Transitional Care in the Emergency Department

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Transitional Consideration in the Crisis Office. Michael A. LaMantia , MD, MPH Place for Maturing and Wellbeing Establishment on Maturing College of North Carolina. Revelations. Work bolstered by: NIA Gift # 2T32AG000272-06A2

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Transitional Care in the Emergency Department Michael A. LaMantia , MD, MPH Center for Aging and Health Institute on Aging University of North Carolina

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Disclosures Work upheld by: NIA Grant # 2T32AG000272-06A2 UNC John A. Hartford Foundation Center of Excellence in Geriatric Medicine and Training

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Outline Challenges of Care of the Elderly in the ED UNC's Efforts to Improve Care of Elderly: Understanding our patients/understanding results of their care Coordinating Care with different Providers Areas for Future Research

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Transitional Care Definition: "A set of activities intended to guarantee the coordination and congruity of human services as patients exchange between various areas or diverse levels of care inside a similar organization." –American Geriatrics Society (2003)

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Transitional Care During moves, patients are at hazard for: Medical blunders Service duplication Inappropriate care Critical components of care plan "falling however the breaks" -AGS (2003)

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Aging: Impact on Emergency Departments Elderly patients: Are all the more sick at introduction Arrive by rescue vehicle more as often as possible Receive a greater number of tests than more youthful patients Suffer from more constant therapeutic comorbidities Are admitted to the clinic at higher rates Experienced longer ED stays Incurred higher doctor's visit expenses Return much of the time to the ED subsequent to having been seen there 3/11/2014 6

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Background Elderly patients get a high volume of asset escalated mind in EDs 1,2 EDs are seeing more patients than any other time in recent memory and are every now and again stuffed According to NHAMCS and AHA: ED use expanded 26% between 1993-2003 and larger part of EDs were at/over limit no less than half of time in 2003 3 Concern exists that the maturing of the time of increased birth rates era will strain EDs later on Identification of patients at hazard for healing facility confirmation or come back to the ED may encourage intercessions to enhance care of elderly patients and diminish packing McCusker J, Cardin S, Bellavance F, Belzile E. Come back to the crisis office among senior citizens: Patterns and indicators. Acad Emerg Med . 2000;7:249-259. McCusker J, Verdon J. Do geriatric mediations lessen crisis office visits? An orderly audit. Diaries of Gerontology Series A: Biological and Medical Sciences . 2006;61:53-62. Chase KA, Weber EJ, Showstack JA, Colby DC, Callaham ML. Attributes of continuous clients of crisis divisions. Ann Emerg Med . 2006;48:1-8.

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Investments for the Future Grant UNC School of Medicine Improving the Health of North Carolina's Underserved Elders Jan Busby-Whitehead, MD J. Stephen Kizer, MD Carol Giuliani, PhD, PT

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Specific Aims To set up and keep up a group UNC-HCS association to enhance care of defenseless senior citizens in Orange County and give a stage to research and educating To enhance the entrance to, route through, and moves to and from the UNC-HCS for group living slight older folks incorporating those in long haul mind offices To extend group based preventive administrations for powerless seniors in Orange County, through the advancement of a counteractive action center and adjust program

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Transitional Care of the Elderly in the Emergency Department Aims Create a profile of elderly folks who utilize the ED Develop a comprehension of reasons that: senior citizens look for care in the ED are admitted to the doctor's facility from the ED come back to the ED Build and test mediations to streamline and enhance the care of elderly patients as they move into/out of ED

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Predicting Admission to the Hospital or Return to the Emergency Department Hypothesis: An arrangement of factors can be distinguished among elderly ED patients that could foresee confirmation or come back to the ED Methods: Retrospective outline audit with preparing and approval informational collections Reviewed all diagrams (n=4,873) amid 2007 at a solitary, scholastic ED serving a substantial elderly group Chief grumbling, triage score, Charlson comorbidity score, imperative signs, and statistic information were gathered

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Methods (proceeded with) Logistic relapse models were produced from the 2007 information for: Patient affirmation Patient come back to the ED These models were then connected in a blinded way to the 2008 information to anticipate these two results. These expectations were then contrasted with the real results for these two endpoints. Recipient Operating Characteristic (ROC) bends were created and Area Under the Curve (AUC) ascertained

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Results Five factors were available in definite model for patient confirmation: Age Triage Score Heart Rate Diastolic BP Chief protest

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Chief Complaint Some central objections improve probability of affirmation: General Weakness: OR 2.00 (95% CI 1.4-2.8) Shortness of Breath: OR 3.27 (95% CI 2.4-4.5) Hip Injury: OR 4.70 (95% CI 2.4-9.1)

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Chief Complaint Some main grievances improve probability of confirmation: General Weakness: OR 2.00 (95% CI 1.4-2.8) Shortness of Breath: OR 3.27 (95% CI 2.4-4.5) Hip Injury: OR 4.70 (95% CI 2.4-9.1) Some main dissensions diminish probability of affirmation: Blood in pee: OR 0.47 (95% CI 0.3-0.9) Painful pee: OR 0.09 (95% CI 0.01-0.8) Head/neck cut: OR 0.28 (95% CI 0.1-0.7)

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ROC Curve for Admission Prediction

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ROC Curve for Return Prediction

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Conclusions from Initial Work in Emergency Department Our models can give a sensibly precise expectation of the likelihood of confirmation of elderly patients This may prompt to utilization of an affirmation forecast device which would empower a sped up confirmation handle for elderly patients We can't deliver models that anticipate come back to the ED for elderly patients

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Communications Initiative Partnership amongst UNC and neighborhood NH's Goal: To build up a bidirectional correspondence connect amongst NH and ED suppliers Format: Web-based referral archive for NH patients sent to ED that is joined into medicinal record Faxing of ED notes/directions back to office on release

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Communications Initiative Challenges: Nursing Home: Staff turnover Staff preparing Computer get to Buy-in from staff and office "Another frame" to round out Emergency Department: Residents from different offices Demands for time "Another shape" to round out

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Next Steps: ED Transitional Care Research RCT of capacity of affirmation expectation device to influence ED length of stay Validation of Tool somewhere else Refinement Communications Initiative Evaluation of Triage of Elderly Patients Telephone Follow-up of Discharged Elderly

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Acknowledgments UNC Futures Group Team: Drs. Jan Busby-Whitehead, J. Stephen Kizer, Charles Cairns, Timothy Platts-Mills, Kevin Biese, Laura Patel, Christine Khandelwal, Debbie Travers, Ellen Roberts Cory Forbach, Brenda McCall, and Sergio Rabinovich UNC Center for Aging and Health: Dr. Laura Hanson Amy Rix UNC Institute on Aging: Drs. Victor Marshall and Daniel Lee

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Thank You! Questions/Comments? My contact data: Michael LaMantia, MD, MPH Center for Aging and Health CB 7550 Chapel Hill, NC 27599-7550 919-966-5945 x 263