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Gagliano M, Bula CJ, Seematter-Bagnoud L, Michalski-Monnerat C, Nguyen S, Carron PN, Mabire C. Older patients referred for geriatric consultation in the emergency department: characteristics and healthcare utilization. BMC Geriatr 2023; 23:642. [PMID: 37817072 PMCID: PMC10565963 DOI: 10.1186/s12877-023-04321-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 09/15/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Comprehensive geriatric assessment (CGA) is difficult to perform in the emergency department (ED) environment and performance of screening tools in identifying vulnerable older ED patients who are best candidates for a geriatric consultation remain questionable. AIM To determine the characteristics of older patients referred for a geriatric consultation by ED staff and to investigate these patients' subsequent healthcare utilization. METHODS Secondary analysis of data previously collected for a prospective observational study of patients aged 75 + years visiting the ED of an academic hospital in Switzerland over four months (Michalski-Monnerat et al., J Am Geriatr Soc 68(12):2914-20, 2020). Socio-demographic, health, functional (basic activities of daily living; BADL), cognitive, and affective status data were collected at admission by a research nurse using a standardized brief geriatric assessment. Information on geriatric consultations, hospitalization, discharge destination, and 30-day readmission were retrieved from hospital database. Bivariable and multivariable analyses were performed using this data set collected previously. RESULTS Thirty-two (15.8%) of the 202 enrolled patients were referred for a geriatric consultation. Compared to the others, they were older (84.9 ± 5.4 vs 82.9 ± 5.4 years, p = .03), more impaired in BADL (4.8 ± 1.6 vs 5.5 ± 1.0, p = .01), with more comorbid conditions (5.3 ± 1.5 vs 4.5 ± 1.9, p = .03), more frequently admitted after a fall (43.7% vs 19.4%, p = .01), and hospitalized over the previous 6-month period (53.1% vs 30.6%, p = .02). Multivariable analyses that adjusted for variables significantly associated with outcomes in bivariable analysis found that being admitted after a fall (AdjOR 4.0, 95%CI 1.7-9.4, p < .01) and previously hospitalized (AdjOR 2.7, 95% CI 1.2-6.2, p = .02) remained associated with increased odds of consultation, whereas the inverse association with BADL performance remained (AdjOR 0.7, 95%CI 0.5-0.9, p = .01). Patients referred for geriatric consultation had higher odds of hospitalization (84.4% vs 49.4%; AdjOR 5.9, 95%CI 2.1-16.8, p < .01), but similar odds of home discharge when admitted, and of 30-day readmission. CONCLUSION About one in six older ED patients were referred for a geriatric consultation who appeared to be those most vulnerable, as suggested by their increased hospitalization rate. Alternative strategies are needed to enhance access to geriatric consultation in the ED.
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Affiliation(s)
- Mariangela Gagliano
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne, Chemin de Mont Paisible 16, Lausanne, CH-1011, Switzerland.
- Department of Geriatrics, Rehabilitation and Palliative Care, Neuchâtel Hospital Network, Rue du Chasseral 20, La Chaux-de-Fonds, CH-2300, Switzerland.
