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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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Moloney E, O'Donovan MR, Sezgin D, McGrath K, Timmons S, O'Caoimh R. Frailty Knowledge, Use of Screening Tools, and Educational Challenges in Emergency Departments in Ireland: A Multisite Survey. J Emerg Nurs 2024; 50:22-35. [PMID: 37804277 DOI: 10.1016/j.jen.2023.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 08/13/2023] [Accepted: 08/24/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND Recognizing frailty and providing evidenced-based management in busy emergency departments is challenging. Understanding the knowledge and educational needs of ED staff is important to design training that might improve patient outcomes. OBJECTIVE This study aimed to explore frailty knowledge of ED staff, use of frailty screening instruments in Irish emergency departments, and educational challenges in the emergency department. METHODS A multisite survey of ED staff (different specialties) was conducted between April and September 2021. An anonymous online survey was distributed via email. Free-text sections were analyzed using content analysis. RESULTS In total, 168 staff (nursing, medical and allied health) participated, representing 9 of 26 Irish emergency departments (35%). Most respondents were nurses (n = 78, 46%). Less than half of respondents had received frailty identification training (n = 81, 48%). One-fifth of emergency doctors and nurses (20%) were unsure how to define frailty. Major barriers to ED frailty screening were resource deficits, insufficient diagnostic pathways from the emergency departments, and lack of education on suitable instruments. CONCLUSIONS Most of the ED staff surveyed relied on clinical judgment rather than formal training in frailty identification. A high proportion reported poor knowledge and low confidence in recognizing frailty. Dedicated staff with frailty management expertise, bespoke education initiatives, and clearly defined frailty screening pathways may help address the issues identified.
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Knight T, Atkin C, Kamwa V, Cooksley T, Subbe C, Holland M, Sapey E, Lasserson D. The impact of frailty and geriatric syndromes on metrics of acute care performance: results of a national day of care survey. EClinicalMedicine 2023; 66:102278. [PMID: 38192597 PMCID: PMC10772156 DOI: 10.1016/j.eclinm.2023.102278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 09/24/2023] [Accepted: 10/02/2023] [Indexed: 01/10/2024] Open
Abstract
Background Frailty is associated with a range of adverse clinical outcomes in the acute hospital setting. We sought to determine whether frailty and related factors affected clinical processes such as time to assessment during emergency hospital admission within the National Health Service (NHS) in the UK. Methods The Society for Acute Medicine Benchmarking Audit (SAMBA) is an annual cross-sectional day of care survey. SAMBA 2022 was conducted on Thursday 23rd June 2022. We assessed whether the Clinical Frailty Scale (CFS) and presence of a geriatric syndrome affected performance against nationally recognised clinical quality indicators based on time to initial assessment and time to consultant review. CFS was graded into robust (CFS1-3), mild (CFS 4-5), moderate (CFS 6), severe (CFS7-8) and terminal illness (CFS 9). Plausible values were created for missing variables using multi-level multiple imputation. The association was described using mixed effect generalised linear models adjusting for initial National Early Warning Score 2 (NEWS2) and time of arrival. Findings A total of 152 hospitals provided patient level data relating to 7248 emergency medical admissions. Patients with mild, moderate and severe frailty were less likely to be assessed within 4 h of arrival (adjusted OR, mild 0.79, 95% CI 0.68-0.96, moderate 0.67 95% CI 0.53-0.84, severe, 0.75 95% CI 0.58-0.96, terminally ill 0.59 95% CI 0.23-1.43) and less likely to be achieve the clinical quality indicator for consultant review (adjusted OR, mild 0.69 95% CI 0.58-0.83, moderate 0.55 95% CI 0.44-0.70, severe 0.54 95% CI 0.41-0.69, terminally ill 0.76 95% CI 0.42-1.5). Patients with geriatric syndromes were also less likely to be assessed within 4 h of arrival (adjusted OR 0.66 95% CI 0.56-0.76) or by a consultant within the recommended time frame (adjusted OR 0.45 95% CI 0.39-0.51). The difference was partially explained by differential use of SDEC pathways. Sub-group analysis of 5148 patients assessed outside of SDEC areas demonstrated patients with geriatric syndromes (adjusted OR 0.71, 95% CI 0.60-0.83), but not frailty defined by CFS were less likely to be assessed within 4 h of arrival. Moderate and severe frailty and the presence of a geriatric syndrome were associated with a decreased likelihood of achieving the consultant review standard (moderate, adjusted OR 0.75, 95% CI 0.59-0.94, severe adjusted OR 0.75 95% CI 0.58-0.96, geriatric syndrome adjusted OR 0.59, 95% CI 0.50-0.69). Interpretation Frailty is associated with delayed clinical assessment. This association may suggest a systemic issue with clinical prioritisation, with important implications for acute care policy. Funding The database for SAMBA is funded by the Society for Acute Medicine.
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Affiliation(s)
- Thomas Knight
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, UK
| | - Catherine Atkin
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, UK
| | - Vicky Kamwa
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, UK
| | - Tim Cooksley
- The Christie NHS Foundation Trust, Manchester, UK
| | - Chris Subbe
- School of Medical and Health Sciences, Bangor University, UK
| | - Mark Holland
- School of Clinical and Biomedical Sciences, University of Bolton, UK
| | - Elizabeth Sapey
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, UK
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Wang GQ, Gao YL, Deng P. Validation of a seven-question tool (PRISMA-7) in predicting prognosis of older adults in the emergency department: A prospective study. Am J Emerg Med 2023; 73:131-136. [PMID: 37657142 DOI: 10.1016/j.ajem.2023.08.030] [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: 04/01/2023] [Revised: 08/14/2023] [Accepted: 08/14/2023] [Indexed: 09/03/2023] Open
Abstract
OBJECTIVES Older patients arrive at the emergency department (ED) with complex medical challenges, and the current ED triage models frequently undertriage the severity of illness in older adults. There is increasing awareness regarding the importance of identifying frailty in older patients in the context of urgent care. Therefore, this study aimed to assess the predictive accuracy of the seven-question tool of the Program on Research for Integrating Services of the Maintenance of Autonomy (PRISMA-7) in the ED for 28-day mortality among older adults. DESIGN A prospective polycentric observational study. SETTING West China Hospital of Sichuan University, Shangjinnanfu of West China Hospital, and People's Hospital of Henan Province. PARTICIPANTS ED patients aged ≥65 years from the three tertiary care centers over an 8-week period. PRIMARY AND SECONDARY OUTCOMES The primary outcome, 28-day all-cause mortality, was investigated using a Cox proportional hazards regression model to assess the predictive validity. The secondary endpoints, intensive care unit (ICU) transfer was investigated using multivariable logistic regression, compared with trained study assistants. RESULTS The final study population comprised 1043 consecutive patients aged ≥65 years. The area under the receiver operating characteristic (ROC) curve (AUC) for 28-day mortality was 0.80 (95% confidence interval [CI]: 0.76-0.84), 0.73 (95% CI: 0.68-0.77), and 0.78 (95% CI: 0.73-0.83) for PRISMA-7, Emergency Severity Index (ESI), and quick Sepsis Related Organ Failure Assessment (qSOFA), respectively.There was no difference in the AUC between PRISMA-7 and qSOFA(p = 0.374).The AUC for ICU admission was 0.78 (95% CI: 0.75-0.80), 0.62 (95% CI: 0.59-0.66), and 0.68 (95% CI: 0.64-0.72) for PRISMA-7, ESI, and qSOFA, respectively.The AUC for ICU admission between PRISMA-7 and ESI(p<0.001), PRISMA-7 and qSOFA(p<0.001), qSOFA and ESI(p = 0.005) was statistically significant. CONCLUSION Our findings reveal that PRISMA-7 improves the prediction of ICU admission, but there is no significant difference when it comes to all-cause mortality. PRISMA-7 appears to be a reliable and valid instrument for identifying frailty in the ED. TRIAL REGISTRATION NUMBER ChiCTR2100046545.
