Exploring Predictive Factors for Potentially Avoidable Emergency Department Transfers: Findings From the FINE Study.

OBJECTIVES: To assess the prevalence of potentially avoidable transfers (PAT) and identify factors associated with these transfers to emergency departments (EDs) among nursing home (NH) residents. DESIGN: This is a secondary outcome analysis of the FINE study, a multicenter observational study collecting data on NH residents, NH settings, and contextual factors of ED transfers. SETTINGS AND PARTICIPANTS: NHs in the former Midi-Pyrénées region of the southwest of France (n = 312); a total of 1037 NH residents who experienced ED transfers (n = 1017) between January 2016 and December 2016. METHODS: The analysis included resident baseline characteristics and NH and transfer decision-making characteristics. An expert group categorized the transfer status as either PAT or unavoidable. Multivariable analysis using a mixed logistic model, accounting for intra-NH correlation, was conducted to assess factors independently associated with PAT. RESULTS: Among 1017 included transfers, 87.02% (n = 885) were identified as PAT and 12.98% (n = 132) unavoidable transfers. Multivariable analysis revealed that the following patient-related factors were associated with a likely high rate of PAT: usual behavior disturbances before transfer, including productive trouble (OR 2.04, 95% CI 1.25-3.33; P = .0044) and unusual symptom of falling during the week preceding the transfer (OR 4.55, 95% CI 1.76-11.82; P = .0019). On the other hand, distance between ED and NH (OR 0.98, 95% CI 0.97-0.998; P = .0231), NH staff trained in palliative care in the last 3 years (OR 0.52, 95% CI 0.29-0.95; P = .0324), the impossibility of direct hospitalization to an appropriate unit (OR 0.54, 95% CI 0.34-0.87; P = .0117), and the resident Charlson Comorbidity Index (OR 0.90, 95% CI 0.82-0.99; P = .0369) were associated with a lower probability of PAT. CONCLUSION AND IMPLICATIONS: Transfers from NHs to hospital EDs were frequently potentially avoidable, meaning that there are still significant opportunities to reduce PAT. Our findings may help to specifically identify interventions that should be targeted at both NH and resident levels.

Mobile health in the specific management of first-episode psychosis: a systematic literature review.

Purpose: The purpose of this systematic literature review is to assess the therapeutic efficacy of mobile health methods in the management of patients with first-episode psychosis (FEP). Method: The participants are patients with FEP. The interventions are smartphone applications. The studies assess the preliminary efficacy of various types of application. Results: One study found that monitoring symptoms minimized relapses, visits to A&E and hospital admissions, while one study showed a decrease in positive psychotic symptoms. One study found an improvement in anxiety symptoms and two studies noted an improvement in psychotic symptoms. One study demonstrated its efficacy in helping participants return to studying and employment and one study reported improved motivation. Conclusion: The studies suggest that mobile applications have potential value in the management of young patients with FEP through the use of various assessment and intervention tools. This systematic review has several limitations due to the lack of randomized controlled studies available in the literature.

Factors Associated with Potentially Inappropriate Transfer to the Emergency Department among Nursing Home Residents.

