Return to the Emergency Department among Elders: Patterns And Predictors

OBJECTIVES: 1) To describe the pattern of return visits to the emergency department (ED) among elders over the six months following an index visit; 2) to identify the predictors of early return (within 30 days) and frequent return (three or more return visits in six months); and 3) to evaluate a newly developed screening tool for functional decline, Identification of Seniors At Risk (ISAR), with regard to its ability to predict return visits. METHODS: Subjects were patients aged 65 years or more who visited the EDs of four Canadian hospitals during the weekday shift over a three-month recruitment period. Excluded were patients who: could not be interviewed, due either to their medical conditions or to cognitive impairment, and no other informant was available; refused linkage of study data; or were admitted to hospital at the initial (index) visit. Measures made at the index ED visit included: 27 self-report screening questions on social, physical, and mental risk factors, medical history, use of hospital services, medications, and alcohol. Six of these questions comprised the ISAR scale. Return visits and diagnoses during the six months after the index visit were abstracted from the utilization database. RESULTS: Among 1,122 patients released from the ED, 492 (43.9%) made one or more return visits; 216 (19.3%) returned early and 84 (7.5%) returned frequently. Earlier returns were more likely than later returns to be for the same diagnosis (p = 0.003). Using logistic regression, hospitalization during the previous six months, feeling depressed, and certain diagnoses predicted both early and frequent returns. Also, a history of heart disease, having ever been married, and not drinking alcohol daily predicted early return; a history of diabetes, a recent ED visit, and lack of support predicted frequent use. CONCLUSIONS: In the first month after an ED visit, return rates are highest and are more likely to be for the same diagnosis. Both medical and social factors predict early and frequent returns to the ED; patients at increased risk of return can be quickly identified with a short, self-report questionnaire. The ISAR screening tool, developed to identify patients at increased risk of functional decline, can also identify patients who are more likely to return to the ED.     

Demographics and financial impact of home respiratory care

Healthcare policymakers, governmental and private alike, are now faced with an enormous challenge. Demands for improved access to cost-effective and high quality healthcare are emanating from all segments of our society. Clearly, the traditional model of admitting patients to an acute care hospital as a first-line intervention is losing favor. Although there will always be a role for acute hospital care, utilization of this high-cost setting must be better managed if runaway healthcare costs are to be brought under control. The concept of moving patients along the healthcare continuum as their response to treatment reduces the acuteness of their condition is rapidly gaining support, especially with third-party payors. Accordingly, home healthcare providers, including those offering respiratory home care services, can expect to see an increase in the number of referrals they receive. HME/RT providers must actively promote the benefits they can offer in terms of high quality, cost-effective outcome. It is not unrealistic to suggest that the savings realized by reducing an acute hospital stay by 1 day can easily cover the costs of providing respiratory home care for 4 to 6 weeks. One can only hope that such compelling arguments, occurring at a time when healthcare reform and restructuring is a national priority, will translate to more equitable reimbursement guidelines for respiratory home care providers. The past practice of only reimbursing for equipment and supplies fails to take into account the vital role played by the home respiratory therapist. Home respiratory equipment and supplies, while an important component of managing chronic respiratory disease, are only effective if used safely, properly, and in compliance with the prescribing physician's intentions. The use of skilled and dedicated home respiratory therapists to train patients, monitor and assess outcomes, and communicate with the prescribing physician ensures optimum results. It is time for reimbursement policies to recognize this vital role played by home respiratory therapists.     

Hmong children and their families: consideration of cultural influences in assessment.