| | - Christophe J Bula
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne, Chemin de Mont Paisible 16, Lausanne, CH-1011, Switzerland
| | - Laurence Seematter-Bagnoud
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne, Chemin de Mont Paisible 16, Lausanne, CH-1011, Switzerland
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Route de la Corniche 10, Lausanne, CH-1010, Switzerland
| | - Carole Michalski-Monnerat
- Department of Internal Medicine, Neuchâtel Hospital Network, Rue de la Maladière 45, Neuchâtel, CH-2000, Switzerland
- Institute of Higher Education and Research in Healthcare-IUFRS, Lausanne University Hospital and University of Lausanne, Route de la Corniche 10, Lausanne, CH-1010, Switzerland
| | - Sylvain Nguyen
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne, Chemin de Mont Paisible 16, Lausanne, CH-1011, Switzerland
| | - Pierre-Nicolas Carron
- Emergency Department, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, Lausanne, CH-1011, Switzerland
| | - Cédric Mabire
- Institute of Higher Education and Research in Healthcare-IUFRS, Lausanne University Hospital and University of Lausanne, Route de la Corniche 10, Lausanne, CH-1010, Switzerland
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Leahy A, Corey G, Purtill H, O’Neill A, Devlin C, Barry L, Cummins N, Gabr A, Mohamed A, Shanahan E, Shchetkovsky D, Ryan D, O’Loughlin M, O'Connor M, Galvin R. Screening instruments to predict adverse outcomes for undifferentiated older adults attending the Emergency Department: Results of SOAED prospective cohort study. Age Ageing 2023; 52:afad116. [PMID: 37463282 PMCID: PMC10353758 DOI: 10.1093/ageing/afad116] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND frailty screening facilitates the stratification of older adults at most risk of adverse events for urgent assessment and subsequent intervention. We assessed the validity of the Identification of Seniors at Risk (ISAR), Clinical Frailty Scale (CFS), Programme on Research for Integrating Services for the Maintenance of Autonomy seven item questionnaire (PRISMA-7) and InterRAI-ED at predicting adverse outcomes at 30 days and 6 months amongst older adults presenting to the Emergency Department (ED). METHODS a prospective cohort study of adults ≥65 years who presented to the ED was conducted. The ISAR, CFS, PRISMA-7 and InterRAI-ED were assessed. Blinded follow-up telephone interviews were completed at 30 days and 6 months to assess the incidence of mortality, ED re-attendance, hospital readmission, functional decline and nursing home admission. The sensitivity, specificity, negative predictive value and positive predictive value of the screening tools were calculated using 2 × 2 tables. RESULTS a total of 419 patients were recruited; 47% female with a mean age of 76.9 (Standard deviation = 7.2). The prevalence of frailty varied across the tools (CFS 57% versus InterRAI-ED 70%). At 30 days, the mortality rate was 5.1%, ED re-attendance 18.1%, hospital readmission 14%, functional decline 47.6% and nursing home admission 7.1%. All tools had a high sensitivity and positive predictive value for predicting adverse outcomes. CONCLUSION older adults who screened positive for frailty were at significantly increased risk of experiencing an adverse outcome at 30 days with the ISAR being the most sensitive tool. We would recommend the implementation of the ISAR in the ED setting to support clinicians in identifying older adults most likely to benefit from specialised geriatric assessment and intervention.
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Affiliation(s)
- Aoife Leahy
- Address correspondence to: Aoife Leahy. Tel: 061 301111.
| | - Gillian Corey
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- ALERT, Department of Emergency Medicine, University Hospital Limerick, Limerick, Ireland
| | - Helen Purtill
- Department of Mathematics & Statistics, University of Limerick, Limerick, Ireland
| | - Aoife O’Neill
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- Central Statistics Office, Cork, Ireland
| | - Collette Devlin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Louise Barry
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Niamh Cummins
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Medicine, University of Limerick, Limerick, Ireland
| | - Ahmed Gabr
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Abdirahman Mohamed
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Elaine Shanahan
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Denys Shchetkovsky
