Trends in Geriatric Emergency Medicine

Older Emergency Department Patients: Does Baseline Care Status Matter?

Background

Little is known about the prognostic differences between older emergency department (ED) patients who present with different formal support requirements in the community. We set out to describe and compare the patient profiles and patterns of health service use among three older ED cohorts: home care clients, nursing home residents and those receiving no formal support.

Methods

We conducted a secondary analysis of the Canadian cohort from the interRAI multinational ED study. Data were collected using interRAI ED contact assessment on patients 75 years of age and older (n = 2,274), in eight ED sites across Canada. A series of descriptive statistics were reported. Adjusted associations were determined using logistic regression.

Results

Older adults receiving no formal support services were most stable. However, they were most likely to be hospitalized. Older home care clients were most likely to report depressive symptoms and distressed caregivers. They also had the greatest odds of frequent ED visitation post-discharge (OR=1.9; 95% CI=1.39–2.59). Older adults transferred from a nursing home were the frailest but had the lowest odds of hospital admission (OR=0.14; 95% CI=0.09–0.23).

Conclusion

We demonstrated the importance of inquiring about community-based formal support services and provide data to support decision-making in the ED.

Predicting hospital admission for older emergency department patients: Insights from machine learning

BACKGROUND

Emergency departments (ED) are a portal of entry into the hospital and are uniquely positioned to influence the health care trajectories of older adults seeking medical attention. Older adults present to the ED with distinct needs and complex medical histories, which can make disposition planning more challenging. Machine learning (ML) approaches have been previously used to inform decision-making surrounding ED disposition in the general population. However, little is known about the performance and utility of ML methods in predicting hospital admission among older ED patients. We applied a series of ML algorithms to predict ED admission in older adults and discuss their clinical and policy implications.

MATERIALS AND METHODS

We analyzed the Canadian data from the interRAI multinational ED study, the largest prospective cohort study of older ED patients to date. The data included 2274 ED patients 75 years of age and older from eight ED sites across Canada between November 2009 and April 2012. Data were extracted from the interRAI ED Contact Assessment, with predictors including a series of geriatric syndromes, functional assessments, and baseline care needs. We applied a total of five ML algorithms. Models were trained, assessed, and analyzed using 10-fold cross-validation. The performance of predictive models was measured using the area under the receiver operating characteristic curve (AUC). We also report the accuracy, sensitivity, and specificity of each model to supplement performance interpretation.

RESULTS

Gradient boosted trees was the most accurate model to predict older ED patients who would require hospitalization (AUC = 0.80). The five most informative features include home intravenous therapy, time of ED presentation, a requirement for formal support services, independence in walking, and the presence of an unstable medical condition.

CONCLUSION

To the best of our knowledge, this is the first study to predict hospital admission in older ED patients using a series of geriatric syndromes and functional assessments. We were able to predict hospital admission in older ED patients with good accuracy using the items available in the interRAI ED Contact Assessment. This information can be used to inform decision-making about ED disposition and may expedite admission processes and proactive discharge planning.

Left Mandibular Pain: A Rare Initial Symptom of Acute Aortic Dissection Without Coronary Obstruction

An 88-year-old woman experienced sharp pain in the left mandible for a few minutes 3 days prior to hospital presentation. On the day of hospital presentation, the patient experienced similar pain and cold sweating for more than an hour early in the morning. On arrival, there was only mild discomfort ranging from the left mandible to the neck, without definite pain. Computed tomography revealed Stanford type A acute aortic dissection. Blood vessel prosthesis implantation was performed. Intraoperatively, the coronary arteries were confirmed to be intact. Mandibular pain is a rare but potential symptom of aortic dissection without coronary artery obstruction.

Non-medical needs of older patients in the emergency department

AIM

To determine the non-medical needs of older patients in the emergency department (ED).

METHODS

We undertook a cross-sectional survey of three age groups (50-64, 65-79, 80+ years) using a self-administered questionnaire with five response options (strongly agree-strongly disagree) for 31 items.

RESULTS

There were 548 patients enrolled. Significantly fewer older patients knew how to call for assistance (P < 0.01), knew how the ED works (P < 0.01), felt frightened by their illness (P < 0.01) or felt that the ED lights were too bright (P < 0.03). A substantial proportion of all patients did not agree that their illness and/or treatment had been well explained.