Occupational therapists assessing young Hmong children with developmental problems must consider their families' cultural beliefs as they affect the design of assessment procedures and practices. Choices that families make about health and educational services are influenced by their beliefs. Developmental status can be affected by unresolved medical problems and the child's general health condition. Assessment components based on cultural awareness may improve the effectiveness of early identification of Hmong children with developmental delay. Appropriate use of interpreters, creation of the most beneficial assessment environment, parental report, and observation of functional skills and play provide needed information when determining the child's eligibility for early intervention services. The author has found that trained interpreters provide the most reliable communication between family members and the therapist. Assessments in the home environment are encouraged due to the child's age and the need for family support and interaction. Parents are an excellent source of information about the child's current and past functional abilities. Observations of the child's interaction with family members, with objects and toys during play, and during functional daily living activities provides the therapist with valuable information about the child's need for intervention.     

Clinical reasoning for a patient with neck and upper extremity symptoms: a case requiring referral

The purpose of this case report is to describe a 56-year old female patient with a bizarre pattern of cervicobrachial symptoms. The patient was managed according to the McKenzie "Mechanical Diagnosis and Therapy" principles and the physical examination alongside the movement testing showed inconsistent findings. Due to the patient's cancer-related medical history, presence of night pain, general weakness and the non-response to treatment, a referral to a medical specialist was immediately made. Imaging studies revealed metastases to the axial skeleton in multiple sites and a metastatic lesion was established as a medical diagnosis. With many physical therapists becoming first-entry providers it is likely that encounters with cases other than the purely musculoskeletal will increase. Serious pathologies can mimic musculoskeletal disorders, confusing even the most experienced therapist and as a result, pernicious and possibly life-threatening disease might easily be missed. This would be crucial especially in cases when the patient should immediately be referred to a medical specialist. Physical therapists should hone their clinical skills not only in treatment aspects but also in screening procedures in order to prompt a referral when it is required.     

Dermatomyositis: evolution of a diagnosis

BACKGROUND AND PURPOSE: As direct access evolves, physical therapists will increasingly encounter patients with pathology that might have an underlying systemic origin. The purpose of this case report is to describe the diagnostic process that led a patient's physical therapist to recognize signs and symptoms of dermatomyositis. CASE DESCRIPTION: The patient was an 18-year-old woman who was referred for physical therapy by her primary care physician on 3 occasions with 3 separate musculoskeletal diagnoses. During the third episode, the physical therapist recognized signs and symptoms that could be indicative of dermatologic disease and referred the patient to a dermatologist. OUTCOMES: A rheumatologist diagnosed the patient's condition as dermatomyositis and referred her for physical therapy. The physical therapy plan of care focused on strengthening and stretching, with an emphasis on a home exercise program. The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) indicated that the patient continually made functional improvements over an 18-month period. DISCUSSION: Although diagnosis of diseases such as inflammatory myopathies is not within a physical therapist's scope of practice, this case demonstrates the role a physical therapist can play in recognition of underlying systemic pathology by using the diagnostic process.     

Making sense of physical therapy

Facility-based and payer-based case managers are increasingly having to interact with physical therapists in acute care hospitals, skilled nursing facilities, rehabilitation hospitals, out-patient clinics, and home care settings. Each level of care offers challenges to the case manager and physical therapist. It is critical that communication between the two be efficient and timely. Misunderstandings will interrupt the flow of patient care and have the potential to negatively impact outcomes of care. There are many resources available to the case manager that will help eliminate any of the confusion about services provided by physical therapists. This article explains the role of the physical therapist and strategies offered for successful collaboration between case manager and therapist.     

Multicompetency needs in respiratory care: results of a survey of respiratory therapy alumni and hospital administrators.

I sought to determine (1) respiratory therapists' perceptions of their need for competencies normally associated with other professions, (2) hospital administrators' perceptions of functional combinations of health professions, and (3) the relationship of both sets of these perceptions to the hospital bed size of the employing hospital. METHOD: I mailed pretested and validated survey instruments to all 1981-1984 graduates of The Wichita State University therapist program and a second, similar instrument to all hospital administrators in the state of Kansas. RESULTS: Both groups of respondents perceived a need for therapists to be competent in skills normally associated with other professions. This was true regardless of the size of the hospital concerned. Chi-square analysis revealed no significant difference between the responses of those completing and returning the written survey and the responses of a random sample of nonrespondents to the written survey who were contacted by telephone. Administrators most frequently identified as desirable nursing and physical therapy combinations with respiratory therapy. Respiratory therapists most frequently identified nursing, emergency medical technology, and medical technology as the professions in which they need additional competence. CONCLUSIONS: It would seem prudent for respiratory therapy educators to collaborate with other health care educators to identify a common professional core and to develop curricula that accommodate multicompetency needs.     

