Evaluating methods for risk prediction of Covid-19 mortality in nursing home residents before and after vaccine availability: a retrospective cohort study.

BACKGROUND: SARS-CoV-2 vaccines are effective in reducing hospitalization, COVID-19 symptoms, and COVID-19 mortality for nursing home (NH) residents. We sought to compare the accuracy of various machine learning models, examine changes to model performance, and identify resident characteristics that have the strongest associations with 30-day COVID-19 mortality, before and after vaccine availability. METHODS: We conducted a population-based retrospective cohort study analyzing data from all NH facilities across Ontario, Canada. We included all residents diagnosed with SARS-CoV-2 and living in NHs between March 2020 and July 2021. We employed five machine learning algorithms to predict COVID-19 mortality, including logistic regression, LASSO regression, classification and regression trees (CART), random forests, and gradient boosted trees. The discriminative performance of the models was evaluated using the area under the receiver operating characteristic curve (AUC) for each model using 10-fold cross-validation. Model calibration was determined through evaluation of calibration slopes. Variable importance was calculated by repeatedly and randomly permutating the values of each predictor in the dataset and re-evaluating the model's performance. RESULTS: A total of 14,977 NH residents and 20 resident characteristics were included in the model. The cross-validated AUCs were similar across algorithms and ranged from 0.64 to 0.67. Gradient boosted trees and logistic regression had an AUC of 0.67 pre- and post-vaccine availability. CART had the lowest discrimination ability with an AUC of 0.64 pre-vaccine availability, and 0.65 post-vaccine availability. The most influential resident characteristics, irrespective of vaccine availability, included advanced age (≥ 75 years), health instability, functional and cognitive status, sex (male), and polypharmacy. CONCLUSIONS: The predictive accuracy and discrimination exhibited by all five examined machine learning algorithms were similar. Both logistic regression and gradient boosted trees exhibit comparable performance and display slight superiority over other machine learning algorithms. We observed consistent model performance both before and after vaccine availability. The influence of resident characteristics on COVID-19 mortality remained consistent across time periods, suggesting that changes to pre-vaccination screening practices for high-risk individuals are effective in the post-vaccination era.

Validating the Emergency Department Avoidability Classification (EDAC): A cluster randomized single-blinded agreement study.

INTRODUCTION: The Emergency Department Avoidability Classification (EDAC) retrospectively classifies emergency department (ED) visits that could have been safely managed in subacute primary care settings, but has not been validated against a criterion standard. A validated EDAC could enable accurate and reliable quantification of avoidable ED visits. We compared agreement between the EDAC and ED physician judgements to specify avoidable ED visits. MATERIALS AND METHODS: We conducted a cluster randomized, single-blinded agreement study in an academic hospital in Hamilton, Canada. ED visits between January 1, 2019, and December 31, 2019 were clustered based on EDAC classes and randomly sampled evenly. A total of 160 ED visit charts were randomly assigned to ten participating ED physicians at the academic hospital for evaluation. Physicians judged if the ED visit could have been managed appropriately in subacute primary care (an avoidable visit); each ED visit was evaluated by two physicians independently. We measured interrater agreement between physicians with a Cohen's kappa and 95% confidence intervals (CI). We evaluated the correlation between the EDAC and physician judgements using a Spearman rank correlation and ordinal logistic regression with odds ratios (ORs) and 95% CIs. We examined the EDAC's precision to identify avoidable ED visits using accuracy, sensitivity and specificity. RESULTS: ED physicians agreed on 139 visits (86.9%) with a kappa of 0.69 (95% CI 0.59-0.79), indicating substantial agreement. Physicians judged 96.2% of ED visits classified as avoidable by the EDAC as suitable for management in subacute primary care. We found a high correlation between the EDAC and physician judgements (0.64), as well as a very strong association to classify avoidable ED visits (OR 80.0, 95% CI 17.1-374.9). The EDACs avoidable and potentially avoidable classes demonstrated strong accuracy to identify ED visits suitable for management in subacute care (82.8%, 95% CI 78.2-86.8). DISCUSSION: The EDAC demonstrated strong evidence of criterion validity to classify avoidable ED visits. This classification has important potential for accurately monitoring trends in avoidable ED utilization, measuring proportions of ED volume attributed to avoidable visits and informing interventions intended at reducing ED use by patients who do not require emergency or life-saving healthcare.

Prevalence and predictors of elder abuse among older adults attending emergency departments: a prospective cohort study.