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Affiliation(s)
- Gui-Qun Wang
- Department of Emergency Medicine, West China Hospital, Sichuan University, China
| | - Yong-Li Gao
- Department of Emergency Medicine, West China Hospital, Sichuan University, China
| | - Peng Deng
- Department of Emergency Medicine, West China Hospital, Sichuan University, China.
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O'Shaughnessy Í, Fitzgerald C, Whiston A, Harnett P, Whitty H, Mulligan D, Mullaney M, Devaney C, Lang D, Hardimann J, Condon B, Hayes C, Holmes A, Barry L, McCormack C, Bounds M, Robinson K, O'Connor M, Ryan D, Shchetkovsky D, Steed F, Carey L, Ahern E, Galvin R. Establishing the core elements of a frailty at the front door model of care using a modified real-time Delphi technique. BMC Emerg Med 2023; 23:123. [PMID: 37858041 PMCID: PMC10588204 DOI: 10.1186/s12873-023-00893-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/11/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Innovations in models of care for older adults living with frailty presenting to the emergency department (ED) have become a key priority for clinicians, researchers and policymakers due to the deleterious outcomes older adults experience due to prolonged exposure to such an environment. This study aimed to develop a set of expert consensus-based statements underpinning operational design, outcome measurement and evaluation of a Frailty at the Front Door (FFD) model of care for older adults within an Irish context. METHODS A modified real-time Delphi method was used. Facilitation of World Café focus groups with an expert panel of 86 members and seperate advisory groups with a Public and Patient Involvement panel of older adults and members of the Irish Association of Emergency Medicine generated a series of statements on the core elements of the FFD model of care. Statements were analysed thematically and incorporated into a real-time Delphi survey, which was emailed to members of the expert panel. Members were asked to rank 70 statements across nine domains using a 9-point Likert scale. Consensus criteria were defined a priori and guided by previous research using 9-point rating scales. RESULTS Fifty members responded to the survey representing an overall response rate of 58%. Following analyses of the survey responses, the research team reviewed statements for content overlap and refined a final list of statements across the following domains: aims and objectives of the FFD model of care; target population; screening and assessment; interventions; technology; integration of care; evaluation and metrics; and research. CONCLUSION Development of a consensus derived FFD model of care represents an important step in generating national standards, implementation of a service model as intended and enhances opportunities for scientific impact. Future research should focus on the development of a core outcome set for studies involving older adults in the ED.
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Affiliation(s)
- Íde O'Shaughnessy
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland.
| | - Christine Fitzgerald
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Aoife Whiston
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Patrick Harnett
- Clinical Design and Innovation, Health Service Executive, National Clinical Programme for Older People, Dublin, Ireland
| | - Helen Whitty
- Clinical Design and Innovation, Health Service Executive, National Clinical Programme for Older People, Dublin, Ireland
| | - Des Mulligan
- Clinical Design and Innovation, Health Service Executive, National Clinical Programme for Older People, Dublin, Ireland
| | - Marian Mullaney
- Clinical Design and Innovation, Health Service Executive, National Clinical Programme for Older People, Dublin, Ireland
| | - Catherine Devaney
- Clinical Design and Innovation, Health Service Executive, National Clinical Programme for Older People, Dublin, Ireland
| | - Deirdre Lang
- Clinical Design and Innovation, Health Service Executive, National Clinical Programme for Older People, Dublin, Ireland
| | - Jennifer Hardimann
- Clinical Design and Innovation, Health Service Executive, National Clinical Programme for Older People, Dublin, Ireland
| | - Brian Condon
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Christina Hayes
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Alison Holmes
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Louise Barry
- Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
| | - Claire McCormack
- School of Medicine, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Megan Bounds
- School of Medicine, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
- College of Medicine, University of Arizona, Tucson, USA
| | - Katie Robinson
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Margaret O'Connor
- School of Medicine, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
- Department of Ageing and Therapeutics, University Hospital Limerick, Dooradoyle, Limerick, Limerick, Ireland
| | - Damien Ryan
- School of Medicine, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
- Emergency Department, Limerick EM Education Research Training (ALERT), University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Denys Shchetkovsky
- Emergency Department, Limerick EM Education Research Training (ALERT), University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Fiona Steed
- Department of Health, Baggot Street, Dublin, Ireland
| | - Leonora Carey
- Department of Occupational Therapy, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Emer Ahern
- Clinical Design and Innovation, Health Service Executive, National Clinical Programme for Older People, Dublin, Ireland
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
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Moloney E, O’Donovan MR, Sezgin D, Flanagan E, McGrath K, Timmons S, O’Caoimh R. Diagnostic Accuracy of Frailty Screening Instruments Validated for Use among Older Adults Attending Emergency Departments: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6280. [PMID: 37444127 PMCID: PMC10341387 DOI: 10.3390/ijerph20136280] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/25/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023]
Abstract
Early identification of frailty can prevent functional decline. Although multiple frailty screens exist for use in Emergency Departments (EDs), few are validated against diagnostic standards such as comprehensive geriatric assessment. To examine the diagnostic accuracy of ED screens for frailty, scientific databases were searched for prospective diagnostic accuracy test studies from January 2000 to September 2022. Studies were assessed for risk of bias using QUADAS-C. Psychometric properties were extracted and analysed using R. Six studies involving 1,663 participants describing seven frailty screening instruments (PRISMA-7, CFS, VIP, FRESH, BPQ, TRST, and ISAR), representing 13 unique data points, were included. The mean age of participants ranged from 76 to 86 years. The proportion that was female ranged from 45 to 60%. The pooled prevalence rate of frailty was high at 59%. The pooled estimate for sensitivity was 0.85 (95% CI: 0.76-0.91) versus 0.77 (95% CI: 0.62-0.88) for specificity. Pooled accuracy based on area under the ROC curve was 0.89 (95% CI: 0.86-0.90). Although few studies were found, limiting the ability to conduct a meta-analysis of individual instruments, available frailty screens can accurately diagnose frailty in older adults attending the ED. As specificity was comparatively low, additional assessment may be required to identify those requiring inpatient management or onward community referral. Further study is therefore required.
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Affiliation(s)
- Elizabeth Moloney
- HRB Clinical Research Facility, Mercy University Hospital, University College Cork, Grenville Place, T12 WE28 Cork, Ireland; (E.M.); (M.R.O.); (E.F.)
- Department of Geriatric Medicine, Mercy University Hospital, Grenville Place, T12 WE28 Cork, Ireland; (K.M.); (S.T.)
| | - Mark R. O’Donovan
- HRB Clinical Research Facility, Mercy University Hospital, University College Cork, Grenville Place, T12 WE28 Cork, Ireland; (E.M.); (M.R.O.); (E.F.)
| | - Duygu Sezgin
- School of Nursing and Midwifery, University of Galway, H91 TK33 Galway, Ireland;
| | - Evelyn Flanagan
- HRB Clinical Research Facility, Mercy University Hospital, University College Cork, Grenville Place, T12 WE28 Cork, Ireland; (E.M.); (M.R.O.); (E.F.)
| | - Keith McGrath
- Department of Geriatric Medicine, Mercy University Hospital, Grenville Place, T12 WE28 Cork, Ireland; (K.M.); (S.T.)
| | - Suzanne Timmons
- Department of Geriatric Medicine, Mercy University Hospital, Grenville Place, T12 WE28 Cork, Ireland; (K.M.); (S.T.)
- Centre for Gerontology and Rehabilitation, University College Cork, St Finbarr’s Hospital, Douglas Road, T12 XH60 Cork, Ireland
| | - Rónán O’Caoimh
- HRB Clinical Research Facility, Mercy University Hospital, University College Cork, Grenville Place, T12 WE28 Cork, Ireland; (E.M.); (M.R.O.); (E.F.)
