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Moloney E, O’Donovan MR, Carpenter CR, Salvi F, Dent E, Mooijaart S, Hoogendijk EO, Woo J, Morley J, Hubbard RE, Cesari M, Ahern E, Romero-Ortuno R, Mcnamara R, O’Keefe A, Healy A, Heeren P, Mcloughlin D, Deasy C, Martin L, Brousseau AA, Sezgin D, Bernard P, Mcloughlin K, Sri-On J, Melady D, Edge L, O’Shaughnessy I, Van Damme J, Cardona M, Kirby J, Southerland L, Costa A, Sinclair D, Maxwell C, Doyle M, Lewis E, Corcoran G, Eagles D, Dockery F, Conroy S, Timmons S, O’Caoimh R. Core requirements of frailty screening in the emergency department: an international Delphi consensus study. Age Ageing 2024; 53:afae013. [PMID: 38369629 PMCID: PMC10874925 DOI: 10.1093/ageing/afae013] [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: 01/17/2023] [Revised: 10/24/2023] [Indexed: 02/20/2024] Open
Abstract
INTRODUCTION Frailty is associated with adverse outcomes among patients attending emergency departments (EDs). While multiple frailty screens are available, little is known about which variables are important to incorporate and how best to facilitate accurate, yet prompt ED screening. To understand the core requirements of frailty screening in ED, we conducted an international, modified, electronic two-round Delphi consensus study. METHODS A two-round electronic Delphi involving 37 participants from 10 countries was undertaken. Statements were generated from a prior systematic review examining frailty screening instruments in ED (logistic, psychometric and clinimetric properties). Reflexive thematic analysis generated a list of 56 statements for Round 1 (August-September 2021). Four main themes identified were: (i) principles of frailty screening, (ii) practicalities and logistics, (iii) frailty domains and (iv) frailty risk factors. RESULTS In Round 1, 13/56 statements (23%) were accepted. Following feedback, 22 new statements were created and 35 were re-circulated in Round 2 (October 2021). Of these, 19 (54%) were finally accepted. It was agreed that ideal frailty screens should be short (<5 min), multidimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2-4 weeks before presentation. Screening should ideally be routine, prompt (<4 h after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use and social factors were identified as the most important variables to include. CONCLUSIONS Although a clear consensus was reached on important requirements of frailty screening in ED, and variables to include in an ideal screen, more research is required to operationalise screening in clinical practice.
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Affiliation(s)
- Elizabeth Moloney
- HRB Clinical Research Facility, Mercy University Hospital, University College Cork, Cork City, T12 WE28, Ireland
| | - Mark R O’Donovan
- HRB Clinical Research Facility, Mercy University Hospital, University College Cork, Cork City, T12 WE28, Ireland
| | - Christopher R Carpenter
- Department of Emergency Medicine and Emergency Care Research Core, Washington University in St. Louis School of Medicine, St. Louis, MO 63110-1010, USA
| | - Fabio Salvi
- Department of Geriatrics and Emergency Care, INRCA-IRCCS, Ancona 5-60124, Italy
| | - Elsa Dent
- The Centre for Public Health, Equity and Human Flourishing (PHEHF), Torrens University Australia, Adelaide, South Australia 5000, Australia
| | - Simon Mooijaart
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Centre, Leiden 2300, Netherlands
| | - Emiel O Hoogendijk
- Department of Epidemiology and Data Science, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Centre, Amsterdam 1081, Netherlands
| | - Jean Woo
- Department of Medicine, Chinese University of Hong Kong, Hong Kong, Special Administrative Region, China
| | - John Morley
- Divisions of Geriatric Medicine and Endocrinology, Saint Louis University School of Medicine, St. Louis, MO 63104, USA
| | - Ruth E Hubbard
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland 4072, Australia
| | - Matteo Cesari
- IRCCS Istituti Clinici Scientifici Maugeri, University of Milan, Milan 20122, Italy
| | - Emer Ahern
- Department of Geriatric Medicine, Cork University Hospital, Cork, T12 DC4A, Ireland
| | - Roman Romero-Ortuno
- Discipline of Medical Gerontology, School of Medicine, Mercer’s Institute for Successful Ageing, St. James’s Hospital, Dublin, D08 NHY1, Ireland
- Mercers Institute for Successful Ageing, St James's Hospital, Dublin 8, D08 E9P6, Ireland
| | - Rosa Mcnamara
- Emergency Department, St Vincent's University Hospital, Dublin 4, D04 T6F4, Ireland
| | - Anne O’Keefe
- Emergency Department, Mercy University Hospital, Cork, T12WE28, Ireland
| | - Ann Healy
- Emergency Department, Mercy University Hospital, Cork, T12WE28, Ireland
| | - Pieter Heeren
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven 3000, Belgium
| | - Darren Mcloughlin
- Emergency Department, Mercy University Hospital, Cork, T12WE28, Ireland
| | - Conor Deasy
- Emergency Department, Cork University Hospital, Wilton, Cork, T12 DC4A, Ireland
| | - Louise Martin
- Emergency Department, Cork University Hospital, Wilton, Cork, T12 DC4A, Ireland
| | - Audrey Anne Brousseau
- Département de médecine familiale et de médecine d'urgence, Université de Sherbrooke, Sherbrooke, Quebec, J1K 2R1, Canada
| | - Duygu Sezgin
- School of Nursing and Midwifery, University of Galway, Galway City, H91 TK33, Ireland
| | - Paul Bernard
- Beaumont Hospital, Occupational Therapy, Dublin, D09V2N0, Ireland
| | - Kara Mcloughlin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, V94 T9PX, Ireland
| | - Jiraporn Sri-On
- Geriatric Emergency Medicine Unit, Department of Emergency Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok 10300, Thailand
| | - Don Melady
- Department of Family and Community Medicine, Schwarz/Reisman Emergency Medicine Institute, Mount Sinai Health System, University of Toronto, Toronto, Ontario, ON M5G 1E2, Canada
| | - Lucinda Edge
- Department of Physiotherapy, St James’s Hospital, Dublin 8, Dublin, Ireland
| | - Ide O’Shaughnessy
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, V94 T9PX, Ireland
| | - Jill Van Damme
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario N2L 3G1, Canada
| | - Magnolia Cardona
- Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane 4067, Australia
| | - Jennifer Kirby
- Urgent Care Team, University Hospital North Midlands NHS Trust, Stoke-on-Trent, ST4 6QG, UK
| | - Lauren Southerland
- Department of Emergency Medicine, The Ohio State University, Wexner Medical Centre, Columbus, Ohio 43210, USA
| | - Andrew Costa
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, L8S 4L8, Canada
| | - Douglas Sinclair
- Department of Medicine, Quality, and Safety, IWK Health Centre, Halifax, Nova Scotia, B3K 6R8, Canada
| | - Cathy Maxwell
- Vanderbilt University School of Nursing, Nashville, Tennessee 37240, USA
| | - Marie Doyle
- Emergency Department, University Hospital Waterford, Waterford, X91 ER8E, Ireland
| | - Ebony Lewis
- UNSW School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, NSW 2052, Australia
| | - Grace Corcoran
- Department of Physiotherapy, Beaumont Hospital, Dublin, D09V2N0, Ireland
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, K1H 8M5, Canada
| | - Frances Dockery
- Department of Geriatric Medicine, Beaumont Hospital, Dublin, D09V2N0, Ireland
| | - Simon Conroy
- MRC Unit for Lifelong Health and Ageing at UCL, University College London, London, WC1E 6BT, UK
| | - Suzanne Timmons
- HRB Clinical Research Facility, Mercy University Hospital, University College Cork, Cork City, T12 WE28, Ireland
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, T12 YN60, Ireland
| | - Rónán O’Caoimh
- HRB Clinical Research Facility, Mercy University Hospital, University College Cork, Cork City, T12 WE28, Ireland
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, T12 YN60, Ireland
- Department of Geriatric Medicine, Mercy University Hospital, Cork, Ireland
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Cordasco KM, Gable AR, Tan GJ, Yuan AH, Yip K, Khafaf M, Hays RD, Faiz JP, Chawla N, Ganz DA. Veteran knowledge, perceptions, and receipt of care following visits to VA emergency departments for ambulatory care sensitive conditions. Acad Emerg Med 2022; 30:252-261. [PMID: 36578158 DOI: 10.1111/acem.14649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/22/2022] [Accepted: 12/22/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Receipt of follow-up care after emergency department (ED) visits for chronic ambulatory care sensitive conditions (ACSCs)-asthma, chronic obstructive pulmonary disease, heart failure, diabetes, and/or hypertension-is crucial. We assessed Veterans' follow-up care knowledge, perceptions, and receipt of care after visits to Veterans Health Administration (VA) EDs for chronic ACSCs. METHODS Using explanatory sequential mixed methods, we interviewed Veterans with follow-up care needs after ACSC-related ED visits, and manually reviewed ED notes, abstracting interviewees' documented follow-up needs and care received. RESULTS We interviewed and reviewed ED notes of 35 Veterans, 12-27 (mean 19) days after ED visits. Follow-up care was completely received/scheduled in 20, partially received/scheduled in eight, and not received in seven Veterans. Among those who received care, it was received within specified time frames half the time. However, interviewees often did not recall these time frames or reported them to be longer than specified in the ED notes. Veterans who had not yet received or scheduled follow-up care commonly did not recall follow-up care instructions, believed that they did not need this care since they were not currently having symptoms, or thought that such care would be difficult to obtain due to appointment unavailability and/or difficulties communicating with follow-up care providers. Among the 28 Veterans in whom all or some follow-up care had been received/scheduled, for 25 cases VA staff reached out to the Veteran or the appointment was scheduled prior to or during the ED visit. CONCLUSIONS VA should prioritize implementing processes for EDs to efficiently communicate Veterans' needs to follow-up care providers and systems for reaching out to Veterans and/or arranging for care prior to Veterans leaving the ED. VA should also enhance practices using multimodal approaches for educating Veterans about recommended ED follow-up care and improve mechanisms for Veterans to communicate with follow-up care providers.
