Soto Gabriel E, Huenefeldt Elizabeth A, Hengst Masey N, Reimer Arlo J, Samuel Shawn K, Samuel Steven K, Utts Stephen J
SoutheastHEALTH, 1701 Lacey Street, Cape Girardeau, MO, 63701, USA.
Kearny County Hospital, Lakin, KS, USA.
BMC Health Serv Res. 2018 Aug 30;18(1):672. doi: 10.1186/s12913-018-3482-2.
Cardiac-related complaints are leading drivers of Emergency Department (ED) utilization. Although a large proportion of cardiac patients can be discharged with appropriate outpatient follow-up, inadequate care coordination often leads to high revisit rates or unnecessary admissions. We evaluate the impact of implementing a structured transitional care pathway enrolling low-risk cardiac patients on ED discharges, 30-day revisits and admissions, and institutional revenues.
We prospectively enrolled eligible patients presenting to a single-center Emergency Department over a 12-month period. Standardized risk measures were used to identify patients suitable for early discharge with cardiology follow-up within 5 days. The primary endpoints were rates of discharge from the ED and 30-day ED revisit and admission rates, with a secondary endpoint including 30-day returns for myocardial infarction. A cost analysis of the program's impact on institutional revenues was performed.
Among patients presenting with cardiac-related complaints, rates of discharge from the ED increased from 44.4 to 56.6% (p < 0.0001). Enrollment in the transitional care pathway was associated with a reduced risk of cardiac-related ED revisits (RR 0.22, p < 0.0001), all-cause ED revisits (RR 0.30, p < 0.0001), and admission at second ED visit (RR 0.56, p = 0.0047); among enrolled patients, the 30-day rate of return with a myocardial infarction was 0.35%. No significant reductions were seen in 30-day cardiac-related and all-cause revisits in the 12-months following transitional care pathway implementation; however, there was a significant reduction in admissions at second ED visit from 45.6 to 37.7% (p = 0.0338). An early gender disparity in care delivery was identified in the first 120 days following program implementation that was subsequently eliminated through targeted intervention. There was an estimated decline in institutional revenue of $300 per enrolled patient, driven predominantly by a reduction in admissions.
A structured transitional care pathway identifying low-risk cardiac patients who may be safely discharged from the ED can be effective in shifting care delivery from hospital-based to lower cost ambulatory settings without adversely impacting 30-day ED revisit rates or patient outcomes.
与心脏相关的主诉是急诊科（ED）就诊的主要驱动因素。尽管很大一部分心脏病患者在适当的门诊随访后可以出院，但护理协调不足往往导致高复诊率或不必要的住院。我们评估实施结构化过渡护理路径纳入低风险心脏病患者对急诊出院、30天复诊和住院以及机构收入的影响。
我们前瞻性地纳入了在12个月期间到单中心急诊科就诊的符合条件的患者。使用标准化风险测量方法来识别适合在5天内进行心脏病学随访并早期出院的患者。主要终点是急诊出院率、30天急诊复诊率和住院率，次要终点包括心肌梗死的30天复诊率。对该项目对机构收入的影响进行了成本分析。
在有心脏相关主诉的患者中，急诊出院率从44.4%提高到56.6%（p < 0.0001）。纳入过渡护理路径与降低心脏相关急诊复诊风险（RR 0.22，p < 0.0001）、全因急诊复诊风险（RR 0.30，p < 0.0001）以及第二次急诊就诊时的住院风险（RR 0.56，p = 0.0047）相关；在纳入的患者中，心肌梗死的30天复诊率为0.35%。在实施过渡护理路径后的12个月内，30天心脏相关和全因复诊率没有显著降低；然而，第二次急诊就诊时的住院率从45.6%显著降低到37.7%（p = 0.0338）。在项目实施后的前120天内发现了护理提供方面的早期性别差异，随后通过有针对性的干预得以消除。估计每位纳入患者的机构收入下降了300美元，主要是由于住院人数减少。
一种结构化的过渡护理路径，用于识别可能从急诊安全出院的低风险心脏病患者，在将护理从医院环境转移到低成本门诊环境方面可能是有效的，而不会对30天急诊复诊率或患者预后产生不利影响。