INTRODUCTION: Elder abuse is associated with impaired physical and psychological health. It is, however, rarely identified in emergency departments (EDs). The objective was to determine the prevalence and the predictors of elder abuse among older adults visiting EDs. METHODS: This prospective cohort study was conducted in eight Canadian EDs between May and August 2021. Patients were eligible if they were ≥ 65 years old, oriented to time, and with a Canadian Triage and Acuity Scale score 3, 4 or 5. In a private setting, participants were questioned directly about abuse as part of a larger questionnaire exploring ten non-medical problems. We used multivariable logistic regression to identify predictors of elder abuse. RESULTS: A total of 1061 participants were recruited (mean age: 77.1 (SD 7.6) years, female sex: 55.7%, lived alone: 42.5%). Patients mostly attended EDs for pain (19.6%), neurologic (11.3%) or cardiovascular (8.4%) symptoms. The most frequent pre-existing comorbidities were hypertension (67.2%), mental health conditions (33.3%) and cardiac insufficiency (29.6%). Mobility issues outside (41.0%) or inside their home (30.7%) and loneliness (29.4%) were also frequent. Fifty-four (5.1%) participants reported elder abuse, of which 34.3% were aware of available community-based resources. Identified predictors of elder abuse were female sex (OR 2.8 [95%CI 1.4; 5.6]), financial difficulties (OR 3.6 [95%CI 1.8; 7.3]), food insecurity (OR 2.7 [95%CI 1.2; 5.6]), need for a caregiver (OR 2.7 [95%CI 1.5; 5.0]) and at least one pre-existing mental health condition (OR 2.6 [95%CI 1.4; 4.9]). CONCLUSION: When questioned directly, 5.1% of older adults attending EDs reported experiencing abuse. Female sex, functional impairment, social vulnerability, and mental health comorbidities are associated with elder abuse. Given its importance and relatively high prevalence, ED professionals should have a low threshold to ask directly about elder abuse.

RéSUMé: INTRODUCTION: La maltraitance des personnes âgées est associée à une détérioration de la santé physique et psychologique. Elle est cependant rarement identifiée dans les services d'urgence. L'objectif était de déterminer la prévalence et les prédicteurs de l'abus envers les aînés chez les personnes âgées qui consultent dans un service d'urgence. MéTHODES: Cette étude de cohorte prospective a été menée dans huit services d'urgence canadiens entre mai et août 2021. Les patients étaient éligibles s'ils étaient âgés de ≥ 65 ans, s'ils étaient orientés vers le temps et s'ils avaient un score de 3, 4 ou 5 sur l'échelle canadienne de triage et d'acuité. Dans un cadre privé, les participants ont été interrogés directement sur la maltraitance dans le cadre d'un questionnaire plus large explorant 10 problèmes non médicaux. Nous avons utilisé une régression logistique multivariable pour identifier les facteurs prédictifs de la maltraitance envers les personnes âgées. RéSULTATS: Au total, 1 061 participants ont été recrutés (âge moyen : 77,1 (SD 7,6) ans, sexe féminin : 55,7 %, vivant seul : 42,5 %). Les patients se sont surtout rendus aux urgences pour des douleurs (19,6 %), des symptômes neurologiques (11,3 %) ou cardiovasculaires (8,4 %). Les comorbidités préexistantes les plus fréquentes étaient l'hypertension (67,2 %), les problèmes de santé mentale (33,3 %) et l'insuffisance cardiaque (29,6 %). Les problèmes de mobilité à l'extérieur (41,0 %) ou à l'intérieur du domicile (30,7 %) et la solitude (29,4 %) sont également fréquents. Cinquante-quatre (5,1 %) participants ont signalé des cas de maltraitance des personnes âgées, dont 34,3 % connaissaient les ressources communautaires disponibles. Les facteurs prédictifs identifiés de maltraitance envers les personnes âgées étaient le sexe féminin (RC 2,8 [IC 95 % 1,4 ; 5,6]), les difficultés financières (RC 3,6 [IC 95 % 1,8 ; 7,3]), l'insécurité alimentaire (RC 2,7 [IC 95 % 1,2 ; 5,6]), besoin d'un aidant (RC 2,7 [IC 95 % 1,5 ; 5,0]) et au moins un problème de santé mentale préexistant (RC 2,6 [IC 95 % 1,4 ; 4,9]). CONCLUSION: Interrogées directement, 5,1 % des personnes âgées fréquentant les urgences ont déclaré avoir été victimes de maltraitance. Le sexe féminin, les déficits fonctionnels, la vulnérabilité sociale et les problématiques de santé mentale sont associés à la maltraitance des personnes âgées. Compte tenu de son importance et de sa prévalence relativement élevée, les professionnels des urgences ne devraient pas hésiter à poser directement des questions sur la maltraitance aux personnes âgées.

Quantifying the escalating impact of paramedic transported emergency department visits for opioid-related conditions in Ontario, Canada: A population-based cohort study.

