ANNOTATION (Scott Simpson)

The Finding: The authors describe their experience with a transitional psychiatric clinic; patients not connected with outpatient care receive an appointment within two weeks for “bridging” care until long term follow-up is identified. Scheduling patients a follow-up outpatient mental health visit within 3 days of their emergency department (compared to 4-14 days) extended the mean time to repeat emergency psychiatric consultation from 64 days to 130 days. Show rates for follow up appointments were slightly but insignificantly better for patients with sooner appointments (49% versus 39%). However, recidivism for medical complaints was common and similar in both groups (mean 75 days).
Strength and Weaknesses: This study focuses on a common intervention of emergency psychiatrists—identifying follow-up care for patients—and describes a valuable, concrete outcome related to that work. The description of these patients, currently unestablished in community mental health, is also valuable, and the high rates of medical emergency department utilization are striking. (Roughly, half of patients will return for a medical visit within two months.) Given the limitations of this unrandomized naturalistic study, the comparison groups are well chosen to isolate the benefit of sooner follow-up.
Some questions remain unanswered and largely speak to this study’s methodological limitations: Did these patients re-present to other hospitals? Why was recidivism for medical complaints unchanged—the benefit of psychiatric follow-up may have been limited in this regard, or perhaps some patients were not re-referred for psychiatric consultation on presentation to the emergency department. A better description of medical morbidity would have been valuable. Even with smart naturalistic studies, the specter of confounding shadows the findings. That only a single hospital was studied limits generalizability, especially to systems where outpatient clinics are less well integrated into emergency care.
This paper raises more challenging questions, include determining why the now-show rate is so poor and elucidating the mechanism by which sooner appointments reduce return emergency visits.

Relevance: Helping patients obtain an outpatient appointment as soon as possible after their emergency consultation may extend their time away from emergency psychiatric services. This supportive intervention in the emergency department has a meaningful effect months later.

ANNOTATION (Scott Simpson)

The Finding: The authors systematically review literature on the prehospital emergency medical service experiences of older people with dementia. There is little written on this topic. Important clinical concerns are identified: ambulance crews often lack training in working with patients with dementia, and many emergency service guidelines do not attend to the needs of this population. Thus, first responders often fail to collect important medical information (e.g., ascertaining contributors to a fall), adequately assess medical issues (e.g., pain), and may too often transport patients with dementia to the hospital, where these patients are frequently admitted. Calling 911 also reflects families’ underutilization or unavailability of alternatives for managing difficult behavioral symptoms of dementia.

Strength and Weaknesses: The literature review process is well-described and incorporates the diverse viewpoints of academic clinicians, patient advocates, ambulance drivers, and other emergency personnel. The review is extensive and captures published academic literature, government reports, training materials, and even conference abstracts. The authors rightfully point out the varying qualities of all these different products. Multiple authors agreed on the inclusion of each source.
The variety of sources, however, makes it difficult to see conclusive patterns. Other than pointing out current shortcomings in care, the authors find no conclusions on how emergency medical providers’ roles might be different for patients with dementia, nor do they put forth their own original vision. No doubt the unique needs of patients with dementia is neglected in the emergency medical literature; whether better training of ambulance crews results in fewer hospitalizations or better clinical outcomes seem less certain, though the idea is unexplored. The authors call for more research on the role of prehospital providers and opportunities for intervention.

Relevance: This paper is a strong review of an underappreciated, undeveloped topic. Older patients with dementia face deficiencies in emergency care, starting with the initial 911 call and evaluation by emergency responders.