Unnecessary Emergency Department Visits Research Articles

Risk Factors for Return to the Emergency Department and Readmission After Same-Day Discharge Total Joint Arthroplasty

BackgroundSame-day discharge (SDD) after total joint arthroplasty (TJA) is safe and cost effective. However, benefits may be offset by the potential cost of emergency department (ED) visits and readmissions. We identified risk factors for return to the ED and readmission in patients who underwent SDD and inpatient (IP) stays after TJA. MethodsWe performed a retrospective review of patients who underwent primary TJA at an academic institution over the course of one year. There were 1,708 consecutive TJAs (721 THA [total hip arthroplasty] and 987 TKA [total knee arthroplasty]) included. A SDD occurred after 1,199 (70%) TJAs, 523 THAs, and 676 TKAs. We compared the demographics and comorbidities of patients who have SDD or IP who stayed following TJA. We documented rates of return to the ED or readmission within 90 days of surgery. Cohorts were compared using the Student’s t-test or Chi-square test. Significant findings were those with P value < .05. ResultsThe SDD cohort had a significantly higher rate of young, non-White men who had a lower body mass index and fewer comorbidities than the IP cohort. Rates of return to ED and readmission were similar between SDD and IP cohorts after TJA and similar between THA and TKA. Factors that significantly influenced return to ED included a higher American Society of Anaesthesiologists score (SDD, IP), a higher Charlson Comorbidity Index score (SDD, IP), a lower body mass index (IP), and a psychological diagnosis (SDD, IP). Factors that significantly influenced readmission rates included a higher American Society of Anaesthesiologists score (SDD), older age (SDD), and psychological diagnosis (SDD, IP). ConclusionsPatients who discharged the same day after primary TJA have similar rates of return to the ED and readmission as those admitted as an IP. Patients who had a psychological diagnosis, and particularly a diagnosis of depression, are at higher risk for return to the ED and readmission after primary TJA, regardless of discharge the same-day or IP admission. Improved measures that attempt to further treat and optimize this patient population could reduce unnecessary postoperative ED visits.

Efficacy of DIY Cast Covers: An In Vivo Study.

Casting is routinely used in orthopaedics. Preventing a wet cast is crucial for maintaining structural integrity and reducing unwanted complications like unnecessary skin irritation/ulceration, bacterial overgrowth, and unnecessary emergency department visits. Using experimental models, studies have tested various contemporary methods to prevent a wet cast. One such study found that in comparison the most effective and cost-conscious approach was to use a Do-It-Yourself cast cover using a double-bag technique sealed with tape. There is a paucity of literature on the utility of this technique in vivo. The purpose of this study was to investigate the efficacy of the Do-It-Yourself cast cover on human test subjects. Ten volunteers for the study were obtained. Each received one short arm cast and one short leg cast. Each cast was removed after they were deemed dry. These casts were subsequently weighed until they achieved a stable weight. Each cast was then reapplied to the subject's arm and held together with Scotch tape. A trash bag was then applied around the cast and then secured with Duct tape to the skin. This was repeated to create a double seal. These covered, reapplied casts were submerged under water for 2 minutes. After submersion, the cover was removed, and the cast was reweighed. The casts were then submerged completely without any protection for 2 minutes and their fully saturated weight was recorded. Efficacy was determined by comparing the postsubmersion and full-submersion weights. Data was analyzed using the Mann-Whitney test. The percentage of water absorption prevention ranged from 96.8% to 99.9%, with an average of 99.6% across the entire study sample ( P <0.0001). No adverse effects were reported. Our findings conclude that the double-bag with Duct-tape method is effective at preventing external water absorption. This in vivo study demonstrates that almost all external water absorption can be prevented using this simple and inexpensive technique. Level II, prospective comparative study.

Telehealth: Moving Older People Along the Adoption Trajectory.

