A novel multidimensional geriatric screening tool in the ED: evaluation of feasibility and clinical relevance

Prevalence of frailty and associated factors in older adults seeking care at Swedish emergency departments

BACKGROUND

Internationally, prolonged length of stay for older adults in the emergency department (ED) is associated with increased risk of in-hospital adverse events. In Sweden patients 65 years and older account for 35% of emergency visits, and according to consensus from an international expert group, all persons over 70 should be screened for frailty. This is not routinely done in Swedish EDs, and therefore, knowledge about prevalence, characteristics and clinical outcomes associated with frailty is limited.

AIM

To describe the prevalence of frailty and associated factors in older adults seeking care at Swedish EDs.

METHODS

The study has a cross-sectional design. Data was collected at three hospital-based EDs, varying in level and size of setting, for one month. Patients age 70 and older presenting at the EDs and agreed to participate were screened for frailty using the FRail Elderly Support researcH group (FRESH) instrument. Data were analysed using descriptive statistics to assess the distribution of patient characteristics and clinical outcomes. Multivariate logistic regression was used to model the association between frailty and demographic characteristics, and Cox regression was used to model the association between frailty and clinical outcomes.

RESULTS

A total of 3101 patients were eligible for inclusion; of these, 984 (32%) were included and screened for frailty. Of the final sample, 57.3% were assessed as frail. Characteristics significantly associated with frailty were living in a residential care facility, age (> 80 years), being a woman and arriving with emergency medical service (EMS). There was a significant association between frailty and admittance to in-hospital care.

CONCLUSION

Our study shows a high prevalence of frailty in older people. Factors associated with frailty were living in a residential care facility, age ≥ 80 years, being a woman and arriving with EMS to the ED and being admitted to in-hospital care. Frailty screening should be incorporated in the triage system to identify frail patients who need tailored interventions. More studies using the FRESH instrument are needed to further confirm our findings and to develop the methods for screening for frailty in the ED.

Feasibility of frailty screening among patients with advanced heart failure

BACKGROUND

Frailty is common among patients with advanced heart failure (HF), and screening for frailty to guide care is recommended. Although multiple tools are available to screen for frailty, the feasibility of routinely incorporating frailty screening into daily clinical practice among hospitalised advanced HF patients has not been rigorously tested.

METHODS

This was a prospective, single-centre, quality improvement study. Two brief frailty screening tools were incorporated into palliative care consultations for all patients ≥50 years from August 2021 to October 2022. In the first phase, the Clinical Frailty Scale (CFS) was implemented, followed by the Study of Osteoporotic Fracture (SOF) tool or a modified SOF (mSOF) version in the second phase. The primary outcome was feasibility (%) of performing frailty screenings for this high-risk population.

RESULTS

A total of 212 patients (mean age 69±10 years, 69% male, 79% white, 30% with ischaemic HF) were referred for palliative care consultation during the study period. Overall, frailty screens were completed in 86% (n=183) of patients. CFS and mSOF reached >80% of adoption, while SOF adoption was 54%. Altogether, 52% of the population screened frail by use of CFS and 52% also by mSOF. All clinicians (n=6) participating in the study reported that frailty screening tools were useful and acceptable, and 83% reported plans for continued utilisation in future clinical practice.

CONCLUSIONS

Frailty screening with CFS or mSOF tools was feasible in hospitalised patients with advanced HF. Tools that require physical assessment were more challenging to implement. These data support the feasibility of incorporating questionnaire-based frailty screening in a busy hospital setting.

Detecting Cognitive Impairment and Dementia in the Emergency Department: A Scoping Review

OBJECTIVES

To identify research and practice gaps to establish future research priorities to advance the detection of cognitive impairment and dementia in the emergency department (ED).

DESIGN

Literature review and consensus-based rankings by a transdisciplinary, stakeholder task force of experts, persons living with dementia, and care partners.

SETTING AND PARTICIPANTS

Scoping reviews focused on adult ED patients.

