Purpose
Patients with cancer often experience medical events that require immediate evaluation. These evaluations typically occur in an emergency department (ED), but there is increasing interest in ...providing this care in other settings. We report on a novel care model whereby a nursing hotline is used to triage patients to the ED or to the North Carolina Cancer Hospital Infusion Center (NCCHIC).
Methods
A retrospective study of adult patients with a neoplasm diagnosis seeking acute care at a large academic hospital pre- and post-initiation of the novel care model in January of 2016. Patients were identified by querying the electronic medical record and clinic administrative data during matched 6 month pre- and post-periods.
Results
During the pre-initiation period, 1346 patients visited the ED on 1651 occasions (76.1% admission rate). In the post-initiation period, 1434 patients visited the ED on 1797 occasions (81.5% admission rate), and 246 patients visited the NCCHIC on 322 occasions (68.9% admission rate). The emergency severity index (ESI) in the pre-initiation ED group was primarily ESI 2 (30.6%) and ESI 3 (65.4%). In the post-initiation ED group, the ESI was similar (32.6% ESI 2 and 64.2% ESI 3). In contrast, the NCCHIC predominantly treated lower acuity patients (65.8% calculated ESI of 4/5).
Conclusions
This model demonstrates a multidisciplinary partnership to providing acute unscheduled care for patients with cancer. In the early implementation phase of this model, approximately 15% of patients, generally of lower acuity, were seen in the NCCHIC.
Emergency departments (EDs) have been increasingly utilized over time for psychiatric care. While multiple studies have assessed these trends in nationally representative data, few have evaluated ...these trends in state-level data. This investigation seeks to understand the mental health-related ED burden in North Carolina (NC) by describing trends in ED visits associated with a mental health diagnosis (MHD) over time.
Using data from NC DETECT, this investigation describes trends in NC ED visits from January 1, 2008 through December 31, 2014 by presence of a MHD code. A visit was classified by the first listed MHD ICD-9-CM code in the surveillance record and MHD codes were grouped into related categories for analysis. Visits were summarized by MHD status and by MHD category.
Over 32 million ED visits were recorded from 2008 to 2014, of which 3,030,746 (9.4%) were MHD-related visits. The average age at presentation for MHD-related visits was 50 years (SD 23.5) and 63.9% of visits were from female patients. The proportion of ED visits with a MHD increased from 8.3 to 10.2% from 2008 to 2014. Annually and overall, the largest diagnostic category was stress/anxiety/depression. Hospital admissions resulting from MHD-related visits declined from 32.2 to 18.5% from 2008 to 2014 but remained consistently higher than the rate of admissions among non-MHD visits.
Similar to national trends, the proportion of ED visits associated with a MHD in NC has increased over time. This indicates a need for continued surveillance, both stateside and nationally, in order to inform future efforts to mitigate the growing ED burden.
Purpose
The objectives of this study were to investigate sensitivity and specificity of myocardial infarction (MI) case definitions using multiple discharge code positions and multiple diagnosis ...codes when comparing administrative data to hospital surveillance data.
Methods
Hospital surveillance data for ARIC Study cohort participants with matching participant ID and service dates to Centers for Medicare and Medicaid Services (CMS) hospitalization records for hospitalizations occurring between 2001 and 2013 were included in this study. Classification of Definite or Probable MI from ARIC medical record review defined “gold standard” comparison for validation measures. In primary analyses, an MI was defined with ICD9 code 410 from CMS records. Secondary analyses defined MI using code 410 in combination with additional codes.
Results
A total of 25 549 hospitalization records met study criteria. In primary analysis, specificity was at least 0.98 for all CMS definitions by discharge code position. Sensitivity ranged from 0.48 for primary position only to 0.63 when definition included any discharge code position. The sensitivity of definitions including codes 410 and 411.1 were higher than sensitivity observed when using code 410 alone. Specificity of these alternate definitions was higher for women (0.98) than for men (0.96).
Conclusion
Algorithms that rely exclusively on primary discharge code position will miss approximately 50% of all MI cases due to low sensitivity of this definition. We recommend defining MI by code 410 in any of first 5 discharge code positions overall and by codes 410 and 411.1 in any of first 3 positions for sensitivity analyses of women.
Professional health organizations recommend that outpatient cardiac rehabilitation programs include activities to optimize the physical, mental, and social well-being of patients. The study ...objectives were to describe among cardiac rehabilitation programs (1) mental health assessments performed; (2) psychosocial services offered; and (3) leadership's perception of barriers to psychosocial services offerings.
