Patient‐centered Outcomes Research in Emergency Care: Opportunities,Challenges, and Future Directions

The Patient‐Centered Outcomes Research Institute (PCORI) was established by Congress in 2010 to promote the conduct of research that could better inform patients in making decisions that reflect their desired health outcomes. PCORI has established five national priorities for research around which specific funding opportunities are issued: 1) assessment of prevention, diagnosis, and treatment options; 2) improving healthcare systems; 3) communication and dissemination research; 4) addressing disparities; and 5) improving methods for conducting patient‐centered outcomes research. To date, implementation of patient‐centered research in the emergency care setting has been limited, in part because of perceived challenges in meeting PCORI priorities such as the need to focus on a specific disease state or to have planned follow up. We suggest that these same factors that have been seen as challenges to performing patient‐centered research within the emergency setting are also potential strengths to be leveraged to conduct PCORI research. This paper explores factors unique to patient‐centered emergency care research and highlights specific areas of potential alignment within each PCORI priority.     

Ethics Seminars: A Best‐practice Approach to Navigating the Against‐Medical‐Advice Discharge

Patients who sign out or choose to leave the emergency department (ED) against medical advice (AMA) present important challenges. The current approach to the complex legal, ethical, and medical challenges that arise when adult patients decline medical care in the ED would benefit from a systematic best‐practice strategy to maximize patient care outcomes, minimize legal risk, and reach the optimal ethical standard for this at‐risk population. Professional responsibilities generated during an AMA encounter include determination of patient decision‐making capacity, balancing protection of patient autonomy with prevention of harm, providing the best alternatives for patients who decline some or all of the proposed plan, negotiating to encourage patients to stay, planning for subsequent care, and documenting what transpired. We present two cases that illustrate key insights into a best‐practice approach for emergency physicians (EPs) to address problems arising when patients want or need to leave the ED prior to completion of their care. We propose a practical, systematic framework, “AIMED” (assess, investigate, mitigate, explain, and document), that can be consistently applied in situations where patients consider leaving or do leave before their evaluations and urgent treatment are complete. Our goal is to maximize patient outcomes, minimize legal risk, and encourage a consistent and ethical approach to these vulnerable patients.     

The meaning of follow-up in intensive care: patients' perspective

The growing understanding of correlations between experiences and memories from a period of intensive care treatment and complaints of mental character has led to the development of various patient follow‐up offers. Little, however, is known about what follow‐up may mean to patients. The aim of this study was to explore the meaning of patients’ lived experience of being followed‐up in a programme consisting of patient diaries, post‐intensive care unit (ICU) conversations and visits back to the ICU. Field notes were made from encounters with patients (n = 10) during follow‐up. Then they were interviewed twice, at about 6 months (n = 8) and at about 18 months (n = 6) after discharge from hospital. The first interview focused on the patients’ experience during intensive care and on their reflections on the experience. The second interview had a particular focus on the meaning for each individual of the sources for understanding that they had been offered. The data was analysed by using a hermeneutic‐phenomenological approach. The study corroborated earlier research that found that patients seek to understand experiences they have undergone. They search for meaning in experiences and memories. It is realized that the diary as text and photos, in addition to conveying care and love, is important to induce postexperience reflections. It provided guideposts that follow‐up conversations could pursue in the patient’s quest for meaning. The conversation also provided an opening for, and could in itself be essential to, the patient’s willingness to talk about experiences. It allowed the nurse to accompany the patient in his quest for meaning. The return visit appeared to be significant in the patient’s quest for meaning. It was via ‘feeling’ the room that ‘things’ fell into place. The study is important in elucidating aspects that are beneficial in the patient’s follow‐up and which lay the basis for further development of existing and new follow‐up offers.     

Hypertension: current trends and choices in pharmacotherapeutics.

Many new choices exist in the management of hypertension. Armed with a basic understanding of the definition and causes of hypertension, the pharmacotherapeutics, and special patient populations, health care professionals should be able to optimally educate, treat, and follow up patients with hypertension. In the step-care approach, four different classes of agents may be used as Step 1 choices. Selection is determined by concurrent illnesses, patient age, or concomitant drug therapy. In emergency situations, additional choices exist. Tailoring therapy in hypertensive crises may prevent or minimize end-organ damage. These areas are reviewed, and guidelines for patient assessment and education are presented.     