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Affiliation(s)
- Kristina M Cordasco
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
| | - Alicia R Gable
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Gracielle J Tan
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Anita H Yuan
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Kathleen Yip
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Emergency Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
| | - Mana Khafaf
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
| | - Ron D Hays
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA.,RAND Corporation, Santa Monica, California, USA
| | - Jessica P Faiz
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,National Clinician Scholars Program, University of California, Los Angeles, Los Angeles, California, USA
| | - Neetu Chawla
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - David A Ganz
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA.,RAND Corporation, Santa Monica, California, USA
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Conneely M, Leahy S, Dore L, Trépel D, Robinson K, Jordan F, Galvin R. The effectiveness of interventions to reduce adverse outcomes among older adults following Emergency Department discharge: umbrella review. BMC Geriatr 2022; 22:462. [PMID: 35643453 PMCID: PMC9145107 DOI: 10.1186/s12877-022-03007-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/30/2022] [Indexed: 12/04/2022] Open
Abstract
Background Population ageing is increasing rapidly worldwide. Older adults are frequent users of health care services including the Emergency Department (ED) and experience a number of adverse outcomes following an ED visit. Adverse outcomes include functional decline, unplanned hospital admission and an ED revisit. Given these adverse outcomes a number of interventions have been examined to improve the outcomes of older adults following presentation to the ED. The aim of this umbrella review was to evaluate the effectiveness of ED interventions in reducing adverse outcomes in older adults discharged from the ED. Methods Systematic reviews of randomised controlled trials investigating ED interventions for older adults presenting to the ED exploring clinical, patient experience and healthcare utilisation outcomes were included. A comprehensive search strategy was employed in eleven databases and the PROSPERO register up until June 2020. Grey literature was also searched. Quality was assessed using the A MeaSurement Tool to Assess Systematic Reviews 2 tool. Overlap between systematic reviews was assessed using a matrix of evidence table. An algorithm to assign the Grading of Recommendations Assessment, Development and Evaluation to assess the strength of evidence was applied for all outcomes. Results Nine systematic reviews including 29 randomised controlled trials were included. Interventions comprised of solely ED-based or transitional interventions. The specific interventions delivered were highly variable. There was high overlap and low methodological quality of the trials informing the systematic reviews. There is low quality evidence to support ED interventions in reducing functional decline, improving patient experience and improving quality of life. The quality of evidence of the effectiveness of ED interventions to reduce mortality and ED revisits varied from very low to moderate. Results were presented narratively and summary of evidence tables created. Conclusion Older adults are the most important emerging group in healthcare for several economic, social and political reasons. The existing evidence for the effectiveness of ED interventions for older adults is limited. This umbrella review highlights the challenge of synthesising evidence due to significant heterogeneity in methods, intervention content and reporting of outcomes. Higher quality intervention studies in line with current geriatric medicine research guidelines are recommended, rather than the publication of further systematic reviews. Trial registration UMBRELLA REVIEW REGISTRATION: PROSPERO (CRD42020145315). Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03007-5.
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Functional Decline After Nonhospitalized Injuries in Older Patients: Results From the Canadian Emergency Team Initiative Cohort in Elders. Ann Emerg Med 2022; 80:154-164. [DOI: 10.1016/j.annemergmed.2022.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 11/23/2021] [Accepted: 01/20/2022] [Indexed: 11/17/2022]
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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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Geriatric assessment for older adults admitted to the emergency department: A systematic review and meta-analysis. Exp Gerontol 2020; 144:111184. [PMID: 33279664 DOI: 10.1016/j.exger.2020.111184] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 11/12/2020] [Accepted: 11/28/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Older adults are the most frequent users of emergency services. Comprehensive geriatric assessment (CGA) can help identify high-risk older adults at an early stage. We conducted a systematic review and meta-analysis to identify and evaluate CGA tools used in the emergency department (ED), analyze their predictive validity for adverse outcomes and recommend tools for this particular situation. METHODS We systematically searched Medline, Web of Science and CENTRAL for eligible articles published in peer-reviewed journals that observed patients ≥65 years admitted to the ED, used at least one assessment tool and reported adverse outcomes of interest. We performed a descriptive analysis and a bivariate meta-analysis of the diagnostic accuracy and predictive validity of the assessment tools for the chosen adverse outcomes. RESULTS 28 eligible studies were included. The pooled sensitivity (95% CI) of the assessment tools for predicting mortality within short (28-90 days) and long (180-365 days) periods after the first ED visit was 0.77 (0.61-0.89) and 0.79 (0.46-0.96), respectively, with specificity (95% CI) values of 0.45 (0.32-0.59) and 0.37 (0.14-0.65). These findings indicate that the tools used in the included studies had modest predictive accuracy for mortality and were more appropriate for identifying individuals at high risk of readmission in the short term than in the long term. CONCLUSIONS Early use of assessment tools in the ED might improve clinical decision making and reduce negative outcomes for older adults.
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Exercise Interventions for Community-Dwelling Older Adults Following an Emergency Department Consultation for a Minor Injury. J Aging Phys Act 2020; 29:267-279. [PMID: 33108761 DOI: 10.1123/japa.2019-0200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 07/05/2020] [Accepted: 07/05/2020] [Indexed: 11/18/2022]
Abstract
This study compared effects of exercise-based interventions with usual care on functional decline, physical performance, and health-related quality of life (12-item Short-Form health survey) at 3 and 6 months after minor injuries, in older adults discharged from emergency departments. Participants were randomized either to the intervention or control groups. The interventions consisted of 12-week exercise programs available in their communities. Groups were compared on cumulative incidences of functional decline, physical performances, and 12-item Short-Form health survey scores at all time points. Functional decline incidences were: intervention, 4.8% versus control, 15.4% (p = .11) at 3 months, and 5.3% versus 17.0% (p = .06) at 6 months. While the control group remained stable, the intervention group improved in Five Times Sit-To-Stand Test (3.0 ± 4.5 s, p < .01). The 12-item Short-Form health survey role physical score improvement was twice as high following intervention compared with control. Early exercises improved leg strength and reduced self-perceived limitations following a minor injury.
