Exploring the Factors Associated with Non-Urgent Emergency Department Utilization by Individuals with Mental Illness in Southwestern Ontario

There has been an increase in Emergency Department (ED) visits for mental health care across North America. Those with mental illness are at an increased risk for frequent ED visitation, often visiting for non-urgent reasons. While a plethora of literature exists examining frequent ED use for mental health care, there is little known about those who use the ED for non-urgent psychiatric complaints. The purpose of this secondary data analysis was to explore the independent predictors of non-urgent ED use for mental health care. A total of 13,114 observations were examined using logistic regression with generalized estimating equations modeling. The findings suggest the following characteristics are predictive of non-urgent ED use for mental health care: age, season, time of day, access to primary health care, mode of arrival, hospital type, patient diagnosis and referral source. Unadjusted analyses also suggest that the wait time, the main provider in the ED, residential status, and the disposition status are associated with non-urgent ED use for mental health care. Future research should aim to incorporate a prospective study design and a qualitative methodology to gain an understanding of the contextual factors that influence those using the ED for nonurgent mental health care

Physical Assessment Skills Used by Registered Nurses

Background: Nurses work in a wide variety of settings. Therefore, it is essential for nursing educators to continually evaluate and adapt nursing programs to ensure that the curricula prepare students to practice in a variety of health care settings. In this study, we sought to determine which skills were routinely used by registered nurses and to examine whether the cumulative number of practice settings influenced the number, and type, of physical assessments used. Methods: An electronic or a paper survey was distributed to registered nurses who worked as nursing clinical instructors at a mid-sized university in this cross-sectional study. Measures of frequency and central tendency described participant characteristics and physical assessment skills. A Kruskal-Wallis test was used to investigate an association between the number of practice settings and physical assessment skills used. Results: Forty-nine surveys were completed (59.8% return rate), with 47 surveys used for inferential statistics. Practice settings ranged from one to six, with a median of two employment areas. Medical-surgical was the most common setting (65.3%). Respondents identified 25 physical assessment skills as being performed routinely in their clinical practice; 11 skills were routinely performed by 80% of respondents. The median number of core skills routinely performed in clinical practice was not statistically significant (x2 = 4.03; p = .25). Conclusion:  Academic and clinical nursing educators, policymakers, and nursing managers can use this study’s findings to supplement decision-making concerning nursing employment and continuing education opportunities. Résumé Contexte : Les infirmières sont appelées à travailler dans des milieux de soins très différents. Il est donc essentiel que les formatrices en sciences infirmières évaluent et modifient sur une base régulière les programmes d’études afin d’assurer que ceux-ci préparent les étudiantes à pratiquer dans divers milieux de soins de santé. Dans cette étude, nous avons cherché à cerner les habiletés auxquelles les infirmières font couramment appel et à déterminer si le nombre total de milieux de pratique influence le nombre et le type d’habiletés d’évaluation physique utilisées. Moyens : Dans le cadre de cette étude transversale, un sondage électronique ou papier a été remis aux infirmières qui travaillaient comme formatrices cliniques dans une université de taille moyenne. Les mesures de fréquence et de tendance centrale ont permis de décrire les caractéristiques des participantes et les habilités d’évaluation de la santé physique. Un test de Kruskal-Wallis a permis d’étudier le lien entre le nombre de milieux de pratique d’une infirmière et les habilités d’évaluation physique qu’elle utilise. Résultats : Au total, 49 formulaires furent remplis (taux de réponse de 59,8 %) et 47 d’entre eux furent utilisés à des fins de statistiques. Le nombre de milieux de pratique variait d’un à six, avec une médiane de deux secteurs d’emploi. Le milieu de pratique le plus répandu était celui de la médecine-chirurgie (65,3 %). Les répondantes ont indiqué qu’elles faisaient couramment appel à 25 habiletés d’évaluation physique dans leur pratique clinique; 11 de ces habiletés étaient pratiquées sur une base régulière par 80 % des répondantes. Le nombre médian d’habiletés essentielles couramment mises à profit en pratique clinique n’était pas statistiquement significatif (x2 = 4.03; p = .25). Conclusion :  Les formatrices en milieux universitaires et cliniques, les décideurs politiques et les infirmières gestionnaires peuvent se servir des résultats de cette étude pour étayer leurs décisions concernant les activités de développement professionnel en cours d’emploi pour les infirmières

Prehospital prediction of hospital admission for emergent acuity patients transported by paramedics: A population-based cohort study using machine learning.

