Implementation of Case Management in emergency departments: the view of the involved staff

Introduction

Frequent users of emergency departments (FUED; ≥ 5 ED visits in the previous 12 months) often present with somatic, psychological and substance use problems. Providing a Case Management (CM) intervention may reduce their number ED visits and improve their quality of life. However, there is limited knowledge about the implementation process of CM.

Methods

This study aimed to introduce CM into the EDs in the French-speaking part of Switzerland and to identify the facilitators, barriers and needs encountered in this process. Semi-structured interviews were conducted with ED involved staff. An inductive content analysis was conducted.

Results

Among 13 invited hospitals, 8 implemented CM (62%); 23 ED staff were sampled from all participating ED: 17 nurses (74%), 5 physicians (22%) and 1 healthcare manager (4%). The average age was 48,48 years (SD = 8,64) and 74% were female. Four main facilitators emerged from the analysis: 1) Direct hierarchy support and flexibility (e.g. time management, supplemental paid hours); 2) Exchange with colleagues (e.g. debriefing, support); 3) Supervision by the research team (training and toolkit consisting of a binder and USB stick containing the study presentation and implementation procedures); and 4) Motivation (pleasure to work on an innovative project, benefit for patients and caregivers). Lack of resources was an unanimously mentioned barrier (e. g., time to identify and contact FUED medical and social support). Finally, participants identified the following needs to enable CM implementation: official and protected time for the project, a dedicated room for CM, at least two team members involved in the project since its initiation with complementary skills (e.g.: somatic, psychiatric and social).

Conclusions

Our study suggests that successful CM implementation is a complex process that, in addition to motivated ED staff, requires significant dedicated resources, such as protected time and a devoted support team.

Key messages

Improving communication with hard of hearing and D/deaf patients: a capacity-building intervention

Background

D/deaf and hard of hearing (D&HoH) populations are disproportionally affected by physical and mental health problems while facing barriers to accessing health services. These barriers stem from communication challenges with healthcare providers, who are often unprepared to meet their specific needs. This study aimed to develop and evaluate an intervention to improve healthcare providers’ skills to communicate with these patients.

Methods

This study featured a participative action research design. Consistently, the intervention was developed through iterative phases together with the target populations and key stakeholders. The finale version was tested in healthcare workers in Canton of Vaud in Switzerland. Participants completed a questionnaire before (T0) and 6 months after (T1) the intervention, assessing perceived knowledge of deafness and hard of hearing and tools to improve communication, self-efficacy on how to communicate with D&HoH patients and institutional benefits (application frequency of communication rules and tools).

Results

The final intervention aimed to increase participants’ 1) awareness of D&HoH experience and communication needs, 2) knowledge of the tools and basic rules to improve communication. Two D&HoH trainers led one half-day intervention among 28 healthcare providers (e.g., nurses, pharmacists; mean age=43.6). Paired-sample t-tests revealed significant increases in knowledge between T0 and T1, t (23) = -7.81, p < .001 and in self-efficacy, t (24) = -10.23, p < .001, whereas there was no significant difference between institutional benefits at T0 and T1.

Conclusions

Although findings suggest the intervention is a promising means to increase perceived knowledge and self-efficacy on how communicating with D&HoH patients, complementary approaches, such as a resource person within the institutions providing day-to-day support to the teams besides the intervention, may be necessary to induce institutional changes.

Key messages

• Future research should implement the intervention more broadly within inpatient and outpatient settings in Switzerland to increase knowledge on how communicating with D&HoH patients.

• Intervention implementation should be complemented by an additional structural approach to induce sustainable changes in practice and evaluated over 12 months to ensure sustainability.

Frequent users of ED’s perspectives about a case management intervention in Western Switzerland

Background

Management of frequent users of the emergency department (FUED; ≥5 visits/year) is a known challenge. Studies show that case management (CM) improves FUEDs' quality of life while reducing their number of emergency department visits and associated costs. However, little is known about FUEDs' own perspectives on CM.

Methods

This qualitative study was part of a larger study aiming to implement CM for FUED in French-speaking Switzerland. Participants were FUEDs included in the parent study, who had either completed the CM intervention or were still enrolled. Semi-structured qualitative interviews were conducted with 20 participants (75% female; mean age=40.55, SD = 12.84), randomly drawn from the parent study sample. Content analysis was performed by two researchers to assess participants' perceptions on the CM intervention.

Results

Most participants endorsed general positive perceptions of CM. CM differed from their usual treatment by two characteristics: its holistic approach and the quality of the relationship with the case manager. Also, moral support was perceived as a main benefit. FUEDs perceived four outcomes: an increase in motivation (e.g., day-to-day life or health-related), better orientation in and interaction with the healthcare system and improved health literacy. Finally, FUEDs identified two negative aspects to the CM: few perceived benefits (e.g., not enough concrete outcomes) and negative consequences (e.g., feeling ashamed to come back to ED). Three obstacles were identified: case manager's lack of time, COVID-19's influence (e.g., less personal contact) and uncertainty around the program (e.g., organization, aims). The personal relationship with their case manager was perceived as the main driver to positive outcomes.