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Fear of falling in community-dwelling older adults presenting to the emergency department for minor injuries: Impact on return to the ED and future falls. CAN J EMERG MED 2020; 22:692-700. [PMID: 32638689 DOI: 10.1017/cem.2020.383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES 1) To characterize mild, moderate, and severe fear of falling in older emergency department (ED) patients for minor injuries, and 2) to assess whether fear of falling could predict falls and returns to the ED within 6 months of the initial ED visit. METHODS This study was part of the Canadian Emergency and Trauma Initiative (CETI) prospective cohort (2011-2016). Patients ages ≥ 65, who were independent in their basic daily activities and who were discharged from the ED after consulting for a minor injury, were included. Fear of falling was measured by the Short Falls Efficacy Scale International (SFES-I) in order to stratify fear of falling as mild (SFES-I = 7-8/28), moderate (SFES-I = 9-13/28), or severe (SFES-I = 14-28/28). Many other physical and psychological characteristics where collected. Research assistants conducted follow-up phone interviews at 3 and 6 months' post-ED visit, in which patients were asked to report returns to the ED. RESULTS A total of 2,899 patients were enrolled and 2,009 had complete data at 6 months. Patients with moderate to severe fear of falling were more likely to be of ages ≥ 75, female, frailer with multiple comorbidities, and decreased mobility. Higher baseline fear of falling increased the risk of falling at 3 and 6 months (odds ratio [OR]-moderate-fear of falling: 1.63, p < 0.05, OR-severe-fear of falling 2.37, p < 0.05). Fear of falling positive predictive values for return to the ED or future falls were 7.7% to 17%. CONCLUSION Although a high fear of falling is associated with increased risk of falling within 6 months of a minor injury in older patients, fear of falling considered alone was not shown to be a strong predictor of return to the ED and future falls.
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Fortes-Filho SQ, Aliberti MJR, Apolinario D, Melo-Fortes JA, Sitta MC, Jacob-Filho W, Garcez-Leme LE. Role of Gait Speed, Strength, and Balance in Predicting Adverse Outcomes of Acutely Ill Older Outpatients. J Nutr Health Aging 2020; 24:113-118. [PMID: 31886817 DOI: 10.1007/s12603-019-1279-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
AIM To evaluate the ability of the Short Physical Performance Battery (SPPB) for predicting 1-year adverse outcomes of acutely ill older outpatients. METHODS Prospective study with 512 acutely ill older outpatients (79.4±8.3 years, 63% female) in an acute care day hospital. The SPPB was administered at admission. Participants were classified as low (0-4 points), intermediate (5-8 points), or high (9-12 points) performance. Primary outcomes were new dependence in basic activities of daily living (ADL), hospitalization, and death at 1 year. Cox models tested whether the SPPB predicted outcomes after adjustment for sociodemographic factors, comorbidities and well-known geriatric conditions. We also estimated whether the chair-stand and balance tests improve the SPPB's ability to identify patients at high risk of adverse outcomes. RESULTS Patients with intermediate or low SPPB performance were at higher risk of 1-year new ADL dependence (32% vs 13%: adjusted hazard ratio [aHR]=2.00; 95%CI=1.18-3.37; 58% vs 13%: aHR=3.40; 95%CI=2.00-5.85, respectively), hospitalization (43% vs 29%: aHR=1.56; 95%CI=1.04-2.33; 44% vs 29%: aHR=1.80; 95%CI=1.15-2.82), and death (18% vs 6%: aHR=2.54; 95%CI=1.17-5.53; 21% vs 6%: aHR=2.70; 95%CI=1.17-6.21). Use of all three components (versus gait speed alone) improved predictions of new ADL dependence (Harrell's C=0.73 vs 0.70;P=0.01), hospitalization (Harrell's C=0.60 vs 0.57;P=0.04), and death (Harrell's C=0.67 vs 0.62;P=0.04). CONCLUSIONS The SPPB is as a powerful tool for identifying acutely ill older outpatients at high-risk of adverse outcomes. The combination of the three components of the SPPB resulted in better predictive performance than gait speed alone.
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Affiliation(s)
- S Q Fortes-Filho
- Sileno Queiroz Fortes-Filho, Universidade de Sao Paulo Instituto de Ortopedia e Traumatologia, Sao Paulo, Brazil,
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Piffer I, Goetz C, Zevering Y, André E, Bourouis Z, Blettner N. Ability of Emergency Department Physicians Using a Functional Autonomy-Assessing Version of the Triage Risk Screening Tool to Detect Frail Older Patients Who Require Mobile Geriatric Team Consultation. J Nutr Health Aging 2020; 24:634-641. [PMID: 32510117 DOI: 10.1007/s12603-020-1378-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Frailty in older people associates with poor outcomes. Screening by ED physicians would greatly facilitate detection of frail older patients but our previous attempt to introduce routine ED-physician screening with Short Emergency Geriatric Assessment (SEGA), a 13-item frailty tool that French geriatricians use to identify frail patients, failed due to its length and complexity. A national committee recently generated a new version of the fast and simple 5-item Triage Risk Screening Tool (TRST) in which a subjective item ('nurse concern') was replaced by an item assessing basic activities of daily living. The ability of ED physicians using this French-TRST to accurately detect frail patients who require comprehensive geriatric assessment was assessed. DESIGN Prospective cross-sectional study on diagnostic accuracy relative to the gold standard, namely, geriatrician-administered SEGA. SETTING Tertiary-care hospital, France. SUBJECTS AND MEASUREMENTS The participants were 498 ≥75-year-old patients who visited the ED in 2018-2019 and were administered French-TRSTs by first ED physicians and then geriatricians, followed by SEGA, all within 24 hours. Diagnostic accuracy variables were calculated. Geriatrician-TRST was used to identify TRST items that associated with ED physician misclassification of frail patients. RESULTS Emergency-TRST was significantly less sensitive than Geriatrician-TRST (88% vs. 93%; p=0.04) and tended to have lower negative predictive value (66% vs. 77%; p=0.09). Emergency-TRSTs rated four French-TRST items less well than Geriatrician-TRSTs. CONCLUSIONS As a substitute for SEGA in the ED, the French-TRST performed quite well overall but the ED physicians detected frail patients less well than the geriatricians. Modifications of the French-TRST that may improve the diagnostic performance of ED physicians are discussed.
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Affiliation(s)
- I Piffer
- Yinka Zevering, PhD, SciMeditor Medical Writing and Editing Services, 142 rue d'Alsace Moulins-les-Metz, 57160 Metz, France, Phone: (+33) 7 66231226,
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11
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Espinoza Suarez NR, Walker LE, Jeffery MM, Stanich JA, Campbell RL, Lohse CM, Takahashi PY, Bellolio F. Validation of the Elderly Risk Assessment Index in the Emergency Department. Am J Emerg Med 2019; 38:1441-1445. [PMID: 31839521 DOI: 10.1016/j.ajem.2019.11.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/27/2019] [Accepted: 11/30/2019] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES The Elderly Risk Assessment (ERA) score is a validated index for primary care patients that predict hospitalizations, mortality, and Emergency Department (ED) visits. The score incorporates age, prior hospital days, marital status, and comorbidities. Our aim was to validate the ERA score in ED patients. METHODS Observational cohort study of patients age ≥ 60 presenting to an academic ED over a 1-year period. Regression analyses were performed for associations with outcomes (hospitalization, return visits and death). Medians, interquartile range (IQR), odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS The cohort included 27,397 visits among 18,607 patients. Median age 74 years (66-82), 48% were female and 59% were married. Patients from 54% of visits were admitted to the hospital, 16% returned to the ED within 30 days, and 18% died within one year. Higher ERA scores were associated with: hospital admission (score 10 [4-16] vs 5 [1-11], p < 0.0001), return visits (11 [5-17] vs 7 [2-13], p < 0.0001); and death within one year (14 [7-20] vs 6 [2-13], p < 0.0001). Patients with ERA score ≥ 16 were more likely to be admitted to the hospital, OR 2.14 (2.02-2.28, p < 0.0001), return within 30 days OR 1.99 (1.85-2.14), and to die within a year, OR 2.69 (2.54-2.85). CONCLUSION The ERA score can be automatically calculated within the electronic health record and helps identify patients at increased risk of death, hospitalization and return ED visits. The ERA score can be applied to ED patients, and may help prognosticate the need for advanced care planning.
