Overtaxed US emergency care system needs reorganisation.
Ontology highlight
ABSTRACT:
SUBMITTER: Bristol N
PROVIDER: S-EPMC1482363 | biostudies-literature | 2006 Jun
REPOSITORIES: biostudies-literature
Publications
Overtaxed US emergency care system needs reorganisation.
BMJ (Clinical research ed.) 20060601 7556
Similar Datasets
Project description:IntroductionAcute childhood illnesses, such as malaria, pneumonia, and diarrhoea, represent the leading causes of under-five mortality in Uganda. Given that most early child deaths are treatable with timely interventions, emergency units dedicated to paediatric populations have been established in the country. In light of recent developments, the department of paediatrics at Makerere University requested a needs assessment in the paediatric acute care unit (PACU) at Mulago National Referral Hospital, which could guide the development of a new training curriculum for medical providers.MethodsWe administered a survey for medical providers working in the PACU at Mulago Hospital, which assessed their self-rated comfort levels with paediatric assessment, treatment, and teamwork skills. We also conducted focus groups with a smaller subset of medical providers to understand barriers and facilitators to paediatric emergency and critical care.ResultsOf 35 paediatric assessment, treatment, and teamwork skills, 29 (83%) questions had the median comfort rating of 6 or 7 on a 7-point Likert scale. The remaining 6 (17%) skills had a median comfort rating of 5 or lower. Focus groups identified a number of major barriers to caring for critically ill children, including limited resources and staffing, training gaps, and challenges with interprofessional teamwork. In terms of training development, focus group participants suggested continuous training for all medical providers working in the PACU led by local leaders.DiscussionThis study identified the need and desirability of continuous trainings in the PACU. Key components include objective skills assessment, simulation-based scenarios, and interprofessional teamwork. Training development should be augmented by increases in resources, staffing, and training opportunities in collaboration with the Uganda Ministry of Health.
| S-EPMC8058529 | biostudies-literature
Project description:IntroductionConsideration of the cost of care and value in healthcare is now a recognized element of physician training. Despite the urgency to educate trainees in high-value care (HVC), educational curricula and evaluation of these training paths remain limited, especially with respect to emergency medicine (EM) residents. We aimed to complete a needs assessment and evaluate curricular preferences for instruction on HVC among EM residents.MethodsThis was a qualitative, exploratory study using content analysis of two focus groups including a total of eight EM residents from a single Midwestern EM residency training program. Participants also completed a survey questionnaire.ResultsThere were two themes. Within the overall theme of resident experience with and perception of HVC, we found five sub-themes: 1) understanding of HVC focuses on diagnosis and decision-making; 2) concern about patient costs, including the effects on patients' lives and their ability to engage with recommended outpatient care; 3) conflict between internal beliefs and external expectations, including patients' perceptions of value; 4) approach to HVC changes with increasing clinical experience; and 5) slow-moving, political discussion around HVC. Within the overall theme of desired education and curricular design, we identified four sub-themes: 1) limited prior education on HVC and health economics; 2) motivation to receive training on HVC and health economics; 3) desire for discussion-based format for HVC curriculum; and 4) curriculum targeted to level of training. Respondents indicated greatest acceptability of interactive, discussion-based formats.DiscussionWe conducted a targeted needs assessment for HVC among EM residents. We identified broad interest in the topic and limited self-reported baseline knowledge. Curricular content may benefit from incorporating resident concerns about patient costs and conflict between external expectations and internal beliefs about HVC. Curricular design may benefit from a focus on interactive, discussion-based modalities and tailoring to the learner's level of training.
