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Sharp A, Matthews G, Papageorgiou N, Till R, Raine D, Williams I, Grahame-Clarke C, Nair S, Abdul-Samad O, Vassiliou V, Garg P, Lim WY. Hospitalization for permanent pacemaker implantation in the context of isolated sinus node dysfunction is associated with increased mortality compared with an outpatient strategy. Pacing Clin Electrophysiol 2023; 46:1465-1471. [PMID: 37910470 DOI: 10.1111/pace.14856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Permanent pacemaker (PPM) implantation is a well-established treatment for symptomatic sinus node dysfunction (SND). The optimal timing of this intervention is unclear, with atrioventricular blocks often prioritized in resource stressed waiting lists due to mortality concerns. METHODS Mortality data was compared between patients receiving elective outpatient (OP) PPM implantation, and those presenting to hospital for urgent inpatient (IP) management for symptomatic SND. Survival analysis was conducted using Kaplan-Meier plots and compared using the log-rank test. Univariable and multivariable Cox regression, as well as propensity score matching analyses were performed to assess the prognostic effect on 30-day and 1-year all-cause mortality of inpatient implant. RESULTS Of the 1269 patients identified with isolated SND, 740 (58%) had PPMs implanted on an OP and 529 (42%) on an IP basis. Mortality was significantly worse in patients where management was driven by hospital admission on an urgent basis (Log-Rank χ2 = 21.6, p < 0.001) and remained an independent predictor of 1-year all-cause mortality (HR 3.40, 95% CI 1.97-5.86, p < 0.001) on multivariable analysis. CONCLUSIONS SND is predominantly a disease associated with ageing and comorbid populations, where avoidance of deconditioning, hospitalization acquired infections, and polypharmacy is advantageous. Admission avoidance is therefore the preferable strategy.
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Affiliation(s)
- Alexander Sharp
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK
| | - Gareth Matthews
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK
- Department of Cardiology, Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Richard Till
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK
| | - Daniel Raine
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK
| | - Ian Williams
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK
| | | | - Santosh Nair
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK
| | - Omar Abdul-Samad
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK
| | - Vassilios Vassiliou
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK
- Department of Cardiology, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Pankaj Garg
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK
- Department of Cardiology, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Wei Yao Lim
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK
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Smyth H, Breslin D, Mullany L, Ramiah V, Riches R, Laguna R, Morgan P, Byrne C. Silver Trauma Review Clinic: a novel model of care to manage non-operative injuries in older patients. Emerg Med J 2023; 40:721-725. [PMID: 37640437 DOI: 10.1136/emermed-2022-212982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 07/27/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Increasing numbers of older patients are presenting to the ED following trauma. These patients require multidisciplinary care that the traditional trauma model fails to provide. A Silver Trauma Review Clinic (STRC) was developed in conjunction with the geriatric ED and multidisciplinary services to improve the post-discharge care of patients with non-operative traumatic injuries.We aimed to assess the STRC by reviewing the journey and outcomes of patients who attended the clinic. METHODS A retrospective review of electronic chart data was performed on all patients who attended the clinic over the initial 1-year period. Data were collected on patient demographics, medical history, medications, timelines, trauma assessments and further investigations, fracture types, occult injuries, geriatric assessments (Comprehensive Geriatric Assessment, Clinical Frailty Scale, bone health, falls, Orthostatic Hypotension (OH), cognitive screening, mobility), number of reviews and discharge destination. RESULTS 137 patients were reviewed with a median age of 80 years (IQR 74-86) and 69% were female. The median Clinical Frailty Scale was 3 with a median time from the patient's initial ED presentation to clinic of 15 days (IQR 9.75-21) and median time from initial review to discharge 20 days (IQR 1-35). 71% of presentations were as a result of falls under 2 m. Tertiary survey in the STRC identified previously unrecognised injuries in 24 patients (18%). In total, 56 patients were reviewed with vertebral fractures. 87% of these patients (n=49) were further investigated with a CT or MRI and 95% of patients (n=53) were referred for physiotherapy. Patients attending the STRC had a comprehensive geriatric assessment with abnormal Mini-Cog assessments found in 29%, a new diagnosis of osteoporosis in 43% and orthostatic hypotension diagnosed in 13% of patients. 61% were discharged to primary care and 19% linked into a specialist geriatric clinic. CONCLUSION The STRC is a novel approach allowing timely, patient-focused, comprehensive and collaborative trauma care of older patients following non-operative injuries.
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Affiliation(s)
- Hannah Smyth
- Departments of Emergency Medicine and Geriatric Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Deirdre Breslin
- Departments of Emergency Medicine and Geriatric Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Lorcán Mullany
- Departments of Emergency Medicine and Geriatric Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Vinny Ramiah
- Departments of Emergency Medicine and Geriatric Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Roisin Riches
- Departments of Emergency Medicine and Geriatric Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Rico Laguna
- Departments of Emergency Medicine and Geriatric Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Paula Morgan
- Departments of Emergency Medicine and Geriatric Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Colm Byrne
- Departments of Emergency Medicine and Geriatric Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
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Greene L, Lane R, Crotty M, Whitehead C, Potter E, Bierer P, Laver K. Evaluating a new emergency department avoidance service for older people: patient and relative experiences. Emerg Med J 2023; 40:641-645. [PMID: 37400224 PMCID: PMC10447360 DOI: 10.1136/emermed-2022-212949] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 06/21/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND High emergency department (ED) usage by older individuals for non-emergencies is a global concern. ED avoidance initiatives have proven effective in addressing this issue. To specifically cater to individuals aged 65 and above, the Southern Adelaide Local Health Network introduced an innovative ED avoidance service. This study assessed the acceptability of the service among its users. METHOD The Complex And RestorativE (CARE) Centre is a six-bed unit staffed by a multidisciplinary geriatric team. Patients are transported directly to CARE after calling for an ambulance and being triaged by a paramedic. The evaluation took place between September 2021 and September 2022. Semi-structured interviews were conducted with patients and relatives who had accessed the service. Data analysis was performed using a six-step thematic analysis. RESULTS Seventeen patients and 15 relatives were interviewed, who described the experience of 32 attendances to the urgent CARE centre between them. Patients accessed the service for several reasons but over half were associated with falls. There was a hesitation to call emergency services for several reasons, the primary being long wait times in ED and/or the prospect of an overnight stay in hospital. Some individuals attempted to contact their General Practitioner (GP) for the presenting problem but were unable to get a timely appointment. Most participants had previously attended a local ED and had a negative experience. All individuals reported favouring the CARE centre over the traditional ED for numerous reasons including a quieter and safer environment and specially trained geriatric staff who were less rushed than ED staff. Several participants would have appreciated a standardised follow-up process after discharge. CONCLUSION Our findings suggest that ED admission avoidance programmes may be an acceptable alternative treatment for older people requiring urgent care, potentially benefiting both public health systems and user experience.