Conclusions

FUED perceived the program as useful and considered the relationship with the case manager as key for positive outcomes. Our findings also suggest ways to improve CM, such as clarifying its organization and aims.

Key messages

In FUEDs’ opinion, the CM intervention had many positive outcomes, often relying on the relationship with the case manager.

However, the CM intervention had also some negatives.

Healthcare providers’ perceptions of difficulties related to frequent users of emergency departments

Background

Frequent users of emergency department (FUEDs; ≥ 5 ED visits/ year) are often vulnerable individuals cumulating medical, social and substance use problems. FUEDs often require complex and sustained care coordination generally unavailable in ED and are commonly considered contributing to ED crowding. In view of supporting ED health-care providers through specific training and interventions tailored to FUEDs, this study aimed to explore ED healthcare providers’ perceptions of difficulties related to FUEDs.

Methods

Participants (N = 208) were ED healthcare providers (i.e., nurses, physicians) from 75 university and community hospitals in Switzerland (71% of all EDs) who answered a questionnaire on FUEDs. They were asked to indicate the extent to which FUEDs represent a problem in their ED. Perceived difficulties related to FUEDs were elicited by an open-ended question. Conventional content analysis was used to extract common categories and themes.

Results

Among the 208 participants, 134 (64%) reported that FUEDs represent a problem. Of those, 132 provided 1 to 5 answers to the open-ended question. Twenty-eight categories were identified and organized in 4 themes. First, participants reported difficulties related to FUEDs’ characteristics themselves (e.g., problem’s chronicity; behavioural difficulties) leading to healthcare complexity. Second, participants perceived negative consequences related to the presence of FUEDs in the ED (e.g., work overload, staff helplessness and fatigue). Third, ED healthcare offer was considered inappropriate and inefficient to respond to FUEDs needs and fourth collaborating with FUEDs’ existing healthcare network was perceived as difficult.

Conclusions

ED healthcare providers experience a wide range of difficulties related to the management of FUEDs. Providing training and implementing a case management intervention tailored to FUEDs might support ED health-care providers and contribute to address FUEDs’ complex needs.

Key messages

ED healthcare providers perceive FUEDs to represent a problem. Perceived difficulties might decrease through training and case management support might contribute to better address FUEDs complex needs.

Photonic efficiency of the photodegradation of paracetamol in water by the photo-Fenton process

An experimental study of the homogeneous Fenton and photo-Fenton degradation of 4-amidophenol (paracetamol, PCT) is presented. For all the operation conditions evaluated, PCT degradation is efficiently attained by both Fenton and photo-Fenton processes. Also, photonic efficiencies of PCT degradation and mineralization are determined under different experimental conditions, characterizing the influence of hydrogen peroxide (H2O2) and Fe(II) on both contaminant degradation and sample mineralization. The maximum photonic degradation efficiencies for 5 and 10 mg L(-1) Fe(II) were 3.9 (H2O2 = 189 mg L(-1)) and 5 (H2O2 = 378 mg L(-1)), respectively. For higher concentrations of oxidant, H2O2 acts as a "scavenger" radical, competing in pollutant degradation and reducing the reaction rate. Moreover, in order to quantify the consumption of the oxidizing agent, the specific consumption of the hydrogen peroxide was also evaluated. For all operating conditions of both hydrogen peroxide and Fe(II) concentration, the consumption values obtained for Fenton process were always higher than the corresponding values observed for photo-Fenton. This implies a less efficient use of the oxidizing agent for dark conditions.

Atypical hepatic hemangiomas with intense arterial enhancement and early fading

BACKGROUND

Our purpose is to analyze the prevalence and characteristics of the enhancement patterns of hemangiomas.

METHODS

Fifty-five proven hemangiomas studied with a dynamic single-slice T1-weighted spoiled gradient echo sequence (50/13/65 degrees) were retrospectively selected. Fifteen images of the tumor in 5 min were obtained after a bolus of gadolinium. A temporal planar reconstruction image was generated to analyze the dynamic evolution of a line of interest through the tumor.