A cross-sectional survey of North Carolina licensed outpatient cardiac rehabilitation programs on their 2018 services was conducted. Descriptive statistics were used to summarize survey responses. Thematic analysis of free text questions related to barriers to programmatic establishment or expansion of psychosocial services was performed by two team members until consensus was reached.
Sixty-eight programs (89%) responded to the survey. Forty-eight programs (70%) indicated offering psychosocial services; however, a majority (73%) of programs reported not directly billing for those services. At program enrollment, mental health was assessed in 94% of programs of which 92% repeated the assessment at discharge. Depression was assessed with the 9-item Patient Health Questionnaire by a majority (75%) of programs. Psychosocial services included individual counseling (59%), counseling referrals (49%), and educational classes (29%). Directors reported lack of internal resources (92%) and patient beliefs (45%) as the top barriers to including or expanding psychosocial services at their facilities.
Cardiac rehabilitation programs routinely assess mental health but lack the resources to establish or expand psychosocial services. Interventions aimed at improving patient education and reducing stigma of mental health are important public health opportunities.
Whether patients present to the emergency department (ED) with physical ailments and comorbid psychiatric needs or primary psychiatric complaints, understanding differences in clinically relevant age ...and sex patterns over time is crucial to optimal psychiatric care in the ED setting. We used population-level surveillance data provided by the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) from January 1, 2008, through December 31, 2014. Mental health-related (MHR) ED visits were identified by International Classification of Diseases, Clinical Modification 9th revision (ICD-9-CM) codes analyzed in the Agency for Healthcare Research and Quality (AHRQ) clinical classification software groupings of related diagnostic categories. Trends were assessed based on total and average annual visit counts. We identified approximately 4 million MHR ED visits. The average number of visits per year was highest among 50-year-olds, while patients over the age of 90 had the highest proportion of their ED visits associated with an MHR code. Mood disorders were more prevalent among females, while substance use disorders were more prevalent among males. Within MHR categories, age-related peaks did not differ by sex except for suicide and self-inflicted injury. Whether it be a teenage boy presenting with suicidal ideation, a middle-aged man presenting with alcohol abuse, or an elderly female presenting with dementia, ED MHR visits’ needs vary across the lifespan. Understanding these trends is important to holistic patient care.
•Middle aged adults had the largest average annual number of mental health-related visits.•Geriatric adults were most likely to have a mental health comorbidity with their ED visit.•Visits associated with suicide/self-injury had the largest annual growth rates.•Mood disorders drove the presentation of female patients to the ED.•Substance use disorders were more common among male patients.
This update describes changes to the Brief Educational Tool to Enhance Recovery (BETTER) trial in response to the COVID-19 pandemic.
The original protocol was published in Trials. Due to the COVID-19 ...pandemic, the BETTER trial converted to remote recruitment in April 2020. All recruitment, consent, enrollment, and randomization now occur by phone within 24 h of the acute care visit. Other changes to the original protocol include an expansion of inclusion criteria and addition of new recruitment sites. To increase recruitment numbers, eligibility criteria were expanded to include individuals with chronic pain, non-daily opioid use within 2 weeks of enrollment, presenting musculoskeletal pain (MSP) symptoms for more than 1 week, hospitalization in past 30 days, and not the first time seeking medical treatment for presenting MSP pain. In addition, recruitment sites were expanded to other emergency departments and an orthopedic urgent care clinic.
Recruiting from an orthopedic urgent care clinic and transitioning to remote operations not only allowed for continued participant enrollment during the pandemic but also resulted in some favorable outcomes, including operational efficiencies, increased enrollment, and broader generalizability.
ClinicalTrials.gov NCT04118595 . Registered on October 8, 2019.
Chronic musculoskeletal pain (MSP) affects more than 40% of adults aged 50 years and older and is the leading cause of disability in the USA. Older adults with chronic MSP are at risk for ...analgesic-related side effects, long-term opioid use, and functional decline. Recognizing the burden of chronic MSP, reducing the transition from acute to chronic pain is a public health priority. In this paper, we report the protocol for the Brief EducaTional Tool to Enhance Recovery (BETTER) trial. This trial compares two versions of an intervention to usual care for preventing the transition from acute to chronic MSP among older adults in the emergency department (ED).
