Number Of Emergency Admissions Research Articles

COVID-19 Vaccination and Its Relation to New-Onset Diabetes: A NarrativeReview.

The COVID-19 vaccination has been effective in preventing a lot of complications caused by SARS-CoV-2 and its variants. Meanwhile, diabetes mellitus, one of the root causes of many co-morbidities, exhibited itself during the COVID-19 pandemic and after COVID-19 vaccination. Diabetes mellitus introduced itself in a new perspective, leading to a variety of presentations and causing a significant number ofemergency admissions. Many of the pre-diabetes patients with no prior history of diabetes developed fulminant type 1 diabetes mellitus (T1DM) after the COVID-19 vaccination. Some cases of conversion of type 2 diabetes mellitus (T2DM) into T1DM were reported. Some prediabetes/diabetes patientspresented with the development of diabetic ketoacidosis after COVID-19 vaccination, whereas some previously healthy people with no relation to diabetes also developed acute exacerbations of new-onset T1DM or T2DM along with lethal ketoacidosis. The purpose of writing this review was to explore what kind of people are more prone to develop new-onset diabetes or diabetic complications, including diabetic ketoacidosis, the typical presentation of these patients, possible mechanisms that lead to these complications occurring after the COVID-19 vaccination, how they can be managed, and whether there is a good prognosis after management or not.

COVİD-19 Enfeksiyonunun İkinci Dalgasında Çocuklarda Ev Kazaları: Tek Merkez Deneyimi

Objective: The COVID-19 pandemic has affected the whole world in terms of health, social life, and economics. In this study, the frequency of pediatric home accidents in the second wave of the pandemic, where social isolation continues, was investigated. Material and Methods: This is a single center, retrospective study. We evaluated cases of patients under the age of 18 who were admitted to the hospital due to a home accident between November 1, 2020 and January 31, 2021 (the second wave of the pandemic). Results were compared with the patients who were admitted to the same emergency department within the same period of the previous year. Researchers examined home accidents in three groups: crash-fall-incision (1), intoxication-foreign body ingestion (2), and burns (3). The patients were divided into four age groups: 0-1 year, 2-5 years, 6-11 years, and 12-17 years. Results: The study was completed with 607 cases pre-Covid and 683 cases post-Covid. The median age was 44.4 month (17-57) from 2019-2020 and 49.1 month (18-64) from 2020-2021 (p=0.154). The outpatient and sequela-free discharges were more frequent in both periods (p=0.046). In the second wave of the pandemic, there was an increase in burns and fall related admissions compared to before the pandemic (p<0.001). All types of home accidents were frequently detected at the ages of five years and younger. Conclusion: In this study, analyzing the second wave of the pandemic compared to pre-pandemic times, Researchers noted a decrease in the number of emergency admissions and an increase in admissions related to home accidents.

How heat waves, ozone and sunlight hours affect endocrine and metabolic diseases emergency admissions? A case study in the region of Madrid (Spain)

BackgroundStudies which analyse the joint effect of acoustic or chemical air pollution variables and different meteorological variables on neuroendocrine disease are practically nonexistent. This study therefore sought to analyse the impact of air pollutants and environmental meteorological variables on daily unscheduled admissions due to endocrine and metabolic diseases in the Madrid Region from January 01, 2013 to December 31, 2018. Material and methodsWe conducted a longitudinal, retrospective, ecological study of daily time series analysed by Poisson regression, with emergency neuroendocrine-disease admissions in the Madrid Region as the dependent variable. The independent variables were: mean daily concentrations of PM10, PM2.5, NO2 and O3; acoustic pollution; maximum and minimum daily temperatures; hours of sunlight; relative humidity; wind speed; and air pressure above sea level. Estimators of the statistically significant variables were used to calculate the relative risks (RRs). ResultsA statistically significant association was found between the increase in temperatures in heat waves, RR: 1.123 95% CI (1.001–1.018), and the number of emergency admissions, making it the main risk factor. An association between a decrease in sunlight and an increase in hospital admissions, RR: 1.005 95% CI (1.002 1.008), was likewise observed. Similarly, ozone, in the form of mean daily concentrations in excess of 44 μg/m3, had an impact on admissions due to neuroendocrine disease, RR: 1.010 95% CI (1.007–1.035). The breakdown by sex showed that in the case of women, NO2 was also a risk factor, RR: 1.021 95% CI (1.007–1.035). ConclusionThe results obtained in this study serve to identify risk factors for this disease, such as extreme temperatures in heat waves, O3 or NO2. The robust association found between the decrease in sunlight and increase in hospital admissions due to neuroendocrine disease serves to spotlight an environmental factor which has received scant attention in public health until now.

