Identifying Older Patients at High Risk for Emergency Department Visits and Hospitalization

2019 ◽  
Vol 22 (5) ◽  
pp. 394-398
Author(s):  
Brooke E. Salzman ◽  
Rachel V. Knuth ◽  
Amy T. Cunningham ◽  
Marianna D. LaNoue
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Older Patients ◽  
Emergency Department Visits

scholarly journals Implementation of the acutely presenting older patient (APOP) screening program in routine emergency department care

2021 ◽  
Author(s):  
Laura C. Blomaard ◽  
Bas de Groot ◽  
Jacinta A. Lucke ◽  
Jelle de Gelder ◽  
Anja M. Booijen ◽  
...  
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Older Patients ◽  
Screening Program ◽  
Admission Rate ◽  
Older Patient ◽  
Hospital Admission Rate ◽  
High Risk Patients ◽  
Risk Patients

Abstract Objective The aim of this study was to evaluate the effects of implementation of the acutely presenting older patient (APOP) screening program for older patients in routine emergency department (ED) care shortly after implementation. Methods We conducted an implementation study with before-after design, using the plan-do-study-act (PDSA) model for quality improvement, in the ED of a Dutch academic hospital. All consecutive patients ≥ 70 years during 2 months before and after implementation were included. The APOP program comprises screening for risk of functional decline, mortality and cognitive impairment, targeted interventions for high-risk patients and education of professionals. Outcome measures were compliance with interventions and impact on ED process, length of stay (LOS) and hospital admission rate. Results Two comparable groups of patients (median age 77 years) were included before (n = 920) and after (n = 953) implementation. After implementation 560 (59%) patients were screened of which 190 (34%) were high-risk patients. Some of the program interventions for high-risk patients in the ED were adhered to, some were not. More hospitalized patients received comprehensive geriatric assessment (CGA) after implementation (21% before vs. 31% after; p = 0.002). In 89% of high-risk patients who were discharged to home, telephone follow-up was initiated. Implementation did not influence median ED LOS (202 min before vs. 196 min after; p = 0.152) or hospital admission rate (40% before vs. 39% after; p = 0.410). Conclusion Implementation of the APOP screening program in routine ED care did not negatively impact the ED process and resulted in an increase of CGA and telephone follow-up in older patients. Future studies should investigate whether sustainable changes in management and patient outcomes occur after more PDSA cycles.

Another Day, Another GI Bug

2020 ◽  
pp. 111-122
Author(s):  
Pinaki Mukherji ◽  
Dana Libov
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Inborn Error ◽  
Final Diagnosis ◽  
Emergency Department Visits ◽  
Inborn Error Of Metabolism ◽  
First Case ◽  
Non Accidental Trauma ◽  
Abnormal Radiograph ◽  
Electrolyte Abnormalities

This chapter presents 3 cases of vomiting in children and explores less common diagnoses not to be missed by the astute clinician. The first case of a child with recurrent progressive vomiting has unusual lab abnormalities which leads to the final diagnosis of an inborn error of metabolism. The second case presents a child with several Emergency Department visits for vomiting and a skin finding leads to a final diagnosis of non-accidental trauma. The final case reviews a vomiting child with electrolyte abnormalities and an abnormal radiograph, leading to a diagnosis of malrotation with volvulus. Each case gives the clinician key pearls to distinguish these high risk cases from everyday gastroenteritis.

Inpatient Palliative Care Consult: A Marker for High Risk of Readmission or Death in Discharged Oncology Inpatients

2019 ◽  
pp. 082585971986906
Author(s):  
Debbie Selby ◽  
Anita Chakraborty ◽  
Audrey Kim ◽  
Jeff Myers
Keyword(s):  
Emergency Department ◽  
Palliative Care ◽  
High Risk ◽  
Acute Care ◽  
Disease Process ◽  
Emergency Department Visits ◽  
Advanced Illness ◽  
Phone Calls ◽  
Palliative Care Teams ◽  
Advance Care

Background: Emergency department visits or readmission to hospital are common particularly among those with advanced illness. Little prospective data exist on early outcomes specifically for patients seen by a palliative care consult service during their acute care admission, who are subsequently discharged home. Methods: This study followed 62 oncology patients who had had a palliative care consult during their admission to acute care with weekly phone calls postdischarge for 4 weeks. Events recorded included death, readmission, emergency department visits, and admission to a palliative care unit. Results: By the end of the study, 32 (52%) of 62 had had at least 1 event, (readmission, emergency department visit, or death), with the majority of these occurring in the first 2 weeks postdischarge. The overall 4-week death rate was 14 (22.6%) of 62. Conclusions: These data suggest that the need for a palliative care consult identifies inpatients at very high risk for early deterioration and underlines the critical importance of advance care planning/goals-of-care discussions by the oncology and palliative care teams to ensure patients and families understand their disease process and have the opportunity to direct their care decisions.

scholarly journals 511: Risk factors for postpartum emergency department visits among a high-risk obstetric population