- Department of Geriatric Medicine, Mercy University Hospital, Grenville Place, T12 WE28 Cork, Ireland; (K.M.); (S.T.)
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van Dam CS, Peters MJL, Hoogendijk EO, Nanayakkara PWB, Muller M, Trappenburg MC. Older patients with nonspecific complaints at the Emergency Department are at risk of adverse health outcomes. Eur J Intern Med 2023; 112:86-92. [PMID: 37002150 DOI: 10.1016/j.ejim.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/13/2023] [Accepted: 03/18/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVE Older adults at the Emergency Department (ED) often present with nonspecific complaints (NSC) such as 'weakness' or 'feeling unwell'. Health care workers may underestimate illness in patients with NSC, leading to adverse health outcomes. This study compares characteristics and outcomes of NSC-patients versus specific complaints (SC) patients. METHODS Cohort study in patients ≥ 70 years in two Dutch EDs. NSC was classified according to the BANC-study-framework based on the medical history in the ED letter, before additional diagnostics took place. A second classification was performed at the end of the ED visit/hospital admission. Primary outcomes were functional decline, institutionalization, and mortality at 30 days. RESULTS 26% (n = 228) of a total of 888 included patients presented with NSC. Compared with SC-patients, NSC-patients were older, more frail, and more frequently female. NSC-patients had a higher risk of functional decline and institutionalization at 30 days (adjusted ORs 1.84, 95% CI 1.27 - 2.72, and 2.46, 95% CI 1.51-4.00, respectively), but not mortality (adjusted OR 1.26, 95% CI 0.58 - 2.73). Reclassification to a specific complaint after the ED visit or hospital admission occurred in 54% of NSC-patients. CONCLUSION NSC occur especially in older, frail female patients and are associated with an increased risk of functional decline and institutionalization, even after adjustment for worse baseline status. In half of the patients, a specific complaint revealed during ED or hospital stay. Physicians at the ED should consider NSC as a red flag needing appropriate observation and evaluation of underlying serious conditions and needs of this vulnerable patient group.
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Affiliation(s)
- C S van Dam
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine and Geriatrics, Amsterdam Cardiovascular Sciences research institute, De Boelelaan 1117, Amsterdam, the Netherlands.
| | - M J L Peters
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine and Geriatrics, Amsterdam Cardiovascular Sciences research institute, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine and Vascular Medicine, De Boelelaan 1117, Amsterdam, the Netherlands; Department of Internal Medicine and Geriatrics, UMC Utrecht, the Netherlands
| | - E O Hoogendijk
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Epidemiology and Data Science, Amsterdam Public Health research institute, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Department of General Practice, Amsterdam Public Health research institute, De Boelelaan 1117, Amsterdam, the Netherlands
| | - P W B Nanayakkara
- Amsterdam UMC, Vrije Universiteit Amsterdam, Section General Internal Medicine, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, the Netherlands
| | - M Muller
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine and Geriatrics, Amsterdam Cardiovascular Sciences research institute, De Boelelaan 1117, Amsterdam, the Netherlands
| | - M C Trappenburg
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine and Geriatrics, Amsterdam Cardiovascular Sciences research institute, De Boelelaan 1117, Amsterdam, the Netherlands; Department of Internal Medicine and Geriatrics, Amstelland Hospital, Amstelveen, the Netherlands
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8
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Foucaud A, Gilbert T, Vincent A, Jomard N, Comte B, Porthault S, Comte G, Theurey O, Gueugniaud PY, Bourelly L, Rabilloud M, Boutitie F, Douplat M, Tassa O, Haesebaert J, Termoz A, Schott AM. Evaluation of a training program for emergency medical service physician dispatchers to reduce emergency departments visits. J Am Geriatr Soc 2023; 71:484-495. [PMID: 36317929 DOI: 10.1111/jgs.18101] [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: 05/21/2022] [Revised: 09/08/2022] [Accepted: 09/24/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Emergency Departments (ED) have seen an increasing number of older patients who are mostly referred following a call to the Emergency Medical Services (EMS). Long waiting times in settings, which are not designed to meet older patients' needs, may increase the risk of hospital-acquired complications. Unnecessary visits should therefore be avoided as much as possible. The objective of the study was to evaluate whether a program to provide geriatric knowledge and tools to the dispatching physicians of the EMS could decrease ED referrals of older patients. METHODS Design: Before-and-after study with two 6-month periods before and after intervention. PARTICIPANTS All calls received by a dispatching physician of the Rhône EMS from 8 am to 6 pm concerning patients aged 75 years or above during the study period. INTERVENTION A program consisting of training dispatching physicians in the specific care of older patients and the developing, with a multidisciplinary team, of specific tools for dispatching physicians. OUTCOME Proportion of ED referrals of patients aged 75 years or above after a call to the EMS. RESULTS A total of 2671 calls to the Rhône EMS were included corresponding to 1307 and 1364 patients in the pre-and post-intervention phases, respectively. There was no significant difference in the proportion of referrals to the ED between the pre-intervention (61.7%) and the post-intervention (62.8%) phases (p = 0.57). Contact of the patients with their General Practitioner (GP) in the month preceding the call was associated with a 22% reduced probability of being referred to an ED. CONCLUSIONS No beneficial effect of the intervention was demonstrated. This strategy of intervention is probably not effective enough in such time-constraint environment. Other strategies with a specific parallel dispatching of geriatric calls by geriatricians should be tested to avoid these unnecessary ED referrals. TRIAL REGISTRATION ClinicalTrials NCT02712450.
