Thursday, 20 August 2015

Review of emergency department community transition strategies

SPHPM’s Dr Judy Lowthian, Dr Rosemary McGinnes, Adjunct Associate Professor Caroline Brand, Associate Professor Anna Barker and Professor Peter Cameron have co-authored an article in Age and Ageing of a systematic review on the various emergency department community transition strategies (ED-CTS) to determine their efficacy. 

The authors state there are no unanimous guidelines or consensus for the best method of practice regarding systems of care for patients who are discharged to their home after emergency department presentation. The purpose of this study was to conduct a systematic review coupled with a meta-analysis to examine the various care transition models currently in place; and determine their efficacy on the risk of emergency department re-presentation, unplanned hospitalisation, functional decline in daily activities, need for transfer to a nursing-care home, and mortality in the elderly who are discharged home from the emergency department. This review was part of a larger project known as the Safe Elderly Emergency Discharge project (SEED). SEED seeks to create the best model of care for the elderly who are discharged from the emergency department.

Emergency departments worldwide are facing a shift in demographic presentations. Emergency department patients over the age of 65 are increasing at a faster rate than the ageing population. Eighteen per cent of the total number of emergency department presentations in Australia, the UK, Canada and the U.S.A. are people over 65. These individuals have longer stays in the emergency department and a higher chance of admission due various psychosocial and medical problems. They also often need increased resources to better comprehend their reason for presentation. Clinicians are also under the strain of meeting time-based targets, managing the flow of the emergency department, maintaining adequate quality of care and accounting for appropriate resource allocation.

In the recent paper, the authors define emergency department attendance for the elderly as a ‘sentinel event’, often linked to not only functional decline but paired with other adverse outcomes such as a higher chance of re-presentation. According to literature, 45 per cent of elderly patients are discharged home after presentation to the emergency department. These figures have led to the development ED-CTS of models of care being implemented within Australia, Canada, the U.S.A and the U.K to assist a safe transition post discharge.

The researchers conducted both a systematic review and a meta-analysis through the use of several databases, searching papers dated up until December 2013. The criteria included eligibility, risk of bias and methodological quality. Data that met these criteria were then meta-analysed. The outcomes being searched were unplanned emergency department presentation functional decline, nursing-care home admission and mortality. The results indicated that five experimental and four observational studies were found for the use of qualitative synthesis. The measures being used for ED-CTS included comprehensive geriatric assessment with referrals for community-based assistance.

In the four studies which were included in the meta-analysis, evidence determined that there were no noticeable benefits for ED-CTS in unplanned emergency department re-attendance, hospital admission or death when compared against usual care. Variability between studies limited the analysis of the effect of ED-CTS on both nursing-care home admission and functional decline.

The authors conclude that there is a paucity of high-quality data to assist consistent and strong recommendations regarding the best method of practice for ED-CTS. This indicates that there is a need for more streamlined incorporation of both clinicians and researchers when developing and evaluating ED-CTS.  Furthermore, there needs to be increased rates of reporting such measures and more thorough evaluations of the efficacy of these models of care.

You can read the paper here.


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