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Affiliation(s)
- Leanne Greene
- Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
| | - Rachel Lane
- Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
| | - Maria Crotty
- Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
| | - Craig Whitehead
- Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
| | - Elizabeth Potter
- Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
| | - Petra Bierer
- Rehabilitation, Aged and Extended Care, Southern Adelaide Local Health Network, Bedford Park, South Australia, Australia
| | - Kate Laver
- Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
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Cooper JG, Ferguson J, Donaldson LA, Black KMM, Livock KJ, Horrill JL, Davidson EM, Scott NW, Lee AJ, Fujisawa T, Lee KK, Anand A, Shah ASV, Mills NL. Performance of a prehospital HEART score in patients with possible myocardial infarction: a prospective evaluation. Emerg Med J 2023; 40:474-481. [PMID: 37268413 DOI: 10.1136/emermed-2022-213003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 05/14/2023] [Indexed: 06/04/2023]
Abstract
INTRODUCTION The History, Electrocardiogram (ECG), Age, Risk Factors and Troponin (HEART) score is commonly used to risk stratify patients with possible myocardial infarction as low risk or high risk in the Emergency Department (ED). Whether the HEART score can be used by paramedics to guide care were high-sensitivity cardiac troponin testing available in a prehospital setting is uncertain. METHODS In a prespecified secondary analysis of a prospective cohort study where paramedics enrolled patients with suspected myocardial infarction, a paramedic Heart, ECG, Age, Risk Factors (HEAR) score was recorded contemporaneously, and a prehospital blood sample was obtained for subsequent cardiac troponin testing. HEART and modified HEART scores were derived using laboratory contemporary and high-sensitivity cardiac troponin I assays. HEART and modified HEART scores of ≤3 and ≥7 were applied to define low-risk and high-risk patients, and performance was evaluated for an outcome of major adverse cardiac events (MACEs) at 30 days. RESULTS Between November 2014 and April 2018, 1054 patients were recruited, of whom 960 (mean 64 (SD 15) years, 42% women) were eligible for analysis and 255 (26%) experienced a MACE at 30 days. A HEART score of ≤3 identified 279 (29%) as low risk with a negative predictive value of 93.5% (95% CI 90.0% to 95.9%) for the contemporary assay and 91.4% (95% CI 87.5% to 94.2%) for the high-sensitivity assay. A modified HEART score of ≤3 using the limit of detection of the high-sensitivity assay identified 194 (20%) patients as low risk with a negative predictive value of 95.9% (95% CI 92.1% to 97.9%). A HEART score of ≥7 using either assay gave a lower positive predictive value than using the upper reference limit of either cardiac troponin assay alone. CONCLUSIONS A HEART score derived by paramedics in the prehospital setting, even when modified to harness the precision of a high-sensitivity assay, does not allow safe rule-out of myocardial infarction or enhanced rule-in compared with cardiac troponin testing alone.
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Affiliation(s)
- Jamie G Cooper
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, UK
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - James Ferguson
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Lorna A Donaldson
- Department of Research Development and Innovation, Scottish Ambulance Service, Edinburgh, UK
| | - Kim M M Black
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Kate J Livock
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | | | - Elaine M Davidson
- Department of Clinical Biochemistry, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Neil W Scott
- Medical Statistics Team, University of Aberdeen, Aberdeen, UK
| | - Amanda J Lee
- Medical Statistics Team, University of Aberdeen, Aberdeen, UK
| | - Takeshi Fujisawa
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- BHF Cardiovascular Biomarker Laboratory, University of Edinburgh, Edinburgh, UK
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Atul Anand
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Anoop S V Shah
- Department of Non Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
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Patel S, Khiroya M, Roland D. Feasibility of using a community pharmacist within a Children's Emergency Department. Emerg Med J 2023:emermed-2022-213022. [PMID: 37311621 DOI: 10.1136/emermed-2022-213022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 06/15/2023]
Affiliation(s)
- Seal Patel
- TrustMed Pharmacy, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Mala Khiroya
- TrustMed Pharmacy, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Damian Roland
- SAPPHIRE Group, Department of Population Health Sciences, University of Leicester, Leicester, UK
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, University Hospitals of Leicester NHS Trust, Leicester, UK
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Weber EJ. Did England's national home oxygen monitoring programme for COVID-19 work? Yes… and no. Emerg Med J 2023; 40:394-395. [PMID: 37220971 DOI: 10.1136/emermed-2023-213195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/25/2023]
Affiliation(s)
- Ellen J Weber
- Emergency Medicine, University of California San Francisco, San Francisco, California, USA
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Beaney T, Clarke J, Alboksmaty A, Flott K, Fowler A, Benger J, Aylin PP, Elkin S, Darzi A, Neves AL. Evaluating the impact of a pulse oximetry remote monitoring programme on mortality and healthcare utilisation in patients with COVID-19 assessed in emergency departments in England: a retrospective matched cohort study. Emerg Med J 2023; 40:460-465. [PMID: 36854617 PMCID: PMC10313966 DOI: 10.1136/emermed-2022-212377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 12/21/2022] [Indexed: 03/02/2023]
Abstract
BACKGROUND To identify the impact of enrolment onto a national pulse oximetry remote monitoring programme for COVID-19 (COVID-19 Oximetry @home; CO@h) on health service use and mortality in patients attending Emergency Departments (EDs). METHODS We conducted a retrospective matched cohort study of patients enrolled onto the CO@h pathway from EDs in England. We included all patients with a positive COVID-19 test from 1 October 2020 to 3 May 2021 who attended ED from 3 days before to 10 days after the date of the test. All patients who were admitted or died on the same or following day to the first ED attendance within the time window were excluded. In the primary analysis, participants enrolled onto CO@h were matched using demographic and clinical criteria to participants who were not enrolled. Five outcome measures were examined within 28 days of first ED attendance: (1) Death from any cause; (2) Any subsequent ED attendance; (3) Any emergency hospital admission; (4) Critical care admission; and (5) Length of stay. RESULTS 15 621 participants were included in the primary analysis, of whom 639 were enrolled onto CO@h and 14 982 were controls. Odds of death were 52% lower in those enrolled (95% CI 7% to 75%) compared with those not enrolled onto CO@h. Odds of any ED attendance or admission were 37% (95% CI 16% to 63%) and 59% (95% CI 32% to 91%) higher, respectively, in those enrolled. Of those admitted, those enrolled had 53% (95% CI 7% to 76%) lower odds of critical care admission. There was no significant impact on length of stay. CONCLUSIONS These findings indicate that for patients assessed in ED, pulse oximetry remote monitoring may be a clinically effective and safe model for early detection of hypoxia and escalation. However, possible selection biases might limit the generalisability to other populations.
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Affiliation(s)
- Thomas Beaney
- Department of Primary Care and Public Health, Imperial College London, London, UK
- Patient Safety Translational Research Centre, Institute of Global Health Innovation, Imperial College London, London, UK
| | - Jonathan Clarke
- Patient Safety Translational Research Centre, Institute of Global Health Innovation, Imperial College London, London, UK
- Department of Mathematics, Imperial College London, London, UK
| | - Ahmed Alboksmaty
- Department of Primary Care and Public Health, Imperial College London, London, UK
- Patient Safety Translational Research Centre, Institute of Global Health Innovation, Imperial College London, London, UK
| | - Kelsey Flott
- Patient Safety Translational Research Centre, Institute of Global Health Innovation, Imperial College London, London, UK
| | | | | | - Paul P Aylin
- Department of Primary Care and Public Health, Imperial College London, London, UK
- Patient Safety Translational Research Centre, Institute of Global Health Innovation, Imperial College London, London, UK
| | - Sarah Elkin
- Imperial College Healthcare NHS Trust, London, UK
| | - Ara Darzi
- Patient Safety Translational Research Centre, Institute of Global Health Innovation, Imperial College London, London, UK
| | - Ana Luisa Neves
- Patient Safety Translational Research Centre, Institute of Global Health Innovation, Imperial College London, London, UK
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Gregory J, Noble B, Ward D, Wyrko Z, Laghi L. Admission avoidance for older adults facilitated by telemedicine during the COVID-19 pandemic. Endocr Metab Immune Disord Drug Targets 2023:EMIDDT-EPUB-129200. [PMID: 36725831 DOI: 10.2174/1871530323666230201103920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 11/29/2022] [Accepted: 12/09/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The coronavirus pandemic has disproportionately affected older adults and has provided an incentive to find alternatives to emergency department attendance to avoid unnecessary exposure to the SARS-CoV-2 virus. To address this issue, a specialist geriatric multidisciplinary team at Queen Elizabeth Hospital set up a novel telemedicine approach to the ambulance service with the aim of reducing unnecessary emergency department attendance for older adults. This study provides a service evaluation in its first year of use. METHODS Service evaluation in the first year of the 'Ask OPAL' (older person Assessment and liaison) hotline for ambulance paramedics, run by a multidisciplinary acute geriatrics team at the Queen Elizabeth Hospital, Birmingham. Data on the number, patient demographics, intervention, and outcome of the calls, were recorded. RESULTS During the study period, 2552 'Ask OPAL' calls were conducted. Of the 2552 calls carried out, 1755 patients (69%) remained at home. Of the patients who remained at home, 76% received verbal advice only, while 24% were referred to community services in addition to receiving verbal advice. CONCLUSION In conclusion, the use of an integrated multidisciplinary team communicating with paramedics via telemedicine appears to be successful in preventing avoidable hospital admissions in complex patients.