METHODS

Two systematic scoping reviews of 7 medical research databases focusing on best tools and approaches for detecting cognitive impairment and dementia in the ED in terms of (1) most accurate and (2) most pragmatic to implement. The results were screened, reviewed, and abstracted for relevant information and presented at the stakeholder consensus conference for discussion and ranked prioritization.

RESULTS

We identified a total of 1464 publications and included 45 to review for accurate tools and approaches for detecting cognitive impairment and dementia. Twenty-seven different assessments and instruments have been studied in the ED setting to evaluate cognitive impairment and dementia, with many focusing on sensitivity and specificity of instruments to screen for cognitive impairment. For pragmatic tools, we identified a total of 2166 publications and included 66 in the review. Most extensively studied tools included the Ottawa 3DY and Six-Item Screener (SIS). The SIS was the shortest to administer (1 minute). Instruments with the highest negative predictive value were the SIS (vs MMSE) and the 4 A's Test (vs expert diagnosis). The GEAR 2.0 Advancing Dementia Care Consensus conference ranked research priorities that included the need for more approaches to recognize more effectively and efficiently persons who may be at risk for cognitive impairment and dementia, while balancing the importance of equitable screening, purpose, and consequences of differentiating various forms of cognitive impairment.

CONCLUSIONS AND IMPLICATIONS

The scoping review and consensus process identified gaps in clinical care that should be prioritized for research efforts to detect cognitive impairment and dementia in the ED setting. These gaps will be addressed as future GEAR 2.0 research funding priorities.

Moving the needle on fall prevention: A Geriatric Emergency Care Applied Research (GEAR) Network scoping review and consensus statement

BACKGROUND

Although falls are common, costly, and often preventable, emergency department (ED)-initiated fall screening and prevention efforts are rare. The Geriatric Emergency Medicine Applied Research Falls core (GEAR-Falls) was created to identify existing research gaps and to prioritize future fall research foci.

METHODS

GEAR's 49 transdisciplinary stakeholders included patients, geriatricians, ED physicians, epidemiologists, health services researchers, and nursing scientists. We derived relevant clinical fall ED questions and summarized the applicable research evidence, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. The highest-priority research foci were identified at the GEAR Consensus Conference.

RESULTS

We identified two clinical questions for our review (1) fall prevention interventions (32 studies) and (2) risk stratification and falls care plan (19 studies). For (1) 21 of 32 (66%) of interventions were a falls risk screening assessment and 15 of 21 (71%) of these were combined with an exercise program or physical therapy. For (2) 11 fall screening tools were identified, but none were feasible and sufficiently accurate for ED patients. For both questions, the most frequently reported study outcome was recurrent falls, but various process and patient/clinician-centered outcomes were used. Outcome ascertainment relied on self-reported falls in 18 of 32 (56%) studies for (1) and nine of 19 (47%) studies for (2).

CONCLUSION

Harmonizing definitions, research methods, and outcomes is needed for direct comparison of studies. The need to identify ED-appropriate fall risk assessment tools and role of emergency medical services (EMS) personnel persists. Multifactorial interventions, especially involving exercise, are more efficacious in reducing recurrent falls, but more studies are needed to compare appropriate bundle combinations. GEAR prioritizes five research priorities: (1) EMS role in improving fall-related outcomes, (2) identifying optimal ED fall assessment tools, (3) clarifying patient-prioritized fall interventions and outcomes, (4) standardizing uniform fall ascertainment and measured outcomes, and (5) exploring ideal intervention components.

Five Key Papers About Emergency Department Fall Evaluation: A Curated Collection for Emergency Physicians

The evaluation of patients who have experienced a fall has been an integral part of geriatric emergency care. All physicians who engage in the care of the geriatric population in acute settings need to familiarize themselves with the current literature on this topic. However, it can be challenging to navigate the large body of literature on this topic. The purpose of this article is to identify and summarize the key studies that can be helpful for faculty interested in an evidence-based fall evaluation.