| S-EPMC10777185 | biostudies-literature
Project description:Background/objectivesPeople with dementia (PwD) frequently use emergency care services. To mitigate the disproportionately high rate of emergency care use by PwD, an understanding of contributing factors driving reliance on emergency care services and identification of feasible alternatives are needed. This study aimed to identify clinician, caregiver, and service providers' views and experiences of unmet needs leading to emergency care use among community-dwelling PwD and alternative ways of addressing these needs.DesignQualitative, employing semistructured interviews with clinicians, informal caregivers, and aging service providers.SettingWisconsin, United States.ParticipantsInformal caregivers of PwD (n = 4), emergency medicine physicians (n = 4), primary care physicians (n = 5), geriatric healthcare providers (n = 5), aging service providers (n = 6), and community paramedics (n = 3).MeasurementsDemographic characteristics of participants and data from semistructured interviews.FindingsFour major themes were identified from interviews: (1) system fragmentation influences emergency care use by PwD, (2) informational, decision-making, and social support needs influence emergency care use by PwD, (3) emergency departments (EDs) are not designed to optimally address PwD and caregiver needs, and (4) options to prevent and address emergency care needs of PwD.ConclusionParticipants identified numerous system and individual-level unmet needs and offered many recommendations to prevent or improve ED use by PwD. These novel findings, aggregating the perspectives of multiple dementia-care stakeholder groups, serve as the first step to developing interventions that prevent the need for emergency care or deliver tailored emergency care services to this vulnerable population through new approaches. J Am Geriatr Soc 67:711-718, 2019.
| S-EPMC6458085 | biostudies-literature
Project description:ObjectivesPatients seeking care in the emergency department (ED) often have unmet social needs that impact their health and health outcomes. Medical-legal partnerships (MLPs) have been shown to positively impact social and legal needs of patients yet few ED-MLPs exist. The goal of this study was to explore the prevalence of health-harming legal needs (HHLNs) that could be addressed through an ED-MLP.MethodsWe conducted a survey study of a convenience sample of patients seeking care in one ED located in the Southeastern United States over a 6-month period. Research assistants conducted a HHLNs survey following the income/insurance, housing and utilities, education and employment, legal status, personal and family stability (I-HELP) framework with eligible consenting participants. Results were analyzed using descriptive statistics.ResultsOf the total 205 participants, almost all the participants reported one or more HHLNs (n = 187, 91.7%) with many reporting 2 or more overlapping HHLNs (n = 152, 74.1%). The most common HHLNs reported were financial issues, access to benefits, and access to government insurance coverage or benefits. Many participants had concerns about housing and food insecurity.ConclusionOur results demonstrate that patients seeking care in the ED had multiple overlapping social and legal needs that could be addressed through an MLP. As EDs increasingly utilize social screeners to identify unmet needs, inclusion of HHLNs would be an important addition to expand resources and interventions available to patients.
| S-EPMC11868935 | biostudies-literature
Project description:ObjectivesTo quantify preoperative illness burden in older adults undergoing emergency major abdominal surgery (EMAS), to examine the association between illness burden and postoperative outcomes, and to describe end-of-life care in the year after discharge.DesignRetrospective study using data from Health and Retirement Study interviews linked to Medicare claims (2000-2012).SettingNational population-based dataset.ParticipantsMedicare beneficiaries who underwent EMAS.MeasurementsHigh illness burden, defined as ≥2 of the following vulnerabilities: functional dependence, dementia, use of helpers, multimorbidity, poor prognosis, high healthcare utilization. In-hospital outcomes were complications and mortality. Postdischarge outcomes included emergency department (ED) visits, hospitalization, intensive care unit (ICU) stay, and 365-day mortality. For individuals discharged alive who died within 365 days of surgery, outcomes included hospice use, hospitalization, ICU use, and ED use in the last 30 days of life. Multivariable regression was used to determine the association between illness burden and outcomes.ResultsOf 411 participants, 57% had high illness burden. More individuals with high illness burden had complications (45% vs 28% p=0.00) and in-hospital death (20% vs 9%, p=0.00) than those without. After discharge (n=349), individuals with high illness burden experienced more ED visits (57% vs 46%, P=.04) and were more likely to die (35% vs 13%, p=0.00). Of those who died after discharge (n=86), 75% had high illness burden, median survival was 67 days (range 21-141 days), 48% enrolled in hospice, 32% died in the hospital, 23% were in the ICU in the last 30 days of life and 37% had an ED visit in the last 30 days of life.ConclusionMost older adults undergoing EMAS have preexisting high illness burden and experience high mortality and healthcare use in the year after surgery, particularly near the end of life. Concurrent surgical and palliative care may improve quality of life and end-of-life care in these people. J Am Geriatr Soc 66:2072-2078, 2018.