Discharge of the older person from the emergency department - the perceptions of health professionals

Aims of study. This study aimed to examine the management of the older person in preparation for discharge home from an emergency department by exploring the perceptions of health professionals on procedures undertaken particularly in relation to the planned support, supply of medications, dressings, and contact information given to patients. An additional aim related to the perceived satisfaction levels of older patients and their carers. Background. It is imperative that older patients are adequately prepared for discharge home from the emergency department so as to avoid unnecessary anxiety, increase in health problems and possible re‐attendance or admission to hospital. Design. The sample in this study comprised the total population (n = 222) of all medical and nursing staff in both the emergency department and the primary care area. Methods. The method adopted was a survey approach which employed the use of standardized questionnaires comprising both open and closed questioning styles. Results. The data obtained identified results similar to previous research in that a discrepancy exists between hospital and community staff in relation to the procedures undertaken when discharging older people from the emergency department, such as arranging follow‐up care and appointments and giving the patient relevant contact numbers and dressings. Conclusion. The findings of this study support previous research in that there is a need to provide patients with planned support, aids and appliances, clear instructions and relevant contact numbers on discharge from the emergency department. Relevance to clinical practice. Good quality discharge planning is essential for a continuum of care for older people discharged from the emergency department. While patient education is often difficult in the busy emergency department, the provision of relevant information to older patients prior to discharge is essential particularly in relation to prescribed medications and wound care.     

Using holistic interpretive synthesis to create practice‐relevant guidance for person‐centred fundamental care delivered by nurses

Nursing policy and healthcare reform are focusing on two, interconnected areas: person‐centred care and fundamental care. Each initiative emphasises a positive nurse–patient relationship. For these initiatives to work, nurses require guidance for how they can best develop and maintain relationships with their patients in practice. Although empirical evidence on the nurse–patient relationship is increasing, findings derived from this research are not readily or easily transferable to the complexities and diversities of nursing practice. This study describes a novel methodological approach, called holistic interpretive synthesis (HIS), for interpreting empirical research findings to create practice‐relevant recommendations for nurses. Using HIS, umbrella review findings on the nurse–patient relationship are interpreted through the lens of the Fundamentals of Care Framework. The recommendations for the nurse–patient relationship created through this approach can be used by nurses to establish, maintain and evaluate therapeutic relationships with patients to deliver person‐centred fundamental care. Future research should evaluate the validity and impact of these recommendations and test the feasibility of using HIS for other areas of nursing practice and further refine the approach.     

Nurse-led vs. conventional physician-led follow-up for patients with cancer: systematic review

Title. Nurse‐led vs. conventional physician‐led follow‐up for patients with cancer: systematic review. Aim. This paper is a report of a systematic review of the effectiveness and cost‐effectiveness of nurse‐led follow‐up for patients with cancer. Background. As cancer survivorship increases, conventional follow‐up puts a major burden on outpatient services. Nurse‐led follow‐up is a promising alternative. Data sources. Searches were conducted covering a period from inception to February 2007 of 19 electronic databases, seven online trial registries, five conference proceedings reference lists of previous reviews and included studies. Review methods. Standard systematic review methodology was used. Comparative studies and economic evaluations of nurse‐led vs. physician‐led follow‐up were eligible. Studies comparing different types of nurse‐led follow‐up were excluded. Any cancer was considered; any outcome measure included. Results. Four randomised controlled trials were identified, two including cost analyses. There were no statistically significant differences in survival, recurrence or psychological morbidity. One study showed better HRQL measures for nurse‐led follow‐up, but one showed no difference, two showed a statistically significant difference for patient satisfaction, but two did not. Patients with lung cancer were more satisfied with nurse‐led telephone follow‐up and more were able to die at home. Patients with breast cancer thought patient‐initiated follow‐up convenient, but found conventional follow‐up more reassuring. One study showed the cost of nurse‐led follow‐up to be less than that of physician‐led follow‐up, but no statistical comparison was made. Conclusion. Patients appeared satisfied with nurse‐led follow‐up. Patient‐initiated or telephone follow‐up could be practical alternatives to conventional care. However, well‐conducted research is needed before equivalence to physician‐led follow‐up can be assured in terms of survival, recurrence, patient well‐being and cost‐effectiveness.     