INTRODUCTION: While overdoses comprise the majority of opioid research, the comprehensive impact of the opioid crisis on emergency departments (EDs) and paramedic services has not been reported. We examined temporal changes in population-adjusted incidence rates of ED visits and paramedic transports due to opioid-related conditions. MATERIALS AND METHODS: We conducted a population-based cohort study of all ED visits in the National Ambulatory Care Reporting System from January 1, 2009 to December 31, 2019 in Ontario, Canada. We included all patients with a primary diagnosis naming opioids as the underlying cause for the visit, without any other drugs or substances. We clustered geographic regions using Local Health Integration Network boundaries. Descriptive statistics, incidence rate ratios (IRR) and 95% confidence intervals (CIs) were calculated to analyze population-adjusted temporal changes. RESULTS: Overall, 86,403 ED visits were included in our study. Incidence of opioid-related ED visits increased by 165% in the study timeframe, with paramedic transported patients increasing by 429%. Per 100,000 residents, annual ED visits increased from 40.4 to 97.2, and paramedic transported patients from 12.1 to 67.9. The proportion of opioid-related ED visits transported by paramedics increased from 35.0% to 69.9%. The medical acuity of opioid-related ED visits increased throughout the years (IRR 6.8. 95% CI 5.9-7.7), though the proportion of discharges remained constant (~75%). The largest increases in ED visits and paramedic transports were concentrated to urbanized regions. DISCUSSION: Opioid-related ED visits and paramedic transports increased substantially between 2009 and 2019. The proportion of ED visits transported by paramedics doubled. Our findings could provide valuable support to health stakeholders in implementing timely strategies aimed at safely reducing opioid-related ED visits. The increased use of paramedics followed by high rates of ED discharge calls for exploration of alternative care models within paramedic systems, such as direct transport to specialized substance abuse centres.

Prehospital prediction of hospital admission for emergent acuity patients transported by paramedics: A population-based cohort study using machine learning.

INTRODUCTION: The closest emergency department (ED) may not always be the optimal hospital for certain stable high acuity patients if further distanced ED's can provide specialized care or are less overcrowded. Machine learning (ML) predictions may support paramedic decision-making to transport a subgroup of emergent patients to a more suitable, albeit more distanced, ED if hospital admission is unlikely. We examined whether characteristics known to paramedics in the prehospital setting were predictive of hospital admission in emergent acuity patients. MATERIALS AND METHODS: We conducted a population-level cohort study using four ML algorithms to analyze ED visits of the National Ambulatory Care Reporting System from January 1, 2018 to December 31, 2019 in Ontario, Canada. We included all adult patients (≥18 years) transported to the ED by paramedics with an emergent Canadian Triage Acuity Scale score. We included eight characteristic classes as model predictors that are recorded at ED triage. All ML algorithms were trained and assessed using 10-fold cross-validation to predict hospital admission from the ED. Predictive model performance was determined using the area under curve (AUC) with 95% confidence intervals and probabilistic accuracy using the Brier Scaled score. Variable importance scores were computed to determine the top 10 predictors of hospital admission. RESULTS: All machine learning algorithms demonstrated acceptable accuracy in predicting hospital admission (AUC 0.77-0.78, Brier Scaled 0.22-0.24). The characteristics most predictive of admission were age between 65 to 105 years, referral source from a residential care facility, presenting with a respiratory complaint, and receiving home care. DISCUSSION: Hospital admission was accurately predicted based on patient characteristics known prehospital to paramedics prior to arrival. Our results support consideration of policy modification to permit certain emergent acuity patients to be transported to a further distanced ED. Additionally, this study demonstrates the utility of ML in paramedic and prehospital research.

Wearable Devices and Nurses' Health: Protocol for an Integrative Review.

BACKGROUND: Nurses comprise over half of the global health care workforce, and the nursing care they provide is critical for the global population's health. High patient volumes and increased medical complexity have increased the workload and stress of nurses. As a result, the health of nurses is often negatively impacted. Wearables are used within the health care setting to assess patient outcomes; however, efforts to synthesize the use of wearable devices focusing on nurses' health are limited. OBJECTIVE: The primary objective of our integrative review is to synthesize available data concerning the utility of wearable devices for evaluating or improving (or both) the health of nurses. METHODS: We are conducting an integrative review synthesizing data specific to wearable devices and nurses' health. The research question for this review aims to answer how wearable devices are used to evaluate health outcomes among nurses. We searched the following electronic databases from inception until July 2022: PubMed, Embase, CINAHL, Web of Science, IEEE Explore, and AS&T. Titles and abstracts were imported into Covidence software, where citations were screened and duplicates removed. Title and abstract screening has been completed; however, full-text screening has not been started. Further screening is being conducted independently and in duplicate by 2 teams of 2 reviewers each. These reviewers will extract data independently. RESULTS: Search strategies have been developed, and data were extracted from 6 databases. After the removal of duplicates, we collected 8603 studies for title and abstract screening. Two independent reviewers conducted the title and abstract review, and after resolving conflicts, 277 full-text articles are available for review to determine whether they meet the inclusion criteria. CONCLUSIONS: This integrative review will provide synthesized data to inform nurses and other stakeholders about the extent of wearable device-related work done with nurses and provide direction for future research. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/48178.

Evaluating emergency department transfers from urgent care centres: insights for paramedic integration with subacute healthcare.