| S-EPMC6494102 | biostudies-literature
Project description:ObjectivesIndividual-level social needs have been shown to substantially impact emergency department (ED) care transitions of older adults. The Geriatric Emergency care Applied Research (GEAR) Network aimed to identify care transition interventions, particularly addressing social needs, and prioritize future research questions.MethodsGEAR engaged 49 interdisciplinary stakeholders, derived clinical questions, and conducted searches of electronic databases to identify ED discharge care transition interventions in older adult populations. Informed by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) framework, data extraction and synthesis of included studies included the degree that intervention components addressed social needs and their association with patient outcomes. GEAR convened a consensus conference to identify topics of highest priority for future care transitions research.ResultsOur search identified 248 unique articles addressing care transition interventions in older adult populations. Of these, 17 individual care transition intervention studies were included in the current literature synthesis. Overall, common care transition interventions included coordination efforts, comprehensive geriatric assessments, discharge planning, and telephone or in-person follow-up. Fourteen of the 17 care transition intervention studies in older adults specifically addressed at least one social need within the PRAPARE framework, most commonly related to access to food, medicine, or health care. No care transition intervention addressing social needs in older adult populations consistently reduced subsequent health care utilization or other patient-centered outcomes. GEAR stakeholders identified that determining optimal outcome measures for ED-home transition interventions was the highest priority area for future care transitions research.ConclusionsED care transition intervention studies in older adults frequently address at least one social need component and exhibit variation in the degree of success on a wide array of health care utilization outcomes.
| S-EPMC8725618 | biostudies-literature
Project description:BackgroundEmergency care (EC) describes team-based, multidisciplinary clinical service provision, advocacy and health systems strengthening to address all urgent aspects of illness and injury for all people. In order to improve facility-based EC delivery, a structured framework is necessary to outline current capacity and future needs. This paper draws on examples of EC Needs Assessments performed at the national hospitals of three different Pacific Island Countries (PICs), to describe the development, implementation and validation of a structured assessment tool and methodological approach to conducting an EC Needs Assessment in the Pacific region.MethodsThis is a retrospective, descriptive analysis of the development of the Pacific Emergency Care Assessment (PECA) table using patient-focused principles within an EC systems framework. Tool implementation occurred through observation, literature review and interviews using a strengths-based, action-research and ethnographic methodological approach in Timor-Leste, Kiribati and the Solomon Islands. The 2014 Solomon Islands EC Needs Assessment provides the main context to illustrate and discuss the overall conduct, feasibility, validity and reliability of the PECA tool and methodological approach.ResultsIn each site, the methodological implementation enabled completion of both the PECA table and comprehensive report within approximately 6 weeks of first arriving in country. Reports synthesising findings, recommendations, priority action areas and strategies were distributed widely amongst stakeholders. Examples illustrate Face and Content, Construct and Catalytic validity, including subsequent process and infrastructure improvements triggered by the EC Needs Assessment in each site. Triangulation of information and consistency of use over time enhanced reliability of the PECA tool. Compared to other EC assessment models, the Pacific approach enabled rich data on capacity and real-life function of EC facilities. The qualitative, strengths-based method engenders long-term partnerships and positive action, but takes time and requires tailoring to a specific site.ConclusionIn PICs and other global contexts where EC resources are underdeveloped, a PECA-style approach to conducting an EC Needs Assessment can trigger positive change through high local stakeholder engagement. Testing this qualitative implementation method with a standardised EC assessment tool in other limited resource contexts is the next step to further improve global EC.
| S-EPMC7304213 | biostudies-literature
Project description:ObjectiveThis study examined family-reported ambulatory care quality and its association with emergency department and hospital utilization, and how these relationships differed across levels of medical complexity.Data sourcesThe 2006-2013 Medical Expenditure Panel Survey (MEPS).Study designSecondary analysis of MEPS data. Variables fitting the National Quality Measures Clearinghouse clinical quality measures domain framework were selected. Exploratory factor analysis grouped ambulatory quality into 12 access, experience, or process measures. Weighted negative binomial regression stratified by health status identified associations between ambulatory quality and ED visits or hospitalizations.Data collection41,497 children ≤18 years were included. The 5-item special health care needs (SHCN) screener categorized health status as complex, less complex, or no SHCN.Principal findingsWeighted SHCN proportions were 1.6 Percent complex, 18.2 Percent less complex, and 80.0 Percent no SHCN. Mean ED visits were 130 and 335 visits/1000 children/year for no/ complex SHCN, respectively. Mean hospitalizations were 20 and 175 hospitalizations/1000 children/year for no/complex SHCN, respectively. ED visits were associated with 8 of 12 quality measures for no/less complex SHCN. For example, usually/always receiving needed care right away was associated with 22 Percent lower ED visit rate (95% CI 0.64-0.96). Hospitalizations were associated with 4 of 12 quality measures for less complex SHCN. In complex SHCN, associations between ambulatory quality and ED/hospital use were weak and inconsistent.ConclusionsAmbulatory quality may best predict ED and hospital use for children with no or less complex SHCN. Whether and how ambulatory care predicts emergency and hospital care in complex SHCN remains an important question.