- ALERT, Department of Emergency Medicine, University Hospital Limerick, Limerick, Ireland
| | - Damien Ryan
- ALERT, Department of Emergency Medicine, University Hospital Limerick, Limerick, Ireland
- School of Medicine, University of Limerick, Limerick, Ireland
| | | | - Margaret O'Connor
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- Ageing Research Centre, University of Limerick, Limerick, Ireland
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3
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Mowbray FI, Heckman G, Hirdes JP, Costa AP, Beauchet O, Archambault P, Eagles D, Wang HT, Perry JJ, Sinha SK, Jantzi M, Hebert P. Agreement and prognostic accuracy of three ED vulnerability screeners: findings from a prospective multi-site cohort study. CAN J EMERG MED 2023; 25:209-217. [PMID: 36857018 PMCID: PMC10014815 DOI: 10.1007/s43678-023-00458-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 01/13/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVES To evaluate the agreement between three emergency department (ED) vulnerability screeners, including the InterRAI ED Screener, ER2, and PRISMA-7. Our secondary objective was to evaluate the discriminative accuracy of screeners in predicting discharge home and extended ED lengths-of-stay (> 24 h). METHODS We conducted a nested sub-group study using data from a prospective multi-site cohort study evaluating frailty in older ED patients presenting to four Quebec hospitals. Research nurses assessed patients consecutively with the three screeners. We employed Cohen's Kappa to determine agreement, with high-risk cut-offs of three and four for the PRISMA-7, six for the ER2, and five for the interRAI ED Screener. We used logistic regression to evaluate the discriminative accuracy of instruments, testing them in their dichotomous, full, and adjusted forms (adjusting for age, sex, and hospital academic status). RESULTS We evaluated 1855 older ED patients across the four hospital sites. The mean age of our sample was 84 years. Agreement between the interRAI ED Screener and the ER2 was fair (K = 0.37; 95% CI 0.33-0.40); agreement between the PRISMA-7 and ER2 was also fair (K = 0.39; 95% CI = 0.36-0.43). Agreement between interRAI ED Screener and PRISMA-7 was poor (K = 0.19; 95% CI 0.16-0.22). Using a cut-off of four for PRISMA-7 improved agreement with the ER2 (K = 0.55; 95% CI 0.51-0.59) and the ED Screener (K = 0.32; 95% CI 0.2-0.36). When predicting discharge home, the concordance statistics among models were similar in their dichotomous (c = 0.57-0.61), full (c = 0.61-0.64), and adjusted forms (c = 0.63-0.65), and poor for all models when predicting extended length-of-stay. CONCLUSION ED vulnerability scores from the three instruments had a fair agreement and were associated with important patient outcomes. The interRAI ED Screener best identifies older ED patients at greatest risk, while the PRISMA-7 and ER2 are more sensitive instruments.
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Affiliation(s)
- Fabrice I Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - George Heckman
- School of Public Health Science, University of Waterloo, Waterloo, ON, Canada
- Schlegel Research Institute for Aging, Waterloo, ON, Canada
| | - John P Hirdes
- School of Public Health Science, University of Waterloo, Waterloo, ON, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Olivier Beauchet
- Department of Medicine and Research Center of the Geriatric University Institute of Montreal, University of Montreal, Montreal, QC, Canada
- Division of Geriatric Medicine, Department of Medicine, Sir Mortimer B. Davis Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, Montreal, QC, Canada
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec, QC, Canada
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Sainte-Marie, QC, Canada
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada
| | - Debra Eagles
- Department of Emergency Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Han Ting Wang
- Division of Critical Care Medicine, Department of Medicine, Universite de Montreal, Montreal, QC, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Samir K Sinha
- Division of Geriatric Medicine, Department of Medicine, Sinai Health and University Health Network, Toronto, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Micaela Jantzi
- School of Public Health Science, University of Waterloo, Waterloo, ON, Canada
| | - Paul Hebert
- Division of Palliative Care, Department of Medicine, Bruyere Research Institute, University of Ottawa, Ottawa, ON, Canada.