IntroductionThe closest emergency department (ED) may not always be the optimal hospital for certain stable high acuity patients if further distanced ED's can provide specialized care or are less overcrowded. Machine learning (ML) predictions may support paramedic decision-making to transport a subgroup of emergent patients to a more suitable, albeit more distanced, ED if hospital admission is unlikely. We examined whether characteristics known to paramedics in the prehospital setting were predictive of hospital admission in emergent acuity patients.Materials and methodsWe conducted a population-level cohort study using four ML algorithms to analyze ED visits of the National Ambulatory Care Reporting System from January 1, 2018 to December 31, 2019 in Ontario, Canada. We included all adult patients (≥18 years) transported to the ED by paramedics with an emergent Canadian Triage Acuity Scale score. We included eight characteristic classes as model predictors that are recorded at ED triage. All ML algorithms were trained and assessed using 10-fold cross-validation to predict hospital admission from the ED. Predictive model performance was determined using the area under curve (AUC) with 95% confidence intervals and probabilistic accuracy using the Brier Scaled score. Variable importance scores were computed to determine the top 10 predictors of hospital admission.ResultsAll machine learning algorithms demonstrated acceptable accuracy in predicting hospital admission (AUC 0.77-0.78, Brier Scaled 0.22-0.24). The characteristics most predictive of admission were age between 65 to 105 years, referral source from a residential care facility, presenting with a respiratory complaint, and receiving home care.DiscussionHospital admission was accurately predicted based on patient characteristics known prehospital to paramedics prior to arrival. Our results support consideration of policy modification to permit certain emergent acuity patients to be transported to a further distanced ED. Additionally, this study demonstrates the utility of ML in paramedic and prehospital research

Evaluating emergency department transfers from urgent care centres: insights for paramedic integration with subacute healthcare

Objective Paramedics redirecting non-emergent patients from emergency departments (EDs) to urgent care centres is a new and forthcoming strategy to reduce overcrowding and improve primary care integration. Which patients are likely not suitable for paramedic redirection are unknown. To describe and specify patients inappropriate for urgent care centres, we examined associations between patient characteristics and transfer to the ED after patients initially presented to an urgent care centre.Methods A population-based retrospective cohort study of all adult (≥18 years) visits to an urgent care centre from 1 April 2015 to 31 March 2020 in Ontario, Canada. Binary logistic regression was used to determine unadjusted and adjusted associations between patient characteristics and being transferred to an ED using OR and 95% CIs. We calculated the absolute risk difference for the adjusted model.Results A total of 1 448 621 urgent care visits were reported, with 63 343 (4.4%) visits transferred to an ED for definitive care. Being 65 years and older (OR 2.29, 95% CI 2.23 to 2.35), scored an emergent Canadian Triage and Acuity Scale of 1 or 2 (OR 14.27, 95% CI 13.45 to 15.12) and higher comorbidity count (OR 1.51, 95% CI 1.46 to 1.58) had added odds of association with being transferred out to an ED.Conclusion Readily available patient characteristics were independently associated with interfacility transfers between urgent care centres and the ED. This study can support paramedic redirection protocol development, highlighting which patients may not be best suited for ED redirection

Quantifying the escalating impact of paramedic transported emergency department visits for opioid-related conditions in Ontario, Canada: A population-based cohort study.

IntroductionWhile overdoses comprise the majority of opioid research, the comprehensive impact of the opioid crisis on emergency departments (EDs) and paramedic services has not been reported. We examined temporal changes in population-adjusted incidence rates of ED visits and paramedic transports due to opioid-related conditions.Materials and methodsWe conducted a population-based cohort study of all ED visits in the National Ambulatory Care Reporting System from January 1, 2009 to December 31, 2019 in Ontario, Canada. We included all patients with a primary diagnosis naming opioids as the underlying cause for the visit, without any other drugs or substances. We clustered geographic regions using Local Health Integration Network boundaries. Descriptive statistics, incidence rate ratios (IRR) and 95% confidence intervals (CIs) were calculated to analyze population-adjusted temporal changes.ResultsOverall, 86,403 ED visits were included in our study. Incidence of opioid-related ED visits increased by 165% in the study timeframe, with paramedic transported patients increasing by 429%. Per 100,000 residents, annual ED visits increased from 40.4 to 97.2, and paramedic transported patients from 12.1 to 67.9. The proportion of opioid-related ED visits transported by paramedics increased from 35.0% to 69.9%. The medical acuity of opioid-related ED visits increased throughout the years (IRR 6.8. 95% CI 5.9-7.7), though the proportion of discharges remained constant (~75%). The largest increases in ED visits and paramedic transports were concentrated to urbanized regions.DiscussionOpioid-related ED visits and paramedic transports increased substantially between 2009 and 2019. The proportion of ED visits transported by paramedics doubled. Our findings could provide valuable support to health stakeholders in implementing timely strategies aimed at safely reducing opioid-related ED visits. The increased use of paramedics followed by high rates of ED discharge calls for exploration of alternative care models within paramedic systems, such as direct transport to specialized substance abuse centres

