Paramedic-Initiated Home Care Referrals and Use of Home Care and Emergency Medical Services

Objective: We examined the association between paramedic-initiated home care referrals and utilization of home care, 9-1-1, and Emergency Department (ED) services. Methods: This was a retrospective cohort study of individuals who received a paramedic-initiated home care referral after a 9-1-1 call between January 1, 2011 and December 31, 2012 in Toronto, Ontario, Canada. Home care, 9-1-1, and ED utilization were compared in the 6 months before and after home care referral. Nonparametric longitudinal regression was performed to assess changes in hours of home care service use and zero-inflated Poisson regression was performed to assess changes in the number of 9-1-1 calls and ambulance transports to ED. Results: During the 24-month study period, 2,382 individuals received a paramedic-initiated home care referral. After excluding individuals who died, were hospitalized, or were admitted to a nursing home, the final study cohort was 1,851. The proportion of the study population receiving home care services increased from 18.2% to 42.5% after referral, representing 450 additional people receiving services. In longitudinal regression analysis, there was an increase of 17.4 hours in total services per person in the six months after referral (95% CI: 1.7–33.1, p = 0.03). The mean number of 9-1-1 calls per person was 1.44 (SD 9.58) before home care referral and 1.20 (SD 7.04) after home care referral in the overall study cohort. This represented a 10% reduction in 9-1-1 calls (95% CI: 7–13%, p < 0.001) in Poisson regression analysis. The mean number of ambulance transports to ED per person was 0.91 (SD 8.90) before home care referral and 0.79 (SD 6.27) after home care referral, representing a 7% reduction (95% CI: 3–11%, p < 0.001) in Poisson regression analysis. When only the participants with complete paramedic and home care records were included in the analysis, the reductions in 9-1-1 calls and ambulance transports to ED were attenuated but remained statistically significant. Conclusions: Paramedic-initiated home care referrals in Toronto were associated with improved access to and use of home care services and may have been associated with reduced 9-1-1 calls and ambulance transports to ED.     

医院开展产褥期母婴保健延伸服务的研究

目的探索医院开展产褥期母婴保健延伸服务的方式与途经,充分利用医疗资源,为产妇提供连续的多种形式的支持与帮助,促进母婴健康。方法实验组产妇(100例)接受产褥期母婴保健延伸服务,与以往接受常规服务的常规组产妇(100例)做对比研究。在产后复查时,分别对产褥期接受医院延伸服务情况、母婴健康状况及服务需求进行问卷调查,由产妇按5分制评定。结果在反映母乳喂养,母亲生理、心理与新生儿健康诸项目中,两组比较,实验组优于常规组,差异具有统计学意义(P<0.05)。尤其在母乳喂养成功率、乳腺病发生率、自信心、新生儿便秘、脐部感染等项目上,差异有高度显著性意义(P<0.01)。结论多样化的延伸服务能较好地满足产褥期母婴保健的需求,有效地促进母婴健康,为医院开展产褥期母婴保健延伸服务提供了有益的经验。     

Patient and physician perception of need for emergency medical care: A prospective and retrospective analysis

The purpose of this study was to examine patients' and physicians' perceptions of the urgency of need for emergency medical care, and why patients come to the emergency department (ED). Survey instruments were utilized at EDs at an academic tertiary care center and a community hospital. Physicians' prospective assessment indicated that 65.8% (921 of 1,400) of the patients seen needed attention within 12 hours, whereas the patients' perception was that 86.5% (957 of 1,106) needed care within 12 hours. Patients' and physicians' retrospective responses were compared; in 19.5% (152 of 781) of cases patients rated urgency of their condition lower than the physician. These results indicate that patients and the physicians who treat them, despite the passage of a decade since a previous report of a similar study and a vastly different patient and physician population, have similar perceptions of the need for emergency care. Additionally, patients presented to EDs for a multitude of reasons; however, in strikingly different patient populations, a number of reasons are identified consistently.     