Consensus Statement on Advancing Research in Emergency Department Operations and Its Impact on Patient Care

The consensus conference on “Advancing Research in Emergency Department (ED) Operations and Its Impact on Patient Care,” hosted by The ED Operations Study Group (EDOSG), convened to craft a framework for future investigations in this important but understudied area. The EDOSG is a research consortium dedicated to promoting evidence‐based clinical practice in emergency medicine. The consensus process format was a modified version of the NIH Model for Consensus Conference Development. Recommendations provide an action plan for how to improve ED operations study design, create a facilitating research environment, identify data measures of value for process and outcomes research, and disseminate new knowledge in this area. Specifically, we call for eight key initiatives: 1) the development of universal measures for ED patient care processes; 2) attention to patient outcomes, in addition to process efficiency and best practice compliance; 3) the promotion of multisite clinical operations studies to create more generalizable knowledge; 4) encouraging the use of mixed methods to understand the social community and human behavior factors that influence ED operations; 5) the creation of robust ED operations research registries to drive stronger evidence‐based research; 6) prioritizing key clinical questions with the input of patients, clinicians, medical leadership, emergency medicine organizations, payers, and other government stakeholders; 7) more consistently defining the functional components of the ED care system, including observation units, fast tracks, waiting rooms, laboratories, and radiology subunits; and 8) maximizing multidisciplinary knowledge dissemination via emergency medicine, public health, general medicine, operations research, and nontraditional publications.     

Tracking Inner City Substance Users from the Emergency Department: How Many Contacts Does It Take?

Background: Longitudinal studies of substance users report difficulty in locating and completing 12‐month interviews, which may compromise study validity. Objectives: This study examined rates and predictors of contact difficulty and in‐person follow‐up completion among patients presenting with cocaine‐related chest pain to an inner‐city emergency department (ED). The authors hypothesize that less staff effort in contacting patients and lower follow‐up rates would bias subsequent substance use analysis by missing those with heavier substance misuse. Methods: A total of 219 patients aged 19 to 60 years (65% males; 78% African American) with cocaine‐related chest pain were interviewed in the ED and then in person at 3, 6, and 12 months. Demographics, substance use measures, and amount/type of research staff contacts (telephone, letters, home visits, and locating patient during return ED visits) were recorded. Poisson and negative binomial regression analyses were conducted to predict quantity of patient contacts for the 12‐month follow‐up. Results: Interview completion rates at 3, 6, and 12 months were 78, 82, and 80%, respectively. Average contact attempts to obtain each interview were 10 at 3 months (range 3–44), 8 at 6 months (1–31), and 8 at 12 months (1–49); 13% of patients required a home visit to complete the 12‐month interview. Participants requiring more contact attempts by staff were younger and reported more frequent binge drinking at baseline (p < 0.05), but were less likely to meet criteria for substance abuse or dependence (p < 0.5), or to report prior mental health treatment (p < 0.05). Comparisons of parallel regressions predicting contact difficulty based on the entire sample, the low‐effort group, and the difficult‐to‐reach group showed variation in findings. Conclusions: This study demonstrates that substantial staff effort is required to achieve adequate retention over 12 months of patients with substance misuse. Without these extensive efforts at follow‐up, longitudinal analyses may be biased.     

After critical care: a study to explore patients' experiences of a follow-up service

Aims and objectives. To establish patients’ experiences after discharge from critical care and to evaluate implementation of a follow‐up service. Background. Government recommendations advise critical care follow‐up to prevent readmission and address problems after discharge. Admission to critical care results in significant psychological and physiological sequelae. Design. A prospective, longitudinal and exploratory study of surgical cancer patients requiring >48 hours in critical care. Qualitative interviews were conducted and short questionnaires were used. Methods. Patient Expert Advisory Groups were invited to participate in research design. Patients were visited in the ward at days 1 and 5 after discharge, invited to nurse‐led follow‐up clinic and interviewed at three and six months. Short questionnaires were administered at six and 12 months. Findings. Twenty‐seven patients participated in the study. All patients experienced benefit from the service. Emergent themes included: rehabilitation from critical care: physiological issues and needs, memories: real and unreal, uncertainty and fear and empathy. A core theme of reassurance was underlying through the research. Issues while in critical care included: the need for nursing presence, nightmares, delusions, confusion, fear of ward transfer, inability to remember, disorientation and being prepared for the experience. After discharge, issues shifted to longer term needs. Psychological support, in the form of the follow‐up clinic, proved useful. The ability to move on with life after discharge varied and uncertainty about the future and their cancer had an impact upon this. Recovery was made easier through the follow‐up clinic. Patients required reassurances that their experiences were valid and also wanted reassurances about their cancer. Conclusion. Critical care causes various difficulties for patients that may impinge on recovery. Incorporating patients into the design process helps identify needs more closely. Follow‐up proved beneficial and highlighted the role nurses have in improving patient experiences after discharge from critical care. Nurses should be vigilant for both immediate and longer‐term needs. Relevance to clinical practice. This research into nurse‐led follow‐up clinics after critical care highlights an important, and often neglected, part of the critical illness continuum. Attending such clinics may help reassure patients after discharge from critical care.     

