Older persons in the emergency medical care system

Admission Gatekeeping and Safe Discharge for the Elderly: Referral by the Emergency Department to the Community Nursing Service for Home Visits

Objective

To assess the gatekeeping effect and discharge safety in elderly referrals to the community nursing service (CNS) in a major accident & emergency department (AED).

Methods

Descriptive review analysis of the referrals in 2002–2004.

Results

Altogether 333 patients were accepted, comprising 5% of the total CNS referrals in the hospital: 323 were aged ≥65 (median age 81), 13.8% were living alone, 21.6% had unscheduled return to the AED within 14 days, and 11.7% in 15–28 days. The ≤14 days and 15–28 days admission to hospital was 15.0% and 6.0%, with 4.8% and 0.6% patients admitted with the same or related diagnosis as the first visit respectively, including missed fractures and stroke. One patient died 17 days after discharge. Eight of the 162 falls returned within 28 days with a second fall. Overall, 317 admissions were avoided with 1,978 bed-days saved. Living alone was strongly associated with unscheduled return and admission ≤14 and ≤28 days, while age was not. The six categories of community nursing care were fall-related, tube care, skin and soft tissue care, pain control, medical and diabetic care. Injections were given for cellulitis, pain, and diabetics. Forty-nine patients had phone follow-ups.

Conclusion

The gatekeeping effect of AED referrals to CNS remained small. The commonest referrals were falls with head injury. It was safe to discharge the elderly for CNS care. A wide range of home nursing care was feasible. CNS referral could decrease elderly return visits with falls. Living alone was strongly associated with return visit and admission.

Examining Home Care in Other Countries: The Policy Issues

This article uses Canada as a case study to demonstrate how one country with a strong social welfare focus has addressed the policy and delivery issues embedded in home care. It moves on to briefly discuss recent home care developments in Germany, Japan, and Great Britain to provide examples of how other countries are coping with such issues as access to care, financing, and consumer preferences. It ends with a discussion of policy issues that many countries are facing today.

Emergency Presentations With Nonspecific Complaints-the Burden of Morbidity and the Spectrum of Underlying Disease: Nonspecific Complaints and Underlying Disease

The prevalence of diagnoses, morbidity, and mortality of patients with nonspecific complaints (NSC) presenting to the emergency department (ED) is unknown.To determine the prevalence of diagnoses, acute morbidity, and mortality of patients with NSC.Prospective observational study with a 30-day follow-up. Patients presenting to 2 EDs were enrolled by a study team and diagnosed according to the World Health Organization ICD-10 System.Of 217,699 presentations to the ED from May 2007 through to February 2011, a total of 1300 patients were enrolled. After exclusion of 90 patients who fulfilled exclusion criteria, 1210 patients were analyzed. No patient was lost to follow-up. In patients with NSC, the underlying diseases were spread throughout 18 chapters of the ICD-10. A total of 58.7% of the patients were diagnosed with acute morbidity. Thirty-day mortality was 6.4% overall. Patients with acute morbidity and suffering from heart failure and pneumonia had mortalities >15%; patients lacking acute morbidity, but suffering from functional impairment or depression/anxiety had mortalities of 0%. Although the history did not allow any prediction, age and sex were predictive of morbidity and mortality.The differential diagnoses in patients presenting with NSC is broad. Acute morbidity and mortality were high in the presented cohort, the predictors of morbidity and mortality being age and sex rather than the nature of the complaints. Urgently needed management strategies could be based on these results.ClinicalTrials.gov (#NCT00920491).

Effects of fall injury type and discharge placement on mortality, hospitalization, falls, and ADL changes among older people in Taiwan

A longitudinal study was conducted to investigate the effects of injury type and discharge placement on mortality, falls, hospital admissions, and changes in activities of daily living (ADLs) over a 12-month period among older fallers. Of 762 community-dwelling people aged 65 years or older who visited an emergency department (ED) of a general hospital in Taiwan due to a fall, 273 sustained a hip fracture, 157 had a vertebral fracture, 47 had a distal forearm fracture, 102 had a traumatic brain injury, and 183 had soft-tissue injuries. Results showed that, compared to patients with a soft-tissue injury, those with TBI had significantly higher risks of dying (rate ratio (RR)=3.59) and hospital admissions (RR=3.23) and better improvement in ADLs (1.93 points) at 6 months post-injury, and those who sustained a hip fracture (4.26 and 4.41 points), a vertebral fracture (3.81 and 3.83 points), or a distal-forearm fracture (2.80 and 2.80 points) had significantly better improvement in ADLs at 6 and 12 months post-injury. Patients discharged to a nursing home had a significantly increased risk of death (RR=2.08) and hospital admission (RR=2.05) than those returning to their usual residence during the first year post-injury. No significant differences in the occurrence of falls during the first post-injury year were found among patients with different injury types or between those with different discharge placements. In conclusion, among the five major fall injury types in older people, TBIs result in the highest risk of death and hospital admissions, while hip and vertebral fractures exhibited the largest improvement during the first year after injury. Additionally, nursing home care may be associated with increased risks of death and hospital admissions than home care. In addition to primary prevention of falls, further research to investigate mechanisms leading to TBIs during a fall is needed to facilitate effective secondary fall-prevention programs for older people.