医院船拉美国家医疗服务导医模式的优化与效果

目的 探索医院船在国外医疗服务中的导医模式,优化服务流程,提高就诊速度,改善就医秩序.方法 根据到访国不同医疗需求,采用一对一专人引导,分组引导,楼层(甲板)固定引导,流动引导与医生及志愿者接力和交叉引导,及专项检查定位引导等方式.对就诊患者发放自制调查表,行满意度调查.结果 楼层(甲板)固定引导、流动引导与医生及志愿者接力和交叉引导能有效、合理地疏导就诊患者,缓解易造成患者滞留诊室的压力,保持井然有序的就医环境,患者集中在心电图、B超、X线检查及口腔科停留等候时间由15 min左右缩短为5 min左右.发放的服务满意度调查问卷统计结果显示,满意度为100％,并收到英语表扬信4封,西班牙语表扬信1封.结论 统筹协调,灵活引导,全方位、多渠道参与协同的导医模式,是国外医疗服务顺利进行的有力保证.合理、有效的引导服务受到了到访国政府和民众的欢迎和肯定.     

Psychiatry in the emergency department: factors associated with treatment and disposition

Patients with psychiatric problems present difficult treatment and dispositional decisions to physicians in general hospital emergency departments (ED). We studied the relationships between the psychosocial characteristics of patients given psychiatric diagnoses and clinical decisions made by nonpsychiatrists and psychiatrists in our ED. Decisions concerning psychiatric consultation in the ED, dispositional decisions (admission, discharge), and referral for psychiatric outpatient care for patients discharged were reviewed for 246 patients. The relationships between decisions and 13 indicators of patients' psychosocial characteristics were evaluated by use of stepwise logistic regression techniques. Psychiatric-related variables (severity of symptoms, history of psychiatric hospitalization or outpatient treatment, and psychotropic medications at entry to the ED) were associated with decisions made by both psychiatrists and nonpsychiatrists. However, nonpsychiatric variables including patient's age, "rudeness," diffuseness of medical complaints, time of day, and month of presentation also were related to decisions. Practitioners should be sensitive to social factors that affect their decisions about psychiatric patients.     

Helpful and unhelpful responses after suicide: Experiences of bereaved family members

Individuals who are bereaved by suicide and other traumatic natured deaths are thought to be at greater risk of psychological complications, than people bereaved by other means. While it is recognized that interventions can influence the bereavement process, there remains limited communications about both helpful responses and those that may adversely influence the grieving process for the suicide bereaved. This paper presents findings from a narrative study, which sought the experiences of family members after the loss of a loved one as a result of suicide. The study findings demonstrated that responses by agencies are often insensitive and not aligned with the needs of those bereaved. We argue that training is paramount for all services to increase awareness of the needs of people bereaved by suicide and available support services. Changes to organizational policies in relation to finance support would greatly support the bereaved during their time of grief and heightened distress.     

癌症患者家居服务的护理

目的 探讨家居服务护理模式对晚期癌症患者的重要性。方法采取家居宁养服务模式，由宁养院医师、护士对1836例晚期癌症患者上门进行“家居服务，晚癌止痛，心理辅导”的服务。结果1836例患者得到免费止痛和心理辅导，解除身心痛苦，重拾尊严。结论免费宁养服务计划秉承着“造福社会、造福病人”的理念，坚持“以人为本，全人服务的宗旨”，充分地体现了对晚期癌症患者的关爱精神。     

Perceived Need and Unmet Need for Vocational, Mental Health, and Other Support Services After Severe Lower-Extremity Trauma

Archer KR, Castillo RC, MacKenzie EJ, Bosse MJ, and the LEAP Study Group. Perceived need and unmet need for vocational, mental health, and other support services following severe lower-extremity trauma.

Objectives

To examine the perceived need and unmet need for support services, the reasons for not obtaining services, and the factors contributing to unmet need for vocational and mental health services in patients with traumatic lower-extremity injury.

Design

Multicenter, prospective observational study.

Setting

Eight level I trauma centers.