Although the concept of telehealth has been in development for many years, the global pandemic galvanized its growth and utility. In general, people adopt technological advancements at different velocities that, when plotted in a chart, resemble a bell-shaped curve. People who are quick to adopt new technologies are designated innovators, while those who are the very last to adopt new technologies are dubbed laggards. Often, older people fall into the laggard category for several reasons including physical, mental, and emotional barriers. In some cases, they lack the technology or experience with various programs that would make such programs accessible. Regardless, telehealth has proven its worth as a way to deliver care in areas distant to the health care provider when physical examination is unnecessary. It can reduce the likelihood of exposure to contagious disease. Telehealth also has the potential to reduce unnecessary emergency department visits, and long-term care facilities that have used telehealth have demonstrated cost savings. Little study has been conducted to determine how pharmacists are using telehealth, but after examining available research on telehealth, pharmacists can identify pitfalls and implement steps that reduce barriers for older people.

Understanding the Clinical Profile and Hospitalisation Patterns of Residents From Aged Care Facilities: A Regional Victorian Hospital Study.

Introduction Residents of residential aged care facilities (RACFs) are typically frailer than their community-dwelling counterparts. They often present to the emergency department (ED) with varied health issues, frequently leading to hospital admissions. These admissions can exacerbate patient frailty and strain the healthcare system. Despite global efforts to reduce ED presentations from RACFs, effective strategies still need to be discovered. This study examines the clinical profile and hospitalisation patterns of RACF residents in a regional Victorian town. Aims The study aimed to assess the prevalence of ED presentations and representations from RACFs, investigate the causes and outcomes of hospital admissions stemming from these presentations, and evaluate the prevalence of documented (advanced care directives) ACDs within this patient cohort. Methods Following ethical approval, we conducted a retrospective analysis of 467 ED presentations from 310 RACF patients admitted to Goulburn Valley Health's (GVH) ED from January to June 2022. We collected and examined data on demographics, ACD existence, ED presentation characteristics, and hospital admissions, classifying admission reasons into eleven groups. Statistical analysis was performed with GraphPad Prism and IBM SPSS, using inferential tests and logistic regression to assess readmission odds at a significance threshold of p<0.05. Results Our study encompassed 310 patients from multiple RACFs, yielding 467 ED presentations. These constituted 2.28% of total ED visits and 9.85% of those aged 65 and above. Most of the cohort were females (59.4%), aged between 79 and 91. About 98 patients presented multiple times, and 48.2% of presentations led to hospital admissions, with 6.2% of admitted patients succumbing during the hospital stay. A documented ACD was absent in 42.9% of the cohort. Statistically significant results include a correlation between male sex and an increased frequency of ED representations (p=0.0422) and a longer ED stay duration for admitted patients (p<0.0001). No significant associations were found between ACD presence and ED representations, ACD and sex, or between age and duration of stay in the ED. Age did not differ significantly among patients with single or multiple presentations or between patients with or without ACD. Regarding fall-related presentations, no significant sex-based difference in admission rates was found. The duration of stay between surgical and medical admissions was also statistically indifferent. Conclusion Our study highlights the significant utilisation of ED services by RACF residents, mainly males. The substantial percentage of these presentations resulting in hospital admissions underlines the critical nature of these visits. The absence of ACD in a significant portion of the cohort and the lack of its influence on the frequency of representations signal the need for further exploration. The results underline the ongoing challenge of meeting the complex healthcare needs of RACF residents and emphasise the importance of gender-specific interventions and efficient hospital utilisation strategies to optimise healthcare delivery in this population. Future studies should further investigate the underlying reasons for these findings to inform targeted strategies for reducing unnecessary ED visits and hospital admissions. Furthermore, fall-related presentations necessitate comprehensive ED assessments and integrated management approaches.

Clinical and economic impact of a community-based, hybrid model of in-person and virtual care in a Canadian rural setting: a cross-sectional population-based comparative study

ObjectivesTo determine the clinical and economic impact of a community-based, hybrid model of in-person and virtual care by comparing health-system performance of the rural jurisdiction where this model was implemented...