Low Stroke Risk in Children With Sickle Cell Disease in French Guiana: A Retrospective Cohort Study.

One in every 227 babies born in French Guiana has sickle cell disease, which represents the greatest incidence in France. This study aimed to determine the incidence of stroke in children with sickle cell disease and its associated risk factors. This retrospective cohort study included all children with sickle cell disease diagnosed in the neonatal period who were born in French Guiana between 01/01/1992 and 12/31/2002. Of a total of 218 records, 122 patients were included. There were 70 HbSS/Sβ0 (58%), 40 HbSC (33%), and 11 Sβ + thalassemia (9%). The number of emergency admissions was significantly different between genotypes, with a higher number in SS/Sβ0 children (p = 0.004). There were significantly more acute chest syndromes (p = 0.006) and more elevated Lactate Dehydrogenase in SS/Sβ0 patients (p = 0.003). Three of these patients had ischemic strokes at a mean age of 6.9 years, and one had a hemorrhagic stroke at the age of 9,2 years. The incidence rate of ischemic stroke for SS/Sβ0 children was 3.1 (95% CI: 1.0–9.7) per 1,000 patient-years, and the clinically apparent stroke risk by the age of 15 years and 3 months was 6,4%. The incidence of hemorrhagic stroke was 1.1 (95% CI: 0.1–7.4) per 1,000 patients-years. No patient with SC or Sβ + thalassemia genotypes experienced any stroke.

Individual and organizational predictors of patient care: A multilevel analysis of the English National Health Service Staff Survey.

Growing evidence attests to the importance of doctors’ psychosocial working conditions in relation to the provision of good quality patient care. However, few studies have explored the mechanisms of this relationship, including the role of work-related wellbeing as a mediator. Even fewer have done so from a multilevel perspective with organization-level predictors or informed by a theoretical framework. Drawing on the job demands-resources (JD-R) model, we ran multilevel structural equation models to test: (i) whether individual and organization-level psychosocial predictors influence doctors’ self-reported perception of care provided; and (ii) whether psychological strain and work engagement mediate these relationships. Data was drawn from a national survey of doctors (n=14,066) and metrics from all 157 English hospital organizations. At the individual level, work overload and job control predicted quality of care, while workplace aggression and manager support did not. Indirect effects were observed for all examined psychosocial predictors and quality of care as mediated by work engagement. At the organization level, only work engagement mediated the relationships between the number of emergency admissions and the quality of organization and individual care. These findings emphasize the importance of positive manifestations of work-related wellbeing and the improvement of hospital working conditions. The JD-R model provides a useful framework at the individual level, although study design limitations may explain its incompatibility at the organization level.

Patients with chronic conditions and their complex care needs in a tertiary care hospital

IntroductionHealth care for children with complex chronic conditions (CCC) constitutes an evolving and a challenging part of practices in pediatrics. These children need end-of-life services such as palliative care. The aim of this study was to identify the frequency of patients with CCC among all hospitalized children at our general pediatrics services and to describe the demographics, diagnosis, clinical spectrum, long-term care needs, and mortality data of patients with CCC. Patients and MethodsAll hospitalizations in 2018 at the general pediatric services were screened retrospectively. Patients’ hospitalization diagnoses, gender, age, comorbid conditions, number of emergency admissions in 2018, intensive care unit needs, mortality rates, and the number of hospitalizations in 2018 were investigated. ResultsA total of 1591 patients were hospitalized for 2083 times in 2018. Overall, 145 of 1591 patients (9%) had CCC. Patients with CCC were hospitalized for 472 times (23% of all hospitalizations). The number of emergency admissions, the number of hospitalizations in 2018 and the need for intensive care, and the mortality rate during hospitalization for patients with CCC were significantly higher than those for patients without CCC. The median length of hospitalization in patients with CCC was significantly longer. ConclusionPatients with CCC were hospitalized frequently and longer, had increased emergency and PICU admissions, and special long-term care needs. Pediatricians who pioneer care for children with CCC need education, training, and coordinated support to ensure qualified long-term care for these patients.