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Affiliation(s)
- Amandine Foucaud
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service de Gériatrie, Pierre Bénite, France
| | - Thomas Gilbert
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service de Gériatrie, Pierre Bénite, France.,Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
| | - Adélaïde Vincent
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Gériatrie, Lyon, France
| | - Nathalie Jomard
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service de Gériatrie, Pierre Bénite, France
| | - Brigitte Comte
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Gériatrie, Lyon, France
| | - Sylvie Porthault
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Hôpital Edouard Herriot, SAMU, Lyon, France
| | - Gaële Comte
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Hôpital Edouard Herriot, SAMU, Lyon, France
| | - Odile Theurey
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Hôpital Edouard Herriot, SAMU, Lyon, France
| | - Pierre-Yves Gueugniaud
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Hôpital Edouard Herriot, SAMU, Lyon, France
| | - Laura Bourelly
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Gériatrie, Lyon, France
| | - Muriel Rabilloud
- Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France.,Laboratoire de Biométrie et Biologie Évolutive, CNRS, UMR 5558, Équipe Biostatistique-Santé, Villeurbanne, France
| | - Florent Boutitie
- Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France
| | - Marion Douplat
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service des Urgences, Pierre Bénite, France
| | - Ouazna Tassa
- Hospices Civils de Lyon, Pôle de Sante Publique, Service Recherche et Épidémiologie Cliniques, Lyon, France
| | - Julie Haesebaert
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France.,Hospices Civils de Lyon, Pôle de Sante Publique, Service Recherche et Épidémiologie Cliniques, Lyon, France
| | - Anne Termoz
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France.,Hospices Civils de Lyon, Pôle de Sante Publique, Service Recherche et Épidémiologie Cliniques, Lyon, France
| | - Anne-Marie Schott
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France.,Hospices Civils de Lyon, Pôle de Sante Publique, Service Recherche et Épidémiologie Cliniques, Lyon, France
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9
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Deschasse G, Drumez E, Visade F, Charpentier A, Delecluse C, Loggia G, Lescure P, Attier-Żmudka J, Bloch J, Gaxatte C, Bloch F, Puisieux F, Beuscart JB. Factors Associated with Transfer from an Acute Geriatric Unit to a Post-Acute Care Facility among Community-Dwelling Patients: Results from the DAMAGE Cohort. Clin Interv Aging 2022; 17:1821-1832. [DOI: 10.2147/cia.s370562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/14/2022] [Indexed: 12/13/2022] Open
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10
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O'Shaughnessy Í, Robinson K, O'Connor M, Conneely M, Steed F, Ryan D, Carey L, Shchetkovsky D, Shanahan E, Leahy A, Quinn C, Sheikhi A, Galvin R. Comprehensive geriatric assessment in the emergency department: A protocol for a prospective cohort study. HRB Open Res 2022; 5:26. [PMID: 36313054 PMCID: PMC9582574 DOI: 10.12688/hrbopenres.13504.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Comprehensive geriatric assessment (CGA) has been shown to improve outcomes in hospitalised older adults; however, there is currently no compelling evidence to support CGA interventions within the Emergency Department (ED). The aim of this study is to explore the clinical and process outcomes of older adults who receive ED-CGA over a period of six months after their initial ED attendance. Design: Prospective cohort study. Methods: The STrengthening the Reporting of the OBservational studies in Epidemiology (STROBE) standardised reporting guidelines will be adhered to. Older adults aged ≥65 years who score ≥2 on the Identification of Seniors at Risk (ISAR) tool and present to the ED with a medical complaint during the operational hours of the dedicated interdisciplinary team, will be considered eligible for recruitment. Demographic and health assessment information will be obtained at the ED index attendance followed by completion of an interdisciplinary CGA. A dedicated research nurse will complete follow-up telephone interviews with participants at 30 days and six months. The primary outcome will be incidence of hospital admission from the ED index attendance. Secondary outcomes will include functional decline, patient satisfaction with the ED index attendance, unscheduled ED reattendance(s), unscheduled hospital (re)admission(s), nursing home admission(s), healthcare utilisation, and death. Descriptive statistics will be used to profile the characteristics of the study participants and multivariate logistic and linear regression analysis will be used to analyse risk of adverse outcomes. Ethics and dissemination: Ethical approval was granted by the
University of Limerick Hospital Group Research Ethics Committee (107/2021). The authors will disseminate study findings through publication in a peer-reviewed journal and presentation at national and international conferences. Patient and public involvement will be sought from a panel of older adults at the Ageing Research Centre in the University of Limerick. Clinicaltrials.gov Identifier: NCT05252182.
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Affiliation(s)
- Íde O'Shaughnessy
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Katie Robinson
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Margaret O'Connor
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
- School of Medicine, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Mairéad Conneely
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Fiona Steed
- Medicine Directorate, University Hospital Limerick, Limerick, Ireland
| | - Damien Ryan
- School of Medicine, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
- Limerick EM Education Research Training (ALERT), Emergency Department, University Hospital Limerick, Limerick, Ireland
| | - Leonora Carey
- Department of Occupational Therapy, University Hospital Limerick, Limerick, Ireland
| | - Denys Shchetkovsky
- Limerick EM Education Research Training (ALERT), Emergency Department, University Hospital Limerick, Limerick, Ireland
| | - Elaine Shanahan
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Aoife Leahy
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Colin Quinn
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Ali Sheikhi
- Health Research Institute (HRI), University of Limerick, Limerick, Ireland
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
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11
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O'Shaughnessy Í, Robinson K, O'Connor M, Conneely M, Steed F, Ryan D, Carey L, Shchetkovsky D, Shanahan E, Leahy A, Quinn C, Sheikhi A, Galvin R. Comprehensive geriatric assessment in the emergency department: A protocol for a prospective cohort study. HRB Open Res 2022; 5:26. [PMID: 36313054 PMCID: PMC9582574 DOI: 10.12688/hrbopenres.13504.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2022] [Indexed: 10/21/2023] Open
Abstract
Background: Comprehensive geriatric assessment (CGA) has been shown to improve outcomes in hospitalised older adults; however, there is currently no compelling evidence to support CGA interventions within the Emergency Department (ED). The aim of this study is to explore the clinical and process outcomes of older adults who receive ED-CGA over a period of six months after their initial ED attendance. Design: Prospective cohort study. Methods: The STrengthening the Reporting of the OBservational studies in Epidemiology (STROBE) standardised reporting guidelines will be adhered to. Older adults aged ≥65 years who score ≥2 on the Identification of Seniors at Risk (ISAR) tool and present to the ED with a medical complaint during the operational hours of the dedicated interdisciplinary team, will be considered eligible for recruitment. Demographic and health assessment information will be obtained at the ED index attendance followed by completion of an interdisciplinary CGA. A dedicated research nurse will complete follow-up telephone interviews with participants at 30 days and six months. The primary outcome will be incidence of hospital admission from the ED index attendance. Secondary outcomes will include functional decline, patient satisfaction with the ED index attendance, unscheduled ED reattendance(s), unscheduled hospital (re)admission(s), nursing home admission(s), healthcare utilisation, and death. Descriptive statistics will be used to profile the characteristics of the study participants and multivariate logistic and linear regression analysis will be used to analyse risk of adverse outcomes. Ethics and dissemination: Ethical approval was granted by the University of Limerick Hospital Group Research Ethics Committee (107/2021). The authors will disseminate study findings through publication in a peer-reviewed journal and presentation at national and international conferences. Patient and public involvement will be sought from a panel of older adults at the Ageing Research Centre in the University of Limerick. Clinicaltrials.gov Identifier: NCT05252182.
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Affiliation(s)
- Íde O'Shaughnessy
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Katie Robinson
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Margaret O'Connor
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
- School of Medicine, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Mairéad Conneely
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Fiona Steed
- Medicine Directorate, University Hospital Limerick, Limerick, Ireland
| | - Damien Ryan
- School of Medicine, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
- Limerick EM Education Research Training (ALERT), Emergency Department, University Hospital Limerick, Limerick, Ireland
| | - Leonora Carey
- Department of Occupational Therapy, University Hospital Limerick, Limerick, Ireland
| | - Denys Shchetkovsky
- Limerick EM Education Research Training (ALERT), Emergency Department, University Hospital Limerick, Limerick, Ireland
| | - Elaine Shanahan
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Aoife Leahy
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Colin Quinn
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Ali Sheikhi
- Health Research Institute (HRI), University of Limerick, Limerick, Ireland
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
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12
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O'Shaughnessy Í, Robinson K, O'Connor M, Conneely M, Ryan D, Steed F, Carey L, Leahy A, Galvin R. Effectiveness of acute geriatric unit care on functional decline and process outcomes among older adults admitted to hospital with acute medical complaints: a protocol for a systematic review. BMJ Open 2021; 11:e050524. [PMID: 34706953 PMCID: PMC8552169 DOI: 10.1136/bmjopen-2021-050524] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Older adults are clinically heterogeneous and are at increased risk of adverse outcomes during hospitalisation due to the presence of multiple comorbid conditions and reduced homoeostatic reserves. Acute geriatric units (AGUs) are units designed with their own physical location and structure, which provide care to older adults during the acute phase of illness and are underpinned by an interdisciplinary comprehensive geriatric assessment model of care. This review aims to update and synthesise the totality of evidence related to the effectiveness of AGU care on clinical and process outcomes among older adults admitted to hospital with acute medical complaints. DESIGN Updated systematic review and meta-analysis METHODS AND ANALYSIS: MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Controlled Trials in the Cochrane Library and Embase electronic databases will be systematically searched from 2008 to February 2021. Trials with a randomised design that deliver an AGU intervention to older adults admitted to hospital for acute medical complaints will be included. The primary outcome measure will be functional decline at discharge from hospital and at follow-up. Secondary outcomes will include length of stay, cost of index admission, incidence of unscheduled hospital readmission, living at home (the inverse of death or institutionalisation combined; used to describe someone who is in their own home at follow-up), mortality, cognitive function and patient satisfaction with index admission. Title and abstract screening of studies for full-text extraction will be conducted independently by two authors. The Cochrane risk of bias 2 tool will be used to assess the methodological quality of the included trials. The quality of evidence for outcomes reported will be assessed using the Grading of Recommendations Assessment, Development and Evaluations framework. A pooled meta-analysis will be conducted using Review Manager, depending on the uniformity of the data. ETHICS AND DISSEMINATION Formal ethical approval is not required as all data collected will be secondary data and will be analysed anonymously. The authors will present the findings of the review to a patient and public involvement stakeholder panel of older adults that has been established at the Ageing Research Centre in the University of Limerick. This will enable the views and opinions of older adults to be integrated into the discussion section of the paper. PROSPERO REGISTRATION NUMBER CRD42021237633.