Evaluating the impact of a virtual outpatient care programme in preventing hospitalizations, emergency department visits and mortality for patients with COVID-19: a matched cohort study

ObjectivesTo evaluate the impact of virtual care in preventing unnecessary healthcare visits for patients with SARS-CoV-2. MethodsWe conducted a retrospective matched cohort study, evaluating the COVID-19 Expansion to Outpatients (COVIDEO) programme involving virtual assessments for all positive patients in the Sunnybrook assessment centre from January 2020 to June 2021, followed by risk-stratified routine follow-up, couriering of oxygen saturation devices, and 24 hour/day direct-to-physician pager for urgent questions. We linked COVIDEO data to province-wide datasets, matching each eligible COVIDEO patient to ≤10 other Ontario SARS-CoV-2 patients on age, sex, neighbourhood, and date. The primary outcome was emergency department (ED) visit, hospitalization or death within 30 days. Multivariable regression accounted for comorbidities, vaccination, and pre-pandemic healthcare utilization. ResultsAmong 6508 eligible COVIDEO patients, 4763 (73.1%) were matched to ≥1 non-COVIDEO patient. COVIDEO care was protective against the primary composite outcome (adjusted odds ratio [aOR] 0.91, 95% CI, 0.82–1.02), with a reduction in ED visits (7.8% vs. 9.6%; aOR 0.79, 95% CI, 0.70–0.89), but increase in hospitalizations (3.8% vs. 2.7%, aOR 1.37, 95% CI, 1.14–1.63) reflecting more direct-to-ward admissions (1.3% vs. 0.2%, p < 0.0001). Results were similar when matched comparators were limited to patients who had not received virtual care elsewhere with a decrease in ED visits (7.8 vs. 8.6%, aOR 0.86, 95% CI, 0.75–0.99) and an increase in hospitalizations (3.7 vs. 2.4%, aOR 1.45, 95% CI, 1.17–1.80). DiscussionAn intensive remote care programme can prevent unnecessary ED visits and facilitate direct-to-ward hospitalizations and thereby mitigate the impact of COVID-19 on the healthcare system.

Replacing conventional telecommunication with a freeform HIPAA compliant healthcare texting app: a survey of patient preference.

The ability to effectively communicate with patients continues to be a challenge for physician offices. Mobile healthcare applications have enhanced the accessibility of healthcare providers to their patients. However, the efficacy of unrestricted, personalized, bidirectional, freeform texting has not been previously evaluated. We investigated patient preference and self-reported outcomes using a smartphone HIPAA compliant mobile healthcare texting app, compared to conventional telecommunication, in self-reported quality of care, and impact on preventing unnecessary emergency department visits. A retrospective cohort survey study of a single-surgeon hernia specialist's practice was utilized. Patients with access to a smartphone who received care between July 2017 and March 2020 were instructed to utilize the healthcare texting app as a replacement to calling/receiving calls from the physician's office. Messages to and from patients were delivered directly to their surgeon and the surgical team via non-automated, personalized, freeform text messages, and templates, available to patients at all hours of the day. A depersonalized online survey was then distributed to assess patient perceived quality of care using the app, compared to their past experiences calling physician offices, and whether they preferred using text or conventional telecommunication. Additional statistics were reported using the application's built-in software, including response times, adoption rates, and message volumes. 90 patients successfully completed the entirety of the survey, median age range 50-60years old. 97% of respondents reported the texting app provided at least non-inferior quality of care compared to conventional telecommunication, with a majority (75%) experiencing a relatively improved quality of care. 9% reported an unnecessary ED visit being avoided after consulting their physician through the application. Unrestricted, freeform, non-automated communication via texting may be preferred by patients over conventional telecommunication. However, further research is warranted to assess the external validity and clinical impact of such results.

Advanced Practice Provider Model for Urgent Oncology Care.

Inherent to the cancer disease trajectory are heightened risks for a plethora of comorbid diagnoses. As the treatment landscape for oncology therapeutics continues to rapidly advance, patients are living longer and potentially experiencing more symptoms requiring rapid assessment. Prompt assessment and intervention for cancer or cancer treatment-related symptoms is imperative to achieve patient comfort and obtain the best overall patient outcomes. Traditionally, these patients were frequently referred to the emergency department (ED) when same-day clinic appointments were not obtainable. In order to decrease ED utilization and provide same-day urgent care for oncology patients, the Abramson Cancer Center established an advanced practice provider-led Oncology Evaluation Center where cancer patients are able to receive same-day assessment, symptom relief, and ultimately prevent unnecessary ED visits.