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Affiliation(s)
| | - Laura E Walker
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - Molly M Jeffery
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | | | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - Christine M Lohse
- Department of Biostatistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Paul Y Takahashi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.
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12
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Espinoza Suarez NR, Walker LE, Jeffery MM, Stanich JA, Campbell RL, Lohse CM, Takahashi PY, Bellolio F. Validation of the Elderly Risk Assessment Index in the Emergency Department. Am J Emerg Med 2019. [PMID: 31839521 DOI: 10.1016/j.ajem.2019.11.048.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES The Elderly Risk Assessment (ERA) score is a validated index for primary care patients that predict hospitalizations, mortality, and Emergency Department (ED) visits. The score incorporates age, prior hospital days, marital status, and comorbidities. Our aim was to validate the ERA score in ED patients. METHODS Observational cohort study of patients age ≥ 60 presenting to an academic ED over a 1-year period. Regression analyses were performed for associations with outcomes (hospitalization, return visits and death). Medians, interquartile range (IQR), odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS The cohort included 27,397 visits among 18,607 patients. Median age 74 years (66-82), 48% were female and 59% were married. Patients from 54% of visits were admitted to the hospital, 16% returned to the ED within 30 days, and 18% died within one year. Higher ERA scores were associated with: hospital admission (score 10 [4-16] vs 5 [1-11], p < 0.0001), return visits (11 [5-17] vs 7 [2-13], p < 0.0001); and death within one year (14 [7-20] vs 6 [2-13], p < 0.0001). Patients with ERA score ≥ 16 were more likely to be admitted to the hospital, OR 2.14 (2.02-2.28, p < 0.0001), return within 30 days OR 1.99 (1.85-2.14), and to die within a year, OR 2.69 (2.54-2.85). CONCLUSION The ERA score can be automatically calculated within the electronic health record and helps identify patients at increased risk of death, hospitalization and return ED visits. The ERA score can be applied to ED patients, and may help prognosticate the need for advanced care planning.
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Affiliation(s)
| | - Laura E Walker
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - Molly M Jeffery
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | | | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - Christine M Lohse
- Department of Biostatistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Paul Y Takahashi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.
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Rizka A, Harimurti K, Pitoyo CW, Koesnoe S. Comparison between the Identification of Seniors at Risk and Triage Risk Screening Tool in predicting mortality of older adults visiting the emergency department: Results from Indonesia. Geriatr Gerontol Int 2019; 20:47-51. [PMID: 31755195 DOI: 10.1111/ggi.13817] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 10/06/2019] [Accepted: 10/29/2019] [Indexed: 01/14/2023]
Abstract
AIM Among others, the Identification of Seniors at Risk (ISAR) and Triage Risk Screening Tool (TRST) are widely used screening instruments for risk stratification of older adults visiting the emergency department (ED). In developing countries, such as Indonesia, older patients often present with acute and severe conditions, leading to a high mortality rate, in which the performance of these two instruments have not been studied. This study aimed to measure the performance of the ISAR and TRST to predict 1- and 3-month mortality in older patients visiting the ED in Indonesia. METHODS This was a prospective cohort study of older patients consecutively visiting the ED of Cipto Mangunkusumo Hospital, a national referral hospital in Jakarta, Indonesia, from January to July 2017. The area of under the curve (AUC) of the ISAR and TRST in predicting 1- and 3-month mortality was measured. RESULTS Of 771 participants, 400 (52.8%) were men. The 1 month-mortality incidence was 22.8% (95% CI 21.3-24.8), and 3-month mortality was 31.2% (95% CI 29.3-33.8). For 1-month mortality, the ISAR showed AN AUC of 0.62 (95% CI 0.57-0.68), whereas the TRST showed an AUC of 0.58 (95% CI 0.52-0.64). For 3-month mortality, the ISAR showed an AUC of 0.60 (95% CI 0.54-0.65), whereas the TRST showed an AUC of 0.57 (95% CI 0.51-0.62). CONCLUSIONS Both instruments showed moderate predictive ability, but the ISAR showed better performance in predicting 1- and 3-month mortality of older patients visiting the ED in Indonesia. Geriatr Gerontol Int 2020; 20: 47-51.
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Affiliation(s)
- Aulia Rizka
- Division of Geriatric Medicine, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Kuntjoro Harimurti
- Division of Geriatric Medicine, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Ceva W Pitoyo
- Division of Pulmonology and Critical Care, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Sukamto Koesnoe
- Division of Allergy and Immunology, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
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Romli MH, Wan Yunus F, Mackenzie L. Overview of reviews of standardised occupation-based instruments for use in occupational therapy practice. Aust Occup Ther J 2019; 66:428-445. [PMID: 30821362 DOI: 10.1111/1440-1630.12572] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Using standardised instruments is one approach to support evidence-based practice. Referring to systematic reviews is an option to identify suitable instruments. However, with an abundance of systematic reviews available, therapists are challenged to identify an appropriate instrument to use. Therefore, this overview of reviews aimed to summarise relevant systematic review findings about standardised occupation-based instruments relevant for occupational therapy practice. METHODS An overview of reviews was conducted. A systematic search was performed on four databases up to March 2018. Included systematic reviews were analysed for quality using A MeaSurement Tool to Assess systematic Reviews (AMSTAR). RESULTS A total of 2187 articles were identified after removing duplicates. Ultimately, 58 systematic reviews were identified that yielded 641 instruments. From those, 45 instruments were selected for appraisal as they met the inclusion criteria of being developed mainly by occupational therapists and were recommended in the summarised findings from the systematic reviews. The instruments were classified according to the following occupation domains: (i) multidimensional, (ii) activities of daily living, (iii) productivity, (iv) social, (v) sleep/rest, (vi) sexuality and (vii) spirituality. No systematic review was identified that specifically focussed on occupations related to school/education, leisure and play. DISCUSSION Certain occupation domains such as activities of daily living, social and sleep/rest received high attention amongst researchers. There is a need for systematic reviews of instruments to measure education/school, play and leisure. Limited numbers of instruments were developed by occupational therapists outside the occupation domain of activities of daily living, and in areas of practice other than children and older people. Nevertheless, this overview can give some guidance for occupational therapists in selecting a suitable occupational therapy instrument for practice.