| S-EPMC7518884 | biostudies-literature
Project description:BackgroundPalliative Care offers patient-centered, symptom-focused relief for patients with incurable disease, and early integration of palliative care ensures quality of life and death while reducing medical impoverishment. The Emergency Department is an ideal yet understudied, under-utilized location to initiate palliative care.ObjectiveTo evaluate the palliative care needs of patients with incurable disease and perceived barriers amongst healthcare providers in the Emergency Department of Kiruddu National Referral Hospital, Kampala, Uganda.MethodsA mixed methods survey of Emergency Department healthcare workers and patients was conducted. A crosse sectional survey of ninety-nine patients was conducted using the integrated Palliative Care Outcome Scale (IPOS). Eleven interviews were conducted with healthcare workers at Kiruddu Hospital, identified by purposive sampling. Descriptive and inferential statistics were used to analyze quantitative data.. Grounded theory approach was used to construct the in depth interview questions, code and analyze qualitative results and collapse these results into final themes.ResultsThe most common diagnoses were HIV/HIV-TB (32 %), heart disease (18 %), and sickle cell disease (14 %). The prevalence of unmet palliative care needs was substantial: more that 70 % of patients reported untreated symptoms e.g., pain, fatigue, difficulty breathing. Seventy-seven percent of the population reported severe or overwhelming pain. The main barriers to provision of palliative care in the Emergency Department as identified by healthcare workers were: (1) lack of adequate training in palliative care; (2) Challenges due to patient volume and understaffing; (3) the misconception that palliative care is associated with pain management alone; (4) Financial constraints as the greatest challenge faced by patients with incurable disease.ConclusionsWe report a high prevalence of unmet palliative care needs among patients in this urban Ugandan Emergency Department, and important barriers reported by emergency healthcare providers. Identification of these barriers offers opportunities to overcome them including harnessing novel mHealth interventions such as clinical support apps or telehealth palliative care consultants. Integration of palliative care in this setting would improve the care of vulnerable patients, provide healthcare workers with an additional care modality while likely adding value to the health system.
| S-EPMC10757186 | biostudies-literature
Project description:ObjectivesThis study explored the process of care for persons living with dementia (PLWDs) in various care settings across a tertiary care system and considers challenges and opportunities for change.DesignAimed at quality improvement, qualitative interviews were conducted with key stakeholders in dementia care across geriatric outpatient clinics, medical and psychiatric emergency departments, and the main hospital in 2016.Setting and participantsForty-nine interactive interviews were conducted with a purposive and snowball sampling of health care professionals (physicians, nurses, social workers, administrators) and families in a large, academic health care system.MeasuresQualitative interview guides were developed by the study team to assess the process of care for PLWDs and strengths and challenges to delivering that care.ResultsKey themes emerging from the interviews in each care setting are presented. The outpatient setting offers expertise, a multidisciplinary clinic, and research opportunities, but needs to respond to long waitlists, space limitations, and lack of consensus about who owns dementia care. The emergency department offers a low nurse/patient ratio and expertise in acute medical problems, but experiences competing demands and staff turnover; additionally, dementia does not appear on medical records, which can impede care. The hospital offers consultative services and resources, yet the physical space is confined and chaotic; sitters and antipsychotics can be overused, and placement outside of the hospital for PLWDs can be a challenge.Conclusions and implicationsFive key recommendations are provided to help health systems proactively prepare for the coming boom of PLWD and their caregivers, including outpatient education, a dementia care management program to link services, Internet-based training for providers, and repurposing sitters as Elder Life specialists.
| S-EPMC6768732 | biostudies-literature