RESULTS

Most hemangiomas (60%) had a typical progressive pattern with hyperintensity on late images. Of these, 34.6% had an intense enhancement pattern with the highest slope close to the arterial or portal phases of perfusion and 25.5% had a less intense enhancement with a more constant rate. In 10.9% of cases, the enhancement was slowly progressive with late isointensity and 7.3% had a very slow progressive pattern with late hypointensity; all had a globular peripheral initial enhancement pattern. There were 12 hemangiomas (21.8%) with intense arterial enhancement and early fading; eight of 12 (66.7%) showed peripheral globular enhancement, with all 12 hemangiomas remaining hyperintense to the liver at the end of the dynamic study. In four cases, the initial enhancement was diffuse throughout the entire lesion.

CONCLUSIONS

Hemangiomas can have early intense enhancement with early fading and diffuse intense enhancement.

Reduction of peristaltic artifacts on magnetic resonance imaging of the abdomen: a comparative evaluation of three drugs

BACKGROUND

Peristaltic motion is an omnipresent source of degradation in abdominal magnetic resonance (MR) imaging by blurring images and producing ghost artifacts that can mask or mimic lesions. The objective of this study was to select an effective and easy-to-administer drug to provide consistent reduction of peristaltic motion artifacts on MR images.

METHODS

One hundred forty-eight adult patients with MR examinations of the abdomen were enrolled in a prospective, single-blind comparative study. Four groups were defined: (a) no-drug control group (n = 35), (b) 1 mg of intravenous (IV) glucagon (n = 19), (c) 20 mg of IV butylscopolamine (n = 28), and (d) 20 mg of oral dicyclomine (n = 66). All patients received high-density barium sulphate as a negative oral contrast medium. Quantitative image analysis was performed with operator-defined region-of-interest measurements of signal intensity. Gastrointestinal noise was measured outside the patient at the posterior part of the left hemiabdomen along the phase-encoding direction on a short inversion time inversion recovery (STIR) sequence.

RESULTS

Treatment groups showed reduced gastrointestinal noise (p < 0.01). When compared with the control group, IV butylscopolamine (p < 0.05) and oral dicyclomine (p < 0.05) significantly reduced gastrointestinal noise, whereas glucagon did not.

CONCLUSION

Anticholinergic drugs significantly reduced the intensity of ghost artifacts on MR imaging of the abdomen. Twenty milligrams of oral dicyclomine is an effective and safe alternative to more expensive and parenterally administered drugs such as glucagon and butylscopolamine.

Determination of paracetamol and its four major metabolites in mouse plasma by reversed-phase ion-pair high-performance liquid chromatography

A reversed-phase ion-pair high-performance liquid chromatographic method has been used for the separation of paracetamol and its four major metabolites (glucuronide, sulphate, cysteine and mercapturate conjugates) in mouse plasma samples. An ODS column was used and the mobile phase consisted of an aqueous solution of 0.01 M tetrabutylammonium chloride and 0.01 M Tris buffered to pH 5.0 with phosphoric acid, with methanol as the organic solvent. The gradient elution started with 30% methanol. After a delay of 0.5 min the methanol concentration was increased linearly to 75% over 7.5 min. The column was returned to the initial conditions after a delay of 1 min. A methanol solution of theophylline was added to the mouse plasma sample, centrifuged and immediately injected into the chromatographic system. The advantages of this method include good and rapid separation (last metabolite detected at 6.86 min), well resolved peaks, only a small amount of sample required for assay, adequate precision (no coefficient of variation was greater than 10% for paracetamol metabolites) and a high sensitivity (particularly for unchanged paracetamol and the cysteine conjugate).

Prolactin and its response to the luteinizing hormone-releasing hormone thyrotropin-releasing hormone test in patients with endometriosis before, during, and after treatment with danazol

Basal levels of prolactin (PRL) were studied in 16 normal women and in 60 women with endometriosis, 37 of whom were infertile. In addition, the authors studied the response to an intravenous (IV) injection of luteinizing hormone-releasing hormone (LH-RH) (100 micrograms) plus thyrotropin-releasing hormone (TRH) (300 micrograms) in the 16 normal women and in 18 endometriosis patients, examining the basal PRL and thyrotropin, and at 15, 30, 45, 60, and 120 minutes after the IV bolus. After laparoscopy and/or conservative surgery, the patients were treated with danazol for 6 months and a second laparoscopy was performed. The LH-RH/TRH test was carried out in the third month of danazol treatment in 6 endometriosis patients and before the second laparoscopy in 11 patients. The results show that there was both an increase in the mean basal levels of PRL and in the percentage of cases of moderate hyperprolactinemia in endometriosis patients. There also was a greater rise in PRL with the LH-RH/TRH test in moderate and severe endometriosis. The PRL response was significantly greater in endometriosis than in normal women, and was not related to TSH response. Danazol treatment reduced significantly the PRL response. The PRL response before treatment was significantly higher in patients who after treatment showed persistent endometriosis at the second laparoscopy. This could suggest a lower effectiveness of danazol in patients with endometriosis and a PRL hyper-response to LH-RH/TRH.