Transitional care clinics for patients discharged from hospital without a primary care provider: A systematic review.

BACKGROUND: The transition from hospital to home is a high-risk period. Timely follow-up care is essential to reducing avoidable harms such as adverse drug events, yet may be unattainable for patients who lack attachment to a primary care provider. Transitional care clinics (TCCs) have been proposed as a measure to improve health outcomes for patients discharged from hospital without an established provider. In this systematic review, we compared outcomes for unattached patients seen in TCCs after hospital discharge relative to care as usual. METHODS: We searched the following bibliographic databases for articles published on or before August 12, 2022: MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, PsycINFO, and Web of Science. Five studies were identified that examined the effects of a dedicated postdischarge clinic on emergency department (ED) visits, readmissions, and/or mortality within 90 days of discharge for patients with no attachment to a primary care provider. RESULTS: Studies were heterogeneous in design and quality; all were from urban centers within the United States. Four of the five studies reported a reduction in either the number of ED visits or readmissions in patients seen in a TCC following hospitalization. CONCLUSIONS: TCCs may be effective in reducing hospital contacts in the period following hospital discharge in patients with no established primary care provider. Further studies are required to evaluate the health benefits attributable to the implementation of TCCs across a broad range of practice contexts, as well as the cost implications of this model.

Does implementation of a diagnostic pathway for acute aortic syndrome including D-dimer increase the usage of D-dimer and computed tomography?

INTRODUCTION: The Canadian clinical practice guidelines propose a novel diagnostic pathway incorporating a clinical decision tool and D-dimer to aid in risk stratifying patients for acute aortic syndrome. The objective of this study was to assess if implementation of a diagnostic pathway incorporating D-dimer would increase the usage of D-dimer and computed tomography (CT) in a tertiary care emergency department. METHODS: Prospective single centre before and after study-recruiting patients over a 6-week period from a tertiary care emergency department. INTERVENTION: multi model implementation of a diagnostic pathway for acute aortic syndrome incorporating D-dimer. OUTCOME: proportion of patients receiving D-dimer testing/CT in the 2 weeks before and after implementation. RESULTS: We included 982 patients (Female 55%, Age mean 51.9, N = 492 pre intervention and N = 490 post intervention). The proportion that received a D-dimer test increased from 6.9 to 10.4% (p < 0.051), while the number of CT aortas remained stable (0.6% vs. 0.6%; p = 0.60). Documentation of pretest probability assessment increased from 1 to 3%, (p < 0.009) following the intervention. In the post intervention cohort, the tool was applied correctly in all cases (N = 17). CONCLUSION: This single centre study found that a diagnostic pathway for acute aortic syndrome including D-dimer could be implemented without a significant increase in test ordering during this first 2 weeks after implementation. This study adds to the argument for use of D-dimer to help risk stratify patients for the diagnosis of acute aortic syndrome. Future studies are needed to confirm the diagnostic accuracy of this pathway and the long-term impact on resource utilization.

RéSUMé: INTRODUCTION: Les guides de pratique clinique canadiens proposent une nouvelle voie de diagnostic intégrant un outil de décision clinique et du D-dimère pour aider à stratifier le risque chez les patients atteints du syndrome aortique aigu. L'objectif de cette étude était d'évaluer si la mise en place d'une voie diagnostique intégrant le dimère-D augmenterait l'utilisation du dimère-D et de la tomodensitométrie (TDM) dans un service d'urgence de soins tertiaires. MéTHODES: Centre unique prospectif avant et après l'étude - recrutement de patients sur une période de 6 semaines à partir d'un service d'urgence de soins tertiaires. Intervention : mise en œuvre multi-modèle d'une voie diagnostique pour le syndrome aortique aigu intégrant le D-dimère. Résultat : Proportion de patients ayant subi un test des D-dimères/TDM dans les deux semaines précédant et suivant la mise en œuvre. RéSULTATS: Nous avons inclus 982 patients (femmes 55 %, âge moyen 51,9, N = 492 avant l'intervention et N = 490 après l'intervention). La proportion de personnes ayant reçu un test D-dimère est passée de 6,9 % à 10,4 % (p < 0,051), tandis que le nombre d'aortes CT est demeuré stable (0,6 % contre 0,6 %; p = 0,60). La documentation de l'évaluation de la probabilité avant le test est passée de 1 % à 3 % (p<0,009) après l'intervention. Dans la cohorte post-intervention, l'outil a été appliqué correctement dans tous les cas (n = 17). CONCLUSION: Cette étude menée auprès d'un seul centre a révélé qu'une voie diagnostique pour le syndrome aortique aigu, y compris le D-dimère, pourrait être mise en œuvre sans qu'il y ait une augmentation significative de l'ordre des tests au cours des deux premières semaines suivant la mise en œuvre. Cette étude renforce l'argument en faveur de l'utilisation du D-dimère pour aider à stratifier les risques des patients pour le diagnostic du syndrome aortique aigu. De futures études sont nécessaires pour confirmer la précision du diagnostic de cette voie et l'impact à long terme sur l'utilisation des ressources.