The authors compiled a list of key papers on emergency department (ED) based upon a structured literature search supplemented with suggestions by key informants and an open call on social media; 32 studies on ED evaluation were identified. Our authorship group then engaged in a modified Delphi technique to develop consensus on the most important studies about fall evaluation for emergency physicians. This process eventually resulted in the selection of the top five articles on fall evaluation. Additionally, we summarize these studies with regard to their relevance to emergency medicine (EM) trainees and junior faculty.

Evaluation of older patients with a history of falls is a challenging but crucial component of EM training. We believe our review will be educational for junior and senior EM faculty to better understand these patients' care and to design an evidence-based practice.

Implementation of the acutely presenting older patient (APOP) screening program in routine emergency department care : A before-after study

OBJECTIVE

The aim of this study was to evaluate the effects of implementation of the acutely presenting older patient (APOP) screening program for older patients in routine emergency department (ED) care shortly after implementation.

METHODS

We conducted an implementation study with before-after design, using the plan-do-study-act (PDSA) model for quality improvement, in the ED of a Dutch academic hospital. All consecutive patients ≥ 70 years during 2 months before and after implementation were included. The APOP program comprises screening for risk of functional decline, mortality and cognitive impairment, targeted interventions for high-risk patients and education of professionals. Outcome measures were compliance with interventions and impact on ED process, length of stay (LOS) and hospital admission rate.

RESULTS

Two comparable groups of patients (median age 77 years) were included before (n = 920) and after (n = 953) implementation. After implementation 560 (59%) patients were screened of which 190 (34%) were high-risk patients. Some of the program interventions for high-risk patients in the ED were adhered to, some were not. More hospitalized patients received comprehensive geriatric assessment (CGA) after implementation (21% before vs. 31% after; p = 0.002). In 89% of high-risk patients who were discharged to home, telephone follow-up was initiated. Implementation did not influence median ED LOS (202 min before vs. 196 min after; p = 0.152) or hospital admission rate (40% before vs. 39% after; p = 0.410).

CONCLUSION

Implementation of the APOP screening program in routine ED care did not negatively impact the ED process and resulted in an increase of CGA and telephone follow-up in older patients. Future studies should investigate whether sustainable changes in management and patient outcomes occur after more PDSA cycles.

Feasibility and acceptability of the 'Acutely Presenting Older Patient' screener in routine emergency department care

Background

risk stratification tools for older patients in the emergency department (ED) have rarely been implemented successfully in routine care.

Objective

to evaluate the feasibility and acceptability of the ‘Acutely Presenting Older Patient’ (APOP) screener, which identifies older ED patients at the highest risk of adverse outcomes within 2 minutes at presentation.

Design and setting

2-month prospective cohort study, after the implementation of the APOP screener in ED routine care in the Leiden University Medical Center.

Subjects

all consecutive ED patients aged ≥70 years.

Methods

feasibility of screening was assessed by measuring the screening rate and by identifying patient- and organisation-related determinants of screening completion. Acceptability was assessed by collecting experienced barriers of screening completion from triage-nurses.

Results

we included 953 patients with a median age of 77 (IQR 72–82) years, of which 560 (59%) patients were screened. Patients had a higher probability of being screened when they had a higher age (OR 1.03 (95%CI 1.01–1.06), P = 0.017). Patients had a lower probability of being screened when they were triaged very urgent (OR 0.55 (0.39–0.78), P = 0.001) or when the number of patients upon arrival was high (OR 0.63 (0.47–0.86), P = 0.003). Experienced barriers of screening completion were patient-related (‘patient was too sick’), organisation-related (‘ED was too busy’) and personnel-related (‘forgot to complete screening’).

Conclusion

with more than half of all older patients screened, feasibility and acceptability of screening in routine ED care is very promising. To further improve screening completion, solutions are needed for patients who present with high urgency and during ED rush hours.

The development of a modified comprehensive geriatric assessment for use in the emergency department using a RAND/UCLA appropriateness method

BACKGROUND

The universal screening and comprehensive assessment of older persons presenting to the emergency department is considered useful, yet is difficult to embed. A number of assessment instruments exist however they are not widely used and there is a lack of agreement between clinicians as to which tools are best suited to the emergency department. The aim of this study was to develop a modified comprehensive geriatric assessment using consensus methodology for use by the multidisciplinary team in the emergency department.

