Perspectives on Implementing a Multidomain Approach to Caring for Older Adults With Heart Failure

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/153220/1/jgs16183_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/153220/2/jgs16183-sup-0001-supinfo.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/153220/3/jgs16183.pd

Impact of the ABCDE triage in primary care emergency department on the number of patient visits to different parts of the health care system in Espoo City

<p>Abstract</p> <p>Background</p> <p>Many Finnish emergency departments (ED) serve both primary and secondary health care patients and are therefore referred to as combined emergency departments. Primary care doctors are responsible for the initial assessment and treatment. They, thereby, also regulate referral and access to secondary care. Primary health care EDs are easy for the public to access, leading to non-acute patient visits to the emergency department. This has caused increased queues and unnecessary difficulties in providing immediate treatment for urgent patients. The primary aim of this study was to assess whether the flow of patients was changed by implementing the ABCDE-triage system in the EDs of Espoo City, Finland.</p> <p>Methods</p> <p>The numbers of monthly visits to doctors were recorded before and after intervention in Espoo primary care EDs. To study if the implementation of the triage system redirects patients to other health services, the numbers of monthly visits to doctors were also scored in the private health care, the public sector health services of Espoo primary care during office hours and local secondary health care ED (Jorvi hospital). A face-to-face triage system was applied in the primary care EDs as an attempt to provide immediate treatment for the most acute patients. It is based on the letters A (patient sent directly to secondary care), B (to be examined within 10 min), C (to be examined within 1 h), D (to be examined within 2 h) and E (no need for immediate treatment) for assessing the urgency of patients' treatment needs. The first step was an initial patient assessment by a health care professional (triage nurse). The introduction of this triage system was combined with information to the public on the "correct" use of emergency services.</p> <p>Results</p> <p>After implementation of the ABCDE-triage system the number of patient visits to a primary care doctor decreased by up to 24% (962 visits/month) as compared to the three previous years in the EDs. The Number of visits to public sector GPs during office hours did not alter. Implementation of ABCDE-triage combined with public guidance was associated with decreased total number of doctor visits in public health care. During same period, the number of patient visits in the private health care increased. Simultaneously, the number of doctor visits in secondary health care ED did not alter.</p> <p>Conclusions</p> <p>The present ABCDE-triage system combined with public guidance may reduce patient visits to primary health care EDs but not to the secondary health care EDs. Limiting the access of less urgent patients to ED may redirect the demands of patients to private sector rather than office hours GP services.</p

Acute Management and Outcomes of Patients with Diabetes Mellitus Presenting to Canadian Emergency Departments with Hypoglycemia

Objectifs: Cette vérification rétrospective des dossiers a permis d\u27examiner les données démographiques, les examens, la prise en charge et les résultats des patients adultes souffrant de diabète sucré qui se sont présentés aux services des urgences (SU) au Canada. Méthodes: Tous les sites ont mené une recherche dans leurs dossiers médicaux électroniques à l\u27aide des codes de la Classification internationale des maladies, dixième révision, pour relever les visites aux SU entre 2008 et 2010 qui étaient liées à l\u27hypoglycémie. Les caractéristiques des patients, les données démographiques, la prise en charge aux SU, les ressources des SU et les résultats sont rapportés. Résultats: Un total de 1039 patients de plus de 17 ans ont été inclus dans l\u27étude; 347 (33,4 %) ont été classifiés comme étant des cas de diabète de type 1 et 692 (66,6 %) ont été classifiés comme étant des cas de diabète de type 2. Les patients souffrant du diabète de type 2 étaient beaucoup plus âgés (73 ans vs 49 ans; p\u3c0,0001) et avaient plus d\u27affections chroniques inscrites à leur dossier (tous p\u3c0,001). La plupart des sujets arrivaient par ambulance, et 39 % des cas montraient des scores de triage qui révélaient des tableaux cliniques graves. Les traitements contre l\u27hypoglycémie étaient fréquents (75,7 %) durant le transport préhospitalier; 38,5 % recevaient du glucose et 40,1 % recevaient du glucagon par voie intraveineuse. Les traitements administrés dans les SU contre l\u27hypoglycémie comprenaient le glucose par voie orale (76,8 %), le glucose par voie intraveineuse (29,6 %) et en perfusion continue (27,7 %). Les examens diagnostiques (81,9 %) comprenaient fréquemment les électrocardiogrammes (51,9 %), la radiographie thoracique (37,5 %) et la tomodensitométrie crânienne (14,5 %). La plupart des patients (73,5 %) recevaient leur congé. Cependant, plus de sujets souffrant du diabète de type 2 nécessitaient une admission (30,3 vs 8,8 %). Les instructions de congé étaient étayées chez seulement 55,5 % des patients, et l\u27orientation vers des services de diabète se rencontrait chez moins de 20 % des cas. Une variation considérable dans la prise en charge de l\u27hypoglycémie existait entre les SU. Conclusions: Les patients souffrant de diabète qui se présentaient à un SU en raison d\u27une hypoglycémie consomment considérablement de ressources en soins de santé, puis une variation est observée dans la pratique. Les SU devraient élaborer des protocoles de prise en charge de l\u27hypoglycémie en portant une attention à la planification du congé pour réduire la récurrence