Restraint Use in the Elderly Emergency Department Patient

Background

The elderly frequently suffer from altered mental status and other medical conditions requiring physical or chemical restraint for safety in the Emergency Department (ED).

Objective

This study examined outcomes of restrained elderly patients in the ED.

Methods

A 2-year retrospective study was conducted in an urban community teaching hospital ED. Included were patients ≥65 years of age who were physically restrained in the ED and hospitalized. Data collected included age, gender, restraint indications, restraint type, restraint duration, adverse outcomes, ED discharge diagnosis, ED disposition, hospital length of stay, and disposition.

Results

There were 83 patients in the study. Forty-seven (56.6%) were nursing home residents. Twenty-seven (32.5%) were admitted to the intensive care unit. Thirty-five (42.2%) received both chemical and physical restraint. The average number of patient medications on arrival to the ED was eight, and 3 patients were on a medication that could adversely interact with a chemical restraint medication. The mean inpatient length of stay was 7.2 days (SD 5.7 days). Ten patients expired, 14 were discharged home, and 59 were discharged to a nursing facility (8 with new behavioral medications). Of the 36 patients originally presenting to the ED from home, only 11 (30.6%) were discharged back to home. There were no significant differences in outcome between patients who received a combination of both chemical and physical restraints and patients who received physical restraint alone.

Conclusion

In this 2-year retrospective study, elderly patients placed in physical restraints in the ED had no recorded adverse outcomes. In addition, there were no adverse outcomes when they received both physical and chemical restraint. Elderly patients who were originally admitted from home and subsequently required physical restraint were unlikely to return home.     

Planning playgrounds for children with disabilities

Occupational therapists are well qualified for involvement in playground planning. They know how to eliminate architectural barriers, adapt equipment to maximize independence and functional levels, and use play in facilitating children's development. By participating in playground planning or adaptation, the occupational therapist can present play opportunities for children with disabilities, increase public awareness of occupational therapy, and extend the use of treatment modalities. This paper makes specific suggestions for planning and building to make the idea for a playground a realistic goal. A case example illustrates the planning of a playground in a hospital setting.     

Malpractice litigation for uninformed consent. Implications for physical therapists

Although physicians generally are expected to secure their patients' informed consent to medical treatment, an emerging body of legal opinion holds that in certain situations nurses and allied health care professionals may be found similarly responsible. Failure of a health care provider to protect a patient's right of informed consent might result in a lawsuit alleging that serious harm was sustained needlessly because the patient plaintiff was not informed of certain significant risks of or consequences that resulted from treatment. As a professional group that puts patients at risk of harm during treatment, physical therapists need to know about their legal duty to facilitate a patient's awareness of and consent to treatment. This article discusses the nature of that duty and how a patient plaintiff might try to prove negligence against a physical therapist who allegedly fails to secure a valid statement of informed consent. The article also provides recommendations so that physical therapists might protect themselves from malpractice suits alleging "uninformed" consent.     

Legislative change to permit direct access to physical therapy services: a study of process and content issues

The purpose of this study was to examine process and content issues related to legislative change to permit direct access to physical therapy services. Data sources were survey questionnaires sent to the presidents of the 52 chapters of the American Physical Therapy Association (APTA), APTA publications, state statutes, and personal contacts. Results were based on the experiences of 35 chapters, 17 in direct-access states and 18 in non-direct-access states. The majority of direct-access states obtained their status in a single legislative campaign; the majority of non-direct-access jurisdictions attempting legislative change have been unsuccessful for 2 or more years. Over 80% of the chapters reported using legislative lobbyists. Opposing forces varied from state to state and included hospital and medical associations, physicians, chiropractors, and physical therapists. The following limitations on practice in a direct-access mode are found in the various practice acts: diagnosis requirements, eventual referral requirements, physical therapist qualifications, patient consent requirements, and practice setting restrictions.     

