Association between access to primary care and unplanned emergency department return visits among patients 75 years and older.

OBJECTIVE: To identify factors associated with unplanned return visits to the emergency department (ED) among the population aged 75 years and older. Moreover, it aims to determine the association between patients' access to primary care and unplanned return visits. DESIGN: Data were collected from structured interviews, administrative databases, and medical charts at the index visits, and follow-up telephone calls were made at 3 months. SETTING: Emergency departments of the 3 tertiary care hospitals in Montréal, Que. PARTICIPANTS: Community-dwelling patients aged 75 years and older. MAIN OUTCOME MEASURES: Zero-inflated negative binomial regression analysis was conducted of unplanned return visits within 3 months. Rate ratios (RRs) and odds ratios (ORs) with 95% CIs are presented. RESULTS: During the study period, 4577 patients were identified, 2303 were recruited, and 1998 were retained for the analysis. Among the analysis sample, 33% were 85 and older, 34% lived alone, and 91% had a family physician. Before their ED visits, 16% of patients attempted to contact their family physicians. More than half of the patients reported having difficulty seeing their physicians for urgent problems, more than 40% had difficulty speaking with their family physicians by telephone, and more than one-third had difficulty booking appointments for new health problems. Within 3 months, 562 patients (28%) had made 894 return visits. Factors associated with a lower return visit rate included age 85 years and older (RR=0.80; 95% CI 0.67 to 0.96), less severe triage score (RR=0.83; 95% CI 0.74 to 0.92), and hospitalization at the index visit (RR=0.76; 95% CI 0.64 to 0.90). Factors that resulted in a higher return visit rate were difficulty booking appointments for new problems with their family physicians (RR=1.19; 95% CI 1.01 to 1.41), having had ED visits within the previous 6 months (RR=1.47; 95% CI 1.28 to 1.68), and higher Charlson comorbidity index scores (RR=1.06; 95% CI 1.01 to 1.11). Having had ED visits within the previous 6 months (OR=2.11; 95% CI 1.27 to 3.49), having a higher Charlson comorbidity index score (OR=1.41; 95% CI 1.19 to 1.68), and having received community care services (OR=3.00; 95% CI 0.95 to 9.53) also increased the odds of return visits. CONCLUSION: Although most people 75 years and older have a family physician, problems still exist in terms of timely access. Unplanned return visits to the ED are associated with having more comorbidities, having had previous ED visits, having already received community services, and having difficulty booking appointments with family physicians for new problems.

Opt-out universal HCV and HIV screening in a Canadian emergency room: a cross-sectional study.

OBJECTIVES: To determine the prevalence of undiagnosed hepatitis C virus (HCV) and HIV cases in a population sample tested in the emergency room (ER) and to evaluate linkage-to-care. SETTING: Canadian university hospital. PARTICIPANTS: Adults born after 1945 who consulted at ER for any condition and on any shift were included. Patients unable to opt-out were excluded. INTERVENTIONS: ER nurse confirmed patients' eligibility and provided them with the option to opt-out. A physician met patients with a new diagnosis. Linkage-to-care was assessed 3 months postdiagnosis. Patients newly diagnosed with HCV were considered linked if they had an HCV RNA test, genotype, liver fibrosis evaluation, and if indicated, treatment prescription. Patients newly diagnosed with HIV were considered linked to care if they had an HIV serology confirmation test, viral load, CD4 cell count and started antiretroviral therapy. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary objective: to determine the prevalence (overall and undiagnosed cases) of HIV and HCV among the patients who consult the ER. Secondary objectives: to determine the proportion of patients who opt-out, assess the adherence of emergency staff to the offer of testing, determine the proportion of patients linked to care at 3 months. RESULTS: Among 6350 eligible patients informed of the screening programme, 62.1% of patients were tested for at least one virus (HIV: 3905; HCV: 3910). 25% patients opted-out, 12% were not tested for organisational reasons, 0.3% (18) patients were HCV-HIV coinfected. Overall prevalence of HCV and HIV cases were 1.9% and 1.2%, respectively. Prevalence of new cases was 0.23% (95% CI 0.12% 0.45%) for HCV and 0.05% (95% CI 0.01% to 0.20%) for HIV. Among the new cases, only two HCV-infected and one HIV-infected patients were linked-to-care 3 months postdiagnosis. CONCLUSIONS: Identification of new cases of HCV and HIV through universal screening at the ER and linkage-to-care were both low. TRIAL REGISTRATION NUMBER: NCT03595527; Results.