Three hundred sixty patients from the ED will be randomized to one of three arms: full intervention (an interactive educational video about pain medications and recovery-promoting behaviors, a telecare phone call from a nurse 48 to 72 h after discharge from the ED, and an electronic communication containing clinical information to the patient's primary care provider); video-only intervention (the interactive educational video but no telecare or primary care provider communication); or usual care. Data collection will occur at baseline and at 1 week and 1, 3, 6, and 12 months after study enrollment. The primary outcome is a composite measure of pain severity and interference. Secondary outcomes include physical function, overall health, opioid use, healthcare utilization, and an assessment of the economic value of the intervention.
This trial is the first patient-facing ED-based intervention aimed at helping older adults to better manage their MSP and reduce their risk of developing chronic pain. If effective, future studies will examine the effectiveness of implementation strategies.
ClinicalTrials.gov NCT04118595 . Registered on 8 October 2019.
Objective
To determine whether a Brief Negotiation Interview (BNI) performed in the emergency department (ED) can reduce future rates of alcohol use among older adults who are high‐risk drinkers.
...Methods
Adults aged 65 years and older in a single academic ED were screened for high‐risk alcohol use based on the National Institute for Alcohol Abuse and Alcoholism definition of >7 drinks per week or >3 drinks per occasion. Eligible individuals who were high‐risk drinkers who passed a cognitive impairment screener and who consented to enrollment were randomly assigned to receive the BNI versus usual care. Outcomes were assessed at 3, 6, and 12 months. The primary outcome was the rate of high‐risk alcohol use at 6 months.
Results
Of 2250 ED patients who were screened, 183 (8%) met the criteria for high‐risk alcohol use. Of those, 98 (53%) patients met full criteria and consented to participation. Of the participants, 67% were men and 83% were non‐Hispanic White. There was no significant difference in the primary outcome of high‐risk alcohol use at 6 months between the BNI at 59.1% (95% confidence interval CI, 45.5%–76.8%) and the control at 49.1% (95% CI, 36.9%–65.2%). However, there was a significant time‐effect reduction in alcohol consumption and rates of high‐risk alcohol use for both groups.
Conclusion
Among older adults who met the criteria for high‐risk alcohol use, the BNI in the ED did not result in a reduction in high‐risk alcohol use at 6 months, although both groups showed significant reductions after their ED visit. Further work is needed to determine the optimal setting and time to use the BNI to impact high‐risk alcohol use in this population.
Musculoskeletal pain is a common reason for emergency department (ED) visits. Following discharge from the ED, patients, particularly older patients, often have difficulty controlling their pain and ...managing analgesic side effects. We conducted a pilot study of an educational video about pain management with and without follow-up telephone support for older adults presenting to the ED with musculoskeletal pain.
ED patients aged 50 years and older with musculoskeletal pain were randomized to: (1) usual care, (2) a brief educational video only, or (3) a brief educational video plus a protocol-guided follow-up telephone call from a physician 48-72 hours after discharge (telecare). The primary outcome was the change from the average pain severity before the ED visit to the average pain severity during the past week assessed one month after the ED visit. Pain was assessed using a 0-10 numerical rating scale.
Of 75 patients randomized (mean age 64 years), 57 (76%) completed follow up at one month. Of the 18 patients lost to follow up, 12 (67%) had non-working phone numbers. Among patients randomized to the video (arms 2 and 3), 46/50 viewed the entire video; among the 25 patients randomized to the video plus telecare (arm 3), 23 were reached for telecare. Baseline pain scores for the usual care, video, and video plus telecare groups were 7.3, 7.1, and 7.5. At one month, pain scores were 5.8, 4.9, and 4.5, corresponding to average decreases in pain of -1.5, -2.2, and -3.0, respectively. In the pairwise comparison between intervention groups, the video plus telecare group had a 1.7-point (95% CI 1.2, 2.1) greater decrease in pain compared to usual care, and the video group had a 1.1-point (95% CI 0.6, 1.6) greater decrease in pain compared to usual care after adjustment for baseline pain, age, and gender. At one month, clinically important differences were also observed between the video plus telecare and usual care groups for analgesic side effects, ongoing opioid use, and physical function.
Results of this pilot trial suggest the potential value of an educational video plus telecare to improve outcomes for older adults presenting to the ED with musculoskeletal pain. Changes to the protocol are identified to increase retention for assessment of outcomes.
ClinicalTrials.gov, NCT02438384 . Registered on 5 May 2015.
The nationwide prevalence of mental illness among pediatric patients is rising. Subsequently, reliance upon the emergency department (ED) for psychiatric care is increasing. EDs are not equipped to ...handle this growing patient population. In the face of limited health care resources, there is a need to further understand these patients and their health care outcomes to further improve the capacity of emergency psychiatric care.
PDF