Assessing the impact of a shadowing programme on in-hospital mortality following trainee doctors\u2019 changeover

BackgroundTo assess the impact on seven-day in-hospital mortality following the introduction in 2012 of a shadowing programme for new UK medical graduates requiring them to observe the doctor they are replacing for at least 4 days before starting work.MethodsData on emergency admissions were derived from Hospital Episode Statistics between 2003 and 2019. A generalised estimating equation model was used to examine whether the introduction of the programme was associated with a change in mortality.ResultsThere were 644,018 emergency admissions, of which 1.8% (7612) ended in death in hospital within a week following the admission. Throughout the study period, there was an annual increase in the number of emergency admissions during July and August, though in-hospital mortality rates declined. The generalised estimating equation analysis found no significant change in the odds of death within 7 days after admission for patients admitted on the first Wednesday in August compared with patients admitted on the last Wednesday in July (OR = 1.03, 95% CI 0.94–1.13, p = 0.53). Furthermore, there was no significant change observed for any clinical diagnosis category following the introduction of the shadowing programme.ConclusionThere was a rising trend in the number of emergency admissions over the study period, though mortality was decreasing. We found no significant association between the introduction of shadowing programme and in-hospital mortality; however, lack of power means that we cannot rule out a small effect on mortality. There are other outcomes that might have changed but were not examined in this study.

MO186MORTALITY IN FRAIL ELDERLY WITH CHRONIC KIDNEY DISEASE – WHAT CAN MAKE US CHOOSE BETWEEN HEMODIALYSIS AND A CONSERVATIVE APPROACH?

Abstract Background and Aims The prevalence of Chronic Kidney Disease (CKD) is increasing worldwide including a significant number of frail elderly patients. This reflects the need to create tools that could help the nephrologists to choose between the best renal replacement treatment and a conservative approach. The identification of prognostic factors and their correlation with mortality could be crucial. The aim of this study was to identify and compare some variables that could be associated with mortality in CKD patients whether receiving hemodialysis or in a conservative approach. Method The authors realized a single center retrospective study in older (≥ 75years) and frail patients admitted in Nephrology department between in the last seven years. Baseline characteristics were collected from electronic medical records. Three groups were characterized: group 1 (G1) represents non deceased patients in hemodyalisis (HD), group 2 (G2) represents deceased patients in HD and group 3 (G3) represents deceased patients treated with a conservative approach. The comorbidities were stratified according with modified Charlson comorbidity index (mCCI) ≥ 5; the frailty according to Clinical Frailty Scale (CFS) ≥ 5). The eGFR was calculated through Chronic Kidney Disease Epidemiology Collaboration formula (CKD-EPI) at the time of admission. The nutritional status (based in Body Mass Index and seric albumin), ferritine value as a marker of inflammation and the number of hospitalizations during 2014-2020 were analyzed. Quantitative variables are described with their mean and compared with Student´s T-test. A p-value <0.05 was considered statistically significant. SPSS Statistics version 23 (Chicago, IL) was used for all statistical analyses. Results A total of 398 patients with CKD stage 4 and 5 presented with dyalitic indication or conservative approach (CA) at time of admission were included: 72 (18.1%) were in CA group. Clinical characteristics are presented in Table 1. We analyzed the difference between patients who were still alive (G1) versus patients who died during this observational period of seven years, accordingly with which treatment modality (CA or HD). We found no significant differences regarding gender and CKD etiology between groups. There were significant differences in age (G1: median age 77 vs G2:median age 76, p value < 0,001; G1: median age 77 vs G3:median age 82, p value <0,001). In our study, deceased population had a higher degree of frailty (G1: 2,5 vs G2:5,2, p value < 0,001; G1: 2,5 vs G3:5,7, p value 0,015), a higher Charlson comorbidity score (G1:3 vs G2: 4,3, p value 0,000018; G1: 3 vs G3:5,7, p value <0,001), a poorer nutritional status (Body Mass Index: G1:25,7 vs G2:22,8, p value < 0,001; G1:25,7 vs G3:23,2, p value <0,001 and lower albumin levels: G1: 3,86 vs G2:3,23, p value 0,00001; G1: 3,83 vs G3:3,23, p value <0,001 ), higher ferritine levels (G1:258 vs G2:436, p value <0,001; G1: 258 vs G3:386, p value < 0,001). The number of emergency admissions were higher in deceased groups (G1:0,3 vs G2:1,2, p value < 0,001; G1:0,3 vs G3:0,8, p value < 0,001). Conclusion We concluded that G2 and G3 had more comorbidities and more frailty, as we expected. Knowledge of the factors associated with mortality could be of value in shared decision-making and useful to help improve outcomes in CKD population. In the absence of a model completely capable of predicting mortality among patients who initiate hemodialysis versus patients undergoing conservative treatment, the analysis of these variables can contribute to a better selection of patients who will really benefit from a conservative treatment approach. Further studies are needed to validate a prognostic tool to choose the better treatment for elderly frail patients.