Patient Needs, Required Level of Care, and Reasons Delaying Hospital Discharge for Nonacute Patients Occupying Acute Hospital Beds.

This study aims to determine the proportion of nonacute patients occupying acute care beds and to describe their needs, the appropriate level of alternative care, and reasons preventing discharge. Data from 952 patients hospitalized in an acute care unit for 30 days were obtained from their medical charts and by consulting with the medical team at two tertiary teaching hospitals. Among them, 333 (35%) were determined nonacute on day 30 of hospitalization. According to the Appropriateness Evaluation Protocol (AEP), 55% had no medical, nursing, or patient needs. Among nonacute patients with AEP needs, 88% were related to nursing/life-support services and 12% related to patient condition factors. Regarding alternative level of care, 186 (56%) were waiting for out-of-hospital resources, of which 36% were waiting for palliative care, 33% for long-term care, 18% for rehabilitation, and 12% for home care. For the remaining 147 (44%) nonacute patients, the alternative resources remained undetermined although acute care was no longer required. Main reasons preventing discharge included unavailability of alternative resources, ongoing assessment to determine appropriate resources, ongoing process with community care, and family/patient education/counseling. Available subacute facilities and community-based care would liberate acute care beds and facilitate their appropriate use.

Characteristics and Needs of Psychiatric Patients With Prolonged Hospital Stay.

OBJECTIVE: To describe the characteristics and needs prior to, on admission, during the first month in hospital, at the thirtieth day of hospitalization and posthospital discharge of psychiatric patients occupying acute beds. METHODS: This prospective observational study was conducted in 2 tertiary care hospitals. Adult patients hospitalized on a psychiatric unit for 30 days were identified. Data was collected from their medical charts and interviews with their health care team. The categorization of acute and nonacute status at day 30 was based on the health care professional's evaluation. Descriptive and univariate analyses were performed. RESULTS: A total of 262 patients were identified (mean age 45 years), 66% lived at home and 11% were homeless. More than one-half were cognitively impaired and a few had special medical needs. Ninety-seven per cent had been admitted from the emergency department. At day 30, 81% of patients required acute care, while 19% (95% CI 15% to 24%) occupied an acute care bed, despite the resolution of their acute condition. The main reason preventing discharge of nonacute patients was the difficulty or inability to find appropriate resources that met patients' needs. As for patients who required acute care, the most common psychiatric issues were delusions or hallucinations (34%), inability to take medications independently (23.6%), and inadequate control of aggression or impulsivity (16.5%). CONCLUSIONS: Prevention of the discharge of nonacute patients is largely due to the difficulty in finding appropriate resources that meet patients' needs. Improved access to community and subacute care resources could potentially facilitate the hospital discharge of psychiatric nonacute patients.

Hospital stay on acute care units for non-acute reasons: Effects of patient pre-hospitalization and admission factors.

This study identifies patient risk factors present prior to an acute hospitalization that are associated with occupying acute care beds for non-acute reasons on the 30th day of a hospitalization. Data from 952 adult patients were obtained, among which 333 (35%) were evaluated as non-acute on their 30th day. Inability to move in and out of the bed, cognitive impairment, receiving home or community healthcare services prior to hospitalization, unavailable family resources, a secondary diagnosis within the mental and behavioural category, and age ≥75 years were found to increase the risk of occupying acute care beds for non-acute reasons, while patients with a feeding tube were less likely to be non-acute at day 30.