OBJECTIVE: Paramedics redirecting non-emergent patients from emergency departments (EDs) to urgent care centres is a new and forthcoming strategy to reduce overcrowding and improve primary care integration. Which patients are likely not suitable for paramedic redirection are unknown. To describe and specify patients inappropriate for urgent care centres, we examined associations between patient characteristics and transfer to the ED after patients initially presented to an urgent care centre. METHODS: A population-based retrospective cohort study of all adult (≥18 years) visits to an urgent care centre from 1 April 2015 to 31 March 2020 in Ontario, Canada. Binary logistic regression was used to determine unadjusted and adjusted associations between patient characteristics and being transferred to an ED using OR and 95% CIs. We calculated the absolute risk difference for the adjusted model. RESULTS: A total of 1 448 621 urgent care visits were reported, with 63 343 (4.4%) visits transferred to an ED for definitive care. Being 65 years and older (OR 2.29, 95% CI 2.23 to 2.35), scored an emergent Canadian Triage and Acuity Scale of 1 or 2 (OR 14.27, 95% CI 13.45 to 15.12) and higher comorbidity count (OR 1.51, 95% CI 1.46 to 1.58) had added odds of association with being transferred out to an ED. CONCLUSION: Readily available patient characteristics were independently associated with interfacility transfers between urgent care centres and the ED. This study can support paramedic redirection protocol development, highlighting which patients may not be best suited for ED redirection.

Agreement and prognostic accuracy of three ED vulnerability screeners: findings from a prospective multi-site cohort study.

OBJECTIVES: To evaluate the agreement between three emergency department (ED) vulnerability screeners, including the InterRAI ED Screener, ER2, and PRISMA-7. Our secondary objective was to evaluate the discriminative accuracy of screeners in predicting discharge home and extended ED lengths-of-stay (> 24 h). METHODS: We conducted a nested sub-group study using data from a prospective multi-site cohort study evaluating frailty in older ED patients presenting to four Quebec hospitals. Research nurses assessed patients consecutively with the three screeners. We employed Cohen's Kappa to determine agreement, with high-risk cut-offs of three and four for the PRISMA-7, six for the ER2, and five for the interRAI ED Screener. We used logistic regression to evaluate the discriminative accuracy of instruments, testing them in their dichotomous, full, and adjusted forms (adjusting for age, sex, and hospital academic status). RESULTS: We evaluated 1855 older ED patients across the four hospital sites. The mean age of our sample was 84 years. Agreement between the interRAI ED Screener and the ER2 was fair (K = 0.37; 95% CI 0.33-0.40); agreement between the PRISMA-7 and ER2 was also fair (K = 0.39; 95% CI = 0.36-0.43). Agreement between interRAI ED Screener and PRISMA-7 was poor (K = 0.19; 95% CI 0.16-0.22). Using a cut-off of four for PRISMA-7 improved agreement with the ER2 (K = 0.55; 95% CI 0.51-0.59) and the ED Screener (K = 0.32; 95% CI 0.2-0.36). When predicting discharge home, the concordance statistics among models were similar in their dichotomous (c = 0.57-0.61), full (c = 0.61-0.64), and adjusted forms (c = 0.63-0.65), and poor for all models when predicting extended length-of-stay. CONCLUSION: ED vulnerability scores from the three instruments had a fair agreement and were associated with important patient outcomes. The interRAI ED Screener best identifies older ED patients at greatest risk, while the PRISMA-7 and ER2 are more sensitive instruments.

RéSUMé: OBJECTIFS: Évaluer la concordance entre trois outils de dépistage de la vulnérabilité des urgences, notamment l'InterRAI ED Screener, ER2 et PRISMA-7. Notre objectif secondaire était d'évaluer la précision discriminative des agents de dépistage dans la prédiction de la sortie à domicile et des durées de séjour prolongées à l'urgence (> 24 heures). MéTHODES: Nous avons mené une étude de sous-groupe emboîtée à partir des données d'une étude de cohorte prospective multi-sites évaluant la fragilité chez les patients plus âgés se présentant aux urgences de quatre hôpitaux québécois. Les infirmières de recherche ont évalué les patients consécutivement avec les trois dépisteurs. Nous avons utilisé le Kappa de Cohen pour déterminer la concordance, avec des seuils de risque élevé de trois et quatre pour le PRISMA-7, de six pour l'ER2 et de cinq pour l' interRAI ED Screener. Nous avons utilisé la régression logistique pour évaluer la précision discriminante des instruments, en les testant dans leur forme dichotomique, complète et ajustée (en ajustant pour l'âge, le sexe et le statut académique). RéSULTATS: Nous avons évalué 1 855 patients âgés aux urgences dans les quatre sites hospitaliers. L'âge moyen de notre échantillon était de 84 ans. La concordance entre l'interRAI ED Screener et l'ER2 était équitable (K =0,37 ; IC à 95 % =0,33-0,40) ; la concordance entre le PRISMA-7 et l'ER2 était également équitable (K = 0,39 ; IC à 95 % =0,36-0,43). La concordance entre interRAI ED Screener et PRISMA-7 était faible (K = 0,19 ; IC à 95 % = 0,16-0,22). L'utilisation d'un seuil de quatre pour PRISMA-7 a amélioré la concordance avec l'ER2 (K =0,55 ; IC à 95% =0,51-0,59) et l'ED Screener (K =0,32 ; IC à 95 % =0,2-0,36). En ce qui concerne la prédiction du retour à domicile, les statistiques de concordance entre les modèles étaient similaires dans leurs formes dichotomiques (c = 0,57-0,61), complètes (c =0,61-0,64) et ajustées (c =0,63-0,65), et faibles pour tous les modèles en ce qui concerne la prédiction de la durée de séjour prolongée. CONCLUSION: Les scores de vulnérabilité aux urgences des trois instruments concordaient assez bien et étaient associés à des résultats importants pour les patients.