METHOD

The modified comprehensive geriatric assessment was formulated using the RAND/UCLA appropriateness methodology incorporating consensus opinion from an expert group of clinicians and the best scientific evidence available. A series of pre and post survey and expert group meetings were held with expert multidisciplinary clinicians. Emphasis was placed on a pragmatic approach to the development of a document which reflected consensus opinion.

RESULTS

Between nine and 15 expert group members participated in the stages of the process. A tiered approach incorporating different aspects of screening and/or assessments was considered optimal to reflect the stages of decision-making in the emergency department process.

CONCLUSION

A unique approach to the screening and assessment of the frail older person was developed using consensus methodology to develop a modified comprehensive geriatric assessment for use in the emergency department. Associated actions and interventions are an important next step, with pilot site testing.

Comparison of Frailty Screening Instruments in the Emergency Department

Early identification of frailty through targeted screening can facilitate the delivery of comprehensive geriatric assessment (CGA) and may improve outcomes for older inpatients. As several instruments are available, we aimed to investigate which is the most accurate and reliable in the Emergency Department (ED). We compared the ability of three validated, short, frailty screening instruments to identify frailty in a large University Hospital ED. Consecutive patients aged ≥70 attending ED were screened using the Clinical Frailty Scale (CFS), Identification of Seniors at Risk Tool (ISAR), and the Programme on Research for Integrating Services for the Maintenance of Autonomy 7 item questionnaire (PRISMA-7). An independent CGA using a battery of assessments determined each patient’s frailty status. Of the 280 patients screened, complete data were available for 265, with a median age of 79 (interquartile ±9); 54% were female. The median CFS score was 4/9 (±2), ISAR 3/6 (±2), and PRISMA-7 was 3/7 (±3). Based upon the CGA, 58% were frail and the most accurate instrument for separating frail from non-frail was the PRISMA-7 (AUC 0.88; 95% CI:0.83–0.93) followed by the CFS (AUC 0.83; 95% CI:0.77–0.88), and the ISAR (AUC 0.78; 95% CI:0.71–0.84). The PRISMA-7 was statistically significantly more accurate than the ISAR (p = 0.008) but not the CFS (p = 0.15). Screening for frailty in the ED with a selection of short screening instruments, but particularly the PRISMA-7, is reliable and accurate.

What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review

Background

Emergency departments (EDs) are facing unprecedented levels of demand. One of the causes of this increased demand is the ageing population. Older people represent a particular challenge to the ED as those older people who are frail will require management that considers their frailty alongside their presenting complaint. How to identify these older people as frail and how best to manage them in the ED is a major challenge for the health service to address.

Objectives

To systematically map interventions to identify frail and high-risk older people in the ED and interventions to manage older people in the ED and to map the outcomes of these interventions and examine whether or not there is any evidence of the impact of these interventions on patient and health service outcomes.

Design

A systematic mapping review.

Setting

Evidence from developed countries on interventions delivered in the ED.

Participants

Frail and high-risk older people and general populations of older people (aged > 65 years).

Interventions

Interventions to identify older people who are frail or who are at high risk of adverse outcomes and to manage (frail) older people within the ED.

Main outcome measures

Patient outcomes (direct and indirect) and health service outcomes.

Data sources

Evidence from 103 peer-reviewed articles and conference abstracts and 17 systematic reviews published from 2005 to 2016.

Review methods

A review protocol was drawn up and a systematic database search was undertaken for the years 2005–2016 (using MEDLINE, EMBASE, The Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium and PROSPERO). Studies were included according to predefined criteria. Following data extraction, evidence was classified into interventions relating to the identification of frail/high-risk older people in the ED and interventions relating to their management. A narrative synthesis of interventions/outcomes relating to these categories was undertaken. A quality assessment of individual studies was not undertaken; instead, an assessment of the overall evidence base in this area was made.