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Affiliation(s)
- Muhammad Hibatullah Romli
- Department of Nursing and Rehabilitation, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia.,Malaysian Research Institute on Ageing (MyAgeing), Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Farahiyah Wan Yunus
- Occupational Therapy Programme, Faculty of Health Sciences, Centre for Rehabilitation and Special Needs, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Lynette Mackenzie
- Discipline of Occupational Therapy, Faculty of Health Sciences, Cumberland Campus, University of Sydney, Lidcombe, New South Wales, Australia
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Southerland LT, Pearson S, Hullick C, Carpenter CR, Arendts G. Safe to send home? Discharge risk assessment in the emergency department. Emerg Med Australas 2019; 31:266-270. [DOI: 10.1111/1742-6723.13250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 01/20/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Lauren T Southerland
- Department of Emergency MedicineThe Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Scott Pearson
- Department of Emergency MedicineChristchurch Hospital Christchurch New Zealand
| | - Carolyn Hullick
- Faculty of HealthThe University of Newcastle Newcastle New South Wales Australia
- Hunter Medical Research Institute Newcastle New South Wales Australia
| | | | - Glenn Arendts
- School of MedicineThe University of Western Australia Perth Western Australia Australia
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Moura LVC, Pedreira LC, Menezes TMDO, Gomes NP, Coifman AHM, Santos ADA. Management of elderly people with Stroke: strategies based on action research. Rev Bras Enferm 2018; 71:3054-3062. [PMID: 30517412 DOI: 10.1590/0034-7167-2017-0915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 05/25/2018] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To elaborate and implement, through an educational intervention with the nursing team of the Emergency Unit, strategies that contribute to the management of elderly people suspected/affected by Stroke. METHOD Action research with eighteen nursing professionals working in the Emergency Unit of a reference hospital. The data were collected through five pedagogical workshops and systematized through the thematic analysis. RESULTS After a situational analysis and identification of the difficulties in the management of these elderly, a synthesis chart was prepared with strategic actions, responsible professionals and perspectives for implementation in the short, medium and long term. Short-term strategies had, for the most part, immediate implementation; the others were agreed on the need for further implementation. FINAL CONSIDERATIONS The educational intervention allowed the construction of strategies that were implemented or agreed with the management for later applicability, sensitizing the group regarding the importance of the qualification and prompt care in the management of the elderly suspected/affected by Stroke.
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Saucier A, Biron A. Développement d’un consensus professionnel face aux interventions de l’infirmière pivot en oncologie en vue de soutenir la planification des effectifs au Québec. Can Oncol Nurs J 2018; 28:301-307. [PMID: 31148842 PMCID: PMC6516936 DOI: 10.5737/23688076284301307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Au Québec, près de 250 infirmières pivot en oncologie (IPO) sont déployées au Québec pour soutenir les personnes atteintes d’un cancer. Il devient toutefois de plus en plus évident que ce nombre est insuffisant. Une étude a été menée afin d’estimer les besoins en IPO pour la province. L’établissement d’un consensus professionnel par la technique du groupe nominal et la méthode Delphi ont été utilisés pour atteindre cet objectif. Les données obtenues permettent de baser les décisions de planification des effectifs sur des évidences mesurées dans la réalité du travail actuel des IPO. Ainsi, il est espéré que celles-ci contribueront à une meilleure planification des effectifs pour répondre aux besoins de personnes atteintes de cancer et leurs proches.
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Affiliation(s)
| | - Alain Biron
- Volet pratique professionnelle, Professeur adjoint, Ingram School of Nursing-McGill University
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Preston L, Chambers D, Campbell F, Cantrell A, Turner J, Goyder E. What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06160] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BackgroundEmergency 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.ObjectivesTo 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.DesignA systematic mapping review.SettingEvidence from developed countries on interventions delivered in the ED.ParticipantsFrail and high-risk older people and general populations of older people (aged > 65 years).InterventionsInterventions 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 measuresPatient outcomes (direct and indirect) and health service outcomes.Data sourcesEvidence from 103 peer-reviewed articles and conference abstracts and 17 systematic reviews published from 2005 to 2016.Review methodsA 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.ResultsOf 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.LimitationsThis 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.ConclusionsA substantial body of evidence on interventions for frail and high-risk older people was identified and mapped.Future workFuture 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 registrationThis study is registered as PROSPERO CRD42016043260.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Louise Preston
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Fiona Campbell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Janette Turner
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Taylor A, Broadbent M, Wallis M, Marsden E. The use of functional and cognitive assessment in the emergency department to inform decision making: A scoping review. Australas Emerg Care 2018; 21:13-22. [PMID: 30998859 DOI: 10.1016/j.auec.2017.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/21/2017] [Accepted: 12/14/2017] [Indexed: 10/17/2022]
Abstract
BACKGROUND The use of functional and/or cognitive assessment in the emergency department (ED) to inform decision making in the complex older adult is considered important, yet not routinely administered. METHOD Electronic databases were searched to identify eligible published research studies: older adults >65 years; the administration of a functional and/or cognition assessment instrument whilst the older adult is in any part of the ED; interventions resulting from the administration of the instrument; and a measured outcome post ED visit. A revised scoping review methodology was applied to chart study data and to identify key differences. RESULTS Ten research studies were identified that met the criteria for review. There are a variety of assessments, aimed at different age groups, for several purposes and used at different times in the ED journey. Assessments are not being used in conjunction with routine medical assessment early in the ED patient journey. CONCLUSION This scoping review identified no consistent suite of tools being administered in the ED to influence the disposition decision with measurable outcomes. Further research is required to identify a suite of assessment instruments suitable for use in the ED setting aimed at improving disposition decision making in the complex elderly person.
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Affiliation(s)
- Andrea Taylor
- University of the Sunshine Coast, Australia; Sunshine Coast Hospital and Health Service, Australia.
| | | | | | - Elizabeth Marsden
- University of the Sunshine Coast, Australia; Sunshine Coast Hospital and Health Service, Australia
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Bruun IH, Maribo T, Nørgaard B, Schiøttz-Christensen B, Mogensen CB. A prediction model to identify hospitalised, older adults with reduced physical performance. BMC Geriatr 2017; 17:281. [PMID: 29216838 PMCID: PMC5719737 DOI: 10.1186/s12877-017-0671-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 11/20/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Identifying older adults with reduced physical performance at the time of hospital admission can significantly affect patient management and trajectory. For example, such patients could receive targeted hospital interventions such as routine mobilisation. Furthermore, at the time of discharge, health systems could offer these patients additional therapy to maintain or improve health and prevent institutionalisation or readmission. The principle aim of this study was to identify predictors for persisting, reduced physical performance in older adults following acute hospitalisation. METHODS This was a prospective cohort study that enrolled 117 medical patients, ages 65 or older, who were admitted to a short-stay unit in a Danish emergency department. Patients were included in the study if at the time of admission they performed ≤8 repetitions in the 30-s Chair-Stand Test (30s-CST). The primary outcome measure was the number of 30s-CST repetitions (≤ 8 or >8) performed at the time of follow-up, 34 days after admission. Potential predictors within the first 48 h of admission included: age, gender, ability to climb stairs and walk 400 m, difficulties with activities of daily living before admission, falls, physical activity level, self-rated health, use of a walking aid before admission, number of prescribed medications, 30s-CST, and the De Morton Mobility Index. RESULTS A total of 78 (67%) patients improved in physical performance in the interval between admission and follow-up assessment, but 76 patients (65%) had persistent reduced physical performance when compared to their baseline (30s-CST ≤ 8). The number of potential predictors was reduced in order to create a simplified prediction model based on 4 variables, namely the use of a walking aid before hospitalisation (score = 1.5), a 30s-CST ≤ 5 (1.8), age > 85 (0.1), and female gender (0.6). A score > 1.8 identified 78% of the older adults who continued to have reduced physical performance following acute hospitalisation. CONCLUSION At the time of admission, the variables of age, gender, walking aid use, and a 30s-CST score ≤ 5 enabled clinicians to identify 78% of older adults who had persisting reduced physical performance following acute hospitalisation. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02474277 . (12.10.2014).
