[Triage, screening, and assessment of geriatric patients in the emergency department]

Comparison of Manchester, qSOFA, emergency severity index, and national early warning scores for prognostic estimation and effective triage system in geriatric patients

BACKGROUND

Triage refers to classifying and prioritizing patients based on the severity of their injuries or illnesses in the health care setting. The increasing number of elderly patients seeking care in emergency departments (EDs) highlights the need for special attention to the unique needs of this patient population.

AIM

We aimed to compare the qSOFA, Emergency Severity Index (ESI), National Early Warning Score (NEWS), and Manchester Triage System (MTS) scores to assist ED physicians in assessing the severity of elderly patients' clinical conditions and triaging them appropriately.

METHODS

This cross-sectional study included 1066 patients aged 65 and over who presented to our ED as outpatients or by ambulance between September 1, 2022, and August 30, 2023. Scoring systems at the time of admission to the ED were recorded separately for outpatients and arriving by ambulance.

RESULTS

According to the qSOFA, patients with a score of 0 were 0.976 times less likely to arrive by ambulance compared to those scoring 1 and above (OR = 0.976, p = .934). According to the NEWS, patients in the moderate-risk category were 0.447 times less likely to arrive by ambulance (OR = 0.447, p = .054). According to the ESI score, patients requiring high resource use with normal vital signs were 146.758 times more likely to arrive by ambulance (OR = 146.758, p = .001).

CONCLUSION

Significant differences in patients' methods of presentation to the ED were observed based on the MTS, qSOFA, NEWS, and ESI scores.

Clinical Acuity in the Emergency Department and Injury Severity Determine Hospital Admission of Older Patients with Low Energy Falls: Outcomes from a Prospective Feasibility Study

BACKGROUND

Low energy falls (LEF) in older adults constitute a relevant cause for emergency department (ED) visits, hospital admission and in-hospital mortality. Patient-reported outcome measures containing information about patients' medical, mental and social health problems might support disposition and therapy decisions. We investigated the value of a tablet-based (self-)assessment in predicting hospital admission and in-hospital mortality.

METHODS

Patients 65 years or older, consecutively presenting with LEF to our level I trauma center ED (from November 2020 to March 2021), were eligible for inclusion in this prospective observational study. The primary endpoint was hospital admission; secondary endpoints were in-hospital mortality and the use of the tablet for self-reported assessment. Multivariate logistic regression models were calculated to measure the association between clinical findings and endpoints.

RESULTS

Of 618 eligible patients, 201 patients were included. The median age was 82 years (62.7% women). The hospital admission rate was 45.3% (110/201), with an in-hospital mortality rate of 3.6% (4/110). Polypharmacy (odds ratio (OR): 8.48; 95% confidence interval (95%CI) 1.21-59.37, p = 0.03), lower emergency severity index (ESI) scores (OR: 0.33; 95%CI 0.17-0.64, p = 0.001) and increasing injury severity score (ISS) (OR: 1.54; 95%CI 1.32-1.79, p < 0.001) were associated with hospital admission. The Charlson comorbidity index (CCI) was significantly associated with in-hospital mortality (OR: 2.60; 95%CI: 1.17-5.81, p = 0.03). Increasing age (OR: 0.94; 95%CI: 0.89-0.99, p = 0.03) and frailty (OR: 0.71; 95%CI: 0.51-0.99, p = 0.04) were associated with the incapability of tablet use.

CONCLUSIONS

The severity of fall-related injuries and the clinical acuity are easily accessible, relevant predictors for hospital admission. Tablet-based (self-)assessment may be feasible and acceptable during ED visits and might help facilitate comprehensive geriatric assessments during ED stay.

[Availability of patient information in the emergency department : Wish and reality]

BACKGROUND

Fast access to information from other healthcare service providers is particularly important in emergency medicine, as the patients are often unknown and treatment decisions have to be made promptly.

OBJECTIVES

The study aims to identify the challenges that emergency departments face in obtaining information on patient history, the expected benefits of easier access to information and which information is most urgently needed.

