De l'innovation au changement - Gouvernement du Québec

6. POTENTIEL DE GÉNÉRALISATION
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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
be due to the modest intervention effect on the patient’s functional status, or a lack of sensitivity of our caregiver instruments, or selection
bias.
There was also no apparent effect of the intervention on patient or caregiver satisfaction with care during the month after the ED visit.
Although patients and caregivers in the intervention group had consistently slightly higher 1-month satisfaction scores than those in the
control group, none of these differences were statistically significant.
6.1 Pérennité The results of this project suggest that this brief, 2-stage ED intervention for seniors improved the continuity of care between the hospital
and community and significantly reduced the rate of functional decline 4 months after the ED visit, without any concomitant increase in
length of stay in the ED or in societal costs over the 4-month period following the ED visit.
6.2 Conditions nécessaires Interventions should focus on those at increased risk. The ISAR screening tool is a feasible and efficient means of identifying high risk
patients. The screening component of the intervention, using the ISAR screen, appears to have identified patients with clinically significant
problems.
Key information from the ED must be rapidly transferred to partners in the community The approach used in this project is feasible and
effective. Efforts to improve communication and coordination between the ED, the primary physician, and home care services through
systematic application of simple screening tools and various liaison-type interventions, not limited to traditional approaches (telephone, fax,
mail) but considering internet and other computer technologies.
Rapid response is needed from community partners, especially the primary physician and CLSC services. Access to CLSC services
should be improved so that needed services can be provided more quickly, and on nights and weekends. More appropriate settings
should be developed for the care of high-risk patients, which may either prevent inappropriate ED visits or allow for rapid transfer of care
(e.g., special and/or assessment clinics).
6.3 Avantages généralisation The standardized nursing assessment allowed us to identify numerous unresolved problems (an average of 2 per patient), many of which
may have otherwise remained unrecognized.
This project has demonstrated the critical role played by liaison staff in ensuring the continuity of care between hospital-based and
community-based services. It has also demonstrated that the efficiency of delivery of these liaison services can be improved. Currently, in
most EDs that have such liaison staff (usually nurses or social workers), referrals to these staff are made on an ad hoc basis and are
highly dependent on volume. A systematic approach, using tools for the identification of high risk patients and the rapid assessment of
those at high risk, has the potential to assuring the quality and consistency of liaison interventions even in the face of rising patient
volumes. The approach tested in this study can help improve the process of care in ED for those discharged to the community. By
providing key information on the risk of functional decline to partners in the community, the rate of further functional decline can be
significantly reduced.
Screening patients aged 65 and over in the ED with the ISAR tool is a feasible and efficient way to identify those at increased risk of
adverse health outcomes (functional decline, death, need for long-term care) and increased rates of use of hospital services (ED and
inpatient).
The intervention did not increase overall societal costs, considering public and private costs incurred either at or during the 4 months after,
the ED visit. Thus, as regards cost-effectiveness, the intervention is preferred because beneficial outcomes were observed (a reduced
rate of functional decline) and overall societal costs were no higher than if usual care only were given.