Assessment of a chief complaint-based curriculum for resident education in geriatric emergency medicine

INTRODUCTION

We hypothesized that a geriatric chief complaint-based didactic curriculum would improve resident documentation of elderly patient care in the emergency department (ED).

METHODS

A geriatric chief complaint curriculum addressing the 3 most common chief complaints-abdominal pain, weakness, and falls-was developed and presented. A pre- and postcurriculum implementation chart review assessed resident documentation of the 5 components of geriatric ED care: 1) differential diagnosis/patient evaluation considering atypical presentations, 2) determination of baseline function, 3) chronic care facility/caregiver communication, 4) cognitive assessment, and 5) assessment of polypharmacy. A single reviewer assessed 5 pre- and 5 postimplementation charts for each of 18 residents included in the study. We calculated 95% confidence and determined that statistical significance was determined by a 2-tailed z test for 2 proportions, with statistical significance at 0.003 by Bonferroni correction.

RESULTS

For falls, resident documentation improved significantly for 1 of 5 measures. For abdominal pain, 2 of 5 components improved. For weakness, 3 of 5 components improved.

CONCLUSION

A geriatric chief complaint-based curriculum improved emergency medicine resident documentation for the care of elderly patients in the ED compared with a non-age-specific chief complaint-based curriculum.

[Utilization of an emergency department by elderly people in a university hospital in Santiago de Chile]

INTRODUCTION

An increase in visits to Emergency Departments by older adults has been reported, but there are no data available on this in countries in the early phases of demographic and epidemiological transition. This paper describes the characteristics of people over 60 years-old (AM) who visited the Emergency Department of the Hospital Clínico Universitario de la Pontificia Universidad Católica, Chile (SU-PUC), compared to those less than 60 years-old (AJ).

MATERIAL AND METHODS

Demographic data and reasons for admission and re-admission were collected retrospectively from the SU-PUC monthly statistics report. Obstetrics, paediatrics and «scheduled admissions» were excluded. The frequencies were compared using Chi-squared (significance: P < .05).

RESULTS

A total of 37,660 visits to the SU-PUC were recorded (81% AJ; 19% AM; with 8% being older than 75 years). No statistical differences were found in the visit time (70% daytime), or by season between the groups. A total of 7,414 (19.6%) of those who visited were hospitalised, with differences being detected between groups (AM: 48.9% vs 12.9% AJ; P < .001), particularly in those over 75 years (59%). The primary cause of admission was cardiopulmonary in AM (22%) and gastrointestinal in AJ (31%). Re-admissions were 10% in AM and 6% in AJ (P < .001).

CONCLUSION

The use of SU by AM and some characteristics of their care process (hospitalisation) are similar to those found in countries in more advanced phases of demographic transition.

Effectiveness of gerontologically informed nursing assessment and referral interventions for older persons attending the emergency department: systematic review

AIM

This paper is a report of a literature review conducted to analyse data from published studies reporting nursing interventions targeted at older attendees of emergency departments (EDs), and to provide a critical appraisal of the evidence concerning their effectiveness.

BACKGROUND

Attendance at hospital EDs by older persons presents opportunities for targeted interventions to address actual and potential problems associated with or in addition to the presenting problem. The evidence concerning the effectiveness of such interventions is mixed.

DATA SOURCES

Studies were retrieved from a systematic search of published works indexed in CINAHL, MEDLINE (PubMed), Science Direct and the Cochrane Central Register of Controlled Trials (CENTRAL).

METHODS

A systematic review of effectiveness was conducted using the Cochrane Effective Practice and Organisation of Care guidelines and a narrative synthesis approach for data handling and presentation. The review period was 1992 to 31 August 2008.

RESULTS

Nursing assessment and referral interventions have demonstrated effectiveness in reducing service use and improving physical function, but have failed to demonstrate statistically significant effects on predicted patient and/or health systems outcomes.

CONCLUSION

The evidence of the effectiveness of gerontologically informed nursing assessment and referral interventions in EDs must be accepted with caution, as not all studies demonstrated effectiveness in predicted patient and/or health systems outcomes, and the testing of complex social interventions in randomized clinical trials is inherently problematic. Further evidence of the effectiveness of nursing interventions is required, and such evidence might be usefully demonstrated using pragmatic, as opposed to explanatory, trials.

[Medical short stay unit for geriatric patients in the emergency department: clinical and healthcare benefits]

INTRODUCTION

To evaluate the impact of comprehensive geriatric assessment and management of high-risk elders in a medical short stay unit located in the emergency department of a general hospital.

MATERIAL AND METHODS

We performed a descriptive, prospective study of patients admitted to the medical short stay unit for geriatric patients of the emergency department in 2006.