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Affiliation(s)
- Íde O'Shaughnessy
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Ireland, Limerick, Ireland
| | - Katie Robinson
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Ireland, Limerick, Ireland
| | - Margaret O'Connor
- Department of Ageing and Therapeutics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Mairéad Conneely
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Ireland, Limerick, Ireland
| | - Damien Ryan
- Limerick EM Education Research Training (ALERT), Emergency Department, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Fiona Steed
- Department of Medicine, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Leonora Carey
- Department of Occupational Therapy, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Aoife Leahy
- Department of Ageing and Therapeutics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Ireland, Limerick, Ireland
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13
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O'Shaughnessy Í, Romero-Ortuno R, Edge L, Dillon A, Flynn S, Briggs R, Shields D, McMahon G, Hennessy A, Kennedy U, Staunton P, McNamara R, Timmons S, Horgan F, Cunningham C. Home FIRsT: interdisciplinary geriatric assessment and disposition outcomes in the Emergency Department. Eur J Intern Med 2021; 85:50-55. [PMID: 33243612 DOI: 10.1016/j.ejim.2020.11.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/08/2020] [Accepted: 11/15/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Older people in the Emergency Department (ED) are clinically heterogenous and some presentations may be better suited to alternative out-of-hospital pathways. A new interdisciplinary comprehensive geriatric assessment (CGA) team (Home FIRsT) was embedded in our acute hospital's ED in 2017. AIM To evaluate if routinely collected CGA metrics were associated with ED disposition outcomes. DESIGN Retrospective observational study. METHODS We included all first patients seen by Home FIRsT between 7th May and 19th October 2018. Collected measures were sociodemographic, baseline frailty (Clinical Frailty Scale), major diagnostic categories, illness acuity (Manchester Triage Score) and cognitive impairment/delirium (4AT). Multivariate binary logistic regression models were computed to predict ED disposition outcomes: hospital admission; discharge to GP and/or community services; discharge to specialist geriatric outpatients; discharge to the Geriatric Day Hospital. RESULTS In the study period, there were 1,045 Home FIRsT assessments (mean age 80.1 years). For hospital admission, strong independent predictors were acute illness severity (OR 2.01, 95% CI 1.50-2.70, P<0.001) and 4AT (OR 1.26, 95% CI 1.13 - 1.42, P<0.001). Discharge to specialist outpatients (e.g. falls/bone health) was predicted by musculoskeletal/injuries/trauma presentations (OR 6.45, 95% CI 1.52 - 27.32, P=0.011). Discharge to the Geriatric Day Hospital was only predicted by frailty (OR 1.52, 95% CI 1.17 - 1.97, P=0.002). Age and sex were not predictive in any of the models. CONCLUSIONS Routinely collected CGA metrics are useful to predict ED disposition. The ability of baseline frailty to predict ED outcomes needs to be considered together with acute illness severity and delirium.
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Affiliation(s)
- Íde O'Shaughnessy
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Roman Romero-Ortuno
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland; Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Ireland; Global Brain Health Institute, Trinity College Dublin, Ireland.
| | - Lucinda Edge
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Aoife Dillon
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Sinéad Flynn
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Robert Briggs
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland; Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Ireland
| | | | | | | | - Una Kennedy
- Emergency Department, St James's Hospital, Dublin, Ireland
| | - Paul Staunton
- Emergency Department, St James's Hospital, Dublin, Ireland
| | - Rosa McNamara
- Emergency Department, St James's Hospital, Dublin, Ireland
| | - Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Ireland
| | - Frances Horgan
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Conal Cunningham
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland; Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Ireland
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Rahman S, Thompson D, Clayton A, Conroy S, Tite M. Analysis of the Experience-Based Design Feedback Data on a National Scale. J Patient Exp 2021; 7:1068-1076. [PMID: 33457547 PMCID: PMC7786651 DOI: 10.1177/2374373520969253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
The United Kingdom Office of National Statistics population estimates that 10 million people are aged 65 years and older, of which some would be considered frail. This is conceptualized as a complex progressive loss of physiological and social function. In order to establish and evaluate appropriate services, feedback tools designed for this patient group have begun to take greater importance, which the Acute Frailty Network has been developing using experience-based design. These tools focus on the experience of frail patients in the settings of accident and emergency and the acute medical unit. An analysis of data from 12 hospitals was used to look at the common emotions and comments expressed at the key touchpoints. A total of 609 respondents were used in the analysis, revealing that patients expressed mostly positive experiences. The areas with the most negative emotions and comments were in the domains "being admitted," "first assessment," and "preparing to leave hospital." We would recommend that future quality improvement projects focus in improving the communication standards around the admission and discharge process.
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Affiliation(s)
- Sakib Rahman
- Joondalup Health Campus, Putney, London, United Kingdom
| | | | - Alice Clayton
- Joondalup Health Campus, Putney, London, United Kingdom
| | - Simon Conroy
- University of Leicester Hospitals Trust, London, United Kingdom
| | - Matt Tite
- Joondalup Health Campus, Putney, London, United Kingdom
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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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Varg S, Vicente V, Castren M, Lindgren P, Rehnberg C. Healthcare pathways and resource use: mapping consequences of ambulance assessment for direct care with alternative healthcare providers. BMC Emerg Med 2020; 20:85. [PMID: 33126854 PMCID: PMC7602326 DOI: 10.1186/s12873-020-00380-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 10/16/2020] [Indexed: 11/10/2022] Open
Abstract
Background A decision system in the ambulance allowing alternative pathways to alternate healthcare providers has been developed for older patients in Stockholm, Sweden. However, subsequent healthcare resource use resulting from these pathways has not yet been addressed. The aim of this study was therefore to describe patient pathways, healthcare utilisation and costs following ambulance transportation to alternative healthcare providers. Methods The design of this study was descriptive and observational. Data from a previous RCT, where a decision system in the ambulance enabled alternative healthcare pathways to alternate healthcare providers were linked to register data. The receiving providers were: primary acute care centre or secondary geriatric ward, both located at the same community hospital, or the conventional pathway to the emergency department at an acute hospital. Resource use over 10 days, subsequent to assessment with the decision system, was mapped in terms of healthcare pathways, utilisation and costs for the 98 included cases. Results Almost 90% were transported to the acute care centre or geriatric ward. The vast majority arriving to the geriatric ward stayed there until the end of follow-up or until discharged, whereas patients conveyed to the acute care centre to a large extent were admitted to hospital. The median patient had 6 hospital days, 2 outpatient visits and costed roughly 4000 euros over the 10-day period. Arrival destination geriatric ward indicated the longest hospital stay and the emergency department the shortest. However, the cost for the 10-day period was lower for cases arriving to the geriatric ward than for those arriving to the emergency department. Conclusions The findings support the appropriateness of admittance directly to secondary geriatric care for older adults. However, patients conveyed to the acute care centre ought to be studied in more detail with regards to appropriate level of care.