The impact of SARS-CoV-2 on emergency health care in a referral acute-care center in northern Italy

Abstract To assess how SARS-CoV-2 has changed the demand for in-person health care, we retrospectively analyzed data on access to the emergency department (ED) of San Martino Hospital, the referral acute-care center in the Liguria region (Northwest Italy). 181,699 records of patients diagnosed with an ICD-9 code between 2019 and 2021 were considered. In comparison to pre-pandemic levels, following the introduction of social distancing measures, the median number of ED visits declined by 41.4% in 2020 and by 28.1% in 2021. The period of maximum drop in access (-58.6%) corresponded to the 2020 11-12th calendar weeks and coincided with the highest rates of COVID-like illness - defined as either ILI or LRTI cases - identified through an operator-dependent syndromic surveillance system (+340%; 19.5% of total ED attendances). In terms of relative impact, in 2020 and 2021 non-urgent ED codes decreased (by 6.7% and 7.3%) and both urgent and emergency ED codes increased (by 4.8% and 3.8% the former; 5.5% and 8.8% the latter), even so, the absolute number of ED access fell drastically for all codes. Urgent codes, in particular, experienced the most severe decrease, shifting from a pre-pandemic value of 25,009 to 18,826 in 2020 and 19,528 in 2021. With regards to diagnosis, in 2020, respiratory infections saw the highest increase (+3.3%) while traumas and eye diseases saw the highest decrease (-1.1% and -3.8%, respectively). This trend reversed in 2021 during which respiratory infections decreased (-2.2%) and traumas increased (+2.2%). Despite the admissions of males and the elderly being routinely lower, these categories experienced the greatest increase in access for respiratory infections: +3.9% and +10.1% in 2020; +2.8% and +7.4% in 2021. While reduction of non-urgent ED visits indicates that the high pre-pandemic access levels may have been avoidable, the significant decline in non-COVID-19 urgent accesses potentially points to an increase in delayed and missed care. Key messages • During the COVID-19 pandemic – possibly due to fear and underestimation of symptoms – there was an overall reduction in ED accesses that potentially points to an increase in delayed or missed care. • The reduction in non-urgent attendances indicates that high pre-pandemic accesses may have been avoidable and that a reduction in unnecessary ED visits is an attainable goal for healthcare systems.

Initial Experience with Telemedicine for Interstage Monitoring in Infants with Palliated Congenital Heart Disease.

Infants with staged surgical palliation for congenital heart disease are at high-risk for interstage morbidity and mortality; home monitoring programs have mitigated these risks. In 2019, we instituted telemedicine (TM) in our established Infant Single Ventricle Monitoring Program. All consecutive patients discharged following neonatal operation/intervention were monitored until subsequent stage 2 surgical palliation. We offered TM (synchronous video) visits as part of regularly scheduled follow-up, replacing at least one in-person primary care visit with a TM cardiologist visit. We tracked emergency department (ED) visits, hospitalizations, how TM identified clinical concerns, and whether use of TM prevented unnecessary ED visits or expedited in-person assessment. We assessed caregiver and clinician satisfaction. Between 8/2019 and 5/2020, we conducted 60 TM visits for 29 patients. Of 31 eligible patients, 2 families (6.9%) declined. Median monitoring time was 199 days (range 75–264) and median number of TM visits/patient was 2 (range 1–5). In 6 visits (10%), significant clinical findings were identified which avoided an ED visit. Five TM visits led to expedited outpatient assessments, of which 1 patient required hospitalization. There were no missed events or deaths. Median ED visits/patient/month were significantly lower compared to the same calendar period of the prior year (0.0 (0–2.5) vs. 0.4 (0–3.7), p = 0.0004). Caregivers and clinicians expressed high levels of satisfaction with TM. TM for this high-risk population is feasible and effective in identifying clinical concerns and preventing unnecessary ED visits. TM was particularly effective during the COVID-19 pandemic, allowing for easy adaptation of care to ensure patient safety in this fragile cohort.

Telemedicine in pediatric cardiology: pros and cons.