RESULTS

A total of 749 patients were evaluated, with a mean (standard deviation) stay in the unit of 37 (16) h. The mean age was 86 (7) years; 57% were women, and 50% had moderate-severe physical impairment and dementia. Thirty-five percent lived in a nursing home. The most frequent reason for admission was exacerbation of chronic cardiopulmonary disease. Multiple geriatric syndromes were identified. The most frequent were immobility, pressure sores and behavioral disorders related to dementia. Seventy percent of the patients were discharged to home after being stabilized and were followed-up by the geriatric clinic and day hospital (39%), the home care medical team (11%), or the nursing home or primary care physician (20%). During the month after discharge, 17% were readmitted and 7.7% died, especially patients with more advanced age or functional impairment. After the unit was opened, admissions to the acute geriatric unit fell by 18.2%.

CONCLUSIONS

Medical short stay units for geriatric patients in emergency departments may be useful for geriatric assessment and treatment of exacerbations of chronic diseases. These units can help to reduce the number of admissions and optimize the care provided in other ambulatory and domiciliary geriatric settings.

The elderly in the emergency department: a critical review of problems and solutions

The elderly are an ever increasing population in overcrowded emergency departments (EDs) in many countries. They have multiple health problems and consume more time and resources than younger patients. They are more frequently admitted and experience adverse outcomes after they are discharged from the ED. These frail patients could require specific skills, instruments and organisational models of emergency care in order to look after their complex needs. As such, several approaches have been tried and tested to improve emergency care for them. This article analyses the epidemiological load and problems faced when confronted with elder ED patients. We critically review organisational models, clinical approaches and methodologies in order to reduce ED physicians' difficulties and to improve quality of care and outcomes for elder patients. Triage, clinical assessment and discharge are identified as critical moments during an emergency care process, and interesting and useful instruments are proposed as possible solutions.

Functional assessment of older patients in the emergency department: comparison between standard instruments, medical records and physicians' perceptions

Background

We evaluated the accuracy of physician recognition of functional status impairment in older emergency departments (ED) patients. In particular, we evaluated the accuracy of medical records (a comparison of the information in the medical record with the functional status based on proxy interviews), and the accuracy of physician knowledge (a comparison of the information obtained from the responsible physician with the functional status based on proxy interviews).

Methods

Cross-sectional study on 101 frail older patients selected at random from among those attending ED, their ED physicians, and respondents. The study was conducted at ED in four general university teaching hospitals in a city, from July through November 2003. Functional data shown on patients' medical records were compared against functional data obtained from respondents (family members), using Kendall's Tau-b statistic. In addition patients' Katz Indices (which assesses six basic activities of daily living – basic ADL) based on interviews with ED physicians were compared against those obtained from respondents, using the coefficient of concordance weighted kappa (κ). Each patient and his respondent were paired with a single physician.

Results

The correlation between information on dependence for basic ADL obtained from medical records and that furnished by respondents, was 0.41 (95% CI 0.27–0.55). Concordance between the respective Katz Indices obtained from physicians and respondents was 0.47 (95% CI 0.38–0.57).

Conclusion

Older subjects' functional status is not properly assessed by emergency department physicians.

A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department--the DEED II study

OBJECTIVES

To study the effects of comprehensive geriatric assessment (CGA) and multidisciplinary intervention on elderly patients sent home from the emergency department (ED).

DESIGN

Prospective, randomized, controlled trial with 18 months of follow-up.

SETTING

Large medical school-affiliated public hospital in an urban setting in Sydney, Australia.

PARTICIPANTS

A total of 739 patients aged 75 and older discharged home from the ED were randomized into two groups.

INTERVENTION

Patients randomized to the treatment group underwent initial CGA and were followed at home for up to 28 days by a hospital-based multidisciplinary outreach team. The team implemented or coordinated recommendations. The control group received usual care.

MEASUREMENTS

The primary outcome measure was all admissions, to the hospital within 30 days of the initial ED visit. Secondary outcome measures were elective and emergency admissions, and nursing home admissions and mortality. Additional outcomes included physical function (Barthel Index (total possible score=20) and instrumental activities of daily living (/12) and cognitive function (mental status questionnaire (/10)).

RESULTS

Intervention patients had a lower rate of all admissions to the hospital during the first 30 days after the initial ED visit (16.5% vs 22.2%; P=.048), a lower rate of emergency admissions during the 18-month follow-up (44.4% vs 54.3%; P=.007), and longer time to first emergency admission (382 vs 348 days; P=.011). There was no difference in admission to nursing homes or mortality. Patients randomized to the intervention group maintained a greater degree of physical and mental function (Barthel Index change from baseline at 6 months: -0.25 vs -0.75; P<.001; mental status questionnaire change from baseline at 12 months: -0.21 vs -0.64; P<.001).

CONCLUSION

CGA and multidisciplinary intervention can improve health outcomes of older people at risk of deteriorating health and admission to hospital. Patients aged 75 and older should be referred for CGA after an ED visit.