The significance of eosinophil and eosinophil lymphocyte ratio (ELR) in predicting response to omalizumab treatment in patients with severe allergic asthma.

Th2/Th1 mix pathological pathway may be seen as a common set of low eosinophilic phenotype in severe allergic asthma. This may affect omalizumab treatment response. In our study, we aimed to investigate whether eosinophil count (EOS) and percentage (EOS%), eosinophil lymphocyte ratio (ELR) and neutrophil lymphocyte ratio (NLR) may predict omalizumab treatment. Patients who received omalizumab treatment at least for one year in our allergy clinic were screened retrospectively. Baseline hemogram parameters, pre- and post-treatment emergency admissions, annual attacks requiring steroid use, hospitalizations, spirometric changes, and asthma control tests (ACT) were recorded. According the global efficacy assessment (phisician's GETE) scale patients was recorded as responder and nonresponder. By looking at EOS, EOS%, ELR and NLR distributions in these groups, the role of these parameters in representation of the treatment efficacy was investigated. The study was carried out with 83 patients, 77.1% of whom were women with an average age of 50.03 ± 10.7. While ACT scores and FEV1, FEF25-75 was significantly increased, the number of emergency admissions, annual attacks and hospitalizations decreased significantly (p<0.05). The rate of patients signed as responder was 75.9%, while the rate of nonresponder was %24.1. When the two groups were compared, it was found that the EOS, EOS% and ELR were significantly higher in the responder group. The cut-off values according to the ROC curve were determined as 0.12, 310/ml and 3.1% respectively. Considering the sensitivity (58.73%); specificity (85.00%); positive predictive value (92.50%), it was determined that ELR was a more valuable test. Instead of expensive and invasive methods for predicting the response of omalizumab therapy in severe allergic asthma, the ELR is correlated with treatment response and giving hope to be easier way to reach.

Does admission prevalence change after reconfiguration of inpatient services? An interrupted time series analysis of the impact of reconfiguration in five centres