The aim of this article is to review recent uses of telemedicine in pediatric cardiology, highlighting merits, challenges, and future directions. The COVID-19 pandemic accelerated telemedicine use, which has had a positive impact with respect to providers, patients, and their caregivers. Recent data have demonstrated the feasibility and effectiveness of telemedicine through expediting needed care and reducing healthcare utilization, including unnecessary emergency department visits, transports, and hospitalizations. With increasing complexity of cardiac care, telecardiology allows for establishing a medical home, improving access, and continuity of care. Great potential also exists for telecardiology to permit more consistent preventive care, possibly resulting in improved health equity, reduced morbidity and mortality, and associated costs. Challenges to optimal implementation of telecardiology, which are all surmountable, include the currently unaccounted additional workload and administrative burden, licensing restrictions, disparities in access to care, insurance reimbursement, and potential fraud and abuse. Telecardiology allows for efficient, quality, effective, collaborative care and is foundational to creating innovative, high-value care models. Through integration with accelerating technology and in-person visits, a sustainable hybrid model of optimal care can be achieved. Addressing barriers to progress in telecardiology is critical.

Patient Experiences With a Remote Monitoring Pathway for COVID-19.

Introduction: Due to the coronavirus disease 2019 (COVID-19) pandemic, a remote monitoring pathway was developed at Michael Garron Hospital to allow individuals with confirmed or presumed COVID-19 infection to successfully manage their illness at home. This study aims to understand patients’ experiences on this remote monitoring pathway and to investigate the effectiveness of the pathway in preventing unnecessary emergency department (ED) visits and detecting severe infection.Methods: A total of 35 semi-structured interviews were conducted over the phone. Researchers reviewed transcripts to come up with an index of nodes. Two researchers initially coded the same four transcripts to ensure high inter-rater reliability. The remaining 31 transcripts were coded by one researcher.Results: Of patients, 80% (n = 28) had a positive experience on the pathway. Remote monitoring was effective in reassuring 22.9% of patients (n = 8) with mild-moderate symptoms that their symptoms were not significant enough to go to the ED and they were monitored at home. A total of 8.6% of patients (n = 3) were correctly identified as having severe symptoms while on the pathway and were asked to present to the hospital. For 8.6% of patients (n = 3), remote monitoring did not identify their severe COVID-19 illness. Of patients, 2.9% (n = 1) were incorrectly identified as having severe COVID-19 symptoms when they were clinically well.Discussion: Remote monitoring is an effective tool to optimize healthcare resources during a pandemic. It reduces ER visits and provides a means for routine follow-up while minimizing virus exposure. Patients generally had a positive experience; however, more research needs to be done on optimizing the detection of severe infection.

Activating people to partner in health and self-care: use of the Patient Activation Measure.

Summary Patient activation is a behavioural concept and is at the heart of personalised care. It is defined as an individual’s knowledge, skill and confidence for managing their health and health care.Evidence indicates that patient activation scores can predict health behaviour and are closely linked to various clinical outcomes: reduced unnecessary emergency department visits, hospital admissions and re‐admissions. Patients with lower activation levels (25–40% of the population) are less likely to adopt healthy behaviour, and more likely to have poorer clinical outcomes and higher rates of hospitalisation.Effective interventions can improve a patient’s activation level, and positive change in activation equates to positive change in self‐care behaviour. But to improve patient activation, we must first measure it using a robust evidence‐based tool such as the Patient Activation Measure (PAM) survey.Armed with the patient’s PAM score, providers can tailor their care and help patients achieve better self‐care, which can improve outcomes of care and reduce unnecessary health care utilisation.The PAM is also useful for population segmentation and risk stratification — to target interventions and health strategies to meet the needs of patients who are at different points along the activation continuum, to measure the performance of health care systems, and to evaluate the effectiveness of health care interventions.The role of patient activation requires further serious consideration if we are to improve the long‐term health and wellbeing of all Australians. The PAM tool is a feasible and cost‐effective solution for achieving the Quadruple Aim — improving population health, the cost‐efficiency of the health system, and patient and provider experience.

Perspectives of individuals with sickle cell disease on barriers to care.

