RESUMO
BACKGROUND: People living in nursing homes face the risk of visiting the emergency department (ED). Outreach services are developing to prevent unnecessary transfers to ED. AIMS: We aim to assess the performance of acute care services provided to people living in nursing homes or long-term homecare, focusing on ED transfer prevention, safety, cost-effectiveness and experiences. MATERIALS & METHODS: This review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies were eligible for inclusion if they were peer-reviewed and examined acute outreach services dedicated to delivering care to people in nursing homes or long-term homecare. The service models could also have preventive components. The databases searched were Scopus and CINAHL. In addition, Robins-I and SIGN checklists were used. The primary outcomes of prevented ED transfers or hospitalisations and the composite outcome of adverse events (mortality/Emergency Medical Service or ED visit after outreach service contact related to the same clinical condition) were graded with GRADE. RESULTS: Fifteen relevant original studies were found-all were observational and focused on nursing homes. The certainty of evidence for acute outreach services with preventive components to prevent ED transfers or hospitalisations was low. Stakeholders were satisfied with these services. The certainty of evidence for solely acute outreach services to prevent ED transfers or hospitalisations was very low and inconclusive. Reporting of adverse events was inconsistent, certainty of evidence for adverse events was low. CONCLUSION: Published data might support adopting acute outreach services with preventive components for people living in nursing homes to reduce ED transfers, hospitalisations and possibly costs. If an outreach service is started, it is recommended that a cluster-randomised or quasi-experimental research design be incorporated to assess the effectiveness and safety of the service. More evidence is also needed on cost-effectiveness and stakeholders' satisfaction. Systematic review registration number: PROSPERO CRD42020211048, date of registration: 25.09.2020.
Assuntos
Serviços Médicos de Emergência , Hospitalização , Humanos , Casas de Saúde , Serviço Hospitalar de EmergênciaRESUMO
Emergency department (ED) overcrowding is a global issue setting challenges to all care providers. Elderly patients are frequent visitors of the ED and their risk stratification is demanding due to insufficient assessment methods. A prospective cohort study was conducted to determine the risk-predicting value of a prognostic biomarker, soluble urokinase plasminogen activator receptor (suPAR), in the ED, concentrating on elderly patients. SuPAR levels were determined as part of standard blood sampling of 1858 ED patients. The outcomes were assessed in the group of <75 years (=younger) and ≥75 years (=elderly). The elderly had higher median suPAR levels than the younger (5.4 ng/mL vs. 3.7 ng/mL, p < 0.001). Increasing suPAR levels were associated with higher probability for 30-day mortality and hospital admission in all age groups. SuPAR also predicted 30-day mortality when adjusted to other clinical factors. SuPAR acts successfully as a nonspecific risk predictor for 30-day mortality, independently and with other risk-assessment tools. Low suPAR levels predict positive outcomes and could be used in the discharging process. A cut-off value of 4 ng/mL could be used for all ED patients, 5 ng/mL being a potential alternative in elderly patients.
RESUMO
Introduction: Risk stratification in the emergency departments (EDs) is in critical need for new applications due to ED overcrowding and hospitalization of older people. We aimed to evaluate the expediency, efficiency and safety of a prognostic biomarker, soluble urokinase plasminogen activator receptor (suPAR), as a tool for the risk assessment of patients arriving at the ED. Methods: We performed a comparative cross-sectional study in 2 emergency departments (EDs), suPAR measurements being incorporated into routine blood sampling in the intervention ED. The primary outcome was the number of discharges from the ED. The importance of the outcomes was examined by appropriate multi- or bivariate analysis. Results: The absolute and relative number of discharges were similar between the intervention and control groups [121 (55.3%) vs 62 (55.9%)]. No significant differences between the groups were seen in the length of stays in the ED. Patients with low suPAR values were more likely discharged and patients with high suPAR values more likely admitted to hospital. Two admitted patients with low suPAR values could have been discharged safely. Conclusion: The utilization of suPAR did not increase the risk for neither positive nor negative outcomes. Low suPAR values could be potential in discharging more patients safely. Instead of unselected patient populations, the benefits of suPAR measurements in the ED could emerge in the assessment of a more precisely determined and selected group of patients.