Association of delirium with increased short-term mortality among older emergency department patients: A cohort study

Risk of falls is associated with 30-day mortality among older adults in the emergency department

OBJECTIVE

Falls in older adults correlate with heightened morbidity and mortality. Assessing fall risk in the emergency department (ED) not only aids in identifying candidates for prevention interventions but may also offer insights into overall mortality risk. We sought to examine the link between fall risk and 30-day mortality in older ED adults.

METHODS

Observational cohort study of adults aged ≥ 75years who presented to an academic ED and who were assessed for fall risk using the Memorial Emergency Department Fall Risk Assessment Tool (MEDFRAT), a validated, ED-specific screening tool. The fall risk was classified as low (0-2 points), moderate (3-4 points), or high (≥5) risk. The primary outcome was 30-day mortality. Hazard ratios (HR) with 95% confidence intervals (CIs) were calculated.

RESULTS

A total of 941 patients whose fall risk was assessed in the ED were included in the study. Median age was 83.7 years; 45.6% were male, 75.6% lived in private residences, and 62.7% were admitted. Mortality at 30 days among the high fall risk group was four times that of the low fall risk group (11.8% vs 3.1%; HR 4.00, 95% CI 2.18 to 7.34, p < 0.001). Moderate fall risk individuals had nearly double the mortality rate of the low-risk group (6.0% vs 3.1%), but the difference was not statistically significant (HR 1.98, 95% CI 0.91 to 4.32, p = 0.087).

CONCLUSION

ED fall risk assessments are linked to 30-day mortality. Screening may facilitate the stratification of older adults at risk for health deterioration.

Developing a set of emergency department performance measures to evaluate delirium care quality for older adults: a modified e-Delphi study

BACKGROUND

Older adults are at high risk of developing delirium in the emergency department (ED); however, it is under-recognized in routine clinical care. Lack of detection and treatment is associated with poor outcomes, such as mortality. Performance measures (PMs) are needed to identify variations in quality care to help guide improvement strategies. The purpose of this study is to gain consensus on a set of quality statements and PMs that can be used to evaluate delirium care quality for older ED patients.

METHODS

A 3-round modified e-Delphi study was conducted with ED clinical experts. In each round, participants rated quality statements according to the concepts of importance and actionability, then their associated PMs according to the concept of necessity (1-9 Likert scales), with the ability to comment on each. Consensus and stability were evaluated using a priori criteria using descriptive statistics. Qualitative data was examined to identify themes within and across quality statements and PMs, which went through a participant validation exercise in the final round.

RESULTS

Twenty-two experts participated, 95.5% were from west or central Canada. From 10 quality statements and 24 PMs, consensus was achieved for six quality statements and 22 PMs. Qualitative data supported justification for including three quality statements and one PM that achieved consensus slightly below a priori criteria. Three overarching themes emerged from the qualitative data related to quality statement actionability. Nine quality statements, nine structure PMs, and 14 process PMs are included in the final set, addressing four areas of delirium care: screening, diagnosis, risk reduction and management.

CONCLUSION

Results provide a set of quality statements and PMs that are important, actionable, and necessary to a diverse group of clinical experts. To our knowledge, this is the first known study to develop a de novo set of guideline-based quality statements and PMs to evaluate the quality of delirium care older adults receive in the ED setting.

Geriatric Population Triage: The Risk of Real-Life Over- and Under-Triage in an Overcrowded ED: 4- and 5-Level Triage Systems Compared: The CREONTE (Crowding and R E Organization National TriagE) Study

Elderly patients, when they present to the emergency department (ED) or are admitted to the hospital, are at higher risk of adverse outcomes such as higher mortality and longer hospital stays. This is mainly due to their age and their increased fragility. In order to minimize this already increased risk, adequate triage is of foremost importance for fragile geriatric (>75 years old) patients who present to the ED. The admissions of elderly patients from 1 January 2014 to 31 December 2020 were examined, taking into consideration the presence of two different triage systems, a 4-level (4LT) and a 5-level (5LT) triage system. This study analyzes the difference in wait times and under- (UT) and over-triage (OT) in geriatric and general populations with two different triage models. Another outcome of this study was the analysis of the impact of crowding and its variables on the triage system during the COVID-19 pandemic. A total of 423,257 ED presentations were included. An increase in admissions of geriatric, more fragile, and seriously ill individuals was observed, and a progressive increase in crowding was simultaneously detected. Geriatric patients, when presenting to the emergency department, are subject to the problems of UT and OT in both a 4LT system and a 5LT system. Several indicators and variables of crowding increased, with a net increase in throughput and output factors, notably the length of stay (LOS), exit block, boarding, and processing times. This in turn led to an increase in wait times and an increase in UT in the geriatric population. It has indeed been shown that an increase in crowding results in an increased risk of UT, and this is especially true for 4LT compared to 5LT systems. When observing the pandemic period, an increase in admissions of older and more serious patients was observed. However, in the pandemic period, a general reduction in waiting times was observed, as well as an increase in crowding indices and intrahospital mortality. This study demonstrates how introducing a 5LT system enables better flow and patient care in an ED. Avoiding UT of geriatric patients, however, remains a challenge in EDs.

A Lethal Combination of Delirium and Overcrowding in the Emergency Department

Delirium is a common public health concern that significantly impacts older patients admitted to the Emergency Department (ED). This condition is linked to adverse outcomes such as reduced long-term functionality, higher mortality rates, extended hospital stays, and increased medical costs. The identification of risk factors is crucial for the early recognition and management of delirium in ED patients. Aging, cognitive decline, polypharmacy, and sensory impairment are some of the most common general risk factors described in the literature. Although validated delirium assessment tools already exist, they are not practical for the fast-paced ED environment because of their extended evaluation period or specialized training request. Moreover, clear guidance is needed to select the most suitable tool for detecting delirium, balancing between the accuracy and the swiftness required in an overcrowded, high-stress, and understaffed healthcare setting. This narrative review aims to analyze the updated literature on delirium risk factors in older ED patients and focuses on the methods for better screening, managing, and treating this condition in the ED.