IntroductionSickle cell disease (SCD) is an inherited hemoglobinopathy that predominantly affects African Americans in the United States. The disease is associated with complications leading to high healthcare utilization rates, including emergency department (ED) visits and hospitalizations. Optimal SCD care requires a multidisciplinary approach involving SCD specialists to ensure preventive care, minimize complications and prevent unnecessary ED visits and hospitalizations. However, most individuals with SCD receive sub-optimal care or are unaffiliated with care (have not seen an SCD specialist). We aimed to identify barriers to care from the perspective of individuals with SCD in a multi-state sample.MethodsWe performed a multiple methods study consisting of surveys and interviews in three comprehensive SCD centers from March to June 2018. Interviews were transcribed and coded, exploring themes around barriers to care. Survey questions on the specific themes identified in the interviews were analyzed using summary statistics.ResultsWe administered surveys to 208 individuals and conducted 44 in-depth interviews. Barriers to care were identified and classified according to ecological level (i.e., individual, family/interpersonal, provider, and socio-environmental/organizational level). Individual-level barriers included lack of knowledge in self-management and disease severity. Family/interpersonal level barriers were inadequate caregiver support and competing life demands. Provider level barriers were limited provider knowledge, provider inexperience, poor provider-patient relationship, being treated differently, and the provider’s lack of appreciation of the patient’s SCD knowledge. Socio-environmental/organizational level barriers included limited transportation, lack of insurance, administrative barriers, poor care coordination, and reduced access to care due to limited clinic availability, services provided or clinic refusal to provide SCD care.ConclusionParticipants reported several multilevel barriers to SCD care. Strategies tailored towards reducing these barriers are warranted. Our findings may also inform interventions aiming to locate and link unaffiliated individuals to care.

Mental Disorders in Assisted Living Facilities. A Narrative Review of the Prevalence, Existing Models of Care Delivery, and Outcomes

<h3>Introduction</h3> Arising in the late 1970s as an alternative to nursing homes, Assisted Living Facilities (ALFs) are residential communities for older and disabled adults needing assistance with activities of daily living but in a less restrictive, less institutional/medical setting. Offering a variety of communal home-like living arrangements as well as providing a broad range of health-related services, ALFs are highly heterogeneous. As a whole, they seek to preserve resident independence and autonomy, social wellbeing, and flexibility of service offerings to accommodate evolving resident needs. As of 2016, approximately 811,500 individuals resided in ALFs in the US, across 28,900 facilities with 996,100 licensed beds. The number of licensed beds continues to increase, a trend driven in part by consumer preference; a large national survey indicated that 78% of older adults would prefer to reside in Assisted Living versus 12% in a nursing home in the event they needed more care outside their home. While nursing homes are tightly regulated on the federal level, ALFs are regulated by states and vary widely in their approaches to standards, procedures, and staffing. Regardless of setting, community prevalence of mental illness, defined as "mental, behavioral, or emotional disorders," is 14.1% in adults over 50. In addition, about 11% of people aged 65 and older in the United States have dementia. It is becoming increasingly important to monitor the prevalence of mental illness, including dementia, in ALFs, especially as the older adult population and ALF occupancy increase. The aim of this review is to describe the prevalence of mental illness, including dementia, in Assisted Living residents, to detail existing models of mental health care for Assisted Living residents, and to discuss implications for clinical outcomes, health care utilization, and Assisted Living occupancy. For the purposes of this paper, dementia will be included under the rubric of "mental illness" due to its prevalence among Assisted Living residents, and the overlap of care delivery considerations with non-cognitive mental disorders. <h3>Methods</h3> This narrative review followed the best-practice recommendations outlined by Ferrari (2015). PubMed and Google Scholar were searched in June 2021 for the following key words: assisted living facility, psychiatric illness, limitations, hospitalization, discharge, and behavioral health integration, in addition to synonymous words related to three categories of interest including, prevalence of mental illness in ALFs, behavioral health care models in ALFs, and clinical outcomes of ALF residents. Articles were limited to the English language and to the United States or Canada. Emphasis was placed on recent systematic reviews and randomized controlled trials. All articles were initially screened according to title and abstract and were retained if they contained information on prevalence of mental illness in ALFs, behavioral health care models in ALFs, or clinical outcomes of ALF residents. Reference lists were hand-searched for additional research articles. <h3>Results</h3> Many articles reported various rates of mental illness and cognitive disorders in ALFs, however, the prevalence remains high and continues to increase as the older adult population increases. Across articles, prevalence of non-cognitive psychiatric disorders in ALFs ranged from 26% to 33% depending on methodology and study population. Prevalence of cognitive disorders in ALFs range widely depending on the type of facility: some ALFs admit exclusively persons with dementia, whereas other ALF facilities specialize in residents with fewer functional impairments. Studies have demonstrated that both depression and dementia in ALF residents are more prevalent when compared with community-dwelling controls. Behavioral health problems and high health care needs of ALF residents are common reasons for ALF discharge. Integrated models, which bring together specialty behavioral health care providers with health and supportive service providers, have been shown to reduce behavioral health symptoms and contribute to improved health of residents, improve care, and decrease associate care costs including staff turnover. <h3>Conclusions</h3> This narrative review addresses the importance of behavioral health needs in ALF residents. Articles identified limitations in ALF infrastructure and research, specifically relating to data collection and varying definitions of terms, which limits the generalizability of the results. Greater attention to the study, design, and implementation of behavioral health care for ALF residents may reduce the prevalence of distressing symptoms in those with psychiatric and cognitive disorders, and in turn decrease the need for unnecessary Emergency Department visits, hospitalizations, and premature facility discharge. Future research should consider measuring the effectiveness of mental health care in ALFs since there is limited research currently available. <h3>This research was funded by</h3> Unfunded.