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Affiliation(s)
- Jemma Gregory
- United Kingdom B15 2GW; University of Birmingham, Birmingham, United Kingdom B15
| | - Benjamin Noble
- University of Birmingham, Birmingham, United Kingdom B15 2TT
| | - Donna Ward
- Department of Healthcare for Older People, Queen Elizabeth Hospital, Birmingham, United Kingdom B15 2GW
| | - Zoe Wyrko
- Riverstone Living, 2 Physic Place, Royal Hospital Road, London SW3 4HQ
| | - Luca Laghi
- Department of Healthcare for Older People, Queen Elizabeth Hospital, Birmingham, United Kingdom B15 2GW
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Wyatt S, Joshi R, Mortimore JM, Mohammed MA. Relationship between emergency department and inpatient occupancy and the likelihood of an emergency admission: a retrospective hospital database study. Emerg Med J 2021; 39:174-180. [PMID: 34348997 PMCID: PMC8921568 DOI: 10.1136/emermed-2021-211229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 07/09/2021] [Indexed: 11/25/2022]
Abstract
Background We investigate whether admission from a consultant-led ED is associated with ED occupancy or crowding and inpatient (bed) occupancy. Methods We used general additive logistic regression to explore the relationship between the probability of an ED patient being admitted, ED crowding and inpatient occupancy levels. We adjust for patient, temporal and attendance characteristics using data from 13 English NHS Hospital Trusts in 2019. We define quintiles of occupancy in ED and for four types of inpatients: emergency, overnight elective, day case and maternity. Results Compared with periods of average occupancy in ED, a patient attending during a period of very high (upper quintile) occupancy was 3.3% less likely (relative risk (RR) 0.967, 95% CI 0.958 to 0.977) to be admitted, whereas a patient arriving at a time of low ED occupancy was 3.9% more likely (RR 1.039 95% CI 1.028 to 1.050) to be admitted. When the number of overnight elective, day-case and maternity inpatients reaches the upper quintile then the probability of admission from ED rises by 1.1% (RR 1.011 95% CI 1.001 to 1.021), 3.8% (RR 1.038 95% CI 1.025 to 1.051) and 1.0% (RR 1.010 95% CI 1.001 to 1.020), respectively. Compared with periods of average emergency inpatient occupancy, a patient attending during a period of very high emergency inpatient occupancy was 1.0% less likely (RR 0.990 95% CI 0.980 to 0.999) to be admitted and a patient arriving at a time of very low emergency inpatient occupancy was 0.8% less likely (RR 0.992 95% CI 0.958 to 0.977) to be admitted. Conclusions Admission thresholds are modestly associated with ED and inpatient occupancy when these reach extreme levels. Admission thresholds are higher when the number of emergency inpatients is particularly high. This may indicate that riskier discharge decisions are taken when beds are full. Admission thresholds are also high when pressures within the hospital are particularly low, suggesting the potential to safely reduce avoidable admissions.
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Affiliation(s)
- Steven Wyatt
- Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| | - Ruchi Joshi
- Emergency Department, Walsall Healthcare NHS Trust, Walsall, UK
| | - Janet M Mortimore
- Faculty of Education, Health and Wellbeing, University of Wolverhampton, Wolverhampton, UK.,Performance and Information Team, Walsall Healthcare NHS Trust, Walsall, UK
| | - Mohammed A Mohammed
- Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK.,Faculty of Health Studies, University of Bradford, Bradford, UK
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Tierney B, Melby V, Todd S. Service evaluation comparing Acute Care at Home for older people service and conventional service within an acute hospital care of elderly ward. J Clin Nurs 2021; 30:2978-2989. [PMID: 34216068 DOI: 10.1111/jocn.15805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/27/2021] [Accepted: 03/23/2021] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES This study evaluated the impact of a consultant-led Acute Care at Home service in comparison with conventional hospital admission to a care of elderly ward. BACKGROUND Globally, there has been an increased demand for healthcare services caused by population growth and a rise in chronic conditions and an ageing population. Acute Care at Home services offer acute, hospital-level care in a person's own home. Five services have been commissioned across Northern Ireland since 2014 with limited research investigating their feasibility and effectiveness. DESIGN Quantitative design, using service evaluation methodology. METHODS A 1-year retrospective chart review was undertaken exploring admission demographics and post-discharge clinical outcomes of patients admitted to a Northern Ireland, Care of the Elderly ward (n = 191) and a consultant-led Acute Care at Home Service (n = 314) between April 2018-March 2019. Data were analysed using descriptive and inferential data analysis methods including frequencies, independent t tests and chi-square analysis. Outcome measurements included length of stay, 30-day, 3- and 6-month readmission and mortality rates, functional ability and residence on discharge. STROBE checklist was used in reporting this study. RESULTS Acute Care at Home services are associated with higher readmission and mortality rates at 30 days, 3 and 6 months. Fewer patients die while under Acute Care at Home care. Patients admitted to the Acute Care at Home services experience a reduced length of stay and decreased escalation in domiciliary care packages and are less likely to require subacute rehabilitation on discharge. There is no difference in gender, age and early warnings score between the two cohorts. CONCLUSION The Acute Care at Home service is a viable alternative to hospital for older patients. It prevents functional decline and the need for domiciliary care or nursing home placement. It is likely that the Acute Care at Home service has higher mortality and readmissions rates due to treating a higher proportion of dependent, frail older adults. RELEVANCE TO CLINICAL PRACTICE Acute Care at Home services continue to evolve worldwide. This service evaluation has confirmed that Acute Care at Home services are safe and cost-effective alternatives to traditional older people hospital services. Such services offer patient choice, reduce length of stay and costs and prevent functional decline of older adults. This study accentuates the need to expand Acute Care at Home provision and capacity throughout Northern Ireland.
