Journal reviews
McCusker J, Bellavance F, Cardin S. Prediction of hospital utilization among elderly patients during the six months after an ED visit. Ann Emerg Med 2000; 36:438-445.
A brief self-report questionnaire can identify elderly patients who will experience high utilization of acute-care hospitalization, says this study from St. Mary’s Hospital, McGill University, and University of Montreal Hospital Center, all based in Montreal. The study gave a screening tool, Identification of Seniors at Risk (ISAR) to 1,620 patients 65 years and older who visited the EDs of Montreal hospitals. The tool consisted of six questions to gauge the risk of hospitalization. (See ISAR screening tool, below.)
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More than half of the patients had a score of 2 or higher, indicating an increased risk of adverse health outcomes. The number of acute-care hospital days were reviewed for the patients during the next six months.
The screening tool can help you target interventions to reduce the chances of adverse outcomes and hospital admission, say the researchers. They note that it can be self-administered by patients in the waiting room or given by the caregiver. "As with all screening methods, the screening tool must be linked with effective interventions," they caution. They recommend doing the following for elderly patients who are at high risk for hospitalization:
- flagging the chart of admitted patients who are at increased risk;
- alerting staff to the need for early comprehensive assessment by the geriatric team;
- conducting a short clinical assessment to determine whether the patient can be safely discharged;
- determining whether home care services are needed;
- giving individualized referrals to a family physician or geriatric outpatient clinic.
Gordon JA. Cost-benefit analysis of social work services in the ED: A conceptual model. Acad Emerg Med 2001; 8:54-60.
Although the cost of providing dedicated social workers in the ED is often a deterrent, this practice might actually result in financial benefits, according to this study from Massachusetts General Hospital in Boston. The study evaluated costs and benefits of providing full-time social work services at three levels of ED volume. The researcher used a model to approximate projected costs and benefits of social work services at hypothetical EDs, based on data from previous research. He estimated variables including the percentage of ED patients who would see a social worker and the number of return visits to the ED that could be prevented by social work intervention.
The researcher found that large urban EDs probably would have a net benefit from operating full-time social work services, moderate-size EDs may almost "break even" financially or incur moderate cost, and that small EDs may realize a net loss. However, in any of these scenarios, the cost of social services can be significantly offset by decreased use of hospitalization and ED services and more efficient use of medical staff time, he writes.
The study only took economic benefits into account and did not look at "invaluable" measures such as improved patient quality of life, avoiding psychological crises, and alleviation of suffering, notes the researcher. "Dedicated 24-hour social work staffing of EDs may yield net economic benefits to a hospital system, especially in large urban centers," he concludes.
Tanabe P, Thomas R, Paice J, et al. The effect of standard care, ibuprofen, and music on pain relief and patient satisfaction in adults with musculoskeletal trauma. J Emerg Nurs 2001; 27:124-131.
Patient satisfaction scores might be positive, even when pain is not relieved, as long as pain is addressed, says this study from Northwestern Memorial Hospital in Chicago. The study looked at 77 patients with minor musculoskeletal trauma from sprains and fractures who reported moderate pain with a rating of 4 or greater. The patients were separated into three groups receiving the following interventions: standard care (ice, elevation, and immobilization), standard care and ibuprofen, and standard care plus music distraction. Patients in the music distraction group were given a cassette tape player with headphones and their choice of multiple music tapes or the radio.
The patients were monitored for pain ratings for an hour, and two patient satisfaction questions about pain management were asked upon discharge. Although none of the therapies provided significant pain relief, the patient satisfaction scores were still sometimes positive.
Although distracting patients with music did not provide reductions in pain any more than standard therapy, it did have an impact on patient satisfaction. "Patients enjoyed the opportunity to listen to music of their choice and clearly expressed the desire to listen to music in future visits to the emergency department," the researchers write. They recommend the following:
- considering stronger analgesics for this population;
- including distraction opportunities in triage protocols;
- making follow-up phone calls to determine the effectiveness of discharge prescriptions;
- obtaining pain ratings for patients with all injuries;
- providing interventions based on the patient’s subjective rating, instead of the final diagnosis or how severe the injury appears.
"The attention to pain relief, whether or not it was adequate, and distraction with music appear to increase patient satisfaction," the researchers conclude.
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