BackgroundService reconfiguration of inpatient services in a hospital includes complete and partial closure of all emergency inpatient facilities. The “natural experiment” of service reconfiguration may give insight into drivers for emergency admissions to hospital. This study addressed the question does the prevalence of emergency admission to hospital for children change after reconfiguration of inpatient services?MethodsThere were five service reconfigurations in Scottish hospitals between 2004 and 2018 where emergency admissions to one “reconfigured” hospital were halted (permanently or temporarily) and directed to a second “adjacent” hospital. The number of emergency admissions (standardised to /1000 children in the regional population) per month to the “reconfigured” and “adjacent” hospitals was obtained for five years prior to reconfiguration and up to five years afterwards. An interrupted time series analysis considered the association between reconfiguration and admissions across pairs comprised of “reconfigured” and “adjacent” hospitals, with adjustment for seasonality and an overall rising trend in admissions.ResultsOf the five episodes of reconfiguration, two were immediate closure, two involved closure only to overnight admissions and one with overnight closure for a period and then closure. In “reconfigured” hospitals there was an average fall of 117 admissions/month [95% CI 78, 156] in the year after reconfiguration compared to the year before, and in “adjacent” hospitals admissions rose by 82/month [32, 131]. Across paired reconfigured and adjacent hospitals, in the months post reconfiguration, the overall number of admissions to one hospital pair slowed, in another pair admissions accelerated, and admission prevalence was unchanged in three pairs. After reconfiguration in one hospital, there was a rise in admissions to a third hospital which was closer than the named “adjacent” hospital.ConclusionsThere are diverse outcomes for the number of emergency admissions post reconfiguration of inpatient facilities. Factors including resources placed in the community after local reconfiguration, distance to the “adjacent” hospital and local deprivation may be important drivers for admission pathways after reconfiguration. Policy makers considering reconfiguration might consider a number of factors which may be important determinants of admissions post reconfiguration.

Change in Trauma Patterns in Hilly Areas of Northern India during Nationwide Lockdown: A Cross-sectional Study

Introduction: The countries all over the world are experiencing COVID-19 pandemic. This has led to a change in the operational guidelines in all trauma centres. Lockdown, limiting vehicle traffic, has affected trauma patterns everywhere. Aim: To study the effect of lockdown on orthopaedic trauma in hilly areas of Northern India. Materials and Methods: A cross-sectional retrospectively study collected the data of patients admitted in the emergency trauma ward like age, gender, mechanism of injury, fracture type, number of emergency admissions, and number of surgeries pertaining to the complete lockdown period (25th March to 3rd May 2020 i.e., 40 days) at our hospital situated in the hilly areas of North India. This was compared with the trauma cases dealt during the same time period last year (2019). Results: More than 50% decrease in the outpatient load did not parallel to decrease in admissions in emergency department (164 in 2019 vs 169 in 2020). However, operated trauma cases did decline from 62 in 2019 to 51 in 2020. Some injuries like fracture proximal tibia, cut injuries of hand with sharp object increased while incidence of fragility fractures has remained the same. Conclusion: The trauma pattern in and around the hilly places in our area of Northern India portrays a unique picture where one does not see a foreseeable decline in trauma despite the lockdown. With the lockdown in effect, some patterns have emerged which may prove to be useful adjuncts in our efforts to improve public health and the trauma burden.

Anti-IgE Significantly Changes Circulating Interleukin-25, Vitamin-D and Interleukin-33 Levels in Patients with Allergic Asthma.

Multi-center, randomized-controlled trials and observational studies have demonstrated that, in severe asthmatic patients receiving omalizumab treatment, the frequency of exacerbations, the number of urgent adverse events, and the need for oral steroids tend to decrease. This study included a total of 32 patients. The patients were divided into two groups as Group IA (pre-omalizumab) and Group IB (post-omalizumab). Serum IL-25 and IL-33 levels were measured and the number of emergency admissions, length of hospitalization (day), Asthma Control Test (ACT) scores, eosinophil cationic protein (ECP), and fractional exhaled nitric oxide (FeNO) value were analyzed. ACT and FeNO values increased after omalizumab treatment, while IL-33, IL-25 levels decreased after the completion of omalizumab treatment. Furthermore, there was a weak, positive, and significant relationship between the changes in the ECP levels and IL-33 levels (r=0.38, p=0.03). To the best of our knowledge, this is the first study to compare circulating IL-25 and IL-33 levels with specific IgE synthesis in the literature. Multivariate correlation analysis showed that the changes in serum IL-33 levels were significantly correlated with the changes in the mite sIgE levels and length of hospital stay (Fmodel=11.2, p=0.01, r2=0.45). On the other hand, there was no significant relationship between the other variables and changes in the IL-25 levels.

