De l'innovation au changement - Gouvernement du Québec

4. PROCESSUS DE MISE EN ŒUVRE
Projet 11
Dépistage et intervention auprès des personnes âgées obtenant leur congé du service des urgences d’un hôpital et risquant de
subir des conséquences indésirables, région de Montréal
Seniors discharged from hospital emergency departments at risk of adverse outcomes : screening and intervention
4.1 Modalités de mise en oeuvre Le projet consiste à mettre sur pied un programme de dépistage coordonné par une infirmière clinicienne expérimentée avec les
personnes âgées et possédant idéalement une maîtrise. Cette infirmière procède à une brève évaluation (une trentaine de minutes) des
patients à hauts risques à l’aide de l’ISAR pour les orienter de façon optimale vers les services appropriés, en incluant le guichet unique,
les soins primaires et les services gériatriques.
4.2 Enjeux ou défis posés par
l’innovation
Aucune information à ce sujet
4.3 Conditions favorables ou facilitantes Aucune information à ce sujet
4.4 Obstacles Recruitment of ISAR positive subjects : For several reasons, we were able to recruit only 388 patients, even after prolonging the
recruitment period. (The planned sample size was 600) Reasons for lower than expected recruitment include: 1) Lower numbers of
patients visiting the EDs than expected. The recruitment period (fall-winter 1998-99) included times of severe overcrowding of Montreal
hospital EDs and subsequent closings of EDs on certain days, or obstruction of patient flow leading to smaller numbers of patients who
were ready for discharge. 2) A lower percentage of patients were ISAR positive than expected. In our previous study, 46% of patients
discharged from the ED were ISAR positive; in this study, only 20% of patients screened were ISAR positive.
Delay in receipt of MedEcho data : Our revised time frame called for receipt of MedEcho data from the MSSS by the end of December,
2000, the date we were given by MSSS staff. Unfortunately, this date was revised several times by MSSS and the data were not received
until March 14, 2001. As a result, it was not possible to complete all the planned analyses using this database.
Failure to deliver intervention to all members of intervention group : There were problems in fully implementing the intervention as
planned. First, it was not possible to deliver the intervention to 17.4% of patients in the intervention group, for various reasons including
hospital admission, lack of availability of the intervention nurse when the patients was ready to be discharged, patient refusal, and other
reasons.
Contamination of control group : It was not possible to blind ED staff as to who received the intervention, although no routine or special
efforts were made to inform them. The effect of this contamination may have been to reduce the apparent effectiveness of the
intervention.
Lack of randomization of individuals We did not randomize individuals but days. However, this quasi-randomization was the most feasible
method and resulted in two study groups that were quite similar at baseline
Identification of primary physician from administrative database : Because we were not provided with physician identifiers in the RAMQ
database, we were not able to determine whether patients contacted their primary physician. Instead, we used an algorithm based on
speciality of physician. This may have introduced some misclassification.
Statistical power : With the reduced sample size of 178 subjects in the intervention group and 210 subjects in the usual care group the
minimum statistically detectable difference between rates in the two groups (80% power; two-sided type I error = 5%) varies from 10% to
15%. While this sample size was sufficient to detect a significantly lower functional decline in the intervention group, it may not have been
sufficient to detect smaller, but clinically meaningful, differences in other outcomes, for example, visiting the primary physician following the
index date.
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