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Affiliation(s)
- Barry Tierney
- Western Health and Social Care Trust, Londonderry, UK
| | - Vidar Melby
- School of Nursing and Institute of Nursing and Health Research, Ulster University, Derry, UK
| | - Stephen Todd
- Western Health and Social Care Trust, Londonderry, UK
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Dominic C, Welch C, Melzer M. Missed opportunities to use rapid influenza testing and severity assessment to avoid hospital admission: A cohort study from an East London District General Hospital. J Med Virol 2021; 93:3934-3938. [PMID: 32869890 DOI: 10.1002/jmv.26376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/29/2020] [Indexed: 11/06/2022]
Abstract
Annual outbreaks of seasonal influenza cause a substantial health burden. The aim of this study was to compare patient demographic/clinical data in two influenza patient groups presenting to hospital; those requiring O2 or critical care admission and those requiring less intensive treatment. The study was conducted from 1 December 2017 until 1 April 2019 at a district general hospital in East London. Patient demographic and clinical information was collected for all patients who had tested influenza positive by near-patient testing. χ2 test was used for categorical variables to see if there were significant differences for those admitted and the Wilcoxon rank-sum test to compare the length of inpatient stay. Of 127 patients, 56 (44.1%) required oxygen or critical care. There were significant increases in National Early Warning Score (NEWS) observations (P %3C .001), Charlson comorbidity index (P = .049), length of inpatient stay (P %3C .001), and a strong association with increasing age (P = .066) when the more intensive treatment group was compared with the less intensive treatment group. A total of 13 (18.3%) of 71 patients not requiring oxygen or critical care were not admitted to the hospital. Following rapid influenza testing, NEWS scores, comorbidities, and age should be incorporated into a decision tool in Accident and Emergency to aid hospital admission or discharge decisions.
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Affiliation(s)
- Catherine Dominic
- School of Medicine, Barts and the London School of Medicine - QMUL, Whitechapel, UK
| | - Catherine Welch
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Mark Melzer
- Infectious Diseases and Microbiology Department, Royal London and Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
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Affiliation(s)
- Felix Wood
- Emergency Department, Derriford Hospital, Plymouth, UK .,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - Thomas Roe
- Faculty of Health, University of Plymouth, Plymouth, UK
| | - Jason Newman
- Faculty of Health, University of Plymouth, Plymouth, UK
| | - Leo Wood
- Bristol Medical School, University of Bristol, Bristol, UK
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Yuan N, Ji H, Sun N, Botting P, Nguyen T, Torbati S, Cheng S, Ebinger J. Pseudo-safety in a cohort of patients with COVID-19 discharged home from the emergency department. Emerg Med J 2021; 38:304-307. [PMID: 33602725 DOI: 10.1136/emermed-2020-210041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 01/07/2021] [Accepted: 01/29/2021] [Indexed: 12/22/2022]
Abstract
INTRODUCTION EDs are often the first line of contact with individuals infected with COVID-19 and play a key role in triage. However, there is currently little specific guidance for deciding when patients with COVID-19 require hospitalisation and when they may be safely observed as an outpatient. METHODS In this retrospective study, we characterised all patients with COVID-19 discharged home from EDs in our US multisite healthcare system from March 2020 to August 2020, focusing on individuals who returned within 2 weeks and required hospital admission. We restricted analyses to first-encounter data that do not depend on laboratory or imaging diagnostics in order to inform point-of-care assessments in resource-limited environments. Vitals and comorbidities were extracted from the electronic health record. We performed ordinal logistic regression analyses to identify predictors of inpatient admission, intensive care and intubation. RESULTS Of n=923 patients who were COVID-19 positive discharged from the ED, n=107 (11.6%) returned within 2 weeks and were admitted. In a multivariable-adjusted model including n=788 patients with complete risk factor information, history of hypertension increased odds of hospitalisation and severe illness by 1.92-fold (95% CI 1.07 to 3.41), diabetes by 2.20-fold (1.18 to 4.02), chronic lung disease by 2.21-fold (1.22 to 3.92) and fever by 2.89-fold (1.71 to 4.82). Having at least two of these risk factors increased the odds of future hospitalisation by 6.68-fold (3.54 to 12.70). Patients with hypertension, diabetes, chronic lung disease or fever had significantly longer hospital stays (median 5.92 days, 3.08-10.95 vs 3.21, 1.10-5.75, p<0.01) with numerically higher but not significantly different rates of intensive care unit admission (27.02% vs 14.30%, p=0.27) and intubation (12.16% vs 7.14%, p=0.71). DISCUSSION Patients infected with COVID-19 may appear clinically safe for home convalescence. However, those with hypertension, diabetes, chronic lung disease and fever may in fact be only 'pseudo-safe' and are most at risk for subsequent hospitalisation with more severe illness and longer hospital stays.
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Affiliation(s)
- Neal Yuan
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Hongwei Ji
- Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Nancy Sun
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Patrick Botting
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Trevor Nguyen
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sam Torbati
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Susan Cheng
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Joseph Ebinger
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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14
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Robson S, Stephenson A, McCarthy C, Lowe D, Conlen B, Gray AJ. Identifying opportunities for health promotion and intervention in the ED. Emerg Med J 2020; 38:927-932. [PMID: 33214197 DOI: 10.1136/emermed-2019-209101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 10/06/2020] [Accepted: 10/08/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND ED staff assess patients with modifiable risk factors for acute and chronic illness. Health promotion interventions delivered in the ED have been advocated for these patients. The engagement of staff is essential to provide effective screening and brief interventions for patients. This survey aimed to assess if staff support the ED as an environment for health promotion. METHODS A multicentre, structured survey was conducted in four EDs in Scotland from 2017 to 2018. Physician and nursing staff at two teaching and two district general hospitals (n=423) were study eligible and offered a multicomponent survey. Outcomes measured included perceived barriers to practice and risk factor specific ED interventions. RESULTS Of the 283 respondents, 116 (41%) were physicians and 167 (59%) were nurses. More physicians (86.1%) than nurses (49.7%) reported offering health promotion interventions. Time constraints and a lack of health promotion infrastructure in the ED were cited as challenges to intervention delivery. Staff believed that alcohol (n=170/283, 60.1%) and drug misuse (n=173/283, 61.1%) were more appropriately managed in the ED than primary care. ED staff believed same day brief interventions were more appropriate when alcohol/drug misuse and smoking were directly related to ED presentations. DISCUSSION AND CONCLUSIONS Staff support the concept of the ED as a potential environment for offering health promotion interventions. ED physicians and nurses have different perspectives on the delivery of health promotion. The role of the ED in health promotion is likely to be multimodal and dependant on the reason for ED attendance.
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Affiliation(s)
- Simon Robson
- Department of Emergency Medicine, The University of Edinburgh, Edinburgh Medical School, Edinburgh, UK
| | - Andrew Stephenson
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Colm McCarthy
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - David Lowe
- Emergency Department, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ben Conlen
- Emergency Department, Queen Elizabeth University Hospital, Glasgow, UK
| | - Alasdair James Gray
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
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15
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Affiliation(s)
- Suzanne M Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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16
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Sen B, Clay H, Wright J, Findlay S, Cratchley A. Impact of Emergency Medicine Consultants and Clinical Advisors on a NHS 111 Clinical Assessment Service. Emerg Med J 2019; 36:208-212. [PMID: 30940680 DOI: 10.1136/emermed-2017-207335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 11/20/2018] [Accepted: 01/18/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare outcome of clinical advice given by emergency physicians (EPs) versus non-physician clinical advisors (NPCAs) on a UK National Health Service 111 centre. METHOD This was a prospective study conducted between July 2016 and February 2017. We targeted calls in which call handlers using standard NHS 111 clinical decision support software would have advised the caller to attend a hospital ED. These calls were passed to a clinical assessment service (CAS) and reviewed by either an EP (July to November 2016) or an NPCA (December 2016 to February 2017). RESULTS During the preintervention year, 80.2% of callers were advised to attend the ED within 1 or 4 hours, 1.2% were referred to out of hours (OOH) primary care and 0.3% to self-care. During the study, call handlers designated 2606 calls as needing to attend the ED in 1 or 4 hours and passed these on to the clinical advisors. There was a reduction of 75%-81% in cases advised to attend the ED in both intervention groups; EPs advised 396 of 1558 callers (25.4%) to attend ED; NPCAs advised 194 of 1048 callers (18.5%) to attend ED. For calls not requiring the ED, EPs recommended self/home care management in 38.1% of these calls, NPCAs recommended self-care for 15.7% (difference=22.4%; 95% CI 19.0% to 25.7%). EPs recommended 4.5% to attend OOH primary care, while NPCAs recommended OOH primary care for 42.1% (difference=37.6%, 95% CI 34.3% to 40.8%). CONCLUSIONS A CAS within NHS 111 using clinicians decreases referrals to the ED. EPs use fewer services and resources. Further work needs to be undertaken to determine the workforce skill mix for an NHS 111 CAS.