The inclusion of delirium in version 2 of the National Early Warning Score will substantially increase the alerts for escalating levels of care: findings from a retrospective database study of emergency medical admissions in two hospitals

The National Early Warning Score (NEWS) is being replaced with NEWS2 which adds 3 points for new confusion or delirium. We estimated the impact of adding delirium on the number of medium/high level alerts that are triggers to escalate care. Analysis of emergency medical admissions in two acute hospitals (York Hospital (YH) and Northern Lincolnshire and Goole NHS Foundation Trust hospitals (NH)) in England. Twenty per cent were randomly assigned to have delirium. The number of emergency admissions (YH: 35584; NH: 35795), mortality (YH: 5.7%; NH: 5.5%), index NEWS (YH: 2.5; NH: 2.1) and numbers of NEWS recorded (YH: 879193; NH: 884072) were similar in each hospital. The mean number of patients with medium level alerts per day increased from 55.3 (NEWS) to 69.5 (NEWS2), a 25.7% increase in YH and 64.1 (NEWS) to 77.4 (NEWS2), a 20.7% increase in NH. The mean number of patients with high level alerts per day increased from 27.3 (NEWS) to 34.4 (NEWS2), a 26.0% increase in YH and 29.9 (NEWS) to 37.7 (NEWS2), a 26.1% increase in NH. The addition of delirium in NEWS2 will have a substantial increase in medium and high level alerts in hospitalised emergency medical patients. Rigorous evaluation of NEWS2 is required before widespread implementation because the extent to which staff can cope with this increase without adverse consequences remains unknown.

Pulmonary Rehabilitation Reduces Emergency Admission and Hospitalization Rates of Patients with Chronic Respiratory Diseases.

Chronic respiratory diseases exert a global health burden with high health care costs, morbidity, and mortality. The aim of the present study was to investigate the effect of pulmonary rehabilitation (PR) on emergency admission and hospitalization rates of patients with chronic respiratory disease. In this retrospective cohort study, hospitalization rates and emergency admissions of patients before (December 2014-December 2015) and after PR (January 2015-December 2016) were investigated. Patients with chronic respiratory diseases were included. Chronic obstructive pulmonary disease (COPD) patients were classified based on the Global Initiative Chronic Obstructive Pulmonary Disease assessment scheme. PR was applied by three physiotherapists over 8 weeks (2 days/week). Data on patient demographics, clinical and anthropometric data, spirometry, exercise capacity, and quality of life before and after PR were acquired. This study evaluated 51 patients, of whom 76% were men. A total of 37 (73%) COPD patients and 14 (27%) non-COPD patients (7 bronchiectasis, 4 interstitial lung disease, and 3 kyphoscoliosis) were included. The patients exhibited significantly improved incremental shuttle walk test (ISWT) and endurance test scores (p<0.05) after PR. Similar to exercise capacity, the patients exhibited significantly improved Modified Medical Research Council (mMRC) score, St. George's Respiratory Questionnaire (SGRQ), anxiety and depression scores (p<0.05) after PR. In COPD patients, differences in pre- and post-PR ISWT, COPD assessment test, mMRC, and SGRQ scores were statistically significant (p=0.001). The number of emergency admissions and hospitalizations significantly decreased after PR (p=0.001; p=0.001). The post-PR FEV1% of COPD significantly increased (p=0.029). Pulmonary rehabilitation leads to an increase in exercise capacity as well as improved quality of life, resulting in a decrease in emergency admissions and hospitalization rates. Considering the cost of hospitalization, it is important to add PR to the management of patients with chronic respiratory diseases, in addition to medical therapy.