CONCLUSION

Older patients appear resilient but need to be told to call for assistance when needed, to know how to call for this assistance and how the ED works. Clear information regarding their illness and treatment should be provided, particularly to younger patients who may be anxious.

Risk stratification and rapid geriatric screening in an emergency department - a quasi-randomised controlled trial

Background

To determine if risk stratification followed by rapid geriatric screening in an emergency department (ED) reduced functional decline, ED reattendance and hospitalisation.

Method

This was a quasi-randomised controlled trial. Patients were randomised by the last digit of their national registration identity card (NRIC). Odd number controls received standard ED care; even number patients received geriatric screening, followed by intervention and/or onward referrals. Patients were followed up for 12 months.

Results

There were 500 and 280 patients in the control and intervention groups. The intervention group had higher Triage Risk Screening Tool (TRST) scores (34.3% vs 25.4% TRST ≥3, p = 0.01) and lower baseline Instrumental Activity of Daily Living (IADL) scores (22.84 vs 24.18, p < 0.01). 82.9% of the intervention group had unmet needs; 62.1% accepted our interventions. Common positive findings were fall risk (65.0%), vision (61.4%), and footwear (58.2%). 28.2% were referred to a geriatric clinic and 11.8% were admitted. 425 (85.0%) controls and 234 (83.6%) in the intervention group completed their follow-up. After adjusting for TRST and baseline IADL, the intervention group had significant preservation in function (Basic ADL -0.99 vs -0.24, p < 0.01; IADL -2.57 vs +0.45, p < 0.01) at 12 months. The reduction in ED reattendance (OR0.75, CI 0.55-1.03, p = 0.07) and hospitalization (OR0.77, CI0.57-1.04, p = 0.09) were not significant, however the real difference would have been wider as 21.2% of the control group received geriatric screening at the request of the ED doctor. A major limitation was that a large proportion of patients who were randomized to the intervention group either refused (18.8%) or left the ED before being approached (32.0%). These two groups were not followed up, and hence were excluded in our analysis.

Conclusion

Risk stratification and focused geriatric screening in ED resulted in significant preservation of patients’ function at 12 months.

Trial registration

National Healthcare Group (NHG) Domain Specific Review Board (DSRB) C/09/023. Registered 5th March 2009.

Demography is destiny: an agenda for geriatric emergency medicine in Australasia

The present paper presents an agenda for geriatric emergency medicine research, education and policy development. Herein we will argue: Population ageing is the definitive health policy challenge in Australasia, and the greatest stressor for emergency medicine posed by population ageing is the disproportionate contribution of older people to hospital occupancy. ED practices and models of care may on occasions contribute to rather than reduce high hospital occupancy in older people, benefitting neither individual patients nor the community at large. Geriatric emergency medicine priorities can be conceptualised using a simple framework, and this process will facilitate a research and policy focus on how to achieve equivalent or improved care for older people with less hospital occupancy.

Profiling Acute Presenting Symptoms of Geriatric Patients Attending an Urban Hospital Emergency Department

Objective: To study the profile of geriatric patients warded to the emergency department (ED) of an Asian acute care general hospital and determine if they are ‘more ill’, more likely to have atypical presentations and have a higher utilisation of healthcare resources when compared to a younger group of patients. Materials and Methods: This is a retrospective chart review of consecutive patients aged 45 years and above presenting to the study ED over a period of 4 weeks from 4 June 2006 to 1 July 2006. The following data were obtained: (i) demographics, (ii) mode of arrival and triage acuity, (iii) presence of co-morbidities, (iv) investigations ordered in the ED, (v) clinical symptoms and diagnoses, (vi) disposition, (vii) length of hospital stay, (viii) injuries and outcomes of elderly fallers. The study population was divided into 2 groups – a study group with patients aged 65 years and above, and a control group with patients aged 45 to 64. Results: There were 2847 patients in the study group and these were compared against 2875 in the control group. Those 65 years and above had greater representation in the ED population compared to the general population. In the study group, the proportion of females, the number arriving by ambulance and the likelihood of having a higher triage acuity increased with age. The elderly had higher rates of co-morbidities. They also had a higher resource utilisation rate. Falls was their commonest presenting complaint. Conclusion: It is crucial that EDs recognise the special needs of elderly patients due to the growing ageing population. Healthcare policy makers when allocating resources should take into account the profile of elderly patients presenting to an ED and their resource utilisation. Key words: Elderly, Presentation, Symptomology