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Affiliation(s)
- Sofi Varg
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden. .,Centre for Health Economics, Informatics and Health Services Research, Stockholm Health Care Services, Stockholm, Sweden.
| | - Veronica Vicente
- Ambulance Medical Service in Stockholm [Ambulanssjukvården i Storstockholm AB], Stockholm, Sweden.,Academic Emergency Medical Services, Stockholm, Sweden.,Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
| | - Maaret Castren
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden.,Emergency Medicine, Helsinki University and Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Peter Lindgren
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden.,The Swedish Institute for Health Economics, Lund, Sweden
| | - Clas Rehnberg
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden.,Centre for Health Economics, Informatics and Health Services Research, Stockholm Health Care Services, Stockholm, Sweden
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Positive organisational scholarship in healthcare. JOURNAL OF MANAGEMENT & ORGANIZATION 2020. [DOI: 10.1017/jmo.2020.6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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18
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McGrath J, Almeida P, Law R. The Whittington Frailty Pathway: improving access to comprehensive geriatric assessment: an interdisciplinary quality improvement project. BMJ Open Qual 2019; 8:e000798. [PMID: 31803856 PMCID: PMC6887502 DOI: 10.1136/bmjoq-2019-000798] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/16/2019] [Accepted: 11/01/2019] [Indexed: 11/13/2022] Open
Abstract
National guidelines mandate identification and tailored management of patients living with frailty who attend the acute hospital setting. We describe using quality improvement (QI) techniques to embed a system that allowed identification of frailty in older patients attending the emergency department (ED), creation of a clinical pathway to facilitate comprehensive geriatric assessment and appropriate same-day discharge of suitable patients. Integration of Clinical Frailty Scale (CFS) scoring within an electronic record system, a continuing programme of education and awareness, and dedicated project staff allows patients to be identified for an ambulatory frailty pathway. Our results show a sustained improvement over 9 months of the project, with 73% of patients over the age of 75 years presenting to ED by ambulance now receiving a CFS score. Over 300 patients have been identified, transferred to ambulatory care and treated via a new frailty pathway, with an admission rate for this cohort of 14%, compared with an overall admission rate of 50% for patients over 75 years. We report a decrease in overall ED admission of 1%. Analysis of patients discharged through this same-day pathway showed a 7-day ED reattendance rate of 15.1% and a 30-day readmission rate of 18.9%, which are comparable with current pathways. Consultant review estimated 87% of patients to have avoided a longer admission. Patient and staff satisfaction indicates this pathway to be feasible and acceptable to users. Our data suggest an ambulatory frailty pathway can deliver significant admission avoidance while maintaining low readmission rates. Similar schemes in other hospitals should consider using QI approaches to implementation of frailty pathways.
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Affiliation(s)
- John McGrath
- Islington GP Federation, NHS Islington CCG, London, UK.,Care of the Older Person department, Whittington Hospital NHS Trust, London, UK
| | - Paula Almeida
- Care of the Older Person department, Whittington Hospital NHS Trust, London, UK
| | - Ruth Law
- Care of the Older Person department, Whittington Hospital NHS Trust, London, UK
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O’Donnell D, Ní Shé É, McCarthy M, Thornton S, Doran T, Smith F, O’Brien B, Milton J, Savin B, Donnellan A, Callan E, McAuliffe E, Gray S, Carey T, Boyle N, O’Brien M, Patton A, Bailey J, O’Shea D, Cooney Marie T. Enabling public, patient and practitioner involvement in co-designing frailty pathways in the acute care setting. BMC Health Serv Res 2019; 19:797. [PMID: 31690304 PMCID: PMC6833297 DOI: 10.1186/s12913-019-4626-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 10/10/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Although not an inevitable part of ageing, frailty is an increasingly common condition in older people. Frail older patients are particularly vulnerable to the adverse effects of hospitalisation, including deconditioning, immobility and loss of independence (Chong et al, J Am Med Dir Assoc 18:638.e7-638.e11, 2017). The 'Systematic Approach to improving care for Frail older patients' (SAFE) study co-designed, with public and patient representatives, quality improvement initiatives aimed at enhancing the delivery of care to frail older patients within an acute hospital setting. This paper describes quality improvement initiatives which resulted from a co-design process aiming to improve service delivery in the acute setting for frail older people. These improvement initiatives were aligned to five priority areas identified by patients and public representatives. METHODS The co-design work was supported by four pillars of effective and meaningful public and patient representative (PPR) involvement in health research (Bombard et al, Implement Sci 13:98, 2018; Black et al, J Health Serv Res Policy 23:158-67, 2018). These pillars were: research environment and receptive contexts; expectations and role clarity; support for participation and inclusive representation and; commitment to the value of co-learning involving institutional leadership. RESULTS Five priority areas were identified by the co-design team for targeted quality improvement initiatives: Collaboration along the integrated care continuum; continence care; improved mobility; access to food and hydration and improved patient information. These priority areas and the responding quality improvement initiatives are discussed in relation to patient-centred outcomes for enhanced care delivery for frail older people in an acute hospital setting. CONCLUSIONS The co-design approach to quality improvement places patient-centred outcomes such as dignity, identity, respectful communication as well as independence as key drivers for implementation. Enhanced inter-personal communication was consistently emphasised by the co-design team and much of the quality improvement initiatives target more effective, respectful and clear communication between healthcare personnel and patients. Measurement and evaluation of these patient-centred outcomes, while challenging, should be prioritised in the implementation of quality improvement initiatives. Adequate resourcing and administrative commitment pose the greatest challenges to the sustainability of the interventions developed along the SAFE pathways. The inclusion of organisational leadership in the co-design and implementation teams is a critical factor in the success of interventions targeting service delivery and quality improvement.
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Affiliation(s)
- Deirdre O’Donnell
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Éidín Ní Shé
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Mary McCarthy
- Expert by Experience Representing the Older People’s Empowerment Network, Dublin, Ireland
| | - Shirley Thornton
- Expert by Experience Representing Family Carer’s Ireland, Dublin, Ireland
| | - Thelma Doran
- Expert by Experience Representing the Older People’s Empowerment Network, Dublin, Ireland
| | - Freda Smith
- Expert by Experience Representing Sage Advocacy, Dublin, Ireland
| | - Barry O’Brien
- Expert by Experience Representing Sage Advocacy, Dublin, Ireland
| | - Jim Milton
- Expert by Experience Representing Sage Advocacy, Dublin, Ireland
| | | | - Anne Donnellan
- Expert by Experience Representing Glór and Age Action Ireland, Dublin, Ireland
| | - Eugene Callan
- Expert by Experience Representing the Disability Federation of Ireland, Dublin, Ireland
| | - Eilish McAuliffe
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Simone Gray
- St. Vincent’s University Hospital, Elm Park, Dublin, Ireland
| | - Therese Carey
- St. Vincent’s University Hospital, Elm Park, Dublin, Ireland
| | - Nicola Boyle
- St. Vincent’s University Hospital, Elm Park, Dublin, Ireland
| | | | - Andrew Patton
- St. Vincent’s University Hospital, Elm Park, Dublin, Ireland
| | - Jade Bailey
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Diarmuid O’Shea
- St. Vincent’s University Hospital, Elm Park, Dublin, Ireland
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Comparison of Frailty Screening Instruments in the Emergency Department. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16193626. [PMID: 31569689 PMCID: PMC6801910 DOI: 10.3390/ijerph16193626] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/01/2019] [Accepted: 09/24/2019] [Indexed: 12/14/2022]
Abstract
Early identification of frailty through targeted screening can facilitate the delivery of comprehensive geriatric assessment (CGA) and may improve outcomes for older inpatients. As several instruments are available, we aimed to investigate which is the most accurate and reliable in the Emergency Department (ED). We compared the ability of three validated, short, frailty screening instruments to identify frailty in a large University Hospital ED. Consecutive patients aged ≥70 attending ED were screened using the Clinical Frailty Scale (CFS), Identification of Seniors at Risk Tool (ISAR), and the Programme on Research for Integrating Services for the Maintenance of Autonomy 7 item questionnaire (PRISMA-7). An independent CGA using a battery of assessments determined each patient’s frailty status. Of the 280 patients screened, complete data were available for 265, with a median age of 79 (interquartile ±9); 54% were female. The median CFS score was 4/9 (±2), ISAR 3/6 (±2), and PRISMA-7 was 3/7 (±3). Based upon the CGA, 58% were frail and the most accurate instrument for separating frail from non-frail was the PRISMA-7 (AUC 0.88; 95% CI:0.83–0.93) followed by the CFS (AUC 0.83; 95% CI:0.77–0.88), and the ISAR (AUC 0.78; 95% CI:0.71–0.84). The PRISMA-7 was statistically significantly more accurate than the ISAR (p = 0.008) but not the CFS (p = 0.15). Screening for frailty in the ED with a selection of short screening instruments, but particularly the PRISMA-7, is reliable and accurate.