Sedative hypnotics overdose: Epidemiology, diagnosis and management

Abstract Background Sedative hypnotics class of drugs is increasing become the drug of choice for intentional overdose. The frequent prescription of these agents in those with psychiatric illnesses, insomnia and other substance use disorders has also increased the risk of accidental overdose. The growing use is reflected in the latest epidemiological findings and also underline the importance of the study of factors contributing to fatal overdoses so that appropriate steps can be taken to curb the growing epidemic of sedatives-hypnotic overdose. Methods A literature review was conducted of articles on sedatives-hypnotic overdose/toxicity published in the last few years on search engines PUBMED, EMBASE, PsycINFO and Google Scholar. Results A plethora of studies existed on the epidemiology of sedatives-hypnotic overdose in various developed and developing nations. These data mainly came from countries with good reporting of fatal and non-fatal as well as intentional/accidental poisonings in the healthcare system. There is a lack of Indian studies focusing on sedatives-hypnotic or prescription drugs related deaths, overall. Various factors associated with increased risk of sedative-hypnotic overdosing have been studied in recent years. From the management perspective, use of flumazenil and its associate adverse effects have been extensively reported. Conclusion and significance The increasing number of emergency admissions and deaths owing to sedatives-hypnotics overdose place a huge economic burden. From the public health point it becomes important to regulate the prescription and availability of these drugs to reduce associated fatalities.

Changes in admission thresholds in English emergency departments

BackgroundThe 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...

VP172 Clinical Effectiveness Of A Predictive Risk Model In Primary Care

INTRODUCTION:New approaches are needed to safely reduce emergency admissions to hospital by targeting interventions effectively in primary care. A predictive risk stratification tool (PRISM) identifies each registered patient's risk of an emergency admission in the following year, allowing practitioners to identify and manage those at higher risk. We evaluated the introduction of PRISM in primary care in one area of the United Kingdom, assessing its impact on emergency admissions and other service use.METHODS:We conducted a randomized stepped wedge trial with cluster-defined control and intervention phases, and participant-level anonymized linked outcomes. PRISM was implemented in eleven primary care practice clusters (total thirty-two practices) over a year from March 2013. We analyzed routine linked data outcomes for 18 months.RESULTS:We included outcomes for 230,099 registered patients, assigned to ranked risk groups.Overall, the rate of emergency admissions was higher in the intervention phase than in the control phase: adjusted difference in number of emergency admissions per participant per year at risk, delta = .011 (95 percent Confidence Interval, CI .010, .013). Patients in the intervention phase spent more days in hospital per year: adjusted delta = .029 (95 percent CI .026, .031). Both effects were consistent across risk groups.Primary care activity increased in the intervention phase overall delta = .011 (95 percent CI .007, .014), except for the two highest risk groups which showed a decrease in the number of days with recorded activity.CONCLUSIONS:Introduction of a predictive risk model in primary care was associated with increased emergency episodes across the general practice population and at each risk level, in contrast to the intended purpose of the model. Future evaluation work could assess the impact of targeting of different services to patients across different levels of risk, rather than the current policy focus on those at highest risk.