Improving Utilization of an After-Hours Phone Triage Service: A Resident Quality Improvement Initiative.

Phone triage systems are increasingly used by primary care clinics to improve patient satisfaction and direct low-acuity patients to appropriate care settings. Despite the prevalence of telephone triage, the majority of pediatric training programs do not include this practice in their curricula. Our aim was to increase the volume of after-hours patient phone calls per week by 25% and to secondarily reduce "treat and release" emergency department (ED) visits by 5% over the course of a 9-month quality improvement (QI) study. A resident-led QI project was conducted from 2017 to 2019 at a mixed faculty-resident pediatric primary care practice providing care for an urban, primarily immigrant, underserved population. Eight Plan-Do-Study-Act cycles were developed on the basis of identified key drivers and included efforts to increase the visibility of the call service to patient families. After-hours calls were tracked and compared with similar practices, and ED visits for the first week of each month were reviewed using the electronic medical record system. After promoting the service via various modalities, the number of after-hours calls increased by 30%, from an average of 6.5 calls per week to 8.5. Treat and release ED visits decreased by 6%, from a baseline of 64.3 to 60.3 visits per week. The increased patient awareness of and availability of a reliable after-hours call service in pediatric practices are promising tools for reducing unnecessary ED visits, leveraging resident direction and implementation to promote the service through varying modalities.

Impact of COVID-19 on emergency department visits among palliative home care recipients: a retrospective population-based cohort study in the Piedmont region, Italy.

Integrated palliative home care (IHPC) is delivered to patients with progressive end-stage diseases. During the COVID-19 pandemic, IHPC needed to provide high-quality home care services for patients who were treated at home, with the goal of avoiding unnecessary care, hospital admissions, and emergency department (ED) visits. This study aimed to compare the ED visits of IHPC recipients in a large Italian region before and during the first two waves of the COVID-19 pandemic and to find sociodemographic or clinical characteristics associated with changes in ED visits during the first two waves of COVID-19 pandemic, compared with the period before. Administrative databases were used to identify sociodemographic and clinical variables of IHPC recipients admitted before and during the pandemic. The obtained data were balanced by applying a propensity score. The average number of ED visits before and during the pandemic was calculated by using the Welch's t test and stratified by all the variables. Before and during the pandemic, 5155 and 3177 recipients were admitted to IHPC, respectively. These individuals were primarily affected by neoplasms. ED visits of IHPC recipients reduced from 1346 to 467 before and during the pandemic, respectively. A reduced mortality among IHCP patients who had at least one ED visit during the pandemic (8% during the pandemic versus 15% before the pandemic) was found. The average number of ED visits decreased during the pandemic [0.143, confidence interval (CI) = (0.128-0.158) versus 0.264, CI = (0.242-0.286) before the pandemic; p < 0.001] for all ages and IHPC duration classes. The presence of a formal caregiver led to a significant decrease in ED use. Medium and high emergency ED admissions showed no difference, whereas a decrease in low-level emergency ED admissions during the pandemic [1.27, CI = (1.194-1.345) versus 1.439, CI = (1.3-1.579) before the pandemic; p = 0.036] was found. ED visits among IHPC recipients were significantly decreased during the first two waves of the COVID-19 pandemic, especially in those individuals characterized by a low level of emergency. This did not result in an increase in mortality among IHPC recipients. These findings could inform the reorganization of home care services after the pandemic.