Prognostic Association Between Frailty and Post-Arrest Health Outcomes in Patients Receiving Home Care: A Population-Based Retrospective Cohort Study.

AIM: To evaluate the association between frailty and post-cardiac arrest survival, functional decline, and cognitive decline, among patients receiving home care. METHODS: Frailty was measured using the Clinical Frailty Scale (CFS) and a valid frailty index. We used multivariable logistic regression to measure the association between frailty and post-arrest outcomes after adjusting for age, sex, and arrest setting. Functional independence and cognitive performance were measured using the interRAI ADL Long-Form and Cognitive Performance Scale, respectively. We conducted sub-group analytics of in-hospital and out-of-hospital arrests. RESULTS: Our cohort consisted of 7,901 home care clients; most patients arrested out-of-hospital (55.4%) and were 75 years or older (66.3%). Most were classified as frail (94.2%) with a CFS score of 5 or greater. The 30-day survival rate was higher for in-hospital (26.6%) than out-of-hospital cardiac arrests (5.2%). Most patients who survived to discharge had declines in post-arrest functional independence (65.8%) and cognitive performance (46.5%). A one-point increase in the CFS decreased the odds of 30-day survival by 8% (aOR = 0.92; 95%CI = 0.87-0.97). A 0.1 unit increase in the frailty index reduced the odds of 30-day survival by 9% (aOR = 0.91; 95%CI = 0.86-0.96). The frailty index was associated with declines in functional independence (OR = 1.16; 95%CI = 1.02-1.31) and cognitive performance (OR = 1.24; 95%CI = 1.09-1.42), while the CFS was not. CONCLUSION: Frailty is associated with cardiac arrest survival and post-arrest cognitive and functional status in patients receiving home care. Post-cardiac arrest cognitive and functional status are best predicted using more comprehensive frailty indices.

The Association Between Frailty and a Nurse-Identified Need for Comprehensive Geriatric Assessment Referral from the Emergency Department.

BACKGROUND: Emergency nurses commonly conduct geriatric assessments in the emergency department (ED). However, little is known about what geriatric syndromes or clinical presentations prompt a nurse to document an identified need for comprehensive geriatric assessment (CGA). OBJECTIVES: To examine the association between geriatric syndromes, like frailty, and a nurse-identified need for a CGA following emergency care. METHODS: We conducted a secondary analysis of a multi-province Canadian cohort from the InterRAI Multinational Cohort Study. We collected data at ED registration from patients 75 years of age and older (n = 2,274) from eight ED sites across Canada between November 2009 and April 2012. Geriatric syndromes were assessed by trained emergency nurses using the interRAI ED Contact Assessment; and we retrospectively calculated the ED frailty index. We employed binary logistic regression to determine the adjusted associations between geriatric syndromes and a nurse-identified need for a CGA. RESULTS: Approximately one-quarter (28%) of older adults were identified to need a CGA following emergency care. A 0.1 unit increase in the ED frailty index increased the likelihood of a nurse identify a need for CGA (RD: 6.6; 95% CI = 5.5-7.9). Most geriatric syndromes increased the probability of a nurse documenting the need for a CGA. CONCLUSION: When assessed by emergency nurses, the identified need for CGA is strongly linked to the presence of geriatric syndromes, including frailty. We provide face validity for the continued use of emergency nurses for screening and assessing older ED patients.

Examining the utility and accuracy of the interRAI Emergency Department Screener in identifying high-risk older emergency department patients: A Canadian multiprovince prospective cohort study.

Objectives: We set out to determine the accuracy of the interRAI Emergency Department (ED) Screener in predicting the need for detailed geriatric assessment in the ED. Our secondary objective was to determine the discriminative ability of the interRAI ED Screener for predicting the odds of discharge home and extended ED length of stay (>24 hours). Methods: We conducted a multiprovince prospective cohort study in Canada. The need for detailed geriatric assessment was determined using the interRAI ED Screener and the interRAI ED Contact Assessment as the reference standard. A score of ≥5 was used to classify high-risk patients. Assessments were conducted by emergency and research nurses. We calculated the sensitivity, positive predictive value, and false discovery rate of the interRAI ED Screener. We employed logistic regression to predict ED outcomes while adjusting for age, sex, academic status, and the province of care. Results: A total of 5629 older ED patients across 11 ED sites were evaluated using the interRAI ED Screener and 1061 were evaluated with the interRAI ED Contact Assessment. Approximately one-third of patients were discharged home or experienced an extended ED length of stay. The interRAI ED Screener had a sensitivity of 93%, a positive predictive value of 82%, and a false discovery rate of 18%. The interRAI ED Screener predicted discharge home and extended ED length of stay with fair accuracy. Conclusion: The interRAI ED Screener is able to accurately and rapidly identify individuals with medical complexity. The interRAI ED Screener predicts patient-important health outcomes in older ED patients, highlighting its value for vulnerability screening.