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Affiliation(s)
- Inge H. Bruun
- Department of Physiotherapy, Lillebaelt Hospital, University of Southern Denmark, Kolding, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Thomas Maribo
- Department of Public Health, Aarhus University, Aarhus, Denmark
- DEFACTUM, Central Denmark Region, Aarhus, Denmark
| | - Birgitte Nørgaard
- Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Berit Schiøttz-Christensen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Spine Centre of Southern Denmark, Lillebaelt Hospital, University of Southern Denmark, Odense, Denmark
| | - Christian B. Mogensen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Emergency Department, Hospital of Southern Jutland, University of Southern Denmark, Odense, Denmark
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Tavares JPDA, Sá-Couto P, Boltz M, Capezuti E. Identification of Seniors at Risk (ISAR) in the emergency room: A prospective study. Int Emerg Nurs 2017; 35:19-24. [DOI: 10.1016/j.ienj.2017.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 04/12/2017] [Accepted: 05/31/2017] [Indexed: 01/12/2023]
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Eagles D, Perry JJ, Sirois MJ, Lang E, Daoust R, Lee J, Griffith L, Wilding L, Neveu X, Emond M. Timed Up and Go predicts functional decline in older patients presenting to the emergency department following minor trauma†. Age Ageing 2017; 46:214-218. [PMID: 28399218 PMCID: PMC5385920 DOI: 10.1093/ageing/afw184] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 09/27/2016] [Indexed: 11/13/2022] Open
Abstract
Background there is no standardised test for assessing mobility in the Emergency Department (ED). Objective we wished to evaluate the relationship between the Timed Up and Go (TUG) and frailty, functional decline and falls in community dwelling elders that present to the ED following minor trauma. Methods this was a secondary analysis of a prospective cohort study conducted at eight Canadian hospitals. Evaluations included: TUG; Study of Osteoporotic Fractures Frailty Index; Older American Resources and Service Functional Scale; and self-reported falls. Of note, 3- and 6-month follow-up was conducted. Generalised linear model with log-binomial distribution was utilised. Relative risks (RR) and 95% CI were calculated. Results TUG scores were available for 911/2918 patients, mean age 76.2 (SD 7.8) and 57.9% female. There was an association between TUG scores and frailty (P < 0.05) and functional decline at 3 (P < 0.05) and 6 (P < 0.05) months but not self-reported falls. For TUG scores 10-19 seconds, 20-29 seconds and ≥30 seconds, respectively: (i) frailty RR (95% CI): 1.8 (1.3-2.4), 3.0 (2.2-4.2) and 3.7 (2.6-5.1); (ii) functional decline RR (95% CI): 2.7 (1.1-6.4), 5.5 (2.1-14.3) and 8.9 (3.0-25.8); (iii) falls RR (95% CI): 0.9 (0.5-1.5), 1.3 (0.6-2.5) and 1.1 (0.4-3.5). Conclusion in community dwelling elders presenting to the ED following minor trauma, TUG scores were associated with frailty and strongly associated with functional decline at 3 and 6 months post injury. TUG scores were not associated with self-reported falls. Use of the TUG in the ED will help identify frail patients at risk of functional decline.
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Affiliation(s)
- Debra Eagles
- Université Laval, Québec City, Québec, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jeffrey J. Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Eddy Lang
- Alberta Health Science Center, Calgary, Alberta, Canada
| | - Raoul Daoust
- Hôpital du Sacre-Coeur de Montreal, Montreal, Québec, Canada
| | - Jacques Lee
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Laura Wilding
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Xavier Neveu
- Research Center, CHU de Québec, Québec City, Québec, Canada
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Lee H, Seo S, Song J. Information on functioning found in the medical records of patients with stroke. J Phys Ther Sci 2016; 28:2722-2726. [PMID: 27821922 PMCID: PMC5088113 DOI: 10.1589/jpts.28.2722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/09/2016] [Indexed: 11/24/2022] Open
Abstract
[Purpose] To explore data on functioning in the medical records of patients with stroke
by linking them to the ICF. [Subjects and Methods] The admission and discharge summaries
of patients’ electronic medical records (EMRs) were investigated. Information on
functioning included in the summaries were mapped into the ICF. Each of the linked
categories of ICF was analyzed using frequency and percentage analysis. [Results] Thirty
stroke patients’ records were evaluated. A total of 1,832 items on functioning in the EMRs
were found to be linked to eighty-five categories of the ICF. The majority of those
categories (52.9%) belonged to the body function domain, whereas only 8.2% were
environment factors. Categories in the domain of activity and participation, and body
structure were found to be 22.4% and 16.5% respectively. In each domain, the most
frequently found categories were muscle power function (b730), structure of brain (s110),
walking (d450), and products or substances for personal consumption (e110). [Conclusion]
It was found that the admission and discharge summary in the current medical records of
patients with stroke contained much noticeable information on functioning and the data on
functioning may be linked to the ICF. Further study is needed to adapt ICF in Korean
clinical settings.
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Affiliation(s)
- Haejung Lee
- Department of Physical Therapy, Silla University, Republic of Korea
| | - Sunghwa Seo
- Department of Health and Medical Tourism, Gyeongju University, Republic of Korea
| | - Jumin Song
- Department of Physical Therapy, Silla University, Republic of Korea
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Gauthier J, Kisterman J, Chapalain F, Texier A, Manckoundia P. Réhospitalisation précoce des personnes âgées d’au moins 75 ans admises dans un service de médecine polyvalente post-urgence : taux et facteurs prédictifs. Rev Med Interne 2016; 37:521-8. [DOI: 10.1016/j.revmed.2015.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 07/21/2015] [Accepted: 12/07/2015] [Indexed: 01/10/2023]
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Tucker PW, Evans DD, Clevenger CK, Ardisson M, Hwang U. Feasibility of nurses measuring gait speed in older community-dwelling Emergency Department patients. Geriatr Nurs 2016; 37:453-457. [PMID: 27477084 DOI: 10.1016/j.gerinurse.2016.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 06/13/2016] [Accepted: 06/19/2016] [Indexed: 11/27/2022]
Abstract
Gait speed assessment is a rapid, simple and objective measure for predicting risk of unfavorable outcomes which may provide better prognostic and reliable information than existing geriatric ED (Emergency Department) screening tools. This descriptive pilot project was designed to determine feasibility of implementing gait speed screening into routine nursing practice by objectively identifying patients with sub-optimal gait speeds. Participants included community-dwelling adults 65 years and older with plans for discharge following ED treatment. Patients with a gait speed <1.0 m/s were identified as "high-risk" for an adverse event, and referred to the ED social worker for individualized resources prior to discharge. Thirty-five patients were screened and nurse initiated gait speed screens were completed 60% of the time. This project demonstrates ED gait speed screening may be feasible. Implications for practice should consider incorporating gait speed screening into routine nursing assessment to improve provider ED decision-making and disposition planning.
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Affiliation(s)
- Paula W Tucker
- Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA 30033, USA; Emory University Hospital, Emergency Department, 1364 Clifton Road, NE, Atlanta, GA 30322, USA; Nell Hodgson Woodruff School of Nursing, 1520 Clifton Road, Atlanta, GA 30322, USA.