Examining the association between paramedic transport to the emergency department and hospital admission: a population-based cohort study

Abstract Background Increasing hospitalization rates present unique challenges to manage limited inpatient bed capacity and services. Transport by paramedics to the emergency department (ED) may influence hospital admission decisions independent of patient need/acuity, though this relationship has not been established. We examined whether mode of transportation to the ED was independently associated with hospital admission. Methods We conducted a retrospective cohort study using the National Ambulatory Care Reporting System (NACRS) from April 1, 2015 to March 31, 2020 in Ontario, Canada. We included all adult patients (≥18 years) who received a triage score in the ED and presented via paramedic transport or self-referral (walk-in). Multivariable binary logistic regression was used to determine the association of mode of transportation between hospital admission, after adjusting for important patient and visit characteristics. Results During the study period, 21,764,640 ED visits were eligible for study inclusion. Approximately one-fifth (18.5%) of all ED visits were transported by paramedics. All-cause hospital admission incidence was greater when transported by paramedics (35.0% vs. 7.5%) and with each decreasing Canadian Triage and Acuity Scale level. Paramedic transport was independently associated with hospital admission (OR = 3.76; 95%CI = 3.74–3.77), in addition to higher medical acuity, older age, male sex, greater than two comorbidities, treatment in an urban setting and discharge diagnoses specific to the circulatory or digestive systems. Conclusions Transport by paramedics to an ED was independently associated with hospital admission as the disposition outcome, when compared against self-referred visits. Our findings highlight patient and visit characteristics associated with hospital admission, and can be used to inform proactive healthcare strategizing for in-patient bed management

Examining the utility and accuracy of the interRAI Emergency Department Screener in identifying high‐risk older emergency department patients: A Canadian multiprovince prospective cohort study

Abstract Objectives We set out to determine the accuracy of the interRAI Emergency Department (ED) Screener in predicting the need for detailed geriatric assessment in the ED. Our secondary objective was to determine the discriminative ability of the interRAI ED Screener for predicting the odds of discharge home and extended ED length of stay (>24 hours). Methods We conducted a multiprovince prospective cohort study in Canada. The need for detailed geriatric assessment was determined using the interRAI ED Screener and the interRAI ED Contact Assessment as the reference standard. A score of ≥5 was used to classify high‐risk patients. Assessments were conducted by emergency and research nurses. We calculated the sensitivity, positive predictive value, and false discovery rate of the interRAI ED Screener. We employed logistic regression to predict ED outcomes while adjusting for age, sex, academic status, and the province of care. Results A total of 5629 older ED patients across 11 ED sites were evaluated using the interRAI ED Screener and 1061 were evaluated with the interRAI ED Contact Assessment. Approximately one‐third of patients were discharged home or experienced an extended ED length of stay. The interRAI ED Screener had a sensitivity of 93%, a positive predictive value of 82%, and a false discovery rate of 18%. The interRAI ED Screener predicted discharge home and extended ED length of stay with fair accuracy. Conclusion The interRAI ED Screener is able to accurately and rapidly identify individuals with medical complexity. The interRAI ED Screener predicts patient‐important health outcomes in older ED patients, highlighting its value for vulnerability screening

Agreement between independent emergency physician’s judgments on the suitability of ED visits that could have been managed in subacute primary care.

Agreement between independent emergency physician’s judgments on the suitability of ED visits that could have been managed in subacute primary care.</p

Contingency tables.

Data of EDAC classes and ED physician judgments with different groupings of the Potentially Avoidable class. (DOCX)</p

Clinical and non-clinical characteristics of ED visits used in the study, categorized by EDAC class.

Clinical and non-clinical characteristics of ED visits used in the study, categorized by EDAC class.</p