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González-Colom R, Herranz C, Vela E, Monterde D, Contel JC, Sisó-Almirall A, Piera-Jiménez J, Roca J, Cano I. Prevention of Unplanned Hospital Admissions in Multimorbid Patients Using Computational Modeling: Observational Retrospective Cohort Study. J Med Internet Res 2023; 25:e40846. [PMID: 36795471 PMCID: PMC9982720 DOI: 10.2196/40846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 12/02/2022] [Accepted: 01/10/2023] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Enhanced management of multimorbidity constitutes a major clinical challenge. Multimorbidity shows well-established causal relationships with the high use of health care resources and, specifically, with unplanned hospital admissions. Enhanced patient stratification is vital for achieving effectiveness through personalized postdischarge service selection. OBJECTIVE The study has a 2-fold aim: (1) generation and assessment of predictive models of mortality and readmission at 90 days after discharge; and (2) characterization of patients' profiles for personalized service selection purposes. METHODS Gradient boosting techniques were used to generate predictive models based on multisource data (registries, clinical/functional and social support) from 761 nonsurgical patients admitted in a tertiary hospital over 12 months (October 2017 to November 2018). K-means clustering was used to characterize patient profiles. RESULTS Performance (area under the receiver operating characteristic curve, sensitivity, and specificity) of the predictive models was 0.82, 0.78, and 0.70 and 0.72, 0.70, and 0.63 for mortality and readmissions, respectively. A total of 4 patients' profiles were identified. In brief, the reference patients (cluster 1; 281/761, 36.9%), 53.7% (151/281) men and mean age of 71 (SD 16) years, showed 3.6% (10/281) mortality and 15.7% (44/281) readmissions at 90 days following discharge. The unhealthy lifestyle habit profile (cluster 2; 179/761, 23.5%) predominantly comprised males (137/179, 76.5%) with similar age, mean 70 (SD 13) years, but showed slightly higher mortality (10/179, 5.6%) and markedly higher readmission rate (49/179, 27.4%). Patients in the frailty profile (cluster 3; 152/761, 19.9%) were older (mean 81 years, SD 13 years) and predominantly female (63/152, 41.4%, males). They showed medical complexity with a high level of social vulnerability and the highest mortality rate (23/152, 15.1%), but with a similar hospitalization rate (39/152, 25.7%) compared with cluster 2. Finally, the medical complexity profile (cluster 4; 149/761, 19.6%), mean age 83 (SD 9) years, 55.7% (83/149) males, showed the highest clinical complexity resulting in 12.8% (19/149) mortality and the highest readmission rate (56/149, 37.6%). CONCLUSIONS The results indicated the potential to predict mortality and morbidity-related adverse events leading to unplanned hospital readmissions. The resulting patient profiles fostered recommendations for personalized service selection with the capacity for value generation.
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Affiliation(s)
- Rubèn González-Colom
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Carmen Herranz
- Consorci d'Atenció Primària de Salut Barcelona Esquerra (CAPSBE), Primary Healthcare Transversal Research Group, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Emili Vela
- Catalan Health Service, Barcelona, Spain
- Digitalization for the Sustainability of the Healthcare System DS3-IDIBELL, L'Hospitalet de Llobregat, Spain
| | - David Monterde
- Digitalization for the Sustainability of the Healthcare System DS3-IDIBELL, L'Hospitalet de Llobregat, Spain
- Catalan Institute of Health, Barcelona, Spain
| | | | - Antoni Sisó-Almirall
- Consorci d'Atenció Primària de Salut Barcelona Esquerra (CAPSBE), Primary Healthcare Transversal Research Group, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Jordi Piera-Jiménez
- Catalan Health Service, Barcelona, Spain
- Digitalization for the Sustainability of the Healthcare System DS3-IDIBELL, L'Hospitalet de Llobregat, Spain
- Faculty of Informatics, Multimedia and Telecommunications, Universitat Oberta de Catalunya, Barcelona, Spain
| | - Josep Roca
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Isaac Cano
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
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Ferré C, Llopis F, Martín-Sánchez FJ, Cabello I, Albert A, García-Lamberechts EJ, Del Castillo JG, Martínez C, Jacob J. The utility of the Barthel index as an outcome predictor in older patients with acute infection attending the emergency department. Australas Emerg Care 2022; 25:316-320. [PMID: 35398013 DOI: 10.1016/j.auec.2022.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/01/2022] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Functional decline and frailty are common in older adults and influence the risk of adverse outcomes. We aimed to assess the value of a Barthel index at the Emergency Department (ED-BI) score in predicting 30-day mortality and ED reconsultation among older patients with acute infection. METHODS We performed a prospective multicentre cohort study of older patients (≥75 years) diagnosed with acute infection in 69 Spanish EDs. Demographic, comorbidities, functional status, clinical and analytical data were collected. Unadjusted and adjusted logistic regression models were used to assess the association between ED-BI score, mortality and ED reconsultation. RESULTS In total 1596 patients with a mean age of 84.7 years were included in the study and 51.7% female. The most frequent focus of infection was respiratory in 918 patients (57.5%). Patients with an ED-BI< 60 points were significantly older, predominantly female, more likely institutionalized and more urinary infections. When comparing patients with an ED-BI score ≥ 60 points with those< 60 points no differences were found in ED reconsultation but in the latter group mortality at 30-days was higher (p < 0.001). CONCLUSION An ED-BI score< 60 points appears to be a strong predictor of mortality at the 30-day follow up in older patients with acute infection. DATA AVAILABILITY The data used to support the findings of this study are included within the article.