OBJECTIVES: To determine the factors associated with the potentially inappropriate transfer of nursing home (NH) residents to emergency departments (EDs) and to compare hospitalization costs before and after transfer of individuals addressed inappropriately vs those addressed appropriately. DESIGN: Multicenter, observational, case-control study. SETTING AND PARTICIPANTS: 17 hospitals in France, 1037 NH residents. MEASURES: All NH residents transferred to the 17 public hospitals' EDs in southern France were systematically included for 1 week per season. An expert panel composed of family physicians, emergency physicians, geriatricians, and pharmacists defined whether the transfer was potentially inappropriate or appropriate. Residents' and NHs' characteristics and contextual factors were entered into a mixed logistic regression to determine factors associated independently with potentially inappropriate transfers. Hospital costs were collected in the national health insurance claims database for the 6 months before and after the transfer. RESULTS: A total of 1037 NH residents (mean age 87.2 ± 7.1, 68% female) were transferred to the ED; 220 (21%) transfers were considered potentially inappropriate. After adjustment, anorexia [odds ratio (OR) 2.41, 95% confidence interval (CI) 1.57-3.71], high level of disability (OR 0.90, 95% CI 0.81-0.99), and inability to receive prompt medical advice (OR 1.67, 95% CI 1.20-2.32) were significantly associated with increased likelihood of potentially inappropriate transfers. The existence of an Alzheimer's disease special care unit in the NH (OR 0.66, 95% CI 0.48-0.92), NH staff trained on advance directives (OR 0.61, 95% CI 0.41-0.89), and calling the SAMU (mobile emergency medical unit) (OR 0.47, 95% CI 0.34-0.66) were significantly associated with a lower probability of potentially inappropriate transfer. Although the 6-month hospitalization costs prior to transfer were higher among potentially inappropriate transfers compared with appropriate transfers (€6694 and €4894, respectively), transfer appropriateness was not significantly associated with hospital costs. CONCLUSIONS AND IMPLICATIONS: Transfers from NHs to hospital EDs were frequently appropriate. Transfer appropriateness was conditioned by NH staff training, access to specialists' medical advice, and calling the SAMU before making transfer decisions. TRIAL REGISTRATION: clinicaltrials.gov, NCT02677272.

[From Kraepelin to McGorry: Scientific Vision and Experiential Narrative around a Major Paradigmatic Shift]. / De Kraepelin à McGorry : vision scientifique et récit expérientiel autour d'un changement de paradigme majeur.

Objectives Until the early 1990s, a pessimistic view of psychotic disorders, based on the Kraepelinian perspective, prevailed. Early intervention then introduced a new paradigm, approaching psychosis as a more dynamic phenomenon, for which recovery is possible, provided an appropriate approach is used. As this paradigm has not penetrated all fields of psychiatry, professionals starting in early intervention sometimes experience a real culture shock, the objective of this article being to map its contours in order to facilitate this transition. Methods Based on their knowledge of the literature and their clinical experience, the authors will highlight the aspects that distinguish early intervention practice from traditional practice with psychotic disorders. They adopt an experiential approach to these themes, addressing them not only in light of the scientific literature, but also and especially in the first person of the singular. Results The aspects identified and agreed upon by the three authors were grouped into seven themes: 1. the adoption of a recovery-oriented practice and the rejection of the pessimistic view of psychotic disorders, which refocuses practice on the person's life goals; this is accompanied by a different style of approach; 2. Transdisciplinarity and cross-fertilization of expertise with other team members, community organizations and families, which requires humility and openness; 3. Changes in the pharmacotherapeutic approach, characterized by increased attention to adverse effects (e.g., treatment-induced negative symptoms), the use of lower doses, and the proactive use of clozapine and long-acting injectable antipsychotics; 4. The need to tolerate some diagnostic uncertainty given the difficulties in making an accurate diagnosis, and the presence of complex co-morbidities that blur the picture; 5. The high stakes of the critical period, characterized by high stakes, such as the risk of suicide or social disinsertion, which put pressure on the clinician; 6. The importance of relays in the care trajectory, particularly between adolescent and adult psychiatry, and then between early intervention and other services; 7. The resistance to change that early intervention sometimes faces, as its importance is not always recognized, and its implementation can challenge existing services. Conclusion The differences between the traditional mode of practice with persons with a psychotic disorder and that of early intervention are numerous; while they represent challenges, they are also sources of considerable stimulation and satisfaction.

[Emergency departments and psychiatry]. / Urgences et psychiatrie.

Psychiatric care is becoming an increasingly important part of general emergency departments. Historically incorporated into the psychiatric hospital, emergency mental health care has since been moved to the general hospital. This move was intended to boost the accessibility and deinstitutionalisation of psychiatry. The end of the "asylum" opened up new dialogue with the somatic care network.