2016 ◽  
Vol 214 (1) ◽  
pp. S278
Author(s):  
Jean-Ju Sheen ◽  
Peter S. Bernstein ◽  
Brian Tu ◽  
Ying Liu ◽  
Desmond Sutton-Ramsey ◽  
...  
Keyword(s):  
Risk Factors ◽  
Emergency Department ◽  
High Risk ◽  
Emergency Department Visits ◽  
Obstetric Population

scholarly journals The Efficacy of Bamlanivimab in Reducing Emergency Department Visits and Hospitalizations in a Real-World Setting

2021 ◽  
Author(s):  
Douglas S Corwin ◽  
Peter T Ender ◽  
Nitasa Sahu ◽  
Ryan A Durgham ◽  
Dennis M McGorry ◽  
...  
Keyword(s):  
Emergency Department ◽  
Monoclonal Antibody ◽  
High Risk ◽  
Real World ◽  
Hospital Admissions ◽  
Emergency Department Visits ◽  
Spike Protein ◽  
Ambulatory Treatment ◽  
Real World Setting ◽  
Antibody Targeting

Abstract Bamlanivimab, a monoclonal antibody targeting the spike protein of SARS-CoV-2, is available for ambulatory treatment of COVID-19. This real-world study confirms the efficacy of bamlanivimab in reducing hospital admissions and emergency department visits among high-risk outpatients with mild to moderate COVID-19 illness and reveals a trend toward improved mortality.

scholarly journals Emergency department visits and inpatient hospitalizations among older patients with brain metastases: A dual population- and institution-level analysis

2021 ◽  
Author(s):  
Nayan Lamba ◽  
Paul J Catalano ◽  
Colleen Whitehouse ◽  
Kate L Martin ◽  
Mallika L Mendu ◽  
...  
Keyword(s):  
Emergency Department ◽  
Brain Metastases ◽  
Older Patients ◽  
Emergency Department Visits ◽  
Patient Navigator ◽  
Intracranial Disease ◽  
Morbidity Score ◽  
Co Morbidity ◽  
Inpatient Hospitalizations ◽  
Ed Visits

Abstract Background Older patients with brain metastases (BrM) commonly experience symptoms that prompt acute medical evaluation. We characterized emergency department (ED) visits and inpatient hospitalizations in this population. Methods We identified 17,789 and 361 Medicare enrollees diagnosed with BrM using the Surveillance, Epidemiology, and End Results-Medicare database (2010-2016) and an institutional database (2007-2016), respectively. Predictors of ED visits and hospitalizations were assessed using Poisson regression. Results The institutional cohort averaged 3.3 ED visits/1.9 hospitalizations per person-year, with intracranial disease being the most common reason for presentation/admission. SEER-Medicare patients averaged 2.8 ED visits/2.0 hospitalizations per person-year. For patients with synchronous BrM (N=7,834), adjusted risk factors for ED utilization and hospitalization, respectively, included: male sex (rate ratio [RR]=1.15 [95% CI=1.09-1.22], p<0.001; RR=1.21 [95% CI=1.13-1.29], p<0.001); African American vs. white race (RR=1.30 [95% CI=1.18-1.42], p<0.001; RR=1.25 [95% CI=1.13-1.39], p<0.001); unmarried status (RR=1.07 [95% CI=1.01-1.14], p=0.02; RR=1.09 [95% CI=1.02-1.17], p=0.01); Charlson co-morbidity score >2 (RR=1.27 [95% CI=1.17-1.37], p<0.001; RR=1.36 [95% CI=1.24-1.49], p<0.001); and receipt of non-stereotactic vs. stereotactic radiation (RR=1.44 [95% CI=1.34-1.55, p<0.001; RR=1.49 [95% CI=1.37-1.62, p<0.001). For patients with metachronous BrM (N=9,955), ED visits and hospitalizations were more common after vs. before BrM diagnosis (2.6 vs. 1.2 ED visits per person-year; 1.8 vs. 0.9 hospitalizations per person-year, respectively; RR=2.24 [95% CI=2.15-2.33], p<0.001; RR=2.06 [95% CI=1.98-2.15], p<0.001, respectively). Conclusions Older patients with BrM commonly receive hospital-level care secondary to intracranial disease, especially in select subpopulations. Enhanced care coordination, closer outpatient follow-up, and patient navigator programs seem warranted for this population.

scholarly journals Real-World Effectiveness and Tolerability of Monoclonal Antibodies for Ambulatory Patients with Early COVID-19

2021 ◽  
Author(s):  
Brandon J Webb ◽  
Whitney Buckel ◽  
Todd Vento ◽  
Allison M Butler ◽  
Nancy Grisel ◽  
...  
Keyword(s):  
Emergency Department ◽  
Monoclonal Antibodies ◽  
High Risk ◽  
Emergency Department Visit ◽  
Real World ◽  
Primary Outcome ◽  
Average Treatment Effect ◽  
Emergency Department Visits ◽  
Exploratory Analysis ◽  
Ambulatory Patients