Unna and elastic postoperative dressings: comparison of their effects on function of adults with amputation and vascular disease

OBJECTIVES: To compare the functional outcome associated with the use of Unna semirigid dressings (SRD) and elastic bandage soft dressings (ED) for adults with lower limb amputation. DESIGN: Experimental design. SETTING: Inpatient rehabilitation unit of an urban academic medical center. PARTICIPANTS: A successive series of adults with vascular disease who had lower limb amputation surgery. Subjects were randomly assigned to the SRD (12 patients with 12 recent amputations) or the ED (9 patients with 10 recent amputations) group. Subjects in each group were not significantly different except for age; those in the SRD group were somewhat older. INTERVENTION: Subjects in the SRD group had Unna dressings applied to the amputation limb by physical therapists trained in the technique. Those in the ED group had elastic bandaging by therapists, nurses, family, and themselves, all of whom were trained in the technique. RESULTS: Sixty-seven percent of the SRD group and 20% of those in the ED group were discharged from the rehabilitation unit ambulating with prostheses. Of those who received prostheses, time from admission to the rehabilitation unit to readiness for fitting averaged 20.8 days for the SRD group and 28.7 days for the ED group. Comparison of survival curves shows that the time from surgery to fitting in the SRD group was almost half that of the ED group; 30% of the SRD group was fitted within 34 days, whereas it took 64 days for the same percentage of the ED group to be fitted. CONCLUSIONS: Unna semirigid dressings are more effective in fostering amputation limb wound healing and preparing the amputation limb for prosthetic fitting. Subjects treated with SRDs were more likely to be fitted with prostheses and to return home walking with a prosthesis.     

Productivity among physical therapists. An evaluation of one department

This article describes a method for evaluating the productivity of therapists in a physical therapy department. I applied this method for 20 days in one department of an acute-care hospital and used the data collected to establish a standard based on the best performance by an individual therapist. I found this method could substantially improve the performance of individual therapists and the department as a whole. If all therapists in the department were as productive as the most productive therapist, the dollar sum of procedures performed would be at least $250,000 greater than if the average performance level continued.     

Clinical features of patients inappropriately undiagnosed of pulmonary embolism

PurposesThe objective of this study was to identify clinical factors associated with delayed diagnosis of acute pulmonary embolism (PE) in the emergency department (ED).Basic proceduresA retrospective observational study was performed at three University affiliated Hospitals; 436 consecutive patients who presented to the ED with an acute PE confirmed by chest computed tomography from 2008 to 2011 were included. Patients were divided into 3 groups: group 1, PE was diagnosed while the patient was still in the ED; group 2, PE was diagnosed during hospitalization; group 3, patients who were sent home with a wrong alternative diagnosis and returned to the ED and were diagnosed of PE.Main findingsOne hundred forty-six patients (33.5%) had a delayed diagnosis of PE—21.5% belong to group 2 and 11.9% to Group 3. Chronic coexisting medical conditions like asthma or chronic obstructive pulmonary disease were independent predictors of a delayed diagnosis in patients who were admitted to hospital whereas non-specific and less severe symptoms like the presence of pleuro-mechanic thoracic pain, fever, hemoptysis, or the presence of a pulmonary infiltrate in chest x-ray were independent predictors of a delayed diagnosis in patients who were sent home.Principal conclusionsDelay in diagnosis of acute PE is frequent despite current diagnostic strategies. Patients are sent home or admitted to hospital with a wrong diagnosis depending on clinical presentation or coexisting medical conditions.     