Examining the "Potentially Preventable Emergency Department Transfer" Indicator Among Nursing Home Residents.

OBJECTIVE: To determine if nursing home (NH) resident characteristics associated with potentially preventable emergency department transfers (PPEDs) are similarly associated with non-potentially preventable emergency department transfers (non-PPEDs). DESIGN: We conducted a population-level retrospective cohort study using linked administrative data reported using the Resident Assessment Instrument-Minimum Data Set Version 2.0 and the National Ambulatory Care Reporting System for emergency department transfers. SETTING AND PARTICIPANTS: We assessed all NH residents transferred to the emergency department within 92 days after admission. The cohort included 56,433 NH resident admissions assessment of which 3498 NH residents experienced PPEDs, and 9331 residents experienced non-PPEDs. METHODS: We assessed Ontario NH residents admission assessments collected between January 1, 2017, and December 31, 2018. We used cumulative incidence functions and Cox regression to compare resident characteristics between residents experiencing PPEDs and non-PPEDs. PPEDs were defined based on the International Classification of Diseases, 10th Revision. RESULTS: Approximately 23% of residents experienced an emergency department transfer within 92 days of NH admission. The cumulative incidence of PPEDs was 6.3% and non-PPEDs was 16.8%. After adjusting for clinically relevant features, 14 of 18 resident admission characteristics were associated with both types of transfers. Resident admission characteristics associated with a greater risk of PPEDs solely were pneumonia [hazard ratio (HR) 1.48; CI 1.25-1.70] and oxygen therapy (HR 1.88; CI 1.69-2.10). Resident admission characteristics associated with a greater risk of non-PPEDs solely are experiencing a change in mood (HR 1.09; CI 1.01-1.18) and delirium (HR 1.08; CI 1.04-1.13). CONCLUSIONS AND IMPLICATIONS: PPEDs were associated with a similar cluster of NH resident characteristics as those transferred for non-ambulatory reasons, suggesting that the clinical distinction between PPEDs vs non-PPEDs within the NH might be unclear. These findings highlight that the PPED indicator could be revised to improve specificity.

The association between frailty, long-term care home characteristics and COVID-19 mortality before and after SARS-CoV-2 vaccination: a retrospective cohort study.

BACKGROUND: The relative contributions of long-term care (LTC) resident frailty and home-level characteristics on COVID-19 mortality has not been well studied. We examined the association between resident frailty and home-level characteristics with 30-day COVID-19 mortality before and after the availability of SARS-CoV-2 vaccination in LTC. METHODS: We conducted a population-based retrospective cohort study of LTC residents with confirmed SARS-CoV-2 infection in Ontario, Canada. We used multi-level multivariable logistic regression to examine associations between 30-day COVID-19 mortality, the Hubbard Frailty Index (FI), and resident and home-level characteristics. We compared explanatory models before and after vaccine availability. RESULTS: There were 11,179 and 3,655 COVID-19 cases in the pre- and post-vaccine period, respectively. The 30-day COVID-19 mortality was 25.9 and 20.0% during the same periods. The median odds ratios for 30-day COVID-19 mortality between LTC homes were 1.50 (95% credible interval [CrI]: 1.41-1.65) and 1.62 (95% CrI: 1.46-1.96), respectively. In the pre-vaccine period, 30-day COVID-19 mortality was higher for males and those of greater age. For every 0.1 increase in the Hubbard FI, the odds of death were 1.49 (95% CI: 1.42-1.56) times higher. The association between frailty and mortality remained consistent in the post-vaccine period, but sex and age were partly attenuated. Despite the substantial home-level variation, no home-level characteristic examined was significantly associated with 30-day COVID-19 mortality during either period. INTERPRETATION: Frailty is consistently associated with COVID-19 mortality before and after the availability of SARS-CoV-2 vaccination. Home-level characteristics previously attributed to COVID-19 outcomes do not explain significant home-to-home variation in COVID-19 mortality.

Prognosis of cardiac arrest in home care clients and nursing home residents: A population-level retrospective cohort study.