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Affiliation(s)
- Carles Ferré
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ferran Llopis
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Irene Cabello
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Arantxa Albert
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | | | - Concepción Martínez
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
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The Accuracy of Four Frequently Used Frailty Instruments for the Prediction of Adverse Health Outcomes Among Older Adults at Two Dutch Emergency Departments: Findings of the AmsterGEM Study. Ann Emerg Med 2021; 78:538-548. [PMID: 34304915 DOI: 10.1016/j.annemergmed.2021.04.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Older adults presenting to the emergency department (ED) are at high risk of adverse health outcomes. This study aimed to evaluate the accuracy of 4 frequently used screening instruments for the prediction of adverse health outcomes among older adults in the ED. METHODS This was a prospective cohort study in patients ≥70 years of age presenting to the ED in 2 hospitals in the Netherlands. Screening instruments included the acutely presenting older patient screening program (APOP) (providing 2 risk scores-functional decline [APOP1] and mortality [APOP2]), the International Resident Assessment Instrument Emergendy Department screener (InterRAI ED), the Identification of Seniors At Risk-Hospitalized Patients (ISAR-HP), and the safety management system (VMS). The primary outcome measure was a composite outcome encompassing functional decline, institutionalization, and mortality at 3 months after ED presentation. Other follow-up time points were 1 and 6 months. Analyses were performed to assess prognostic accuracy. RESULTS In total, 889 patients were included. After 3 months, 267 (31%) patients experienced at least 1 adverse outcome. The positive likelihood ratio ranged from 1.67 (VMS) to 3.33 (APOP1), and the negative likelihood ratio ranged from 0.41 (ISAR-HP) to 0.88 (APOP2). Sensitivity ranged from 17% (APOP2) to 74% (ISAR-HP), and specificity ranged from 63% (ISAR-HP) to 94% (APOP2). The area under the curve ranged from 0.62 (APOP2) to 0.72 (APOP1 and ISAR-HP). Calibration was reasonable for APOP1 and VMS. The prognostic accuracy was comparable across all outcomes and at all follow-up time points. CONCLUSION The frailty screening instruments assessed in this study showed poor to moderate prognostic accuracy, which brings into question their usability in the prediction of adverse health outcomes among older adults who present to the ED.
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Loddo S, Costaggiu D, Palimodde A, Cogoni E, Putzu S, Serchisu L, Laconi R, Scuteri A, Mandas A. Emergency department: risk stratification in the elderly. JOURNAL OF GERONTOLOGY AND GERIATRICS 2021. [DOI: 10.36150/2499-6564-n352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Whate A, Elliott J, Carter D, Stolee P. Performance of the interRAI ED Screener for Risk-Screening in Older Adults Accessing Paramedic Services. Can Geriatr J 2021; 24:8-13. [PMID: 33680258 PMCID: PMC7904328 DOI: 10.5770/cgj.24.451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Paramedics respond to a significant number of non-emergency calls generated by older adults each year. Paramedics routinely assess and screen older adults to determine risk level and need for additional follow-up. This project implemented the interRAI ED Screener into routine care to determine whether the screener and resulting Assessment Urgency Algorithm (AUA) score is useful in predicting adverse outcomes. Methods We conducted a population-based retrospective study using administrative health data for patients aged 65+ assessed by paramedics from July 2016 to February 2017. Patients were assigned an AUA score and classified into three risk categories. Outcome data including hospitalizations, Emergency Department (ED) visits, home care status, and survival were collected and compared across AUA risk categories using descriptive and analytical statistics. Results Of the 2,801 patients screened, 31.9% were classified as high risk, 23.6% as moderate risk, and 44.6% as low risk. Patients who scored in the highest risk category were found to have longer hospital stays, and were more likely to require home care (p<.0001). The AUA risk category also predicted survival (p<.001). Conclusions The AUA predicted multiple adverse outcomes in this population. Use of the AUA by paramedics may aid in earlier identification of those in need of additional intervention and services.
