 vs. 1/2 (2.65 [1.07-6.55], 6.31 [2.60-15.35]); negatively associated with 5 + vs. 1- < 3 years of residence (0.46 [0.24-0.86]); and not associated with sex, the number of Elixhauser diseases, and nutritional status. No associations were found with on-call medical services.

CONCLUSIONS

Hospitalizations and emergency medical care utilization were more frequent among nursing home residents than contacts with on-call medical services. Future studies should investigate whether the frequent hospitalizations and emergency medical care utilization among nursing home residents are justified, or whether they can be reduced by strengthening medical care provision by on-call doctors and other professionals.

TRIAL REGISTRATION

DRKS00012383 [2017/12/06].

Outreach acute care for nursing homes: an observational study on the quality and cost-effectiveness of the Mobile Hospital

BACKGROUND

The global trend of emergency department (ED) crowding can be mitigated with outreach care. The Mobile Hospital is an outreach acute care service in Espoo, Finland. This study describes the results of the Mobile Hospital intervention to nursing homes in a pre-post study setting with benchmarking validation data.

METHODS

We compared Emergency Medical Services (EMS) missions, ED visits, hospitalisations and their estimated costs from two 6-month periods in 2018-2019 (1325 nursing home beds). Benchmarking control data for ED visits were obtained from health records of the 10 largest Finnish cities.

RESULTS

The number of EMS missions to nursing homes decreased by 16% (720 vs 604), ED visits decreased by 22% (801 vs 622), there was no significant difference in specialised inpatient episodes (178 vs 162) and primary hospital inpatient episodes were fewer (285 vs 178, decreased 38%). Annual estimated savings per resident were 686 euros (decreased 14%). Annual estimated total savings were 934 908 euros. In the benchmarking analysis, the number of ED visits and acute hospitalisations amongst the older population decreased in Espoo, while in the other cities it increased.

CONCLUSIONS

The Mobile Hospital seems to reduce nursing home residents' ED visits, hospitalisations and overall costs. Advance care planning and on-call physician telephone consultations may be useful components of the service.Implications to practice: This study adds to the growing evidence that outreach care to nursing homes is cost-effective in suburban areas with universal healthcare funding, at least as part of other developments in the acute care pathway.

Managing falls onsite in residential aged care homes reduced hospitalisation: Mixed methods results from the Falls Outreach and Residential Mobile Assessment Team (FORMAT) pilot study

OBJECTIVE

Falls are the leading cause of hospital transfer from residential aged care homes (RACHs). However, many falls do not result in significant injury, and ageing patients are exposed to complications while hospitalised. Inreach services are designed to reduce hospital transfer by providing care, support and assessment to residents at the RACH. This study evaluated a pilot inreach program targeting ageing patients following a fall.

METHODS

We conducted a prospective, mixed methods evaluation of a 5-month (May-September 2022) pilot implementation across 108 government-funded RACHs within a single health-care network in Melbourne, Australia.

RESULTS

A total of 123 residents (median [interquartile range] age: 88 [82, 94] years, female: 49%) were included in the intervention. The majority (n = 116, 94%) of residents were managed onsite and required no further investigation (n = 80, 69%) or treatment (n = 63, 54%). Among the seven residents referred to the emergency department (ED), two received hospital admission and five were transferred back to residential care. In the 7 days following referral to the intervention, four additional residents were referred to the ED and one received hospital admission. Qualitative feedback (n = 40) included specific comments relating to themes of general satisfaction (n = 20, 50%), compliments for staff (n = 16, 40%) and acknowledgement of comprehensiveness (n = 9, 23%).

CONCLUSIONS

Implementation of a specialised fall assessment team to complement an existing geriatric-led RACH assessment service meant that a high rate of eligible residents were managed onsite, with very low need for subsequent hospitalisation. Residents, family members and caregivers expressed high rates of satisfaction with the service.

Emergency department visits by nursing home residents. A retrospective Italian study of administrative databases from 2015 to 2019

BACKGROUND

Visits to Emergency Departments (ED) can be traumatic for Nursing Home (NH) residents. In Italy, the rate of ED visits by NH residents was recently calculated as 3.3%. The reduction of inappropriate ED visits represents a priority for National Healthcare Systems worldwide. Nevertheless, research on factors associated with ED visits is still under-studied in the Italian setting. This study has two main aims: (i) to describe the baseline characteristics of NH residents visiting ED at regional level; (ii) to assess the characteristics, trends, and factors associated with these visits.

METHODS

A retrospective study of administrative data for five years was performed in the Piedmont Region. Data from 24,208 NH residents were analysed. Data were obtained by merging two ministerial databases of residential care and ED use. Sociodemographic and clinical characteristics of the residents, trends, and rates of ED visits were collected. A Generalized Linear Model (GLM) regression was used to evaluate the factors associated with ED visits.

RESULTS

In 5 years, 12,672 residents made 24,609 ED visits. Aspecific symptoms (45%), dyspnea (17%) and trauma (16%) were the most frequent problems reported at ED. 51% of these visits were coded as non-critical, and 58% were discharged to the NH. The regression analysis showed an increased risk of ED visits for men (OR = 1.61, 95% CI 1.51-1.70) and for residents with a stay in NH longer than 400 days (OR = 2.19, 95% CI 2.08-2.31).

CONCLUSIONS

Our study indicates that more than half of NH residents' ED visits could potentially be prevented by treating residents in NH. Investments in the creation of a structured and effective network within primary care services, promoting the use of health technology and palliative care approaches, could reduce ED visits and help clinicians manage residents on-site and remotely.

Telemedicine in Nursing Home Residents Requiring a Call to an Emergency Medical Communication Center

OBJECTIVES

To compare the proportion of nursing home residents dispatched to an emergency department (ED) after a call to the emergency medical communication center (EMCC) according to the availability or nonavailability of telemedicine.

DESIGN

This prospective, observational trial was conducted in the EMCC and 74 nursing homes in a French county.

SETTING AND PARTICIPANTS

All nursing home residents who needed to contact the EMCC between June 2019 and April 2020 were included in the study. We excluded calls notifying the death of a resident, for completing data from a previous call, and for nursing home staff.

METHODS

The primary outcome was the proportion of residents dispatched to an ED after their first call to the EMCC. The secondary outcomes were the proportion of second calls, proportion of residents dispatched to an ED after a second call, and proportion of death within 30 days.

RESULTS

We included 3103 calls in the final analysis (355 from equipped nursing homes and 2748 from unequipped nursing homes). The proportion of patients dispatched to an ED after the first call was lower among telemedicine-equipped than among telemedicine-unequipped nursing homes (41% vs 50%; odds ratio, 0.71; 95% CI, 0.56-0.90). The proportion of a second call for the same purpose within 72 hours, proportion of dispatching to an ED at the second call, and proportion of deaths within 30 days were similar between the groups.

CONCLUSION AND IMPLICATIONS

The use of telemedicine by nursing home residents requiring a call to the EMCC is associated with a reduction in the number of dispatches to an ED without any increase in the number of 72-hour callbacks or 30-day mortality rates.