Alternative Care Pathways Research Articles

Elderly patients’ participation in emergency medical services when offered an alternative care pathway

As organizational changes in the healthcare system are in progress, to enhance care quality and reduce costs, it is important to investigate how these changes affect elderly patients’ experiences and their rights to participate in the choice of healthcare. The aim of this study is to describe elderly patients’ lived experience of participating in the choice of healthcare when being offered an alternative care pathway by the emergency medical services, when the individual patient's medical needs made this choice possible. This study was carried out from the perspective of caring science, and a phenomenological approach was applied, where data were analysed for meaning. Data consist of 11 semi-structured interviews with elderly patients who chose a healthcare pathway to a community-based hospital when they were offered an alternative level of healthcare. The findings show that the essence of the phenomenon is described as “There was a ray of hope about a caring encounter and about being treated like a unique human being”. Five meaningful constituents emerged in the descriptions: endurable waiting, speedy transference, a concerned encounter, trust in competence, and a choice based on memories of suffering from care. The conclusion is that patient participation in the choice of a healthcare alternative instead of the emergency department is an opportunity of avoiding suffering from care and being objectified.

OP24 Assessing the Cost-Effectiveness of Alternative Care Pathways: A Case Study Evaluating Early Transfer to Neuroscience Centres for Critically ill Patients with Acute Traumatic Brain Injury

BackgroundAcute traumatic brain injury (TBI) is a major cause of death, disability and cost. For critically-ill adult TBI patients who present outside a neuroscience centre, and do not require neurosurgery,...

Should Maximum Conservative Management be the Standard Paradigm for Very Elderly Adults with Chronic Kidney Disease or is There a Role for Dialysis?

Should Maximum Conservative Management be the Standard Paradigm for Very Elderly Adults with Chronic Kidney Disease or is There a Role for Dialysis?

Is Dialysis a Viable Option for the Older Patient? Outcomes for Patients Starting Dialysis Aged 80 Years or Older

Background: Maximum conservative management (MCM) has been proposed as an alternative care pathway for the increasing number of elderly patients with progressive chronic kidney disease. Methods: Retrospective analysis of patients aged ≥80 years of age, starting dialysis between 2000 and 2009 in a centre with an established MCM programme. Demographic data, baseline biochemical markers and survival were collected. Results: 93 consecutive patients were studied; median age 83 years (IQR 81–86). 67 male, 32% diabetic. Median survival 46.5 months (range 0–107), with 1- and 5-year survival 78.5 and 38.3%, respectively. Factors predicting poorer survival were Caucasoid ethnicity (p = 0.04) and serum albumin ≤30 g/l (p = 0.01) at dialysis initiation. Duration of nephrology care prior to dialysis initiation did not effect survival. Conclusion: The very elderly electing dialysis were found to have good survival. Further patient characterisation is required to improve decision-making between dialysis and MCM for elderly patients with progressive chronic kidney disease.

Decision-making by ambulance clinicians in London when managing patients with epilepsy: a qualitative study

BackgroundIn the UK, epilepsy is the neurological condition with the highest rate of accident and emergency department re-attendance, with most arriving by ambulance. Ambulance clinicians triage patients and assess their...

09 Can older people who fall be identified in the ambulance call centre to enable alternative responses or care pathways?

BackgroundOlder people who fall make up a substantial proportion of the 999 workload. They are a particularly vulnerable group who may benefit from referral to specialised community based falls services....

Interface geriatrics: evidence-based care for frail older people with medical crises

Frail older people are at risk of long hospital stays, and there is growing emphasis on identifying alternative care pathways in the community. Rapid decisions to discharge older people may not always serve the patient well. Specialist assessment from geriatricians could improve outcomes.

Is Maximum Conservative Management an Equivalent Treatment Option to Dialysis for Elderly Patients with Significant Comorbid Disease?

There is ongoing growth of elderly populations with ESRD in Western Europe and North America. In our center, we offer an alternative care pathway of 'maximum conservative management' (MCM) to patients who elect not to start dialysis, often because of a heavy burden of comorbid illness and advanced age. The objective of our study was to compare clinical outcomes for patients who had ESRD and chose either MCM or renal replacement therapy (RRT). This is an observational study of a single-center cohort in the United Kingdom that evaluating 202 elderly (> or =70 yr) patients who had ESRD and had chosen either MCM (n = 29) or RRT (n = 173). We report survival, hospitalization rates, and location of death for this cohort. Survival was measured from a standardized 'threshold' estimated GFR of 10.8 ml/min per 1.73 m(2). Median survival, including the first 90 d, was 37.8 mo (range 0 to 106 mo) for RRT patients and 13.9 mo (range 2 to 44) for MCM patients (P < 0.01). RRT patients had higher rates of hospitalization (0.069 [95% confidence interval (CI) 0.068 to 0.070]) versus 0.043 [95% CI 0.040 to 0.047] hospital days/patient-days survived) compared with MCM patients. MCM patients were significantly more likely to die at home or in a hospice (odds ratio 4.15; 95% CI 1.67 to 10.25). A survey of the literature describing elderly ESRD outcomes is also presented. Dialysis prolongs survival for elderly patients who have ESRD with significant comorbidity by approximately 2 yr; however, patients who choose MCM can survive a substantial length of time, achieving similar numbers of hospital-free days to patients who choose hemodialysis.

Care home patients in ED.

This prospective study had two aims: to describe the demographics of patients from care homes who attend an ED and to estimate whether appropriate alternative care pathways could be delivered to this patient group allowing safe and appropriate management without the need to attend the ED.

Patients from care homes who attend the emergency department: could they be managed differently

Aims:To describe the demographics of patients from care homes who attend the emergency department (ED) and to estimate whether appropriate alternative care pathways could have been delivered to this patient...

Functional somatic symptoms in accident and emergency – An exploratory study

To identify the extent and nature of functional somatic symptoms (FSS) in a UK Accident and Emergency (A&E) Department. A mixed method design was used. Data on the number and outcomes of attendances of patients who had attended A&E four or more times in a 6-month period, and who had not received a medical diagnosis were collected. Levels of anxiety and depression were explored and patients were invited to attend an interview with a clinical psychologist. One hundred frequent attendees made 595 visits to A&E in 6 months, with 20% of visits resulting in a hospital admission. Participants revealed high levels of health anxiety, with over half of participants reporting a perceived link between psychological factors and their experience of symptoms. Over 80% of participants attending the interview wanted further help to manage their symptoms and health care utilisation. Functional somatic symptoms are highly distressing for patients and place high demands on health care resources. An alternative care pathway to assess and manage FSS in A&E may need to be developed to help patients to manage their health anxiety.