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Affiliation(s)
- Basav Sen
- Emergency Department, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Henry Clay
- Department of Primary Care, Primary Care Foundation UK, Lewes, UK
| | - John Wright
- Emergency Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Stewart Findlay
- NHS Durham Dales Easington and Sedgefield Clinical Commissioning Group, Sedgefield, UK
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17
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Tsiachristas A, Ellis G, Buchanan S, Langhorne P, Stott DJ, Shepperd S. Should I stay or should I go? A retrospective propensity score-matched analysis using administrative data of hospital-at-home for older people in Scotland. BMJ Open 2019; 9:e023350. [PMID: 31072849 PMCID: PMC6527981 DOI: 10.1136/bmjopen-2018-023350] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To compare the characteristics of populations admitted to hospital-at-home services with the population admitted to hospital and assess the association of these services with healthcare costs and mortality. DESIGN In a retrospective observational cohort study of linked patient level data, we used propensity score matching in combination with regression analysis. PARTICIPANTS Patients aged 65 years and older admitted to hospital-at-home or hospital. INTERVENTIONS Three geriatrician-led admission avoidance hospital-at-home services in Scotland. OUTCOME MEASURES Healthcare costs and mortality. RESULTS Patients in hospital-at-home were older and more socioeconomically disadvantaged, had higher rates of previous hospitalisation and there was a greater proportion of women and people with several chronic conditions compared with the population admitted to hospital. The cost of providing hospital-at-home varied between the three sites from £628 to £2928 per admission. Hospital-at-home was associated with 18% lower costs during the follow-up period in site 1 (ratio of means 0.82; 95% CI: 0.76 to 0.89). Limiting the analysis to costs during the 6 months following index discharge, patients in the hospital-at-home cohorts had 27% higher costs (ratio of means 1.27; 95% CI: 1.14 to 1.41) in site 1, 9% (ratio of means 1.09; 95% CI: 0.95 to 1.24) in site 2 and 70% in site 3 (ratio of means 1.70; 95% CI: 1.40 to 2.07) compared with patients in the control cohorts. Admission to hospital-at-home was associated with an increased risk of death during the follow-up period in all three sites (1.09, 95% CI: 1.00 to 1.19 site 1; 1.29, 95% CI: 1.15 to 1.44 site 2; 1.27, 95% CI: 1.06 to 1.54 site 3). CONCLUSIONS Our findings indicate that in these three cohorts, the populations admitted to hospital-at-home and hospital differ. We cannot rule out the risk of residual confounding, as our analysis relied on an administrative data set and we lacked data on disease severity and type of hospitalised care received in the control cohorts.
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Affiliation(s)
- Apostolos Tsiachristas
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Graham Ellis
- Monklands Hospital, NHS Lanarkshire, Airdrie, UK
| | - Scott Buchanan
- Information Services Division, National Services Scotland, Edinburgh, UK
| | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - David J Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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18
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Bunn JG, Croft SJ, O'Keeffe C, Jacques RM, Simpson RM, Stone T, Conroy SP, Mason SM. Urgent care axis for the older adult: where is best to target interventions? Emerg Med J 2018; 36:22-26. [PMID: 30177504 DOI: 10.1136/emermed-2018-207505] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 06/13/2018] [Accepted: 07/28/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND We explored the urgent care axis across EDs in Yorkshire and Humber (Y&H) for patients aged ≥75 years to identify where interventions could be targeted to prevent ED attendances and inpatient admissions. METHODS Hospital Episode Statistics (HES) data for attendances across 18 EDs in Y&H from April 2011 to March 2014 were retrospectively analysed. HES A&E and Admitted Patient Care patient records data were linked to describe the entire patient pathway. The population studied was adult patients attending type 1 EDs, comparing those ≥75 years with those under 75. Data analysed included arrival mode, presentation time, time in ED, outcome (admitted/discharged), admission length of stay, International Classification of Diseases 10th Revision (ICD-10) and cause codes related to admission. Short-stay admissions and admissions with potentially avoidable conditions (identified by ICD-10 codes and cause codes) were identified. Comparative analysis was undertaken between sites. RESULTS There were 3 736 541 ED attendances, of which 625 772 (16.7%) were ≥75 years. Older patients were significantly more likely to attend via ambulance than the younger cohort (OR 7.7, 95% CI 7.6 to 7.7), and had significantly longer median stays within ED (195 vs 136 min, p<0.001) and increased likelihood of admission (OR 4.5, 95% CI 4.5 to 4.6). Short-stay admissions accounted for 28.3% of older adult admissions. 37.3% of older adult admissions were with conditions that were potentially avoidable, accounting for 42.3% of short-stay admissions. There was regional variation in the proportions of older adults admitted (between 34.3% and 40.9%). DISCUSSION Large numbers of older adults present to EDs mainly by ambulance. Significant proportions are admitted for short periods with conditions that might potentially be managed outside of hospital. Variation across the region warrants further study.
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Affiliation(s)
| | - Susan Jane Croft
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Colin O'Keeffe
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Richard M Jacques
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Rebecca M Simpson
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Tony Stone
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Simon Paul Conroy
- Department of Health Sciences, University of Leicester, Sheffield, UK
| | - Suzanne M Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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19
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Voss S, Brandling J, Taylor H, Black S, Buswell M, Cheston R, Cullum S, Foster T, Kirby K, Prothero L, Purdy S, Solway C, Benger JR. How do people with dementia use the ambulance service? A retrospective study in England: the HOMEWARD project. BMJ Open 2018; 8:e022549. [PMID: 30068624 PMCID: PMC6074617 DOI: 10.1136/bmjopen-2018-022549] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES An increasing number of older people are calling ambulances and presenting to accident and emergency departments. The presence of comorbidities and dementia can make managing these patients more challenging and hospital admission more likely, resulting in poorer outcomes for patients. However, we do not know how many of these patients are conveyed to hospital by ambulance. This study aims to determine: how often ambulances are called to older people; how often comorbidities including dementia are recorded; the reason for the call; provisional diagnosis; the amount of time ambulance clinicians spend on scene; the frequency with which these patients are transported to hospital. METHODS We conducted a retrospective cross-sectional study of ambulance patient care records (PCRs) from calls to patients aged 65 years and over. Data were collected from two ambulance services in England during 24 or 48 hours periods in January 2017 and July 2017. The records were examined by two researchers using a standard template and the data were extracted from 3037 PCRs using a coding structure. RESULTS Results were reported as percentages and means with 95% CIs. Dementia was recorded in 421 (13.9%) of PCRs. Patients with dementia were significantly less likely to be conveyed to hospital following an emergency call than those without dementia. The call cycle times were similar for patients regardless of whether or not they had dementia. Calls to people with dementia were more likely to be due to injury following a fall. In the overall sample, one or more comorbidities were reported on the PCR in over 80% of cases. CONCLUSION Rates of hospital conveyance for older people may be related to comorbidities, frailty and complex needs, rather than dementia. Further research is needed to understand the way in which ambulance clinicians make conveyance decisions at scene.