Results

Of the 90 included studies, 32 focused on a frail/high-risk population and 60 focused on an older population. These studies reported on interventions to identify (n = 57) and manage (n = 53) older people. The interventions to identify frail and at-risk older people, on admission and at discharge, utilised a number of different tools. There was extensive evidence on these question-based tools, but the evidence was inconclusive and contradictory. Service delivery innovations comprised changes to staffing, infrastructure and care delivery. There was a general trend towards improved outcomes in admissions avoidance, reduced ED reattendance and improved discharge outcomes.

Limitations

This review was a systematic mapping review. Some of the methods adopted differed from those used in a standard systematic review. Mapping the evidence base has led to the inclusion of a wide variety of evidence (in terms of study type and reporting quality). No recommendations on the effectiveness of specific interventions have been made as this was outside the scope of the review.

Conclusions

A substantial body of evidence on interventions for frail and high-risk older people was identified and mapped.

Future work

Future work in this area needs to determine why interventions work and whether or not they are feasible for the NHS and acceptable to patients.

Study registration

This study is registered as PROSPERO CRD42016043260.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Mobility assessments of geriatric emergency department patients: A systematic review

Objectives

We wished to determine the impact of emergency department (ED) mobility assessments for older patients on hospitalization, return visits, future falls, and frailty.

Methods

We searched MEDLINE, Embase, CINAHL, Cochrane Library, PEDro, and OTseeker (September 2016). Two independent reviewers identified studies of patients ≥65 years with ED physical mobility assessments and outcomes of hospitalization, return to ED, falls, and frailty. Language was not restricted. Only clinical trials and observational studies were included.

Results

We identified 1,365 unique citations. Nine studies (six cohort and three cross-sectional) met full inclusion criteria. Patients (n=2,513) with mean age 75-85 years, admitted to hospital and discharged, underwent these ED evaluations: Timed Up and Go (TUG), Get Up and Go, tandem walk, and a gait assessment. Study quality was moderate to poor. Tandem walk did not predict falls at 90 days. TUG was not associated with return to the ED/hospitalization at 90 days. Get Up and Go was associated with hospital admission but not return to ED visits at 1 or 3 months. Due to clinical heterogeneity in study populations and outcomes, a meta-analysis was not undertaken.

Conclusions

Despite multiple guidelines recommending a mobility assessment prior to ED discharge for older patients, we found that such assessments were neither associated with nor predictive of adverse outcomes. Robust research is required to guide clinicians on the utility of physical mobility assessments in older ED patients.

Frailty identification in the emergency department-a systematic review focussing on feasibility

Introduction

risk-stratifying older people accessing urgent care is a potentially useful first step to ensuring that the most vulnerable are able to access optimal care from the start of the episode. While there are many risk-stratification tools reported in the literature, few have addressed the practical issues of implementation. This review sought evidence about the feasibility of risk stratification for older people with urgent care needs.

Methods

medline was searched for papers addressing risk stratification and implementation (feasibility or evaluation or clinician acceptability). All search stages were conducted by two reviewers, and selected papers were graded for quality using the CASP tool for cohort studies. Data were summarised using descriptive statistics only.

Results

about 1872 titles of potential interest were identified, of which 1827 were excluded on title/abstract review, and a further 43 after full-text review, leaving four papers for analysis. These papers described nine tools, which took between 1 and 10 minutes to complete for most participants. No more than 52% of potentially eligible older people were actually screened using any of the tools. Little detail was reported on the clinical acceptability of the tools tested.

Discussion

the existing literature indicates that commonly used risk-stratification tools are relatively quick to use, but do not cover much more than 50% of the potential population eligible for screening in practice. Additional work is required to appreciate how tools are likely to be used, by whom, and when in order to ensure that they are acceptable to urgent care teams.

Evolution of Cognitive Function After Transcatheter Aortic Valve Implantation

BACKGROUND

This study aimed to assess the evolution of cognitive function after transcatheter aortic valve implantation (TAVI). Previous smaller studies reported conflicting results on the evolution of cognitive function after TAVI.