The use and misuse of the Dix-Hallpike test in the emergency department.

OBJECTIVES: A simple bedside test, the Dix-Hallpike test (DHT), can reliably diagnose benign paroxysmal positional vertigo (BPPV) in patients with acute onset dizziness or vertigo. We evaluated patterns of DHT use by emergency physicians in patients presenting with dizziness and vertigo. Our objective was to assess the frequency and clinically appropriate use of the DHT in an emergency department. METHODS: A health records review was performed using data from patients who presented to a tertiary care emergency department between September 2014 and March 2018 with a primary complaint of vertigo or dizziness. Patient records were reviewed for documentation of symptoms consistent with BPPV and DHT usage. RESULTS: A total of 2309 patients met inclusion criteria. Of all dizzy patients who had complete documentation of signs and symptoms consistent with BPPV, 53% were assessed with a DHT. Of 469 patients who received a DHT, 134 (29%) of tests were done on patients who had documentation of at least one characteristic that was inconsistent with a diagnosis of BPPV. Eight patients who received a DHT were ultimately diagnosed with a central cause for their vertigo. CONCLUSIONS: The DHT is both underutilized and frequently applied to patients whose symptoms are not consistent with BPPV. This may result in prolonged patient discomfort and increased resource utilization, as well as increasing the risk of misdiagnosing central vertigo.

RéSUMé: OBJECTIFS: Un simple test de chevet, le test de Dix-Hallpike (DHT), peut diagnostiquer de manière fiable le vertige positionnel paroxystique bénin (VPPB) chez les patients présentant des étourdissements ou des vertiges d'apparition aiguë. Nous avons évalué les modèles d'utilisation de la DHT par les médecins d'urgence chez les patients présentant des étourdissements et des vertiges. Notre objectif était d'évaluer la fréquence et l'utilisation cliniquement appropriée du DHT dans un service d'urgence. MéTHODES: Un examen des dossiers de santé a été réalisé à partir des données de patients qui se sont présentés à un service d'urgence de soins tertiaires entre septembre 2014 et mars 2018 avec une plainte principale de vertige ou d'étourdissements. Les dossiers des patients ont été examinés afin de documenter les symptômes correspondant à l'utilisation du VPPB et de la DHT. RéSULTATS: Au total, 2 309 patients répondaient aux critères d'inclusion. Parmi tous les patients qui avaient des étourdissements et qui avaient une documentation complète des signes et des symptômes compatibles avec le VPPB, 53 % ont été évalués au moyen d'un DHT. Sur 469 patients qui ont reçu une DHT, 134 (29 %) des tests ont été effectués sur des patients qui avaient une documentation d'au moins une caractéristique incompatible avec un diagnostic de VPPB. Huit patients qui ont reçu une DHT ont finalement été diagnostiqués avec une cause centrale pour leur vertige. CONCLUSIONS: La DHT est à la fois sous-utilisée et fréquemment appliquée aux patients dont les symptômes ne correspondent pas au VPPB. Il peut en résulter une gêne prolongée pour le patient et une utilisation accrue des ressources, ainsi qu'un risque accru de diagnostic erroné du vertige central.

Diagnostic Accuracy of the HINTS Exam in an Emergency Department: A Retrospective Chart Review.

INTRODUCTION: The HINTS exam is a series of bedside ocular motor tests designed to distinguish between central and peripheral causes of dizziness in patients with continuous dizziness, nystagmus, and gait unsteadiness. Previous studies, where the HINTS exam was performed by trained specialists, have shown excellent diagnostic accuracy. Our objective was to assess the diagnostic accuracy of the HINTS exam as performed by emergency physicians on patients presenting to the emergency department (ED) with a primary complaint of vertigo or dizziness. METHODS: A retrospective cohort study was performed using data from patients who presented to a tertiary care ED between September 2014 and March 2018 with a primary complaint of vertigo or dizziness. Patient characteristics of those who received the HINTS exam were assessed along with sensitivity and specificity of the test to rule out a central cause of stroke. RESULTS: A total of 2,309 patients met criteria for inclusion in the study. Physician uptake of the HINTS exam was high, with 450 (19.5%) dizzy patients receiving all or part of the HINTS. A large majority of patients (96.9%) did not meet criteria for receiving the test as described in validation studies; most often this was because patients lacked documentation of nystagmus or described their symptoms as intermittent. In addition, many patients received both HINTS and Dix-Hallpike exams, which are intended for use in mutually exclusive patient populations. In no case was dizziness due to a central cause identified using the HINTS exam. CONCLUSIONS: Our results suggest that despite widespread use of the HINTS exam in our ED, its diagnostic value in that setting was limited. The test was frequently used in patients who did not meet criteria to receive the HINTS exam (i.e., continuous vertigo, nystagmus, and unsteady gait). Additional training of emergency physicians may be required to improve test sensitivity and specificity.