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Affiliation(s)
- Sarah Voss
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Janet Brandling
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Hazel Taylor
- Research Design Service, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Sarah Black
- Research and Audit Department, South Western Ambulance Service NHS Foundation Trust, Plymouth, UK
| | - Marina Buswell
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, UK
| | - Richard Cheston
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Sarah Cullum
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Theresa Foster
- Research Support Services, East of England Ambulance Service NHS Trust, Melbourn, UK
| | - Kim Kirby
- Research and Audit Department, South Western Ambulance Service NHS Foundation Trust, Plymouth, UK
| | - Larissa Prothero
- Research Support Services, East of England Ambulance Service NHS Trust, Melbourn, UK
| | - Sarah Purdy
- School of Social and Community Medicine, University of Bristol, Melbourn, UK
| | - Chris Solway
- Research Network, Alzheimer’s Society, London, UK
| | - Jonathan Richard Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
- Research Design Service, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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20
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Cameron A, Jones D, Logan E, O'Keeffe CA, Mason SM, Lowe DJ. Comparison of Glasgow Admission Prediction Score and Amb Score in predicting need for inpatient care. Emerg Med J 2018; 35:247-251. [PMID: 29444899 DOI: 10.1136/emermed-2017-207246] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/18/2018] [Accepted: 01/26/2018] [Indexed: 11/03/2022]
Abstract
AIM We compared the abilities of two established clinical scores to predict emergency department (ED) disposition: the Glasgow Admission Prediction Score (GAPS) and the Ambulatory Score (Ambs). METHODS The scores were compared in a prospective, multicentre cohort study. We recruited consecutive patients attending ED triage at two UK sites: Northern General Hospital in Sheffield and Glasgow Royal Infirmary, between February and May 2016. Each had a GAPS and Ambs calculated at the time of triage, with the triage nurses and treating clinicians blinded to the scores. Patients were followed up to hospital discharge. The ability of the scores to discriminate discharge from ED and from hospital at 12 and 48 hours after arrival was compared using the area under the curve (AUC) of their receiving-operator characteristics (ROC). RESULTS 1424 triage attendances were suitable for analysis during the study period, of which 567 (39.8%) were admitted. The AUC for predicting admission was significantly higher for GAPS at 0.807 (95% CI 0.785 to 0.830), compared with 0.743 (95% CI 0.717 to 0.769) for Ambs, P<0.00001. Similar results were seen when comparing ability to predict hospital stay of >12 hour and >48 hour. GAPS was also more accurate as a binary test, correctly predicting 1057 outcomes compared with 1004 for Ambs (74.2vs70.5%, P=0.012). CONCLUSION The GAPS is a significantly better predictor of need for hospital admission than Ambs in an unselected ED population.
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Affiliation(s)
- Allan Cameron
- Acute Medicine Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Dominic Jones
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Eilidh Logan
- University of Glasgow, College of Medical Veterinary and Life Sciences, Glasgow, UK
| | - Colin A O'Keeffe
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Suzanne M Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - David J Lowe
- University of Glasgow, College of Medical Veterinary and Life Sciences, Glasgow, UK.,Emergency Department, Queen Elizabeth University Hospital, Glasgow, UK
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21
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D'Souza RS, Mercogliano C, Ojukwu E, D'Souza S, Singles A, Modi J, Short A, Donato A. Effects of prophylactic anticholinergic medications to decrease extrapyramidal side effects in patients taking acute antiemetic drugs: a systematic review and meta-analysis. Emerg Med J 2018; 35:325-331. [PMID: 29431143 DOI: 10.1136/emermed-2017-206944] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 01/02/2018] [Accepted: 01/14/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To determine the effectiveness of prophylactic anticholinergic medications in reducing extrapyramidal symptoms in patients taking acute antiemetics with a dopamine D2 receptor antagonist effect. METHODS Systematic searches of all published studies through March 2017 were identified from PubMed, Cochrane library, Embase, Web of Science and Scopus. Only randomised controlled trials of patients receiving dopamine D2 antagonist antiemetic therapy for acute migraine in which an anticholinergic or placebo was compared were included. Pooled ORs were calculated for incidence of extrapyramidal symptoms and sedation. RESULTS Four placebo-controlled randomised controlled trials consisting of 737 patients met the inclusion criteria for our meta-analysis. The effect of diphenhydramine differed depending on the method of administration of the antiemetic. When the antiemetic was delivered as a 2 min antiemetic bolus, the odds of extrapyramidal symptoms were significantly reduced in the diphenhydramine group compared with placebo (OR 0.42; 95% CI 0.22 to 0.81; P=0.01). However, when the antiemetic was given as a 15 min infusion, there was no significant difference in extrapyramidal symptoms with or without diphenhydramine (OR 1.06; 95% CI 0.58 to 1.91; P=0.85). The lowest incidence of extrapyramidal symptoms was observed in patients receiving a 15 min antiemetic infusion without diphenhydramine prophylaxis (9.8%). In two trials including 351 patients that dichotomously reported sedation scales, diphenhydramine had significantly higher rates of sedation (31.6%vs19.2%, OR 2.01, 95% CI 1.21 to 3.33; P=0.007). CONCLUSION Prophylactic diphenhydramine reduces extrapyramidal symptoms in patients receiving bolus antiemetic therapy with a dopamine D2 antagonist effect, but not when it is given as an infusion. Because of significantly greater sedation with diphenhydramine, the most effective strategy is to administer the D2 antagonist antiemetic as a 15 min infusion without prophylaxis.
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Affiliation(s)
- Ryan S D'Souza
- Department of Medicine, Reading Health System, West Reading, Pennsylvania, USA.,Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | | | - Elizabeth Ojukwu
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA
| | - Shawn D'Souza
- Department of Neuroscience, University of Colorado, Boulder, Colorado, USA
| | - Andrew Singles
- Department of Medicine, Reading Health System, West Reading, Pennsylvania, USA
| | - Jaymin Modi
- Department of Medicine, Reading Health System, West Reading, Pennsylvania, USA
| | - Alexandra Short
- Department of Medicine, Reading Health System, West Reading, Pennsylvania, USA
| | - Anthony Donato
- Department of Medicine, Reading Health System, West Reading, Pennsylvania, USA
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22
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Pope I, Ismail S, Bloom B, Jansen G, Burn H, McCoy D, Harris T. Short-stay admissions at an inner city hospital: a cross-sectional analysis. Emerg Med J 2018; 35:238-246. [PMID: 29305379 DOI: 10.1136/emermed-2016-205803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 11/15/2017] [Accepted: 11/21/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate factors predictive of short hospital admissions and appropriate placement to inpatient versus clinical decision units (CDUs). METHOD This is a retrospective analysis of attendance and discharge data from an inner-city ED in England for December 2013. The primary outcome was admission for less than 48 hours either to an inpatient unit or CDU. Variables included: age, gender, ethnicity, deprivation score, arrival date and time, arrival method, admission outcome and discharge diagnosis. Analysis was performed by cross-tabulation followed by binary logistic regression in three models using the outcome measures above and seeking to identify factors associated with short-stay admission. RESULTS There were 2119 (24%) admissions during the study period and 458 were admitted for less than 24 hours. Those who were admitted in the middle of the week or with ambulatory care sensitive conditions (ACSCs) were significantly more likely to experience short-stays. Older patients and those who arrived by ambulance were significantly more likely to have a longer hospital stay. There was no association of length of inpatient stay with being admitted in the last 10 min of a 4 hours ED stay. CONCLUSION Only a few factors were independently predictive of short stays. Patients with ACSCs were more likely to have short stays, regardless of whether they were admitted to CDU or an inpatient ward. This may be a group of patients that could be targeted for dedicated outpatient management pathways or CDU if they need admission.