| | - Dian Dowling Evans
- Emory University Hospital, Emergency Department, 1364 Clifton Road, NE, Atlanta, GA 30322, USA; Nell Hodgson Woodruff School of Nursing, 1520 Clifton Road, Atlanta, GA 30322, USA
| | - Carolyn K Clevenger
- Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA 30033, USA; Nell Hodgson Woodruff School of Nursing, 1520 Clifton Road, Atlanta, GA 30322, USA
| | - Michelle Ardisson
- Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240, USA
| | - Ula Hwang
- Department of Emergency Medicine, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, P.O. Box 1620, New York, NY 10029, USA; GRECC (Geriatric Research, Education and Clinical Center), James J. Peters VA Medical Center, 130 Kingsbridge Road, Bronx, NY 10468, USA
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Tacchini-Jacquier N, Morin D. Perception des habiletés pratiques et des connaissances en matière de soins gériatriques chez des infirmières des services d’urgence en Suisse. Rech Soins Infirm 2016. [DOI: 10.3917/rsi.124.0097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Warnier RMJ, van Rossum E, van Velthuijsen E, Mulder WJ, Schols JMGA, Kempen GIJM. Validity, Reliability and Feasibility of Tools to Identify Frail Older Patients in Inpatient Hospital Care: A Systematic Review. J Nutr Health Aging 2016; 20:218-30. [PMID: 26812520 DOI: 10.1007/s12603-015-0567-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- R M J Warnier
- RMJ Warnier, Maastricht University Medical Center, Department of Integrated Care, Elderly care, PO-Box 5800, 6202 AZ Maastricht, The Netherlands, Telephone: 0031-433877540, Fax: 0031-433876527,
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Predictive factors for early unplanned rehospitalization of older adults after an ED visit: role of the caregiver burden. Aging Clin Exp Res 2015; 27:883-91. [PMID: 25835219 DOI: 10.1007/s40520-015-0347-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 03/05/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND AIMS For older adults, an Emergency Department (ED) visit represents a period of vulnerability that extends beyond the visit itself. This study aimed to determine the impact of the role of caregiver, and geriatric conditions of patients on early unplanned rehospitalization (EUR) within 3 months after an ED visit. METHODS This prospective longitudinal experimental study included consecutively 173 patients aged 75 and older admitted in an ED over a 2-week period (18.7% of the total visits). Only older patients having a caregiver were analyzed (78.0%, n = 135). Medical conditions and a comprehensive geriatric assessment were recorded for each patient. All caregivers were interviewed about their tasks and emotional impact using the short Zarit Burden Inventory. Three months after, patients or their caregivers were called about the vital status, and EUR of patients. RESULTS Among the patients included, 64.2% had an EUR and 28.9% of their caregivers reported a high level of burden. EUR was strongly associated with a high caregiver burden (OR 8.7, 95% CI 1.5-49.8). No association was found for patient's medical or geriatric status. Caregivers reported a significantly high burden when patients were malnourished, or were at risk of adverse health outcomes based on the ISAR scale, and when they had greater disabilities in IADLs and ADLs, or cognitive impairments. CONCLUSIONS Many hospital readmissions after an ED visit may be preventable by identifying caregiver's high burden. Reasons that lead to this high burden should be checked at the first visit.
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Inzitari M, Gual N, Roig T, Colprim D, Pérez-Bocanegra C, San-José A, Jimenez X. Geriatric Screening Tools to Select Older Adults Susceptible for Direct Transfer From the Emergency Department to Subacute Intermediate-Care Hospitalization. J Am Med Dir Assoc 2015; 16:837-41. [DOI: 10.1016/j.jamda.2015.04.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 02/27/2015] [Accepted: 04/17/2015] [Indexed: 11/26/2022]
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Suffoletto B, Miller T, Shah R, Callaway C, Yealy DM. Predicting older adults who return to the hospital or die within 30 days of emergency department care using the ISAR tool: subjective versus objective risk factors. Emerg Med J 2015; 33:4-9. [DOI: 10.1136/emermed-2014-203936] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 04/27/2015] [Indexed: 11/03/2022]
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Nguyen A, Straney L, Cameron P, Lowthian J. Synthesised geriatric assessment in the Emergency Department setting: is it NEAT? AUST HEALTH REV 2015; 38:370-6. [PMID: 25055343 DOI: 10.1071/ah13217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Accepted: 05/06/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the time taken to complete a Synthesised Geriatric Assessment (SGA) in an Emergency Department (ED) and to determine what secondary patient characteristics affect results. METHODS A convenience sample of 25 patients aged over 65 from an Australian single-centre ED was used for this pilot study. Primary outcome measures included the overall time taken as well as the times for individual screening instruments. Data regarding patient characteristics were taken as secondary outcome measures to assess impact on times. For each of the screening instruments, the mean, median, interquartile range and the 90th percentile for the test duration was calculated. Linear regression was used to evaluate univariate associations between times and patient characteristics. P-values<0.05 were considered as statistically significant. RESULTS Time required for completion of the SGA by 90% of the study population was 20 min and 40s. This represents approximately 8.6% of new 4-h ED targets. Secondary characteristics that affected the time taken for screening included patients from non-English-speaking backgrounds (P<0.05). CONCLUSIONS Use of the SGA for intra-ED geriatric risk stratification is feasible and practical in the time-critical National Emergency Access Target (NEAT) environment. The relatively short amount of time used for screening this vulnerable demographic has implications for interdisciplinary management and potentially represents an efficient intervention to reduce future re-presentations and overcrowding in Australian EDs. Future high-quality trials are required to assess the clinical benefit of the SGA.
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Affiliation(s)
- Alan Nguyen
- Monash University, School of Public Health and Preventive Medicine, Level 6 Alfred Centre, 99 Commercial Road, Melbourne, Vic. 3004, Australia
| | - Lahn Straney
- Monash University, School of Public Health and Preventive Medicine, Level 6 Alfred Centre, 99 Commercial Road, Melbourne, Vic. 3004, Australia
| | - Peter Cameron
- Monash University, School of Public Health and Preventive Medicine, Level 6 Alfred Centre, 99 Commercial Road, Melbourne, Vic. 3004, Australia
| | - Judy Lowthian
- Monash University, School of Public Health and Preventive Medicine, Level 6 Alfred Centre, 99 Commercial Road, Melbourne, Vic. 3004, Australia
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Thiem U, Heppner HJ, Singler K. Instruments to identify elderly patients in the emergency department in need of geriatric care. Z Gerontol Geriatr 2015; 48:4-9. [PMID: 25592177 DOI: 10.1007/s00391-014-0852-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 11/21/2014] [Accepted: 12/16/2014] [Indexed: 12/23/2022]
Abstract
The number of people with functional limitations, cognitive impairment and disability with unscheduled, unintended contact to emergency departments seeking acute medical care is increasing. With this, the problem of how to identify elderly people in need for acute geriatric care has evolved. The best solution to the problem would be to perform comprehensive geriatric assessment during the initial contact; however, comprehensive geriatric assessment is considered too complex and therefore not feasible for emergency departments. Instead, screening instruments have been developed and proposed. In this narrative review, selected screening instruments are discussed. The instrument best studied in various settings and countries is the Identification of Seniors At Risk (ISAR) screening tool which contains six simple questions that are easy to administer and can be assessed even in urgent situations. In recent years, several studies have examined the validity of ISAR in different European countries. Most of these studies, including one German study and a recent systematic review, confirmed the validity of ISAR. Unfortunately, evidence is conflicting, as some studies found only weak or even no association between ISAR and negative health outcomes. Other instruments have been investigated to a lesser extent and do not indicate obvious advantages over ISAR. Despite growing evidence in the field, there are still many uncertainties. Further research is needed to solve existing inconsistencies and to assess how elderly patients screened positive for acute geriatric care needs can best be managed further.