METHODS AND RESULTS

In this prospective cohort, cognitive function was measured in 229 patients ≥70 years using the Mini Mental State Examination before and 6 months after TAVI. Cognitive deterioration or improvement was defined as change of ≥3 points decrease or increase in the Mini Mental State Examination score between baseline and follow-up. Cognitive deterioration was found in 29 patients (12.7%). Predictive analysis using logistic regression did not identify any statistically significant predictor of cognitive deterioration. A review of individual medical records in 8 patients with a major Mini Mental State Examination score decrease of ≥5 points revealed specific causes in 6 cases (postinterventional delirium in 2; postinterventional stroke, progressive renal failure, progressive heart failure, or combination of preexisting cerebrovascular disease and mild cognitive impairment in 1 each). Among 48 patients with impaired baseline cognition (Mini Mental State Examination score <26 points), 18 patients (37.5%) cognitively improved. The preinterventional aortic valve area was lower in patients who cognitively improved (median aortic valve area 0.60 cm²) as compared with patients who did not improve (median aortic valve area 0.70 cm²; P=0.01).

CONCLUSIONS

This is the first study providing evidence that TAVI results in cognitive improvement among patients who had impaired preprocedural cognitive function, possibly related to hemodynamic improvement in patients with severe aortic stenosis. Our results confirm that some patients experience cognitive deterioration after TAVI.

Validity, Reliability and Feasibility of Tools to Identify Frail Older Patients in Inpatient Hospital Care: A Systematic Review

BACKGROUND

The objective of this study is to identify and review screening tools for frailty in older adults admitted to inpatient hospital care with respect to their validity, reliability and feasibility.

METHODS

Studies were identified through systematically searching PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase and PsycINFO and screening reference lists till June 2014. Papers dealing with screening tools aimed at identifying frail older patients in in-hospital care, and including information about validity, reliability or feasibility, were included in the review. The quality of the included studies was critically appraised via the Quality Assessment of Diagnostic Accuracy Studies (QUADAS).

RESULTS

From the originally identified 2001 studies 32 studies met the inclusion criteria, in which 16 screening tools were presented. The screening tools showed different characteristics with respect to the number of items, the method of administration and the domains included. The most frequently studied tools with respect to predictive validity were the Identification Seniors At Risk (ISAR) and Triage Risk Stratification Tool (TRST). Studies retrieved poorer information about reliability and feasibility. Overall sensitivity was fairly good. The ISAR, ISAR-HP (Identification Seniors At Risk Hospitalized Patients) and Multidimensional Prognostic Index (MPI) generally had the best sensitivity.

CONCLUSIONS

Many screening tools are available for daily practice. These tools to identify frail older patients in inpatient hospital care could be useful. For no tool, however, is clear evidence available yet regarding validity, reliability and feasibility. The overall sensitivity of the included screening tools was fairly good, whereas information on reliability and feasibility was lacking for most tools. In future research more attention should be given to the latter items.

Risk of Unplanned Emergency Department Readmission after an Acute-Care Hospital Discharge among Geriatric Inpatients: Results from the Geriatric EDEN Cohort Study

OBJECTIVES

The study aims 1) to examine whether items of the brief geriatric assessment (BGA) or their combinations predicted the risk of unplanned emergency department readmission after an acute care hospital discharge among geriatric inpatients, and 2) to determine whether BGA could be used as a prognostic tool for unplanned emergency department readmission.

METHODS

A total of 312 older patients (mean age, 84.6 ± 5.4 years; 64.1% female) hospitalized in acute care wards after an emergency department visit were recruited in this observational prospective cohort study and separated into 2 groups based on the occurrence or not of an unplanned emergency department readmission during a 12-month follow-up period after their hospital discharge. A 6-item BGA was performed at emergency department admission before the discharge to acute care wards. Information on incident unplanned emergency department readmission was prospectively collected by phone call and by consulting the hospital registry. Several combinations of items of BGA identifying three levels of risk of unplanned emergency department readmission (i.e., low risk, intermediate risk and high risk) were examined.

