Chronic Disease in the Emergency Department: The weakest link in integrated care?

摘要

Objective : Chronic disease (CD) accounts for two-thirds of emergency medical admissions and approximately 80% of all healthcare costs. Presently, “integrated care” refers to GP care punctuated by specialist input on an inpatient/outpatient basis. It does not explicitly involve the Emergency Department (ED). Most (70-80%) patients presenting to ED are discharged. Many of these are also acute episodes of a CD,but are not incorporated as part of any integrated care pathway. This project aims to: (1) Quantify CD-related discharges from the ED (2) Develop an initiative to integrate these visits into CD care. (3) Assess whether such an initiative improves quality. Method : 1000 consecutive ED presentations were reviewed over a 2-month period; patients with coexisting CDs were noted, as was whether CD was a contributing or determining factor to presenting. A pro-forma was developed in conjunction with CD specialists, two of whom are national clinical leads in CD management (COPD and CCF). The pro-forma was implemented in a subset of CD-related discharges, the first 50 of which were also accompanied by a questionnaire to evaluate the pro-forma's usefulness. Multiple accessory quality improvement (QI) initiatives were also initiated such as care bundles and checklists. Results : A diagnosed CD was recorded in 46% of presentations; in 47% of these CD related to the ED presentation. While CD patients were more likely to be admitted (32% vs. 8%), the majority were discharged (68%). The questionnaire response rate was 56% with 95% finding the intervention useful, 45% reporting it affected therapy (55% for diabetes) and 30% reporting it affected patient management in non-therapeutic ways, such as appointment scheduling. We report progress in accessory QI initiatives. Conclusions : The ED is under-represented in the current model of integrated care: (1) The cohort of CD-related discharges from the ED was more than twice those admitted; (2) These presentations constitute a gap in integrated care, which can be closed; (3) In doing so, the ED stands to improve the quality of integrated care.