The impact of early emergency department allied health intervention on admission rates in older people: a non-randomized clinical study

Arendts, Glenn; Fitzhardinge, Sarah; Pronk, Karren; Donaldson, Mark; Hutton, Marani; Nagree, Yusuf

doi:10.1186/1471-2318-12-8

Cited by 46 publications

(59 citation statements)

References 28 publications

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“…Other patient populations have benefited from specialized emergency services, including psychiatric and geriatric patients; however, little has been done thus far with complex surgical populations. (24–27) The challenge moving forward is to determine if the present costs and clinical outcomes associated with recipient ED care are such that they warrant redesign of the acute recipient assessment and management. For a subset of recipients, ED care is certainly the best option as it allows for rapid, effective triage and management of post-surgical emergencies.…”

Section: Discussionmentioning

confidence: 99%

Early Postoperative Emergency Department Care of Abdominal Transplant Recipients

McElroy

Schmidt²,

Richards³

et al. 2015

Transplantation

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Background Research on post-transplant care has predominantly focused on predictors of readmission with little attention to emergency department (ED) visits. The goal of this study was to describe early postoperative ED care of transplant recipients. Methods A secondary database analysis of adult patients who underwent abdominal organ transplantation between January 1, 2008 and December 31, 2013 and sought ED care within one year post-transplantation was conducted. Survival was compared using the Kaplan-Meier method with log-rank test. Cox proportional hazards regression analysis was performed to adjust for pertinent covariates. Results A total of 1,900 abdominal organ transplants were performed during the study period. Of these, 37% (N=711) transplant recipients sought care in the ED (1,343 total visits) with 1.89 mean ED visits per recipient. Of recipients seen in the ED, 58% received a kidney transplant and 28% received a liver transplant, with 45% of recipients presenting within the first 60 postoperative days. The most common chief complaints were gastroenterological (17%) and abnormal laboratory values or vital signs (17%). In total, 74% of recipients were readmitted and 50% of admitted patients were discharged in less than 24 hours. Transplant recipients with ED visits had lower 3-year graft (81% vs. 87%; p<0.001) and patient (89% vs. 93%; p=0.002) survival. Conclusion Transplant recipients have a high frequency of ED visits in the first post-transplantation year and high rates of subsequent hospital admission. Further investigation is needed to understand what drives recipient presentation to the ED and create care models that achieve the best outcomes.

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Section: Discussionmentioning

confidence: 99%

Early Postoperative Emergency Department Care of Abdominal Transplant Recipients

McElroy

Schmidt²,

Richards³

et al. 2015

Transplantation

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“…For example, the effectiveness of a team of allied health professionals offering co-ordinated care to older people in EDs (similar to our rapid assessment teams) found a very small reduction in emergency admissions albeit using a non-randomised design. 59 The use of geriatric assessment in an ED (a type of senior review initiative) identified a lower conversion rate to admission, again using a non-randomised design. 60 However, it is important to evaluate robustly some of the types of schemes discussed in our study, using randomised controlled designs if possible.…”

Section: Effective Interventions For Reducing Emergency Admissionsmentioning

confidence: 99%

Explaining variation in emergency admissions: a mixed-methods study of emergency and urgent care systems

O’Cathain

Knowles

Turner

et al. 2014

Health Services and Delivery Research

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BackgroundRecent increases in emergency admission rates have caused concern. Some emergency admissions may be avoidable if services in the emergency and urgent care system are available and accessible. A set of 14 conditions, likely to be rich in avoidable emergency admissions, was identified by expert consensus.ObjectiveWe aimed to understand variation in avoidable emergency admissions between different emergency and urgent care systems in England.MethodsThe design was a sequential mixed-methods study in three phases. In phase 1 we calculated an age- and sex-adjusted avoidable admission rate for 2008–11. We located routine data on characteristics of emergency and urgent care systems and used linear regression to explain variation in avoidable admissions rates in 150 systems. In phase 2 we undertook in-depth case studies in six systems to identify further factors. A key part of these case studies was interviews with commissioners, service providers and patient representatives, totalling 82 interviews. In phase 3 we returned to the linear regression to test further factors identified in the case studies.ResultsThe 14 conditions accounted for 3,273,395 admissions in 2008–11 (22% of all emergency admissions). The mean age- and sex-adjusted admission rate was 2258 per year per 100,000 population, with a 3.4-fold variation between systems (1268–4359). Characteristics of the population explained the majority of variation: deprivation explained 72% of variation, with urban/rural status explaining 3% more. Systems serving populations with high levels of deprivation and in urban areas had high rates of potentially avoidable admissions. Interviewees described the complexity of deprivation, representing high levels of morbidity, low awareness of alternative services to emergency departments and high expressed need for immediate access to urgent care. Factors related to emergency departments (EDs), hospitals, emergency ambulance services and general practice explained a further 10% of variation in avoidable admissions. Systems with high, potentially avoidable, admission rates had high rates of acute beds (suggesting supply-induced demand), high rates of attendance at EDs (which have been associated with poor perceived access to general practice), high rates of conversion from ED attendances to admissions, and low rates of non-transport to emergency departments by emergency ambulances. The six case studies revealed further possible explanations of variation: there was variation in how hospitals coded admissions; some systems focused proactively on admission avoidance whereas others were more interested in hospital discharge, for example use of multidisciplinary teams based at acute trusts; there were different levels of integration between different services such as health and social care, and acute and community trusts; and some systems faced more challenging problems around geographical boundaries operating for different services in the system. Interviewees often described admission as the easy or safe option.ConclusionsDeprivation explained most of the variation in avoidable admission rates. Research is needed to understand the complex relationship between deprivation and avoidable admission, and to develop interventions tailored to avoid admissions from deprived communities. Standardisation of coding of admissions would reduce variation.FundingThe National Institute for Health Research Health Service and Research Delivery programme.