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Affiliation(s)
- Alexandra Whate
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - Jacobi Elliott
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - Dustin Carter
- Community Paramedicine, Middlesex-London Paramedic Service, London, ON, Canada
| | - Paul Stolee
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
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Liu J, Palmgren T, Ponzer S, Masiello I, Farrokhnia N. Can dedicated emergency team and area for older people reduce the hospital admission rate? - An observational pre- and post-intervention study. BMC Geriatr 2021; 21:115. [PMID: 33568087 PMCID: PMC7877031 DOI: 10.1186/s12877-021-02044-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 01/20/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Emergency department (ED) care of older patients is often complex. Geriatric ED guidelines can help to meet this challenge. However, training requirements, the use of time-consuming tools for comprehensive geriatric assessment (CGA), a lack of golden standard to identify the frail patients, and the weak evidence of positive outcomes of using CGA in EDs pose barriers to introduce the guidelines. Dedicating an interprofessional team of regular ED medical and nursing staff and an older-friendly ED area can be another approach. Previous studies of geriatrician-led CGA in EDs have reported a reduced hospital admission rate. The aim of this study was to investigate whether a dedicated interprofessional emergency team also can reduce the hospital admission rate without the resources required by the formal use of CGA. METHODS An observational pre-post study at a large adult ED, where all patients 80 years or older arriving on weekdays in the intervention period from 2016.09.26 to 2016.11.28 and the corresponding weekdays in the previous year from 2015.09.28 to 2015.11.30 were included. In the intervention period, older patients either received care in the geriatric module by the dedicated team or in the regular team modules for patients of mixed ages. In 2015, all patients received care in regular team modules. The primary outcome measure was the total hospital admission rate and the ED length of stay was the secondary outcome measure. RESULTS We included 2377 arrivals in the intervention period, when 26.7% (N = 634) received care in the geriatric module, and 2207 arrivals in the 2015 period. The total hospital admission rate was 61.7% (N = 1466/2377) in the intervention period compared to 64.8% (N = 1431/2207) in 2015 (p = 0.03). The difference was larger for patients treated in the geriatric module, 51.1% compared to 62.1% (95% CI: 56.3 to 68.0%) for patients who would have been eligible in 2015. The ED length of stay was longer in the intervention period. CONCLUSIONS An interprofessional team and area dedicated to older patients was associated to a lower hospital admission rate. Further studies are needed to confirm the results.
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Affiliation(s)
- Jenny Liu
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden.
| | - Therese Palmgren
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden
| | - Sari Ponzer
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden
| | - Italo Masiello
- Department of Computer Science and Media Technology, Linnaeus University, Växjö, Sweden
| | - Nasim Farrokhnia
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden
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10
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Gretarsdottir E, Jonsdottir AB, Sigurthorsdottir I, Gudmundsdottir EE, Hjaltadottir I, Jakobsdottir IB, Tomasson G, Jonsson PV, Thorsteinsdottir T. Patients in need of comprehensive geriatric assessment: The utility of the InterRAI emergency department screener. Int Emerg Nurs 2020; 54:100943. [PMID: 33370678 DOI: 10.1016/j.ienj.2020.100943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 08/10/2020] [Accepted: 10/25/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The interRAI Emergency Department-Screener (ED-screener) is a risk stratification instrument incorporating functional and social aspects to identify older adults in EDs. The aim was to assess the construct validity and utility of the ED-screener in comparison with more established instruments. METHODS The ED-screener, Triage Risk Screening Tool (TRST) and Identification of Seniors at Risk (ISAR) were administered to older ED-patients. Construct validity was assessed by correlation with TRST and ISAR. The ED-screener scores that corresponded to the established cut-offs for ISAR and TRST were assessed with linear regression. The sensitivity and specificity of the ED-screener for mortality at 4-months were calculated. RESULTS Two hundred patients were included (mean age 78.5 years, 44% male). Majority (85%) lived at home, 43% lived alone and 53% received home care. The scores of 3.02 and 3.01 on ED-screener corresponded to the cut-off score of 2 on the other instruments. The correlation of the ED-screener with ISAR and TRST was 0.56 and 0.41 respectively. A score of 3 on the ED-screener was 100% sensitive and 28% specific for 4-month mortality. CONCLUSION These findings provide support for the construct validity of the ED-screener and its ability to predict outcomes in its intended setting.