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Wressle E, Törnvall E. Comprehensive geriatric assessment in Swedish acute geriatric settings. Int J Health Care Qual Assur 2019; 32:752-764. [PMID: 31111781 DOI: 10.1108/ijhcqa-05-2018-0130] [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] [Indexed: 11/17/2022]
Abstract
PURPOSE Comprehensive geriatric assessment (CGA) is a widely used approach in geriatric care and involves multidisciplinary assessments focused on determining a frail elderly person's medical, psychological and functional capability to develop an integrated plan for treatment. The purpose of this paper is to describe and scrutinize the CGA implementation process at six acute geriatric departments in three county councils and to study the outcome by the documentation in the patient medical records, and the staff perceptions using CGA. DESIGN/METHODOLOGY/APPROACH The paper describes the implementation process stages. Outcome measures were based on patient medical records reviews at baseline and follow-ups at year 1 and year 2. Staff perceptions of using CGA were gathered by a questionnaire at the second follow-up. FINDINGS The implementation had not yet reached sustainability so the implementation process must continue. Results show that documentation on the different areas increased in year 1, as well as the use of standardized assessment tools. However, results from the reviews for year 2 showed some decrease. Staff considered CGA to have high value for the geriatric patient but pointed out the need for continuing education. ORIGINALITY/VALUE Successful strategies for this implementation were strong support from the managers, small seminars, CGA rounds, good introduction routines for new staff and the use of reminders such as pocket-sized focus cards. A high staff turnover occurred during the study, which probably had a significant negative impact on the results.
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Affiliation(s)
- Ewa Wressle
- Institutionen for samhalls-och valfardsstudier, Linkopings Universitet , Linköping, Sweden
| | - Eva Törnvall
- Management Department, Department of Medical and Health Sciences, Linkopings Universitet , Linköping, Sweden
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Conroy SP, Bardsley M, Smith P, Neuburger J, Keeble E, Arora S, Kraindler J, Ariti C, Sherlaw-Johnson C, Street A, Roberts H, Kennedy S, Martin G, Phelps K, Regen E, Kocman D, McCue P, Fisher E, Parker S. Comprehensive geriatric assessment for frail older people in acute hospitals: the HoW-CGA mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07150] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BackgroundThe aim of this study was to provide high-quality evidence on delivering hospital-wide Comprehensive Geriatric Assessment (CGA).Objective(s)(1) To define CGA, its processes, outcomes and costs in the published literature, (2) to identify the processes, outcomes and costs of CGA in existing hospital settings in the UK, (3) to identify the characteristics of the recipients and beneficiaries of CGA in existing hospital settings in the UK and (4) to develop tools that will assist in the implementation of hospital-wide CGA.DesignMixed-methods study combining a mapping review, national survey, large data analysis and qualitative methods.ParticipantsPeople aged ≥ 65 years in acute hospital settings.Data sourcesLiterature review – Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, MEDLINE and EMBASE. Survey – acute hospital trusts. Large data analyses – (1) people aged ≥ 75 years in 2008 living in Leicester, Nottingham or Southampton (development cohort,n = 22,139); (2) older people admitted for short stay (Nottingham/Leicester,n = 825) to a geriatric ward (Southampton,n = 246) or based in the community (Newcastle,n = 754); (3) people aged ≥ 75 years admitted to acute hospitals in England in 2014–15 (validation study,n = 1,013,590). Toolkit development – multidisciplinary national stakeholder group (co-production); field-testing with cancer/surgical teams in Newcastle/Leicester.ResultsLiterature search – common outcomes included clinical, operational and destinational, but not patient-reported, outcome measures. Survey – highly variable provision of multidisciplinary assessment and care across hospitals. Quantitative analyses – in the development cohort, older people with frailty diagnoses formed a distinct group and had higher non-elective hospital use than older people without a frailty diagnosis. Patients with the highest 20% of hospital frailty risk scores had increased odds of 30-day mortality [odds ratio (OR) 1.7], long length of stay (OR 6.0) and 30-day re-admission (OR 1.5). The score had moderate agreement with the Fried and Rockwood scales. Pilot toolkit evaluation – participants across sites were still at the beginning of their work to identify patients and plan change. In particular, competing definitions of the role of geriatricians were evident.LimitationsThe survey was limited by an incomplete response rate but it still provides the largest description of acute hospital care for older people to date. The risk stratification tool is not contemporaneous, although it remains a powerful predictor of patient harms. The toolkit evaluation is still rather nascent and could have meaningfully continued for another year or more.ConclusionsCGA remains the gold standard approach to improving a range of outcomes for older people in acute hospitals. Older people at risk can be identified using routine hospital data. Toolkits aimed at enhancing the delivery of CGA by non-specialists can be useful but require prolonged geriatrician support and implementation phases. Future work could involve comparing the hospital-based frailty index with the electronic Frailty Index and further testing of the clinical toolkits in specialist services.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Simon Paul Conroy
- Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | | | | | | | | | | | | | | | - Andrew Street
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Helen Roberts
- Academic Geriatric Medicine, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Sheila Kennedy
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Graham Martin
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Kay Phelps
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Emma Regen
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - David Kocman
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Patricia McCue
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Stuart Parker
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
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Development of a comprehensive, multidisciplinary program of care for frailty in an emergency department. Eur Geriatr Med 2018; 10:37-46. [DOI: 10.1007/s41999-018-0151-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 12/04/2018] [Indexed: 12/15/2022]
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Alabaf Sabbaghi S, De Souza D, Sarikonda P, Keevil VL, Wallis SJ, Romero‐Ortuno R. Allocating patients to geriatric medicine wards in a tertiary university hospital in England: A service evaluation of the Specialist Advice for the Frail Elderly (SAFE) team. Aging Med (Milton) 2018; 1:120-124. [PMID: 31942488 PMCID: PMC6880728 DOI: 10.1002/agm2.12029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 06/19/2018] [Indexed: 11/12/2022] Open
Abstract
The number of older patients admitted to acute hospitals has increased; however, their needs are heterogeneous and there is no gold-standard method of triaging them towards practicing comprehensive geriatric assessment (CGA). In our hospital, the SAFE (Specialist Advice for the Frail Elderly) team provide an initial geriatric assessment of all emergency admissions of patients aged ≥75 years (with some assessments also occurring in those aged 65 to 74 years) and recommend as to whether CGA in a dedicated Department of Medicine for the Elderly (DME) ward may be required. SAFE assessments include routine screening for geriatric syndromes using validated tools. Our aim was to compare the characteristics (age, gender, acute illness severity on admission as per modified early warning score (MEWS), Charlson Comorbidity Index, Clinical Frailty Scale (CFS), presence of dementia and delirium) and outcomes (length of stay, delayed discharge, inpatient mortality, discharge to usual place of residence, and new institutionalization) of patients listed to a DME ward, to those not listed. We analyzed all SAFE team assessments of patients admitted nonelectively between February 2015 and November 2016. Of 6192 admissions, 16% were listed for a DME ward. Those were older, had higher MEWS and CFS score, were more often affected by cognitive impairment, had longer hospital stay, higher inpatient mortality, and more often required new institutionalization. Higher CFS and presence of dementia and delirium were the strongest predictors of DME ward recommendation. Routine measurement of markers of geriatric complexity may help maximize access to finite inpatient CGA resources.
