Background
For the elderly population living at home, the implementation of professional services tends to mitigate the effect of loss of autonomy and increases their quality of life. While helping in avoiding social isolation, home services could also be associated to different healthcare pathways. For elderly patients, Emergency Departments (EDs) are the main entrance to hospital where previous loss of autonomy is associated to worst hospital outcomes. Part of elderly patients visiting EDs are still admitted to hospital for having difficulties coping at home without presenting any acute medical issue. There is a lack of data concerning elderly patients visiting EDs assisted by home services. Our aim was to compare among elderly patients visiting ED those assisted by professional home services to those who do not in terms of emergency resources’ use and patients’ outcome.
Methods
A multicenter, prospective cohort study was performed in 124 French EDs during a 24-h period on March 2016.Consecutive patients living at home aged ≥80 years were included. The primary objective was to assess the risk of mortality for patients assisted by professional home services vs. those who were not. Secondary objectives included admission rate and specific admission rate for “having difficulties coping at home”. The primary endpoint was in-hospital mortality. Cox proportional-hazards regression model was used to test the association between professional home services and the primary endpoint. Multi variables logistic regressions were performed to assess secondary endpoints.
Results
One thousand one hundred sixty-eight patients were included, median age 86(83–89) years old,32% were assisted by professional home services. The overall in-hospital mortality rate was 7%. Assisted patients had more investigations performed. Home services were not associated with increased in-hospital mortality (HR = 1.34;95%CI [0.68–2.67]), nor with the admission rate (OR = 0.92;95%CI [0.65–1.30]). Assisted patients had a lower risk of being admitted for “having difficulties coping at home” (OR = 0.59;95%CI [0.38–0.92]).
Conclusion
Professional home services which assist one-third of elderly patients visiting EDs, were not associated to lower in-hospital mortality or to an increased admission rate. Assisted patients were associated to a lower risk of being admitted for «having difficulties coping at home».Professional home services could result in avoiding some admissions and their corollary complications.
Trial registration
Clinicaltrial.gov - NCT02900391, 09/14/2016, retrospectively registered
La médecine militaire s'adapte aux dernières évolutions médicales, et l'échographie s'inscrit désormais dans les algorithmes de prise en charge des blessés de guerre. Grâce à la plus-value apportée à la clinique dans l'évaluation des blessés associée à l'amélioration des performances et à la miniaturisation des appareils, le positionnement de l'échographie en médecine de guerre a évolué pour trouver sa place « à l'avant », parfois dans des conditions sanitaires très dégradées. Après avoir rappelé les principes du secourisme au combat pour le blessé de guerre dyspnéique, cet article replace l'intérêt diagnostique et thérapeutique de l'échographie dans la « médecine de l'avant » en détaillant la sémiologie échographique des principales pathologies du blessé de guerre dans la phase de réanimation préhospitalière. L'article souligne aussi l'importance opérationnelle qu'occupe l'échographie, que ce soit sur le terrain lors des évacuations sanitaires ou lors d'afflux massif de victimes. Certains aspects de la doctrine militaire d'emploi pourraient s'adapter à la pratique en préhospitalier ou lors des situations d'exception en métropole. Mots clés Échographie • Blessé de guerre • Réanimation préhospitalière Abstract Military medicine follows medical evolutions in order to optimize the management of war-wounded patients. The ultrasound device is a powerful tool capable of providing additional information to the clinical examination. Its performance and miniaturization permit to transfer it at the battle field and to include it in the "forward medicalization". This article reminds principles of tactical combat casualty care for patient with a dyspnea and, explain the place that sonography can take to confirm a diagnosis. It explains the ultrasound semiology of main pathologies and underlines the operational impact of sonography during a large influx of injured patients and during the medical evacuation. This military practice can be adapted to prehospital care or to an uncommon situation like terrorism attack.
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