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Affiliation(s)
- Elfa Gretarsdottir
- Internal Medicine Services, Landspítali The National University Hospital of Iceland, Iceland; Faculty of Nursing, University of Iceland, Iceland.
| | - Anna Björg Jonsdottir
- Geriatric Department, Landspítali The National University Hospital of Iceland, Iceland
| | - Ingibjörg Sigurthorsdottir
- Emergency, Geriatrics, Rehabilitation Service, Landspitali The National University Hospital of Iceland, Iceland
| | | | - Ingibjörg Hjaltadottir
- Faculty of Nursing, University of Iceland, Iceland; Emergency, Geriatrics, Rehabilitation Service, Landspitali The National University Hospital of Iceland, Iceland
| | - Iris Bjork Jakobsdottir
- Internal Medicine Services, Landspítali The National University Hospital of Iceland, Iceland; Faculty of Nursing, University of Iceland, Iceland
| | - Gunnar Tomasson
- Department of Rheumatology, Landspítali The National University Hospital of Iceland, Iceland; Centre for Rheumatology Research, Landspítali The National University Hospital, Iceland; Faculty of Medicine, University of Iceland, Iceland
| | - Palmi V Jonsson
- Geriatric Department, Landspítali The National University Hospital of Iceland, Iceland; Faculty of Medicine, University of Iceland, Iceland
| | - Thordis Thorsteinsdottir
- Faculty of Nursing, University of Iceland, Iceland; Research Institute in Emergency Care, Landspítali The National University Hospital of Iceland, Iceland
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11
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Calvo M, González R, Seijas N, Vela E, Hernández C, Batiste G, Miralles F, Roca J, Cano I, Jané R. Health Outcomes from Home Hospitalization: Multisource Predictive Modeling. J Med Internet Res 2020; 22:e21367. [PMID: 33026357 PMCID: PMC7578817 DOI: 10.2196/21367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/20/2020] [Accepted: 09/08/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Home hospitalization is widely accepted as a cost-effective alternative to conventional hospitalization for selected patients. A recent analysis of the home hospitalization and early discharge (HH/ED) program at Hospital Clínic de Barcelona over a 10-year period demonstrated high levels of acceptance by patients and professionals, as well as health value-based generation at the provider and health-system levels. However, health risk assessment was identified as an unmet need with the potential to enhance clinical decision making. OBJECTIVE The objective of this study is to generate and assess predictive models of mortality and in-hospital admission at entry and at HH/ED discharge. METHODS Predictive modeling of mortality and in-hospital admission was done in 2 different scenarios: at entry into the HH/ED program and at discharge, from January 2009 to December 2015. Multisource predictive variables, including standard clinical data, patients' functional features, and population health risk assessment, were considered. RESULTS We studied 1925 HH/ED patients by applying a random forest classifier, as it showed the best performance. Average results of the area under the receiver operating characteristic curve (AUROC; sensitivity/specificity) for the prediction of mortality were 0.88 (0.81/0.76) and 0.89 (0.81/0.81) at entry and at home hospitalization discharge, respectively; the AUROC (sensitivity/specificity) values for in-hospital admission were 0.71 (0.67/0.64) and 0.70 (0.71/0.61) at entry and at home hospitalization discharge, respectively. CONCLUSIONS The results showed potential for feeding clinical decision support systems aimed at supporting health professionals for inclusion of candidates into the HH/ED program, and have the capacity to guide transitions toward community-based care at HH discharge.