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“…Although no significant difference in number of emergency admissions at 30 days (P = 0.312).No significant difference in visits to ED (without admission) within 30 days (p = 0.349)Assessments post intervention not blinded. Some control group patients may have had CGA from another service.Arendts et al, 2012, Australia [7]Patients ≥65 yrs presenting to two EDs with one of the ten presenting complaints often resulting in admission (UTI, respiratory tract infection, fall with minor injury, hip/knee pain, back pain, heart failure, angina, syncope, TIA, new confusion/delirium). Patients requiring urgent medical treatment were excluded.Non-randomised controlled clinical trial.…”

Section: Methodsmentioning

confidence: 99%

What is the evidence for the management of patients along the pathway from the emergency department to acute admission to reduce unplanned attendance and admission? An evidence synthesis

Crede

O’Keeffe

Mason

et al. 2017

BMC Health Serv Res

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BackgroundGlobally, the rate of emergency hospital admissions is increasing. However, little evidence exists to inform the development of interventions to reduce unplanned Emergency Department (ED) attendances and hospital admissions. The objective of this evidence synthesis was to review the evidence for interventions, conducted during the patient’s journey through the ED or acute care setting, to manage people with an exacerbation of a medical condition to reduce unplanned emergency hospital attendance and admissions.MethodsA rapid evidence synthesis, using a systematic literature search, was undertaken in the electronic data bases of MEDLINE, EMBASE, CINAHL, the Cochrane Library and Web of Science, for the years 2000–2014. Evidence included in this review was restricted to Randomised Controlled Trials (RCTs) and observational studies (with a control arm) reported in peer-reviewed journals. Studies evaluating interventions for patients with an acute exacerbation of a medical condition in the ED or acute care setting which reported at least one outcome related to ED attendance or unplanned admission were included.ResultsThirty papers met our inclusion criteria: 19 intervention studies (14 RCTs) and 11 controlled observational studies. Sixteen studies were set in the ED and 14 were conducted in an acute setting. Two studies (one RCT), set in the ED were effective in reducing ED attendance and hospital admission. Both of these interventions were initiated in the ED and included a post-discharge community component. Paradoxically 3 ED initiated interventions showed an increase in ED re-attendance. Six studies (1 RCT) set in acute care settings were effective in reducing: hospital admission, ED re-attendance or re-admission (two in an observation ward, one in an ED assessment unit and three in which the intervention was conducted within 72 h of admission).ConclusionsThere is no clear evidence that specific interventions along the patient journey from ED arrival to 72 h after admission benefit ED re-attendance or readmission. Interventions targeted at high-risk patients, particularly the elderly, may reduce ED utilization and warrant future research. Some interventions showing effectiveness in reducing unplanned ED attendances and admissions are delivered by appropriately trained personnel in an environment that allows sufficient time to assess and manage patients.

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The impact of early emergency department allied health intervention on admission rates in older people: a non-randomized clinical study

Cited by 46 publications

References 28 publications

Early Postoperative Emergency Department Care of Abdominal Transplant Recipients

Early Postoperative Emergency Department Care of Abdominal Transplant Recipients

Explaining variation in emergency admissions: a mixed-methods study of emergency and urgent care systems

What is the evidence for the management of patients along the pathway from the emergency department to acute admission to reduce unplanned attendance and admission? An evidence synthesis

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