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Affiliation(s)
- Ian Pope
- Department of Emergency Medicine, Royal London Hospital, London, UK
| | - Sharif Ismail
- Department of Emergency Medicine, Royal London Hospital, London, UK
| | - Benjamin Bloom
- Department of Emergency Medicine, Royal London Hospital, London, UK
| | - Gwyneth Jansen
- School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Helen Burn
- Department of Emergency Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - David McCoy
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Tim Harris
- Department of Emergency Medicine, Royal London Hospital, London, UK
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23
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Ibrahim LF, Hopper SM, Connell TG, Daley AJ, Bryant PA, Babl FE. Evaluating an admission avoidance pathway for children in the emergency department: outpatient intravenous antibiotics for moderate/severe cellulitis. Emerg Med J 2017; 34:780-785. [PMID: 28978652 DOI: 10.1136/emermed-2017-206829] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 08/22/2017] [Accepted: 08/31/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Children with moderate/severe cellulitis requiring intravenous antibiotics are usually admitted to hospital. Admission avoidance is attractive but there are few data in children. We implemented a new pathway for children to be treated with intravenous antibiotics at home and aimed to describe the characteristics of patients treated on this pathway and in hospital and to evaluate the outcomes. METHODS This is a prospective, observational cohort study of children aged 6 months-18 years attending the ED with uncomplicated moderate/severe cellulitis in March 2014-January 2015. Patients received either intravenous ceftriaxone at home or intravenous flucloxacillin in hospital based on physician discretion. Primary outcome was treatment failure defined as antibiotic change within 48 hours due to inadequate clinical improvement or serious adverse events. Secondary outcomes include duration of intravenous antibiotics and complications. RESULTS 115 children were included: 47 (41%) in the home group and 68 (59%) in the hospital group (59 hospital-only, 9 transferred home during treatment). The groups had similar clinical features. 2/47 (4%) of the children in the home group compared with 8/59 (14%) in the hospital group had treatment failure (P=0.10). Duration of intravenous antibiotics (median 1.9 vs 1.8 days, P=0.31) and complications (6% vs 10%, P=0.49) were no different between groups. Home treatment costs less, averaging $A1166 (£705) per episode compared with $A2594 (£1570) in hospital. CONCLUSIONS Children with uncomplicated cellulitis may be able to avoid hospital admission via a home intravenous pathway. This approach has the potential to provide cost and other benefits of home treatment.
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Affiliation(s)
- Laila F Ibrahim
- Department of RCH@Home, The Royal Children's Hospital, Parkville, Victoria, Australia.,Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Department of Pediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Sandy M Hopper
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Department of Emergency, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Tom G Connell
- Department of Pediatrics, University of Melbourne, Parkville, Victoria, Australia.,Department of General Medicine, Infectious Diseases Unit, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Andrew J Daley
- Department of General Medicine, Infectious Diseases Unit, The Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Microbiology, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Penelope A Bryant
- Department of RCH@Home, The Royal Children's Hospital, Parkville, Victoria, Australia.,Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Department of Pediatrics, University of Melbourne, Parkville, Victoria, Australia.,Department of General Medicine, Infectious Diseases Unit, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Franz E Babl
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Department of Pediatrics, University of Melbourne, Parkville, Victoria, Australia.,Department of Emergency, The Royal Children's Hospital, Parkville, Victoria, Australia
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24
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Wyatt S, Child K, Hood A, Cooke M, Mohammed MA. Changes in admission thresholds in English emergency departments. Emerg Med J 2017; 34:773-779. [PMID: 28899922 PMCID: PMC5750365 DOI: 10.1136/emermed-2016-206213] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 06/22/2017] [Accepted: 06/28/2017] [Indexed: 11/30/2022]
Abstract
Background The most common route to a hospital bed in an emergency is via an Emergency Department (ED). Many recent initiatives and interventions have the objective of reducing the number of unnecessary emergency admissions. We aimed to assess whether ED admission thresholds had changed over time taking account of the casemix of patients arriving at ED. Methods We conducted a retrospective cross-sectional analysis of more than 20 million attendances at 47 consultant-led EDs in England between April 2010 and March 2015. We used mixed-effects logistic regression to estimate the odds of a patient being admitted to hospital and the impact of a range of potential explanatory variables. Models were developed and validated for four attendance subgroups: ambulance-conveyed children, walk-in children, ambulance-conveyed adults and walk-in adults. Results 23.8% of attendances were for children aged under 18 years, 49.7% were female and 30.0% were conveyed by ambulance. The number of ED attendances increased by 1.8% per annum between April 2010–March 2011 (year 1) and April 2014–March 2015 (year 5). The proportion of these attendances that were admitted to hospital changed negligiblybetween year 1 (27.0%) and year 5 (27.5%). However, after adjusting for patient and attendance characteristics, the odds of admission over the 5-year period had reduced by 15.2% (95% CI 13.4% to 17.0%) for ambulance-conveyed children, 22.6% (95% CI 21.7% to 23.5%) for walk-in children, 20.9% (95% CI 20.4% to 21.5%) for ambulance conveyed adults and 22.9% (95% CI 22.4% to 23.5%) for walk-in adults. Conclusions The casemix-adjusted odds of admission via ED to NHS hospitals in England have decreased since April 2010. EDs are admitting a similar proportion of patients to hospital despite increases in the complexity and acuity of presenting patients. Without these threshold changes, the number of emergency admissions would have been 11.9% higher than was the case in year 5.
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Affiliation(s)
- Steven Wyatt
- Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| | - Kieran Child
- Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| | - Andrew Hood
- Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| | - Matthew Cooke
- Warwick Medical School, University of Warwick, Coventry, UK
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25
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Abstract
Hospital in the home is a relatively new concept within the UK healthcare system. The Guy’s and St Thomas’s NHS Foundation Trust (GSTT) @home service ‘Bringing hospital care to your home’ was commissioned by Lambeth and Southwark CCG in 2014 to provide acute care in the patients’ place of residence by facilitating rapid discharge from hospital. The service is designed for 260–280 referrals each month from local hospitals, London Ambulance Service, GPs, district nurses and palliative care services. The GSTT@home provides intensive care for a short episode through multidisciplinary team work with the aim of returning the patient to their prior health status following an acute episode of ill health. The main criteria for referrals are adults, living within Lambeth or Southwark with an acute onset of illness often with acute exacerbations of chronic conditions. Care is delivered using 25 clinical pathways using integrated care teams, including those for respiratory disease, heart failure and palliative care services. Recently, the service extended to include overnight palliative care. As care shifts from hospital to the community, it is envisaged that these types of programmes will become an essential component of care provision. This paper describes the service and presents initial service evaluation data.