Intensive Intervention Improves Primary Care Follow-up for Uninsured Emergency Department Patients

Objectives: To test an intervention designed to improve primary care use and decrease emergency department (ED) utilization for uninsured patients using the ED. Methods: Using a randomized design, an intensive case‐management intervention was tested with patients identified at a Level 1 urban trauma center from April 2002 through July 2002. Following assessment in the ED, six‐month follow‐up data were gathered from four primary care sites (two Federally Qualified Health Centers, two hospital outpatient clinics) and two area hospitals. Eligible participants were uninsured, were at least 18 years of age, and did not have a regular primary care provider. Of 281 patients approached, 273 (97.2%) agreed to participate. After 42 patients were eliminated following enrollment due to ineligibility, there were 121 intervention and 109 comparison subjects. Health Promotion Advocates (HPAs) in the ED gathered information from all study participants. On intervention shifts, HPAs assisted patients in choosing a primary care provider and faxed all information to a case worker at the selected site. Case managers attempted to contact patients and schedule appointments. On comparison shifts, patients received care as usual. Primary care contact in 60 days and subsequent ED visits in six months post‐ED assessment were the main outcome measures. Results: Intervention subjects were more likely to have a primary care contact (51.2% vs. 13.8%, p < 0.0001). There was no statistically significant difference between groups in either number of inpatient admissions or postintervention ED visits, although postintervention ED visits for the intervention group were less expensive. Conclusions: This project has demonstrated that it is possible to improve primary care follow‐up for uninsured ED patients.     

From the emergency department to home

Aim. The purpose of this study was to explore dimensions of the management of the older person following care in an emergency department in preparation for discharge home by identifying perceptions and attitudes of staff in both emergency department and primary care sectors. Background. It is recognized that older people discharged home directly from the emergency department are a vulnerable group. Effective communication and liaison are seen to be keys to the provision of high quality care for older people in the emergency department and in ensuring a seamless care between sectors. Design. A purposeful sample was collected that comprised the total population (n = 222) of all grades of medical and nursing staff in both the emergency department and all nursing (Public Health Nurses & Practice nurses) and medical staff (General Practitioners) in the primary care area. Methods. Methodology used was that of a survey approach of nursing and medical staff in both the emergency department and primary care services. Standardized questionnaires were employed which comprised both open and closed questioning style. Raw statistical data were analysed using SPSS for Windows while the qualitative data arising from the open‐ended questions were content analysed for themes. Results. Many staff in the primary care area reported the level of communication between the emergency department and the primary care area as unsatisfactory with confusion regarding follow‐up care and a lack of support for older people on discharge. Hospital staff reported the level of communication to be much greater than that perceived by their colleagues in primary care. There was agreement of staff in both sectors in relation to the perceived usefulness of a discharge liaison nurse in the emergency department. Conclusions. Previous research highlights communication difficulties when patients are discharged from hospital. Findings from this study indicate that this problem can also be applied to the emergency department. Relevance to clinical practice. Implications for practice include a need for a multidisciplinary approach to developing referral guidelines, staff training and a comprehensive dissemination of information between sectors ultimately to improve quality and continuity of care for the older person.     

Advanced Opportunities for Student Education in Emergency Medicine

Many medical students are excited about emergency medicine (EM) following a standard clerkship and seek out additional learning opportunities. An advanced EM elective may accomplish several educational goals, including development of clinical skills in evaluating the undifferentiated patient, broader exploration of the field of EM, and more focused study of one particular aspect of EM. Previously cited examples include pediatric EM, medical toxicology, occupational medicine, sports medicine, and EM research. Numerous other EM specialty courses for senior medical students are emerging, as reflected in the “Undergraduate Rotations” listings on the Society for Academic Emergency Medicine. A few examples drawn from the list include emergency ultrasound, international EM, wilderness medicine, disaster medicine, geriatric EM, and hyperbaric medicine. Educators aspiring to develop, or in the process of developing, an advanced EM elective may benefit from a brief overview of necessary course considerations, including didactic format, the clinical role of the medical student in the emergency department, and involvement with patient procedures. Suggestions are made regarding additional educational opportunities, including follow‐up of patients seen in the emergency department and development of an emergency department radiology case file. This article also addresses several related concerns, including suggested prerequisites, administration and cost considerations, appropriate didactic topics, and methods for evaluating students. Several EM subspecialty areas, namely pediatric EM, medical toxicology, and out‐of‐hospital care, are specifically discussed. Formal advanced cardiac life support training is also often included in an advanced EM elective and is briefly discussed. The overall intent of this article is to provide medical student educators with resources and ideas to assist them in developing a unique advanced EM elective.     