Importance: Interventions to reduce hospitalization of patients with COVID-19 are urgently needed. Randomized trials for efficacy suggest that anti-SARS-CoV2 neutralizing monoclonal antibodies (MAb) may reduce medically-attended visits and hospitalization but effectiveness has not been confirmed in a real-world setting. Objective: Estimate the effectiveness of MAb infusion in a real-world cohort of ambulatory patients with early symptomatic COVID-19 at high risk for hospitalization. Design: Quasi-experimental observational cohort study using target trial emulation and causal inference methodology in pre-and post-implementation groups. Setting: Infusion centers and urgent care clinics within an integrated healthcare system in the United States Participants: 13,534 high-risk adult outpatients with symptomatic, laboratory-confirmed COVID-19 within 7 days of symptom onset. Exposures: A single intravenous infusion of either bamlanivimab 700 mg or casirivimab/imdevimab 1200 mg/1200 mg. Main Outcomes and Measures: The primary outcome was emergency department visit or hospitalization within 14 days of positive test. Patients who received MAb infusion were compared to contemporaneous controls using inverse probability of treatment weighting, and to a pre-implementation cohort using propensity-weighted interrupted time series analysis. An exploratory analysis compared effectiveness of casirivimab/imdevimab and bamlanivimab. Results: 7404 patients who would have been MAb-eligible were identified in a pre-implementation cohort (July 1-November 27, 2020). In the post-implementation period (November 28, 2020-January 28, 2021), 594 received MAb treatment and 5536 MAb-eligible patients did not. Among Mab recipients, 479 (80.6%) received bamlanivimab and 115 (19.4%) casirivimab/imdevimab. The primary outcome occurred in 75 (12.6%) MAb recipients, 1018 (18.4%) contemporaneous controls, and 1525 (20.6%) patients in the pre-implementation cohort. MAb treatment was associated with fewer subsequent emergency department visits and hospitalizations (odds ratio estimating the average treatment effect 0.69, 95% CI 0.60-0.79). After implementation, propensity-weighted probability of emergency department visit or hospitalization decreased by 0.7% per day (95% CI 0.03-0.10%, p<0.001). Overall, 7 (1.2%) MAb patients experienced an adverse event; two (0.3%) were considered serious. In the exploratory analysis, the effect of casirivimab/imdevimab versus bamlanivimab was not significant (OR 0.52, 95% CI 0.17-1.63, p=0.26). Conclusions and Relevance: MAb treatment of high-risk ambulatory patients with early COVID-19 was well-tolerated and effective at preventing the need for subsequent medically-attended care.

Abstract WP373: A Novel High-risk TIA and Minor Stroke Rapid Assessment Day-unit to Improve Quality of Care and Patient Outcomes

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Anne Cayley ◽  
Jemini Abraham ◽  
Libby Kalman ◽  
Cheryl Jaigobin ◽  
Martin del Campo ◽  
...  
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Stroke Prevention ◽  
Mr Angiography ◽  
Emergency Department Visits ◽  
Minor Stroke ◽  
Care Model ◽  
Stroke Patients ◽  
Rapid Access ◽  
Prevention Clinic

Background: About one in four ischemic strokes are preceded by a TIA; 43% of TIAs occur within one week before stroke. Patients with a TIA require urgent assessment, risk stratification, and preventative treatment, but often cannot access a Stroke Prevention Clinic in a timely fashion. Therefore, these patients are often admitted to hospital for evaluation but it is unclear if inpatient evaluation is optimal or specifically necessary for this patient population. Methods: We developed a novel high-risk TIA and Minor Stroke (TAMS) day-unit to provide rapid access to patient assessment, investigations, initiation of prevention strategies, and stroke prevention education. The TAMS Unit patient assessments were based on a collaborative model led by stroke Nurse Practitioners and an attending stroke Neurologist. All patients had cerebrovascular imaging (CT angiography, MR angiography, or carotid Doppler if there were exclusions to CT or MR angiography), and as appropriate, echocardiography and Holter monitoring initiated at the TAMS Unit visit. We evaluated the feasibility of this novel care model. Outcomes including time to assessment, investigations, and treatment for high-risk TIA/stroke etiologies and stroke risk factors, as well as return emergency department visits or readmissions within 30 days were assessed. Results: Between Sept. 6, 2011 and Aug. 8, 2012, 142 patients were seen in the TAMS Unit. Median time from emergency department visit to TAMS Unit assessment was 1 day. The final diagnosis was TIA in 41% of patients and minor stroke (NIHSS < 4) in 27.5% of patients. Atrial fibrillation was diagnosed in 8 (5.6%) patients; anticoagulation was initiated promptly upon diagnosis. High-grade carotid stenosis was diagnosed in 4 (2.8%) patients and these patients were referred for urgent endarterectomy. There were 12 (8.5%) patients that had a return visit to the emergency department within 30 days; 2 (1.4%) with stroke, 8 (5.6%) with recurrent TIA or fluctuating symptoms, and 2 (1.4%) with other diagnoses. Conclusion: Our novel TAMS Unit is a feasible care model that provides rapid access to assessment and treatment of high-risk TIA and minor stroke patients, and is another level of care between hospital admission and the outpatient Stroke Prevention Clinic.

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