Aim: To evaluate the prognosis of 30-day survival post-cardiac arrest among patients receiving home care and nursing home residents. Methods: We conducted a population-level retrospective cohort study of community-dwelling adults (≥18 years) who received cardiac arrest care at a hospital in Ontario, Canada, between 2006 to 2018. We linked population-based health datasets using the Home Care Dataset to identify patients receiving home care and the Continuing Care Reporting System to identify nursing home residents. We included both out-of-hospital and in-hospital cardiac arrests. We determined unadjusted and adjusted associations using logistic regression after adjusting for age and sex. We converted relative measures to absolute risks. Results: Our cohort contained 86,836 individuals. Most arrests (55.5 %) occurred out-of-hospital, with 9,316 patients enrolled in home care and 2,394 residing in a nursing home. When compared to those receiving no support services, the likelihood of survival to 30-days was lower for those receiving home care (RD = -6.5; 95 %CI = -7.5 - -5.0), with similar results found within sub-groups of out-of-hospital (RD = -6.7; 95 %CI = -7.6 - -5.7) and in-hospital arrests (RD = -8.7; 95 %CI = -10.6 - -7.3). The likelihood of 30-day survival was lower for nursing home residents (RD = -7.2; 95 %CI = -9.3 - -5.3) with similar results found within sub-groups of out-of-hospital (RD = -8.6; 95 %CI = -10.6 - -5.7) and in-hospital arrests (RD = -5.0; 95 %CI = -7.8 - -2.1). Conclusion: Patients receiving home care and nursing home residents had worse overall prognoses of survival post-cardiac arrest compared to those receiving no pre-arrest support, highlighting two medically-complex groups likely to benefit from advance care planning.

Variations in long-term care home resident hospitalizations before and during the COVID-19 pandemic in Ontario.

OBJECTIVES: To examine how the COVID-19 pandemic affected the demographic and clinical characteristics, in-hospital care, and outcomes of long-term care residents admitted to general medicine wards for non-COVID-19 reasons. METHODS: We conducted a retrospective cohort study of long-term care residents admitted to general medicine wards, for reasons other than COVID-19, in four hospitals in Toronto, Ontario between January 1, 2018 and December 31, 2020. We used an autoregressive linear model to estimate the change in monthly admission volumes during the pandemic period (March-December 2020) compared to the previous two years, adjusting for any secular trend. We summarized and compared differences in the demographics, comorbidities, interventions, diagnoses, imaging, psychoactive medications, and outcomes of residents before and during the pandemic. RESULTS: Our study included 2,654 long-term care residents who were hospitalized for non-COVID-19 reasons between January 2018 and December 2020. The crude rate of hospitalizations was 79.3 per month between March-December of 2018-2019 and 56.5 per month between March-December of 2020. The was an adjusted absolute difference of 27.0 (95% CI: 10.0, 43.9) fewer hospital admissions during the pandemic period, corresponding to a relative drop of 34%. Residents admitted during the pandemic period had similar demographics and clinical characteristics but were more likely to be admitted for delirium (pandemic: 7% pre-pandemic: 5%, p = 0.01) and were less likely to be admitted for pneumonia (pandemic: 3% pre-pandemic: 6%, p = 0.004). Residents admitted during the pandemic were more likely to be prescribed antipsychotics (pandemic: 37%, pre-pandemic: 29%, p <0.001) and more likely to die in-hospital (pandemic:14% pre-pandemic: 10%, p = 0.04). CONCLUSIONS AND IMPLICATIONS: Better integration between long-term care and hospitals systems, including programs to deliver urgent medical care services within long-term care homes, is needed to ensure that long-term care residents maintain equitable access to acute care during current and future public health emergencies.

Increased demand for paramedic transports to the emergency department in Ontario, Canada: a population-level descriptive study from 2010 to 2019.

PURPOSE: We examined changes in annual paramedic transport incidence over the ten years prior to COVID-19 in comparison to increases in population growth and emergency department (ED) visitation by walk-in. METHODS: We conducted a population-level cohort study using the National Ambulatory Care Reporting System from January 1, 2010 to December 31, 2019 in Ontario, Canada. We included all patients triaged in the ED who arrived by either paramedic transport or walk-in. We clustered geographical regions using the Local Health Integration Network boundaries. Descriptive statistics, rate ratios (RR), and 95% confidence intervals were calculated to explore population-adjusted changes in transport volumes. RESULTS: Overall incidence of paramedic transports increased by 38.3% (n = 264,134), exceeding population growth fourfold (9.4%) and walk-in ED visitation threefold (13.4%). Population-adjusted transport rates increased by 26.2% (rate ratio 1.26, 95% CI 1.26-1.27) compared to 3.4% for ED visit by walk-in (rate ratio 1.03, 95% CI 1.03-1.04). Patient and visit characteristics remained consistent (age, gender, triage acuity, number of comorbidities, ED disposition, 30-day repeat ED visits) across the years of study. The majority of transports in 2019 had non-emergent triage scores (60.0%) and were discharged home directly from the ED (63.7%). The largest users were persons aged 65 or greater (43.7%). The majority of transports occurred in urbanized regions, though rural and northern regions experienced similar paramedic transport growth rates. CONCLUSION: There was a substantial increase in the demand for paramedic transportation. Growth in paramedic demand outpaced population growth markedly and may continue to surge alongside population aging. Increases in the rate of paramedic transports per population were not bound to urbanized regions, but were province-wide. Our findings indicate a mounting need to develop innovative solutions to meet the increased demand on paramedic services and to implement long-term strategies across provincial paramedic systems.