MATERIALS AND METHODS

An online survey throughout Germany was carried out among medical staff working in emergency departments. In all, 181 questionnaires were fully completed and could be included in the data analysis.

RESULTS

Of the respondents, 77.9% said it was difficult or very difficult to receive external data at the point of patient care. The survey participants estimate that they need an average of around 47 min to obtain information about one patient. 99.4% believe that patient care would benefit from an easier and faster information exchange. Medication lists, discharge letters, information on previous illnesses and allergies were classified as the most important data elements.

CONCLUSIONS

There is an urgent need for action with regard to the considerable effort involved in obtaining information on emergency patients. Digital solutions such as the recently introduced emergency data set can offer additional value for clinical emergency care if they are widely used.

Geriatrische Patient_innen in der Notfallambulanz

Zusammenfassung. Hintergrund: Die steigenden Zahlen geriatrischer Patient_innen stellen im Setting Notfallambulanz (NFA) wachsende Herausforderungen dar. Ziel: Ziel dieser Arbeit ist es, anhand der Erfahrungen von Ärzt_innen und Pflegenden Veränderungsbedarfe in der notfallambulanten Versorgung zu identifizieren und den Einsatz einer Advanced Practice Nurse (APN) zu diskutieren. Der Fokus liegt auf der interdisziplinären Zusammenarbeit. Methode: Im Rahmen eines qualitativen Forschungsansatzes wurden leitfadengestützte Interviews mit fünf Ärzt_innen und sieben Pflegenden aus zwei österreichischen NFAs durchgeführt. Die Auswertung erfolgte gemäß der qualitativen Inhaltsanalyse nach Mayring. Ergebnisse: Fünf zentrale Hauptkategorien ergaben sich. Bedingt durch die hohe Arbeitsbelastung, Zeitdruck und Ressourcenmangel beschrieben die Pflegenden und Ärzt_innen zunehmende Herausforderungen in der NFA sowie eine Versorgung, die den Bedürfnissen der geriatrischen Patient_innen nur unzureichend entspricht. Der Einsatz geriatrisch spezialisierter Pflegender wurde mit einer optimierten Patient_innenversorgung assoziiert. Entlang von Struktur-, Prozess- und Outcome-Kriterien des Nursing Role Effectiveness Model (NREM) werden die zentralen Inhalte der Advanced Nursing Practice (ANP)-Rolle beschrieben. Schlussfolgerunge໿n: Ein Ausbau von Kompetenzen und Tätigkeitsbereichen der Pflegenden sowie die Entwicklung definierter Versorgungspfade sollen forciert werden. Die in das NREM integrierten Forschungsergebnisse stellen eine Vorarbeit für die Beschreibung der Rolle der Pflegexpert_innen Geriatric Practice Nurse (GPN) in der NFA dar.

[Nursing roles and competencies in emergency care - focusing on geriatric emergency care: A scoping review]

Nursing roles and competencies in emergency care - focusing on geriatric emergency care: A scoping review Abstract. Background: Older patients make up an increasing number of emergency admissions in Germany. Their complex needs require advanced nursing competencies. Aim: The aim of this scoping review was to identify extended nursing roles in the emergency care of geriatric patients, to describe the training or educational programs that enable nurses to fill these roles and to compare these to the task catalog of German nurses with standard three-year training. Methods: The literature search was conducted in the databases MEDLINE and CINAHL. In addition, forward and backward citation tracking was performed. To describe the situation in Germany a snowballing literature search was carried out using Google and experts were contacted. A sheet created for this review was used for data extraction. Results: A total of 13 publications were included and seven extended competencies were extracted: Collection of information, initial assessment, coordination, medical / nursing care, treatment planning, follow-up, and education. Training qualifying nurses to take on these competencies were academic and / or specialized training measures, partially with the requirement of subject-specific working experience. In Germany advanced training courses are offered, while academic specializations are the exception. A comparison with the German task catalog was not possible. Conclusions: Internationally there are varying nursing roles, which often require both professional experience and academic training. No specific German nursing role profile could be identified. Specific qualification pathways do not exist.