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Affiliation(s)
- Ulrich Thiem
- Department of Geriatrics, Marienhospital Herne - University of Bochum, Widumer Str. 8, 44627, Herne, Germany,
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Carpenter CR, Shelton E, Fowler S, Suffoletto B, Platts-Mills TF, Rothman RE, Hogan TM. Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: a systematic review and meta-analysis. Acad Emerg Med 2015; 22:1-21. [PMID: 25565487 DOI: 10.1111/acem.12569] [Citation(s) in RCA: 215] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 07/21/2014] [Accepted: 08/24/2014] [Indexed: 12/20/2022]
Abstract
OBJECTIVES A significant proportion of geriatric patients experience suboptimal outcomes following episodes of emergency department (ED) care. Risk stratification screening instruments exist to distinguish vulnerable subsets, but their prognostic accuracy varies. This systematic review quantifies the prognostic accuracy of individual risk factors and ED-validated screening instruments to distinguish patients more or less likely to experience short-term adverse outcomes like unanticipated ED returns, hospital readmissions, functional decline, or death. METHODS A medical librarian and two emergency physicians conducted a medical literature search of PubMed, EMBASE, SCOPUS, CENTRAL, and ClinicalTrials.gov using numerous combinations of search terms, including emergency medical services, risk stratification, geriatric, and multiple related MeSH terms in hundreds of combinations. Two authors hand-searched relevant specialty society research abstracts. Two physicians independently reviewed all abstracts and used the revised Quality Assessment of Diagnostic Accuracy Studies instrument to assess individual study quality. When two or more qualitatively similar studies were identified, meta-analysis was conducted using Meta-DiSc software. Primary outcomes were sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for predictors of adverse outcomes at 1 to 12 months after the ED encounters. A hypothetical test-treatment threshold analysis was constructed based on the meta-analytic summary estimate of prognostic accuracy for one outcome. RESULTS A total of 7,940 unique citations were identified yielding 34 studies for inclusion in this systematic review. Studies were significantly heterogeneous in terms of country, outcomes assessed, and the timing of post-ED outcome assessments. All studies occurred in ED settings and none used published clinical decision rule derivation methodology. Individual risk factors assessed included dementia, delirium, age, dependency, malnutrition, pressure sore risk, and self-rated health. None of these risk factors significantly increased the risk of adverse outcome (LR+ range = 0.78 to 2.84). The absence of dependency reduces the risk of 1-year mortality (LR- = 0.27) and nursing home placement (LR- = 0.27). Five constructs of frailty were evaluated, but none increased or decreased the risk of adverse outcome. Three instruments were evaluated in the meta-analysis: Identification of Seniors at Risk, Triage Risk Screening Tool, and Variables Indicative of Placement Risk. None of these instruments significantly increased (LR+ range for various outcomes = 0.98 to 1.40) or decreased (LR- range = 0.53 to 1.11) the risk of adverse outcomes. The test threshold for 3-month functional decline based on the most accurate instrument was 42%, and the treatment threshold was 61%. CONCLUSIONS Risk stratification of geriatric adults following ED care is limited by the lack of pragmatic, accurate, and reliable instruments. Although absence of dependency reduces the risk of 1-year mortality, no individual risk factor, frailty construct, or risk assessment instrument accurately predicts risk of adverse outcomes in older ED patients. Existing instruments designed to risk stratify older ED patients do not accurately distinguish high- or low-risk subsets. Clinicians, educators, and policy-makers should not use these instruments as valid predictors of post-ED adverse outcomes. Future research to derive and validate feasible ED instruments to distinguish vulnerable elders should employ published decision instrument methods and examine the contributions of alternative variables, such as health literacy and dementia, which often remain clinically occult.
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Affiliation(s)
- Christopher R. Carpenter
- The Department of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Erica Shelton
- The Department of Emergency Medicine; Johns Hopkins University; Baltimore MD
| | - Susan Fowler
- The Department of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Brian Suffoletto
- The Department of Emergency Medicine; University of Pittsburgh Medical Center; Pittsburgh PA
| | - Timothy F. Platts-Mills
- The Department of Emergency Medicine; University of North Carolina-Chapel Hill; Chapel Hill NC
| | - Richard E. Rothman
- The Department of Emergency Medicine; Johns Hopkins University; Baltimore MD
| | - Teresita M. Hogan
- The Department of Emergency Medicine; University of Chicago; Chicago IL
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Latham LP, Ackroyd-Stolarz S. Emergency department utilization by older adults: a descriptive study. Can Geriatr J 2014; 17:118-25. [PMID: 25452824 PMCID: PMC4244125 DOI: 10.5770/cgj.17.108] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Emergency Departments (EDs) are playing an increasingly important role in the care of older adults. Characterizing ED usage will facilitate the planning for care delivery more suited to the complex health needs of this population. METHODS In this retrospective cross-sectional study, administrative and clinical data were extracted from four study sites. Visits for patients aged 65 years or older were characterized using standard descriptive statistics. RESULTS We analyzed 34,454 ED visits by older adults, accounting for 21.8% of the total ED visits for our study time period. Overall, 74.2% of patient visits were triaged as urgent or emergent. Almost half (49.8%) of visits involved diagnostic imaging, 62.1% involved lab work, and 30.8% involved consultation with hospital services. The most common ED diagnoses were symptom- or injury-related (25.0%, 17.1%. respectively). Length of stay increased with age group (Mann-Whitney U; p < .0001), as did the proportion of visits involving diagnostic testing and consultation (χ(2); p < .0001). Approximately 20% of older adults in our study population were admitted to hospital following their ED visit. CONCLUSIONS Older adults have distinct patterns of ED use. ED resource use intensity increases with age. These patterns may be used to target future interventions involving alternative care for older adults.
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Affiliation(s)
- Lesley P Latham
- Department of Emergency Medicine, Dalhousie University, Halifax, NS
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Abstract
Changing global demography is resulting in older people presenting to emergency departments (EDs) in greater numbers than ever before. They present with greater urgency and are more likely to be admitted to hospital or re-attend and utilize greater resources. They experience longer waits for care and are less likely to be satisfied with their experiences. Not only that, but older people suffer poorer health outcomes after ED attendance, with higher mortality rates and greater dependence in activities of daily living or rates of admission to nursing homes. Older people's assessment and management in the ED can be complex, time consuming, and require specialist skills. The interplay of multiple comorbidities and functional decline result in the complex state of frailty that can predispose to poor health outcomes and greater care needs. Older people with frailty may present to services in an atypical fashion requiring detailed, multidimensional, and increasingly multidisciplinary care to provide the correct diagnosis and management as well as appropriate placement for ongoing care or admission avoidance. Specific challenges such as delirium, functional decline, or carer strain need to be screened for and managed appropriately. Identifying patients with specific frailty syndromes can be critical to identifying those at highest risk of poor outcomes and most likely to benefit from further specialist interventions. Models of care are evolving that aim to deliver multidimensional assessment and management by multidisciplinary specialist care teams (comprehensive geriatric assessment). Increasingly, these models are demonstrating improved outcomes, including admission avoidance or reduced death and dependence. Delivering this in the ED is an evolving area of practice that adapts the principles of geriatric medicine for the urgent-care environment.
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Affiliation(s)
- Graham Ellis
- Medicine for the Elderly, Monklands Hospital, Airdrie, Scotland, UK
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A novel multidimensional geriatric screening tool in the ED: evaluation of feasibility and clinical relevance. Am J Emerg Med 2014; 32:623-8. [DOI: 10.1016/j.ajem.2014.03.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 03/15/2014] [Accepted: 03/16/2014] [Indexed: 11/18/2022] Open
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37
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The Geriatric ED: Structure, Patient Care, and Considerations for the Emergency Department Geriatric Unit. INT J GERONTOL 2014. [DOI: 10.1016/j.ijge.2014.01.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Abstract
SummaryEmergency care of elderly patients is frequent and complex in the emergency department. Frail older patients have a high risk of poor short-term results following emergency care. There is no practical universal or standardized tool defining frailty. It must be systematically identified in older patients at risk using a screening test, and in those who are positive, a diagnostic scale of frailty or preferably a geriatric scale adapted to emergency care is carried out. An adapted geriatric assessment including brief scales related to clinical, mental, functional and social aspects has been proposed. There are currently no geriatric intervention models with sufficient evidence in frail older patients.
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Sirois MJ, Émond M, Ouellet MC, Perry J, Daoust R, Morin J, Dionne C, Camden S, Moore L, Allain-Boulé N. Cumulative Incidence of Functional Decline After Minor Injuries in Previously Independent Older Canadian Individuals in the Emergency Department. J Am Geriatr Soc 2013; 61:1661-8. [DOI: 10.1111/jgs.12482] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Marie-Josée Sirois
- Department of Rehabilitation; Université Laval; Québec Canada
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
| | - Marcel Émond
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
- Hôpital Enfant-Jésus; Centre Hospitalier Universitaire de Québec; Québec Canada
| | - Marie-Christine Ouellet
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
- Centre Interdisciplinaire de Recherche en Réadaptation et Intégration Sociale; Institut de Réadaptation en Déficience Physique de Québec; Québec Canada
| | | | - Raoul Daoust
- Hôpital du Sacré-Cœur de Montréal; Montreal Canada
| | - Jacques Morin
- Hôpital Enfant-Jésus; Centre Hospitalier Universitaire de Québec; Québec Canada
| | - Clermont Dionne
- Department of Rehabilitation; Université Laval; Québec Canada
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
| | - Stéphanie Camden
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
| | - Lynne Moore
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
| | - Nadine Allain-Boulé
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
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