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Affiliation(s)
- Geraldine A Lee
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing & Midwifery, King's College London, London, UK
| | - Karen Titchener
- Guy's and St Thomas's Trust @home service, Walworth Clinic, London, UK
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26
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Chalder MJE, Wright CL, Morton KJP, Dixon P, Daykin AR, Jenkins S, Benger J, Calvert J, Shaw A, Metcalfe C, Hollingworth W, Purdy S. Study protocol for an evaluation of the effectiveness of 'care bundles' as a means of improving hospital care and reducing hospital readmission for patients with chronic obstructive pulmonary disease (COPD). BMC Pulm Med 2016; 16:35. [PMID: 26916196 PMCID: PMC4766609 DOI: 10.1186/s12890-016-0197-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/15/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic Obstructive Pulmonary Disease is one of the commonest respiratory diseases in the United Kingdom, accounting for 10% of unplanned hospital admissions each year. Nearly a third of these admitted patients are re-admitted to hospital within 28 days of discharge. Whilst there is a move within the NHS to ensure that people with long-term conditions receive more co-ordinated care, there is little research evidence to support an optimum approach to this in COPD. This study aims to evaluate the effectiveness of introducing standardised packages of care i.e. care bundles, for patients with acute exacerbations of COPD as a means of improving hospital care and reducing re-admissions. METHODS / DESIGN This mixed-methods evaluation will use a controlled before-and-after design to examine the effect of, and costs associated with, implementing care bundles for patients admitted to hospital with an acute exacerbation of COPD, compared with usual care. It will quantitatively measure a range of patient and organisational outcomes for two groups of hospitals - those who deliver care using COPD care bundles, and those who deliver care without the use of COPD care bundles. These care bundles may be provided for patients with COPD following admission, prior to discharge or at both points in the care pathway. The primary outcome will be re-admission to hospital within 28 days of discharge, although the study will additionally investigate a number of secondary outcomes including length of stay, total bed days, in-hospital mortality, costs of care and patient / carer experience. A series of nested qualitative case studies will explore in detail the context and process of care as well as the impact of COPD bundles on staff, patients and carers. DISCUSSION The results of the study will provide information about the effectiveness of care bundles as a way of managing in-hospital care for patients with an acute exacerbation of COPD. Given the number of unplanned hospital admissions for this patient group and their rate of subsequent re-admission, it is hoped that this evaluation will make a timely contribution to the evidence on care provision, to the benefit of patients, clinicians, managers and policy-makers. TRIAL REGISTRATION International Standard Randomised Controlled Trials - ISRCTN13022442 - 11 February 2015.
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Affiliation(s)
- M J E Chalder
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - C L Wright
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - K J P Morton
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - P Dixon
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - A R Daykin
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - S Jenkins
- Sue Jenkins Consulting, Taunton, UK.
| | - J Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK.
| | - J Calvert
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
| | - A Shaw
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - C Metcalfe
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK.
| | - W Hollingworth
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - S Purdy
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
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27
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Abstract
This article explores the work of a rapid response team (RRT) in an English city. The RRT is a multiprofessional intermediate care team that is able to support patients to remain at home during clinical crises and changes to their social care needs. The service is popular with patients and cost effective. The National Audit of Intermediate Care is in its fourth year and benchmarks how intermediate care services are delivered across England. RRT data are compared with the national data, and show that keeping the team as a crisis intervention service has enabled it to maintain capacity to support patients at home without requiring hospital admission.
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Affiliation(s)
- Esther Clift
- Solent NHS Trust/Health Education Wessex, Southampton
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28
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Walsh B, Lattimer V, Wintrup J, Brailsford S. Professional perspectives on systemic barriers to admission avoidance: learning from a system dynamics study of older people's admission pathways. Int J Older People Nurs 2014; 10:105-14. [PMID: 24849205 DOI: 10.1111/opn.12056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 03/31/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is debate worldwide about the best way to manage increased healthcare demand within ageing populations, particularly rising rates of unplanned and avoidable hospital admissions. OBJECTIVES To understand health and social care professionals' perspectives on barriers to admission avoidance throughout the admissions journey, in particular: the causes of avoidable admissions in older people; drivers of admission and barriers to use of admission avoidance strategies; and improvements to reduce unnecessary admissions. DESIGN A qualitative framework analysis of interview data from a System dynamics (SD) modelling study. METHODS Semi-structured interviews were conducted with twenty health and social care professionals with experience of older people's admissions. The interviews were used to build understanding of factors facilitating or hindering admission avoidance across the admissions system. Data were analysed using framework analysis. RESULTS Three overarching themes emerged: understanding the needs of the patient group; understanding the whole system; and systemwide access to expertise in care of older people. There were diverse views on the underlying reasons for avoidable admissions and recognition of the need for whole-system approaches to service redesign. CONCLUSIONS Participants recommended system redesign that recognises the specific needs of older people, but there was no consensus on underlying patient needs or specific service developments. Access to expertise in management of older and frailer patients was seen as a barrier to admission avoidance throughout the system. IMPLICATIONS FOR PRACTICE Providing access to expertise and leadership in care of frail older people across the admissions system presents a challenge for service managers and nurse educators but is seen as a prerequisite for effective admission avoidance. System redesign to meet the needs of frail older people requires agreement on causes of avoidable admission and underlying patient needs.
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Affiliation(s)
- Bronagh Walsh
- Centre for Innovation & Leadership in Health Sciences, Faculty of Health Sciences, University of Southampton, Southampton, UK
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29
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Mantokoudis G, Hegner S, Dubach P, Bonel HM, Senn P, Caversaccio MD, Exadaktylos AK. How reliable and safe is full-body low-dose radiography (LODOX Statscan) in detecting foreign bodies ingested by adults? Emerg Med J 2012; 30:559-64. [PMID: 22833594 DOI: 10.1136/emermed-2011-200911] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Foreign body ingestion is common and potentially lethal. This study evaluates the use of low-dose Statscans (LODOX) in emergency departments. DESIGN This comparative cross-sectional study retrospectively assessed 28289 digital chest x-rays and 2301 LODOX scans performed between 2006 and 2010 at a tertiary emergency centre. The radiographic appearance, image quality and location of ingested foreign bodies were evaluated in standard digital chest and LODOX radiography. The mean irradiation (μSv) and cumulative mean radiation dose per patient with the ingested foreign body were calculated according to literature-based data, together with the sensitivity and specificity for each modality. RESULTS A total of 62 foreign bodies were detected in 39 patients, of whom 19 were investigated with LODOX and 20 with conventional digital chest radiography. Thirty-three foreign bodies were located in the two upper abdominal quadrants, 21 in the lower quadrants-which are not visible on conventional digital chest radiography-seven in the oesophagus and one in the bronchial system. The sensitivity and specificity of digital chest radiography were 44.4% and 94.1%, respectively, and for the LODOX Statscan 90% and 100%, respectively. The calculated mean radiation dose for LODOX investigations was 184 μS, compared with 524 μS for digital chest radiography. CONCLUSIONS LODOX Statscan is superior to digital chest radiography in the diagnostic work-up of ingested foreign bodies because it makes it possible to enlarge the field of view to the entire body, has higher sensitivity and specificity, and reduces the radiation dose by 65%.
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Affiliation(s)
- Georgios Mantokoudis
- University Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital Bern, Bern, Switzerland
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30
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Abstract
Intermediate care (IC) has been government policy for implementation in the U.K. for almost 10 years. It was hoped that it would help free up acute hospital resources. However, admission rates continue to rise and are rising fastest in those over the age of 75. Many different models of IC have been tried. Typically, outcomes are very similar to traditional hospital care and they tend to be met with high patient satisfaction. Yet there is no evidence that they reduce acute hospital use or that they are cost efficient. Maybe it is time to rethink our national strategy on this issue?
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