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

Background: 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. Methods: 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. Results: 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. Conclusion: 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

Emergency department visits by nursing home residents. A retrospective Italian study of administrative databases from 2015 to 2019

Background Visits to Emergency Departments (ED) can be traumatic for Nursing Home (NH) residents. In Italy, the rate of ED visits by NH residents was recently calculated as 3.3%. The reduction of inappropriate ED visits represents a priority for National Healthcare Systems worldwide. Nevertheless, research on factors associated with ED visits is still under-studied in the Italian setting. This study has two main aims: (i) to describe the baseline characteristics of NH residents visiting ED at regional level; (ii) to assess the characteristics, trends, and factors associated with these visits.Methods A retrospective study of administrative data for five years was performed in the Piedmont Region. Data from 24,208 NH residents were analysed. Data were obtained by merging two ministerial databases of residential care and ED use. Sociodemographic and clinical characteristics of the residents, trends, and rates of ED visits were collected. A Generalized Linear Model (GLM) regression was used to evaluate the factors associated with ED visits.Results In 5 years, 12,672 residents made 24,609 ED visits. Aspecific symptoms (45%), dyspnea (17%) and trauma (16%) were the most frequent problems reported at ED. 51% of these visits were coded as non-critical, and 58% were discharged to the NH. The regression analysis showed an increased risk of ED visits for men (OR = 1.61, 95% CI 1.51-1.70) and for residents with a stay in NH longer than 400 days (OR = 2.19, 95% CI 2.08-2.31).Conclusions Our study indicates that more than half of NH residents' ED visits could potentially be prevented by treating residents in NH. Investments in the creation of a structured and effective network within primary care services, promoting the use of health technology and palliative care approaches, could reduce ED visits and help clinicians manage residents on-site and remotely

Methodological and Practical Considerations in Rapid Qualitative Research: Lessons Learned From a Team-Based Global Study During COVID-19 Pandemic

Rapid qualitative research (RQR) studies are increasingly employed to inform decision-making in public health emergencies. Despite this trend, there remains a lack of clarity around what these studies actually involve in terms of methodological processes and practical considerations or challenges. Our team conducted a global RQR study during the COVID-19 pandemic. In this article, we provide a detailed account of our methodological processes and decisions taken related to ethics, study design, and analysis. We describe how we navigated limitations on time and resources. We draw attention to several elements that operated as facilitators to the rapid launch and completion of this study. Rendering methodological considerations and rationales for specific RQR studies explicit and available for consideration by others can contribute to the validity of RQR, support further discussion and development of RQR methods, and make findings for particular studies more credible

Impact of the Timing of Integrated Home Palliative Care Enrolment on Emergency Department Visits

Background: The association between timing of integrated home palliative care (IHPC) enrolment and emergency department (ED) visits is still under debate, and no studies investigated the effect of the timing of IPHC enrolment on ED visits, according to their level of emergency. This study aimed to investigate the impact of the timing of IHPC enrolment on different acuity ED visits. Methods: A retrospective, pre-/post-intervention study was conducted from 2013 to 2019 in Italy. Analyses were stratified by IHPC duration (short 90 days) and triage tags (white/green: low level of emergency visit; yellow/red: medium to-high level). The impact of the timing of IHPC enrolment was evaluated in two ways: incidence rate ratios (IRR) of ED visits were determined 1) before and after IHPC enrolment in each group and 2) post-IHPC among groups. Results: A cohort of 17983 patients was analysed. Patients enrolled early in the IHPC programme had a significantly lower incidence rate of ED visits than the pre-enrolment period (IRR=0.65). The incidence rates of white/green and yellow/red ED visits were significantly lower post-IHPC enrolment for patients enrolled early (IRR= 0.63 and 0.67, respectively). All results were statistically significant (p<0.001). Comparing the IHPC groups after enrolment versus the short group, medium and long IHPC groups had a significant reduction of ED visits (IRR=0.37, IRR=0.14 respectively), showing a relation between the timing of IHPC enrolment and the incidence of ED visits. A similar trend was observed after accounting for triage tags of ED visits. Conclusion: The timing of IHPC enrolment is related with a variation of the incidence of ED visits. Early IHPC enrolment is related to a high significant reduction of ED visits when compared to the 90-day pre-IHPC enrolment period and to late IHPC enrolment, accounting for both low-level and medium-to-high level emergency ED visits