RéSUMé: OBJECTIFS: Nous avons examiné l'évolution de l'incidence annuelle du transport paramédical au cours des dix années précédant la COVID-19 par rapport à l'augmentation de la croissance de la population et des visites à l'urgence en personne. MéTHODES: Nous avons mené une étude de cohorte au niveau de la population en utilisant le Système national d'information sur les soins ambulatoires du 1er janvier 2010 au 31 décembre 2019 en Ontario, au Canada. Nous avons inclus tous les patients triés aux urgences qui sont arrivés par transport paramédical ou sans rendez-vous. Nous avons regroupé les régions géographiques en utilisant les limites du Réseau local d'intégration des services de santé. Des statistiques descriptives, des rapports de taux (RR) et des intervalles de confiance à 95% ont été calculés pour examiner les variations des volumes de transport ajustées en fonction de la population. RéSULTATS: L'incidence globale des transports paramédicaux a augmenté de 38.3% (n = 264 134), soit quatre fois plus que la croissance démographique (9.4%) et trois fois plus que la fréquentation des urgences sans rendez-vous (13.4 %). Les taux de transport ajustés à la population ont augmenté de 26.2 % (ratio de taux 1.26, IC à 95% 1.26­1.27), contre 3.4 % pour la visite aux urgences sans rendez-vous (ratio de taux 1.03, IC à 95% 1.03­1.04). Les caractéristiques des patients et des visites sont restées constantes (âge, sexe, acuité du triage, nombre de comorbidités, disposition des urgences, visites répétées aux urgences à 30 jours) au cours des années d'étude. La majorité des transports en 2019 avaient des scores de triage non urgents (60.0 %) et ont été renvoyés chez eux directement du service d'urgence (63.7 %). Les plus grands utilisateurs étaient les personnes âgées de 65 ans ou plus (43.7 %). La majorité des transports ont eu lieu dans les régions urbanisées, bien que les régions rurales et du Nord aient connu des taux de croissance du transport paramédical similaires. CONCLUSION: Il y a eu une augmentation considérable de la demande de transport paramédical. La croissance de la demande de services paramédicaux a nettement dépassé la croissance de la population et pourrait continuer d'augmenter parallèlement au vieillissement de la population. Les augmentations du taux de transports paramédicaux par population n'étaient pas limitées aux régions urbanisées, mais s'étendaient à l'ensemble de la province. Nos constatations indiquent un besoin croissant d'élaborer des solutions novatrices pour répondre à la demande accrue de services paramédicaux et mettre en œuvre des stratégies à long terme dans l'ensemble des systèmes paramédicaux provinciaux.

Sensitivity Analysis: A Method to Promote Certainty and Transparency in Nursing and Health Research.

Nursing and health researchers may be presented with uncertainty regarding the utilization or legitimacy of methodological or analytic decisions. Sensitivity analyses are purposed to gain insight and certainty about the validity of research findings reported. Reporting guidelines and health research methodologists have emphasized the importance of utilizing and reporting sensitivity analyses in clinical research. However, sensitivity analyses are underreported in nursing and health research. The aim of this methodological overview is to provide an introduction to the purpose, conduct, interpretation, and reporting of sensitivity analyses, using a series of simulated and contemporary case examples.

Comparing the scopes of practice of geriatric-focused physicians in Canada: a qualitative study of core competencies.

BACKGROUND: Given long-standing deficits of medical expertise to care for a growing population of older adults, it is important to understand the geriatric medical workforce. We aimed to describe and compare the scopes of practice of the 3 geriatric-focused physician providers in Canada (i.e., family physicians with certification in Care of the Elderly [FM-COE], geriatricians and geriatric psychiatrists). METHODS: We conducted a qualitative study to compare competencies across geriatric-focused physician provider types in Canada, using a directed content analysis approach. We identified and obtained relevant publicly available documents that described the competencies required for certification by searching the websites of The College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada between June 2 and July 31, 2020. An inductive content analysis was used to compare content within each CanMEDS Role according to the CanMEDS Framework. RESULTS: We identified and obtained 4 relevant publicly available documents describing the competencies required for geriatric-focused certification for the 3 geriatric-focused physician provider types. We found substantial overlaps in the expected medical expertise of FM-COE and geriatricians. The few substantive differences across providers may result from different priorities about which competencies were made explicit for providers. The focused nature of mental health care is apparent in several competencies unique to geriatric psychiatry. INTERPRETATION: This work highlights substantial overlaps in the scopes of practice for FM-COE and geriatricians. Our findings may encourage efforts to develop more robust delineations between the scopes of practice of these related professionals to facilitate inter-specialty collaboration to lead to more equitable and accessible medical care for older adults.