Identifying Barriers to Healthcare to Reduce Health Disparity in Zuni Indians Using Focus Group Conducted by Community Health Workers

The Zuni Pueblo is home to an economically disadvantaged population, which faces a public health challenge from the interrelated epidemics of obesity, diabetes and kidney disease. Efforts to decrease the impact of these epidemics have been complicated by historical, economic and cultural barriers, which may limit healthcare utilization. The NIH supported Zuni Health Initiative (ZHI) conducted a study to identify barriers to healthcare in the Zuni Pueblo.Community health representatives (CHRs) led 14 one‐hour focus group sessions at which a total of 112 people participated posed unique questions that took into account the Zuni culture to elicit information on perceived barriers to healthcare. Audiotapes were translated and transcribed by bilingual ZHI staff. We reduced the text to thematic categories, constructed a coding dictionary and inserted the text into NVivo 9 program.We identified nine themes emerged regarding the barriers experienced in receiving healthcare and adhering to medical advice. These included distance; transportation; embarrassment; relating to healthcare professionals; navigating the medical system; awareness of available resources; waiting times; adhering to medication; and incentives in health promotion.In conclusion the implementation of culturally appropriate community‐based health promotion programs and preventive screening techniques will improve access to healthcare and diminish health disparities.     

Screening tools to identify hospitalised elderly patients at risk of functional decline: a systematic review

Background: The elderly patient admitted to the emergency department (ED) of an acute care hospital is at risk of declining functionally, both during the stay at the hospital as an inpatient and postdischarge. Accurate and early identification of this population may lead to improved outcomes through targeted early interventions. Objectives: To identify, critically appraise and characterise available screening tools to screen for elderly patients at risk of functional decline presenting to the ED of acute care hospitals. Selection criteria: Screening tools administered in the ED to identify elderly patients at risk of functional decline during hospital stay and/or postdischarge. All primary quantitative and qualitative study types were included. Population included age > 65 years presenting to the ED of an acute care hospital. Results: Six studies reporting on five screening tools were identified. Two instruments reported acceptable discriminative ability; however, one of these has not been prospectively validated. No studies that validated any of the instruments in a setting other than the development setting were identified. A single study reported good test–retest reliability data for one instrument, the Identification of Seniors at Risk. Conclusion: This review was unable to identify a ‘gold standard’ tool to screen for risk of functional decline for the elderly patient admitted to the ED. Further research should be carried out to determine adjunctive processes to increase the accuracy of the identification of elderly patients at risk of functional decline. Further research should also be carried out to determine the appropriateness, or generalisability of these tools in different healthcare settings.     

Differential diagnosis of endometriosis in a young adult woman with nonspecific low back pain

BACKGROUND AND PURPOSE: Endometriosis is a common gynecological disorder that can cause musculoskeletal symptoms and manifest as nonspecific low back pain. CASE DESCRIPTION: The patient was a 25-year-old woman who reported the sudden onset of severe left-sided lumbosacral, lower quadrant, buttock, and thigh pain. The physical therapist examination revealed findings suggestive of a pelvic visceral disorder during the diagnostic process. The physical therapist referred the patient for medical consultation, and she was later diagnosed by a gynecologist with endometriosis and a left ovarian cyst. OUTCOMES: The patient underwent laser laparoscopy and excision of the ovarian cyst followed by a regimen of gonadotropin-releasing hormone agonists. The intervention resulted in abolition of the lower quadrant pain and a significant reduction of the back and leg pain that enabled the patient to return to her normal activities. DISCUSSION: A thorough physical therapist examination that considers all of the musculoskeletal, visceral, and psychosocial components is essential to identify pelvic disorders such as endometriosis and other disease processes during the differential diagnosis of nonspecific low back pain. Medical consultation is necessary to provide proper diagnosis and intervention of endometriosis, but physical therapists also may have an important role in the identification of endometriosis and the management of the musculoskeletal aspects of the disorder.