Third-party participation in investment-environment disputes: Recent developments

This article outlines recent developments in investor-State dispute settlement related to the participation of third parties in arbitration. A particular focus is given to third party participation in disputes with a clear public interest based on the relevance of the cases to the protection of the environment, or sustainable development more generally. The benefits and drawbacks of third party participation and the relationship of participation to broader issues of transparency are also briefly discussed. © 2007 The Author. Journal compilation © 2007 Blackwell Publishing Ltd

TAVR in Older Adults: Moving Toward a Comprehensive Geriatric Assessment and Away From Chronological Age

Calcific aortic stenosis can be considered a model for geriatric cardiovascular conditions due to a confluence of factors. The remarkable technological development of transcatheter aortic valve replacement was studied initially on older adult populations with prohibitive or high-risk for surgical valve replacement. Through these trials, the cardiovascular community has recognized that stratification of these chronologically older adults can be improved incrementally by invoking the concept of frailty and other geriatric risks. Given the complexity of the aging process, stratification by chronological age should only be the initial step but is no longer sufficient to optimally quantify cardiovascular and noncardiovascular risk. In this review, we employ a geriatric cardiology lens to focus on the diagnosis and the comprehensive management of aortic stenosis in older adults to enhance shared decision-making with patients and their families and optimize patient-centered outcomes. Finally, we highlight knowledge gaps that are critical for future areas of study

Evaluation of an emergency department lean process improvement program to reduce length of stay

Study objective In recent years, lean principles have been applied to improve wait times in the emergency department (ED). In 2009, an ED process improvement program based on lean methods was introduced in Ontario as part of a broad strategy to reduce ED length of stay and improve patient flow. This study seeks to determine the effect of this program on ED wait times and quality of care. Methods We conducted a retrospective cohort study of all ED visits at program and control sites during 3 program waves from April 1, 2007, to June 30, 2011, in Ontario, Canada. Time series analyses of outcomes before and after the program and difference-in-differences analyses comparing changes in program sites with control sites were conducted. Results In before-after models among program sites alone, 90th percentile ED length of stay did not change in wave 1 (–14 minutes [95% confidence interval {CI} –47 to 20]) but decreased after wave 2 (–87 [95% CI –108 to –66]) and wave 3 (–33 [95% CI –50 to –17]); median ED length of stay decreased after wave 1 (–18 [95% CI –24 to –12]), wave 2 (–23 [95% CI –27 to –19]), and wave 3 (–15 [95% CI –18 to –12]). In all waves, decreases were observed in time to physician assessment, left-without-being-seen rates, and 72-hour ED revisit rates. In the difference-in-difference models, in which changes in program sites were compared with controls, the program was associated with no change in 90th percentile ED length of stay in wave 2 (17 [95% CI –0.2 to 33]) and increases in wave 1 (23 [95% CI 0.9 to 45]) and wave 3 (31 [95% CI 10 to 51]), modest reductions in median ED length of stay in waves 2 and 3 alone, and a decrease in time to physician assessment in wave 3 alone. Conclusion Although the program reduced ED waiting times, it appeared that its benefits were diminished or disappeared when compared with that of control sites, which were exposed to system-wide initiatives such as public reporting and pay for performance. This study suggests that further evaluation of the effectiveness of lean methods in the ED is warranted before widespread implementation

Prognostic value of simple frailty and malnutrition screening tools in patients with acute heart failure due to left ventricular systolic dysfunction

Background: Frailty and malnutrition are common in patients with heart failure (HF), and are associated with adverse outcomes. We studied the prognostic value of three malnutrition and three frailty indices in patients admitted acutely to hospital with HF. Methods: 265 consecutive patients [62% males, median age 80 (interquartile range (IQR): 72–86) years, median NTproBNP 3633 (IQR: 2025–6407) ng/l] admitted with HF between 2013 and 2014 were enrolled. Patients were screened for frailty using the Derby frailty index (DFI), acute frailty network (AFN) frailty criteria, and clinical frailty scale (CFS) and for malnutrition using the geriatric nutritional risk index (GNRI), controlling nutritional status (CONUT) score and prognostic nutritional index (PNI). Results: According to the CFS (> 4), DFI, and AFN, 53, 50, and 53% were frail, respectively. According to the GNRI (≤ 98), CONUT score (> 4), and PNI (≤ 38), 46, 46, and 42% patients were malnourished, respectively. During a median follow-up of 598 days (IQR 319–807 days), 113 patients died. One year mortality was 1% for those who were neither frail nor malnourished; 15% for those who were either malnourished or frail; and 65% for those who were both malnourished and frail. Amongst the malnutrition scores, PNI, and amongst the frailty scores, CFS increased model performance most compared with base model. A final model, including CFS and PNI, increased c-statistic for mortality prediction from 0.68 to 0.84. Conclusion: Worsening frailty and malnutrition indices are strongly related to worse outcome in patients hospitalised with HF

The association between older age and receipt of care and outcomes in patients with acute coronary syndromes

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