Trends and Characteristics of Emergency Medical Services in Italy: A 5-Years Population-Based Registry Analysis

Background: Emergency Medical Services (EMS) plays a fundamental role in providing good quality healthcare services to citizens, as they are the first responders in distressing situations. Few studies have used available EMS data to investigate EMS call characteristics and subsequent responses. Methods: Data were extracted from the emergency registry for the period 2013–2017. This included call and rescue vehicle dispatch information. All relationships in analyses and differences in events proportion between 2013 and 2017 were tested against the Pearson’s Chi-Square with a 99% level of confidence. Results: Among the 2,120,838 emergency calls, operators dispatched at least one rescue vehicle for 1,494,855. There was an estimated overall incidence of 96 emergency calls and 75 rescue vehicles dispatched per 1000 inhabitants per year. Most calls were made by private citizens, during the daytime, and were made from home (63.8%); 31% of rescue vehicle dispatches were advanced emergency medical vehicles. The highest number of rescue vehicle dispatches ended at the emergency department (74.7%). Conclusions: Our data showed that, with some exception due to environmental differences, the highest proportion of incoming emergency calls is not acute or urgent and could be more effectively managed in other settings than in an Emergency Departments (ED). Better management of dispatch can reduce crowding and save hospital emergency departments time, personnel, and health system costs.Peer ReviewedPostprint (published version

New Treatment Options for Hyperkalemia in Patients with Chronic Kidney Disease

Hyperkalemia may cause life-threatening cardiac and neuromuscular alterations, and it is associated with high mortality rates. Its treatment includes a multifaceted approach, guided by potassium levels and clinical presentation. In general, treatment of hyperkalemia may be directed towards stabilizing cell membrane potential, promoting transcellular potassium shift and lowering total K+ body content. The latter can be obtained by dialysis, or by increasing potassium elimination by urine or the gastrointestinal tract. Until recently, the only therapeutic option for increasing fecal K+ excretion was represented by the cation-exchanging resin sodium polystyrene sulfonate. However, despite its common use, the efficacy of this drug has been poorly studied in controlled studies, and concerns about its safety have been reported. Interestingly, new drugs, namely patiromer and sodium zirconium cyclosilicate, have been developed to treat hyperkalemia by increasing gastrointestinal potassium elimination. These medications have proved their efficacy and safety in large clinical trials, involving subjects at high risk of hyperkalemia, such as patients with heart failure and chronic kidney disease. In this review, we discuss the mechanisms of action and the updated data of patiromer and sodium zirconium cyclosilicate, considering that the availability of these new treatment options offers the possibility of improving the management of both acute and chronic hyperkalemia

PCDH19 mutations in female patients from Southern Italy

AbstractPurposeMutations in PCDH19, encoding protocadherin 19 on chromosome X, cause familial epilepsy and mental retardation limited to females or Dravet-like syndrome. We wished to explore the causative role of PCDH19 gene (Xq22) in female patients with epilepsy, from Southern Italy.MethodsDirect sequencing of PCDH19 gene was conducted in 31 unrelated female patients with early onset (<1 year of age) epilepsy and a wide spectrum of phenotypes including febrile seizures, focal and generalized forms, with either sporadic or familial distribution.ResultsWe identified two de novo heterozygous novel mutations of PCDH19 gene (p.Arg550Pro, Ile508ProfsX59) in two of 31 unrelated female patients. We also identified a novel silent mutation p.Ser856=.ConclusionsThe present findings confirm that PCDH19 is a major causative gene for infantile onset familial or sporadic epilepsy in female patients with or without mental retardation