Integrated care program for complex chronic patients

Introduction : MutuaTerrassa (MT) provides comprehensive primary care and specialty services as well as mental and socio-healthcare through an integrated service model. MT designed a new model of integrated care for chronic conditions focused on different segments of the population in 2012, with the ultimate goal of achieving a model of care that is more decisive and satisfactory both in prevention and in treatment of chronic patients. Goals : The aim of this project was to develop a new organizational and functional structure called Functional Unit of Chronic Patient (FUCP) to meet the needs of a subgroup of chronic patients with great complexity and fragility, or the so-called Chronic Complex Patient (CCP). Description : The Functional Unit of Chronic Patient made up of a multidisciplinary group of professionals and levels of care, working together on a selected group of patients who are identified based on clinical and social criteria, following defined protocols, making care circuits consensus and sharing information. To develop this unit, some actions were deployed at multiple levels. Among the most important are those relating to designing management and care coordination, selecting and identifying patients in the new unit, creating the structure of the FUCP, defining categories and profiles as well as its functions, reorganizing the various health care facilities in the network to prioritize their co-operation, redesigning working relationship tools between different devices, creating a functional plan, and defining monitoring indicators such as activity, process and outcome. Results : The project results can be summarized in two main areas; firstly, assessing the degree of implementation of the program and, secondly, the results of care measured by indicators of activity (annual healthcare activity conducted by the FUCP), care process (PCC identification and set up of an individual therapeutic plan (PIIC)) and outcome (number of emergency admissions and emergency room visits of patients identified). The overall objective of the project was the implementation of the FCCU in 2012, when the first level FUCP, the second level FUCP devices for outpatients and day hospital, and the intermediate care unit were launched. Likewise, the basic circuits between the three levels of care and support network were defined, and the most important relationship instruments developed. Regarding healthcare monitoring, different areas have been analyzed. The care process has been measured by the number of CCP identified and ITP designed. In December 2015, there were 4.516 CCP registered (1.75% of population) and 76.15% of them had an ITP (1.33% of population). Preliminary results of the global program were evaluated in late 2013, demonstrating a reduction of 32% of emergency hospital admissions and 29% of emergency room visits made by identified patients. Since the creation of a respiratory FUCP until December 2015, 176 patients were identified as CCP and evaluated, 60 of them were included in the unit as new patients. The 92% of patients reduced the number of admissions during the first year monitoring (57% of them without any more hospital admission and 35% with hospital admissions reduction) and there were also a reduction of 67% in the overall number of hospital admissions made by these 60 patients. Likewise, the results of 18 months of mental health FUCP working showed that 45 patients were included, 18 of whom had had 31 emergency hospital admissions over the last 12 months; there were only 4 emergency hospital admissions during follow-up and 14 patients were discharged of the program mainly due to clinical improvement. Discussion and conclusions : The Functional Unit of Chronic Patient of MT is consolidated in our area of reference. Its activity is high and increasing, both in terms of new devices as number of patients registered and monitored in the unit. We can also say that preliminary clinical results have been very good, reaching out the objectives outlined, basically reducing emergency hospital admissions and emergency visits. We are currently following the evaluation process of the different subgroups of patients included in the program and developing new circuits, protocols, devices, and support sub-projects that will allow us to move forward in the continuous improvement of the FUCP of MT. Likewise, we are also working in new indicators to asses quality of care and patient satisfaction.

Cancer Transitional Care for Terminally Ill Cancer Patients Can Reduce the Number of Emergency Admissions and Emergency Department Visits.

Emergency admissions and emergency department visits (EAs/EDVs) have been used as quality indicators of home care in terminally ill cancer patients. We established a cancer transitional care (CTC) program to monitor and manage terminally ill cancer patients receiving care at home. The purpose of this study was to evaluate the effectiveness of CTC by the frequency of EAs/EDVs. In a retrospective chart review, we identified 133 patients with cancer admitted to our department, of whom 56 met study eligibility criteria. The CTC consisted of at least 1 or more following components: (1) a 24-hour hotline for general physicians or home care nurses to reach hospital-based physicians, (2) periodic phone calls from an expert hospital-based oncology nurse to home care medical staff, and (3) reports sent to our department from home care medical staff. The primary outcome variable was the frequency of EAs/EDVs. There were 32 EAs/EDVs and 69 planned admissions during the observation period. In the last 30 days of life, 16 patients (28.6%) had 1 EA/EDV and none had multiple EAs/EDVs. Compared with previous studies, our study found a similar or lower frequency of EAs/EDVs. Our findings suggest that the implementation of CTC reduces the number of EAs/EDVs by replacing them with planned admissions. Further prospective studies to evaluate CTC are warranted.

Geriatricians at the front door: The value of early comprehensive geriatric assessment in the emergency department

The UK population is ageing with increases in both the median age and the numbers and proportion of older people. Fastest growth has been in those aged 85 years and over with percentages of the total UK population increasing from 1–2% between 1985 and 2010. It is projected that by 2035, this figure will rise to 5% of the total UK population (3.5 million people) [1]. In the last 25 years, numbers of in-patient hospital beds have reduced by a third, while numbers of emergency admissions have increased annually, with older people accounting for the largest increase. Historically, hospitals have coped with this demand by reducing length of stay (LOS) for patients. However, in the over 85s, LOS has plateaued and more recently started to rise [2]. Sixty-five percent of people admitted to hospital are over the age of 65 years, with increasing numbers frail or with a diagnosis of dementia [3]. Multimorbidity, the presence of two or more chronic medical conditions, is more common in older people and is associated with functional decline, decreased quality of life and increased healthcare utilization (including emergency admissions) [4,5]. A R T I C L E I N F O