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Affiliation(s)
- Mireia Calvo
- Institute for Bioengineering of Catalonia (IBEC), Barcelona Institute of Science and Technology (BIST), Universitat Politècnica de Catalunya (UPC), CIBER-BBN, Barcelona, Spain
| | - Rubèn González
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona (UB), Barcelona, Spain
| | - Núria Seijas
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona (UB), Barcelona, Spain
| | - Emili Vela
- Àrea de sistemes d'informació, Servei Català de la Salut, Barcelona, Spain
| | - Carme Hernández
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona (UB), Barcelona, Spain
| | - Guillem Batiste
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona (UB), Barcelona, Spain
| | - Felip Miralles
- Eurecat, Technology Center of Catalonia, Barcelona, Spain
| | - Josep Roca
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona (UB), Barcelona, Spain
| | - Isaac Cano
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona (UB), Barcelona, Spain
| | - Raimon Jané
- Institute for Bioengineering of Catalonia (IBEC), Barcelona Institute of Science and Technology (BIST), Universitat Politècnica de Catalunya (UPC), CIBER-BBN, Barcelona, Spain
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12
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Michalski-Monnerat C, Carron PN, Nguyen S, Büla C, Mabire C. Assessing Older Patients' Vulnerability in the Emergency Department: A Study of InterRAI ED Screener Accuracy. J Am Geriatr Soc 2020; 68:2914-2920. [PMID: 32964415 DOI: 10.1111/jgs.16829] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/30/2020] [Accepted: 08/20/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Identifying vulnerable older patients admitted to an emergency department (ED) who are at increased risk for adverse events and require a comprehensive geriatric assessment remains a major challenge. The interRAI Emergency Department Screener (EDS) was developed for this specific purpose, but data regarding its validity are scarce. OBJECTIVES To determine (1) convergent validity of the EDS with results of a geriatrician's assessment in defining the need for prompt versus delayed/no further geriatric assessment and (2) predictive validity of the EDS for hospital admission, prolonged hospital length of stay (LOS), and 30-day readmission. DESIGN Prospective observational study. SETTING ED of an academic hospital in Switzerland. PARTICIPANTS Older patients, aged 75 years or older (N = 202), who visited the ED over a 4-month period. Patients with life-threatening conditions were excluded. MEASUREMENTS Data for EDS were collected by two clinical nurses. A brief geriatric assessment was performed separately and interpreted by a geriatrician blinded to the EDS results. Orientation after ED discharge, hospital LOS, and 30-day readmission were retrieved from the administrative database. RESULTS Participants were aged 83.2 ± 5.4 years, 56.9% were female, and 43.6% lived alone. Frequent findings at geriatric assessment were impairment in gait/balance (69.3%), polypharmacy (64.9%), cognitive impairment/delirium (48.2%), risk of malnutrition (46.0%), and mood impairment (38.1%). The proportions of participants who required prompt, delayed, and no further geriatric assessment, according to the EDS, were 27.2%, 29.2%, and 43.6%, respectively. The EDS had low sensitivity in predicting hospital admission (28.8%), prolonged LOS (26.3%), and 30-day readmission (26.1%), with the Area Under the Receiver Operating Characteristics (AUROC) being 51.8%, 48.1%, and 49.4%, respectively. CONCLUSION The EDS performed poorly in both convergent and predictive validity analyses, precluding its use as a screening tool in this ED environment. Further efforts should be undertaken to better target interventions to reduce adverse health trajectories in the older ED population.
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Affiliation(s)
- Carole Michalski-Monnerat
- Institute of Higher Education and Research in Healthcare-IUFRS, University of Lausanne, Lausanne University Hospital, Lausanne, Switzerland
- Neuchâtel Hospital Network, Neuchâtel, Switzerland
| | - Pierre-Nicolas Carron
- Emergency Department, Lausanne University Hospital (CHUV), and University of Lausanne, Lausanne, Switzerland
| | - Sylvain Nguyen
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital (CHUV), and University of Lausanne, Lausanne, Switzerland
| | - Christophe Büla
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital (CHUV), and University of Lausanne, Lausanne, Switzerland
| | - Cédric Mabire
- Institute of Higher Education and Research in Healthcare-IUFRS, University of Lausanne, Lausanne University Hospital, Lausanne, Switzerland
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