RESULTS

The unplanned emergency department readmission was more frequently associated with a temporal disorientation (P=0.004). Area under receiver operating characteristic curves of unplanned emergency department readmission based on BGA items and their combinations ranged from 0.53 to 0.61. The best predictor of unplanned emergency department readmission was the temporal disorientation (hazard ratio>1.65, P<0.035), which defined the high-risk group. Inpatients classified in high-risk group of unplanned emergency department readmission were more frequently readmitted to emergency department than those in intermediate- and low-risk groups (P log Rank <0.004). Prognostic values for unplanned emergency department readmission of items and their combinations were poor with sensitivity below 67%, specificity ranging from 36.4 to 53.7, and positive likelihood ratio below 1.4.

CONCLUSIONS

The items of BGA and their combinations were significant risk factors for unplanned emergency department readmission, but their prognostic value was poor.

Impact of a Clinical Pharmacy Specialist in an Emergency Department for Seniors

STUDY OBJECTIVE

This study assesses outcomes associated with the implementation of an emergency department (ED) for seniors in which a clinical pharmacy specialist, with specialized geriatric training that included medication management training, is a key member of the ED care team.

METHODS

This was a retrospective cohort analysis of patients aged 65 years or older who presented at an ED between November 1, 2012, and May 31, 2013. Three groups of seniors were assessed: treated by the clinical pharmacy specialist in the ED for seniors, treated in the ED for seniors but not by the clinical pharmacy specialist, and not treated in the ED for seniors. Outcomes included rates of an ED return visit, mortality and hospital admissions, and follow-up total health care costs. Multivariable regression modeling was used to adjust for any potential confounders in the associations between groups and outcomes.

RESULTS

A total of 4,103 patients were included, with 872 (21%) treated in the ED for seniors and 342 (39%) of these treated by the clinical pharmacy specialist. Groups were well matched overall in patient characteristics. Patients who received medication review and management by the clinical pharmacy specialist did not experience a reduction in ED return visits, mortality, cost of follow-up care, or hospital admissions compared with the other groups. Of the patients treated by the clinical pharmacy specialist, 154 (45.0%) were identified as having at least 1 medication-related problem.

CONCLUSION

Although at least 1 medication-related problem was identified in almost half of patients treated by the clinical pharmacy specialist in the ED for seniors, incorporation of a clinical pharmacy specialist into the ED staff did not improve clinical outcomes.

Incremental value of heart-type fatty acid-binding protein in suspected acute myocardial infarction early after symptom onset

BACKGROUND

The early diagnosis of acute myocardial infarction (AMI) very soon after symptom onset remains a major clinical challenge, even when using high-sensitivity cardiac troponin (hs-cTnT).

METHODS AND RESULTS

We investigated the incremental value of heart-type fatty acid-binding protein (hFABP) in a pre-specified subgroup analysis of patients presenting with suspected AMI within 1 h of symptom onset to the emergency department (ED) in a multicentre study. HFABP was measured in a blinded fashion. Two independent cardiologists using all available clinical information, including hs-cTnT, adjudicated the final diagnosis. Overall, 1411 patients were enrolled, of whom 105 patients presented within 1 h of symptom onset. Of these, 34 patients (32.4%) had AMI. The diagnostic accuracy as quantified by the area under the receiver-operating characteristics curve (AUC) of hFABP was high (0.84 (95% CI 0.74-0.94)). However, the additional use of hFABP only marginally increased the diagnostic accuracy of hs-cTnT (AUC 0.88 (95% CI 0.81-0.94) for hs-cTnT alone to 0.90 (95% CI 0.83-0.98) for the combination; p=ns). After the exclusion of 18 AMI patients with ST-segment elevation, similar results were obtained. Among the 16 AMI patients without ST-segment elevation, six had normal hs-cTnT at presentation. Of these, hFABP was elevated in two (33.3%) patients.

CONCLUSIONS

hFABP does not seem to significantly improve the early diagnostic accuracy of hs-cTnT in the important subgroup of patients with suspected AMI presenting to the ED very early after symptom onset.