Enhancing implementation of a standardized initial assessment for demand management in outpatient emergency care in Germany: a quantitative process evaluation

BackgroundInadequate assessment of the severity and urgency of health problems is one of the factors contributing to unnecessary emergency department visits. A software-based instrument for standardized initial assessment (SmED) aims to support healthcare professionals and steer patients to the appropriate source of care. The aim of this study was to evaluate the implementation process of SmED based on the point of view of users in order to facilitate sustainable implementation.MethodsA quantitative process evaluation on the basis of a paper-based questionnaire was carried out alongside the implementation of SmED in 26 outpatient emergency care services within 11 federal states in Germany. Healthcare professionals who worked with SmED either at the joint contact points of the outpatient emergency care service and the emergency departments of hospitals ("Joint Counter", German “Gemeinsamer Tresen”) or at the initial telephone contact points of the outpatient emergency care service (116117) were invited to participate in the survey.Results200 users of SmED completed the questionnaire comprising the five scales: Intervention effectiveness/efficacy, Interprofessional context/occupational Interest, Individual Context, Organisational Framework Conditions, and Medical Context. Several individual characteristics were related to the implementation process of SmED. Female and younger healthcare professionals and participants with less than five years of professional experience tended to evaluate the implementation process as more positive. Factors related to the Individual Context and to the Medical Context were associated with the reported use of SmED (p = 0.004 and 0.041, respectively).ConclusionThe involvement of healthcare professionals, particularly more experienced professionals, in the implementation of SmED may help to facilitate sustainable implementation. In addition, training of potential user prior and during the implementation process and the adaption of Organisational Context factors are crucial.Trial registration The study was registered at the German Clinical Trials Register prior to the start of the study (DRKS00017014).

A Descriptive Study of Emergency Department Visits Within 30 Days of Discharge.

BackgroundUnnecessary emergency department (ED) visits are a crucial consideration in discharge planning for acutely admitted patients. This study aimed to identify the reasons for unnecessary visits to the ED within 30 days of discharge from a medical hospitalist unit.MethodsWe performed a retrospective review of patients discharged in 2018 from a medical unit of tertiary teaching hospital in Korea. The authors discussed in-depth and determined whether or not an ED visit was unnecessary, and further classified the causes of unnecessary visits into three categories.ResultsThe mean age of the patients was 62.9 years (range, 15–99 years), and among the 1,343 patients discharged from the unit, 720 (53.6%) were men. Overall, 215 patients (16.0%) visited the ED within 30 days after discharge; among them, 16.3% were readmitted. Of the 215 cases of ED visits within 30 days after discharge, 57 (26.5%) were considered unnecessary. Of these, 30 (52.6%) were categorized as having failed care transition, 15 (26.3%) had unestablished care plans for predictable issues, and 12 (21.1%) had insufficient patient education.ConclusionA substantial number of short-term ED visits by discharged multimorbid or older medical patients were considered unnecessary. Discharging patients with a thorough discharge plan is essential to avoid unnecessary ED visits.

RELIEF: A Digital Health Tool for the Remote Self-Reporting of Symptoms in Patients with Cancer to Address Palliative Care Needs and Minimize Emergency Department Visits.

The lack of timely symptom reporting remains a barrier to effective symptom management and comfort for patients with cancer-related palliative care needs. Poor symptom management at home can lead to unwanted outcomes, such as emergency department visits and death in hospital. We developed and evaluated RELIEF, a remote symptom self-reporting app for community patients with palliative care needs. A pilot feasibility study was conducted at a large, community hospital in Ontario, Canada. Patients self-reported their symptoms each morning using validated clinical symptom measures and RELIEF would alert for worsening or severe symptoms. RELIEF alerts were monitored by palliative care nurses who would then contact patients to determine if appropriate clinical intervention could be initiated to avoid unnecessary emergency department visits. A total of 20 patients were recruited to use RELIEF for two months. Patients completed 80% of daily self-report assessments; 133 alerts were trigged, half of which required clinical intervention. No patient visited the emergency department for symptom management during the study. Clinical staff estimated five emergency department visits were avoided because of RELIEF—saving an estimated cost of over CAD 60,000. RELIEF is a feasible and acceptable method for the remote monitoring of patients with palliative care needs through regular symptom self-reporting.