The Shortage of On‐call Surgical Specialist Coverage: A National Survey of Emergency Department Directors

Objectives: Problems with on‐call specialist physician coverage have been identified as a significant issue for our nation’s health care system. Despite this, little is known about the full extent of these coverage deficiencies in emergency departments (EDs), their effect on emergency care provision, or the subsequent effect on patient flow should specialist‐requiring patients need to be transferred to centers of higher‐level care. The objective was to report the experiences of a national sample of ED directors regarding the degree of difficulty in providing specialist coverage and the effect of on‐call coverage problems on emergency patient care. Methods: The authors conducted a cross‐sectional self‐administered survey of a national sample of ED directors. How frequently ED directors reported on‐call coverage problems, whether they recently lost on‐call coverage, whether their current on‐call coverage was reliable, and the potential effect on emergency care provision were all assessed. Results: The overall response rate was 62% (442 of 715). Seventy‐four percent of respondents reported on‐call coverage problems with specialist physicians. Sixty percent reported having lost 24/7 coverage for at least one specialty in the past 4 years. Twenty‐six percent reported unreliability in their current on‐call coverage. Twenty‐three percent noted that their trauma center designation level had been affected by on‐call coverage, and 22% noted an increase in patients leaving before being seen by a medically needed specialist. Conclusions: Difficulties in obtaining specialty on‐call coverage are a pervasive issue for EDs at the national level. Emergency care provision appears to have been affected, and this issue is further impacted by a perceived unreliability in current on‐call coverage provision as well as the attrition of coverage for individual specialties. ACADEMIC EMERGENCY MEDICINE 2010; 17:1374–1382 © 2010 by the Society for Academic Emergency Medicine     

Chronic care management for patients with COPD: a critical review of available evidence

Rationale, aims and objectives Clinical diversity and methodological heterogeneity exists between studies on chronic care management. This study aimed to examine the effectiveness of chronic care management in chronic obstructive pulmonary disease (COPD) while taking heterogeneity into account, enabling the understanding of and the decision making about such programmes. Three investigated sources of heterogeneity were study quality, length of follow‐up, and number of intervention components. Methods We performed a review of previously published reviews and meta‐analyses on COPD chronic care management. Their primary studies that were analyzed as statistical, clinical and methodological heterogeneity were present. Meta‐regression analyses were performed to explain the variances among the primary studies. Results Generally, the included reviews showed positive results on quality of life and hospitalizations. Inconclusive effects were found on emergency department visits and no effects on mortality. Pooled effects on hospitalizations, emergency department visits and quality of life of primary studies did not reach significant improvement. No effects were found on mortality. Meta‐regression showed that the number of components of chronic care management programmes explained present heterogeneity for hospitalizations and emergency department visits. Four components showed significant effects on hospitalizations, whereas two components had significant effects on emergency department visits. Methodological study quality and length of follow‐up did not significantly explain heterogeneity. Conclusions This study demonstrated that COPD chronic care management has the potential to improve outcomes of care; heterogeneity in outcomes was explained. Further research is needed to elucidate the diversity between COPD chronic care management studies in terms of the effects measured and strengthen the support for chronic care management.     

Research Opportunities in the Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Acute exacerbations of chronic obstructive pulmonary disease are a common problem in the emergency department. Despite considerable research involving the management of this disease over the past decade, much remains unclear from an emergency medicine perspective. Increased research would better guide the management of these complex patients from the perspectives of the patient, the caregiver, and society. The major areas of research can be divided into diagnosis, therapy, and education. The reliability and validity of different definitions of acute exacerbations of chronic obstructive pulmonary disease need to be assessed. The utility and performance characteristics of diagnostic testing need to be determined for this difficult patient population. Specific diagnostic tests include measures of dyspnea, spirometry and exercise tolerance, measures of gas exchange, airway inflammation, and chest imaging. It remains unclear which patient‐specific therapies (oxygen, bronchodilators, corticosteroids, antibiotics, noninvasive positive pressure ventilation, and methylxanthines) should be used and monitored. Finally, the utility of education of both health care providers and patients and how it may be applied to the acute setting need to be addressed.