Participants

Patients (N=545) undergoing lower-extremity reconstruction or amputation from March 1994 to June 1997.

Interventions

Not applicable.

Main Outcome Measures

Perceived need and unmet need for support services at 3, 6, and 12 months after hospitalization.

Results

Eighty-five percent of patients reported a need for at least 1 support service, and 32% reported an unmet need over the 12 months. The highest perceived need was for home nursing and legal, and for unmet need was vocational and mental health services. The main reason for patients not trying to obtain mental health assistance was thinking they would get better on their own, and for other support services was not knowing where to go. Patients treated by reconstruction compared with amputation, and being nonwhite were statistically associated with unmet needs for vocational and mental health services.

Conclusions

The results suggest a significant amount of unmet need for vocational and mental health services during the first year after hospitalization in the severe lower-extremity trauma population with perceived need. Areas for future research are to objectively measure need and unmet need, and further investigate the disparities in unmet need by race and treatment type in this patient population. Recommendations for trauma centers include education and screening for mental health conditions and the need for support services during hospitalization and clinic visits, and increasing communication between surgeons and providers specializing in vocational, psychological, and socioeconomic issues.     

Women's Talk: Health and Health Services in the East End of London

This short report arises from a survey of women aged 35 to 54 living in the East End of London. It focuses on comments made after a structured interview in which respondents talked about health services. Comments about services specifically for women predominated, and many expressed an interest in the existing women's health clinics, and the possibility of a women's drop-in centre. It is suggested that this is linked to their discontentment with current medical care, and could provide a means for promoting the quality of health care that they want     

Expectations to and evaluation of a palliative home-care team as seen by patients and carers

Objectives Although the number of palliative home-care teams is increasing, knowledge of what patients and principal informal carers expect from a home-care team is sparse. We aimed to elucidate this as well as evaluate a home-care team.Patients and methods Individual semi-structured interviews with nine patients and six carers before receiving home care and 2–4 weeks after. In total, 26 interviews were conducted. Interviews were analysed with Template Analysis. Peer debriefing was performed.Main results Patients and carers expected the team members to have specialised knowledge in palliative care and to improve their sense of security being at home. They also expected respite for carers and activities for patients. They evaluated the team positively but missed respite for carers and 24-h on-call service.Conclusions Patients and carers found the home-care team essential to their sense of security being at home. Primary health care professionals must receive any necessary training outside patients’ homes. Offering respite for carers and 24-h on-call service would be an improvement.     

The Effect of Hospital Occupancy on Emergency Department Length of Stay and Patient Disposition

Emergency department (ED) overcrowding is a common problem. Despite a widespread belief that low hospital bed availability contributes to ED overcrowding, there are few data demonstrating this effect. OBJECTIVES: To identify the effect of hospital occupancy on ED length of stay for admitted patients and patient disposition. METHODS: This was an observational study design using administrative data at a 500-bed acute care teaching hospital. All patients presenting to the ED between April 1993 and June 1999 were included in the study. The predictor variable was daily hospital occupancy. Outcome measures included daily ED length of stay for admitted patients, daily consultation rate, and daily admission rate. The models controlled for the average daily age of ED patients and the average daily "arrival density" index, which adjusts for patient volume and clustering of patient arrivals. RESULTS: The average hospital occupancy was 89.7%. On average 155 patients visited the ED daily; 21% were referred to hospital physicians and 19% were admitted. The median ED length of stay for admitted patients was 5 hours 54 minutes (interquartile range 5 hr 12 min to 6 hr 42 min). Daily ED length of stay for admitted patients increased 18 minutes (95% CI = 12 to 24) when there was an absolute increase in occupancy of 10%. The ED length of stay appeared to increase extensively when hospital occupancy exceeded a threshold of 90%. Consultation and admission rates were not influenced by hospital occupancy. CONCLUSIONS: Increased hospital occupancy is strongly associated with ED length of stay for admitted patients. Increasing hospital bed availability might reduce ED overcrowding.