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Affiliation(s)
- Setareh Alabaf Sabbaghi
- Department of Medicine for the ElderlyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Darryl De Souza
- Specialist Advice for the Frail Elderly (SAFE) TeamAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Premchand Sarikonda
- Specialist Advice for the Frail Elderly (SAFE) TeamAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Victoria L. Keevil
- Department of Medicine for the ElderlyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
- Clinical Gerontology UnitDepartment of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | - Stephen J. Wallis
- Department of Medicine for the ElderlyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Roman Romero‐Ortuno
- Department of Medicine for the ElderlyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
- Clinical Gerontology UnitDepartment of Public Health and Primary CareUniversity of CambridgeCambridgeUK
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Ivanoff SD, Duner A, Eklund K, Wilhelmson K, Lidén E, Holmgren E. Comprehensive geriatric assessment of frail older people: ideals and reality. J Interprof Care 2018; 32:728-734. [PMID: 30156945 DOI: 10.1080/13561820.2018.1508130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
We explored different professionals' views on and experiences of comprehensive geriatric assessment (CGA) of frail older people. Forty-six professionals working in hospitals, primary care, or municipal health and social care participated in 10 focus groups. Professional groups comprised of occupational therapists, physiotherapists, nurses, physicians, and social workers. Participants shared an ideal image of how the CGA of frail elderly people should be conducted. Experience-based competence was more often used as an assessment tool than standardized tests. The ideal image contrasted with reality, listening to the needs expressed, with the person's problems, needs, and priorities in the foreground, as described by the categories: a need that can be met; different perspectives on needs; needs can be hidden; and needs assessment is affected by the collaboration around the person, by the context, and by the dialogue. The health and social care professionals' first priority is to make a person-centred tailor-made comprehensive geriatric assessment and not be bound to instruments. Clear guidelines need to be developed, stating which profession assesses what, when and how in order to ensure that person-centred needs are assessed including structures and procedures for how communication and collaboration within the team as well as between the organizations are achieved in order to perform a good person-centred CGA.
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Affiliation(s)
- Synneve Dahlin Ivanoff
- Center of Aging and Health-AGECAP, Institute of Neuroscience and Physiology, Section of Health and Rehabilitation, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Anna Duner
- Center of Aging and Health-AGECAP, Department of Social work, University of Gothenburg, Gothenburg, Sweden
| | - Kajsa Eklund
- Center of Aging and Health-AGECAP, Institute of Neuroscience and Physiology, Section of Health and Rehabilitation, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Katarina Wilhelmson
- Center of Aging and Health-AGECAP, Department of Geriatrics, The Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eva Lidén
- Center of Aging and Health-AGECAP,Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Eva Holmgren
- Center of Aging and Health-AGECAP, Institute of Neuroscience and Physiology, Section of Health and Rehabilitation, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
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Giroux M, Sirois MJ, Boucher V, Daoust R, Gouin É, Pelletier M, Berthelot S, Voyer P, Émond M. Frailty Assessment to Help Predict Patients at Risk of Delirium When Consulting the Emergency Department. J Emerg Med 2018; 55:157-164. [DOI: 10.1016/j.jemermed.2018.02.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 01/31/2018] [Accepted: 02/22/2018] [Indexed: 12/20/2022]
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Brabrand M, Kellett J, Opio M, Cooksley T, Nickel CH. Should impaired mobility on presentation be a vital sign? Acta Anaesthesiol Scand 2018; 62:945-952. [PMID: 29512139 DOI: 10.1111/aas.13098] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/31/2018] [Accepted: 02/10/2018] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Vital signs are routinely used to assess acutely ill patients, but they do not detect all patients at risk of death. This retrospective multicenter cohort study compares the prediction of death by impaired mobility with age, co-morbidities, and vital sign changes. METHODS On first assessment, patients from a combined cohort of 9684 Danish and Irish patients and a separate cohort of 1010 Ugandan patients were stratified by impaired mobility on presentation (IMOP), vital sign changes assessed by the National Early Warning Score (NEWS), the Charlson Co-morbidity Index, and age. RESULTS Fourteen percent of Danish and Irish patients had IMOP compared with 42% of Ugandan patients. The odds ratios of IMOP for 7-day mortality were similar for both cohorts (i.e. 11.8, 95% CI 5.8-24.0 for Ugandan patients versus 6.7, 95% CI 5.0-9.0 for Danish and Irish patients). Univariate analysis of Ugandan patients showed that none of the parameters tested (i.e. low blood pressure, pulse, elevated respiratory rate, hypothermia, low oxygen saturation, old age, and coma) had a statistically higher odds ratio for either 7-day mortality than IMOP. Multivariate logistic regression analysis of Danish and Irish patients also showed that none of these parameters or the Charlson Co-morbidity Index had a statistically higher odds ratio than IMOP for either 7-day or 30-day mortality. CONCLUSION Immobility on presentation is a vital sign and predicts mortality for acutely ill patients independently of the traditional vital signs, age, and co-morbidities.
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Affiliation(s)
- M. Brabrand
- Department of Emergency Medicine; Hospital of South West Jutland; Esbjerg Denmark
- Department of Emergency Medicine; Odense University Hospital; Odense Denmark
| | - J. Kellett
- Department of Emergency Medicine; Hospital of South West Jutland; Esbjerg Denmark
| | - M. Opio
- Department of Medicine; Kitovu Hospital; Kitovu Uganda
| | - T. Cooksley
- Department of Acute Medicine; University Hospital of South Manchester; Manchester UK
| | - C. H. Nickel
- Emergency Department; University Hospital Basel; Basel Switzerland
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Abstract
This is the second in an occasional series of paired commentaries in Age and Ageing, the Journal of the British Geriatrics Society and the Journal of the American Geriatrics Society (JAGS). The aim is to address issues of current significance and to foster dialogue and increased understanding between academics and clinicians working in comparative international settings. Both commentaries address the urgent need to improve palliative care for older people, with a critique of some stereotypes surrounding palliative care and the 'good death'. The companion commentary, published in JAGS, was written by Alexander Smith and Vyjeyanthi Periyakoil, and is grounded in their experience as academic clinicians (Smith AK, Periyakoil V. Should we bury 'The Good Death'? Journal of the American Geriatrics Society 2018; in press). In the present paper, we offer a perspective on the outcome and wider consequences of misalignment between current UK policy and aspirations for end of life care in relation to epidemiological trends and patient experience of death and dying.
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Affiliation(s)
- Kristian Pollock
- School of Health Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2HA, UK
| | - Jane Seymour
- School of Nursing and Midwifery, University of Sheffield, Barber House Annexe, 3a Clarkhouse Road, Sheffield S10 2LA, UK
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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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Ní Shé É, McCarthy M, O'Donnell D, Collins O, Hughes G, Salter N, Cogan L, O'Donoghue C, McGrath E, O'Donovan J, Patton A, McAuliffe E, O'Shea D, Cooney MT. The systematic approach to improving care for Frail Older Patients (SAFE) study: A protocol for co-designing a frail older person's pathway. HRB Open Res 2018; 1:9. [PMID: 32002503 PMCID: PMC6973535 DOI: 10.12688/hrbopenres.12804.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2018] [Indexed: 11/30/2022] Open
Abstract
Background: Frailty is the age-accelerated decline across multiple organ systems which leads to vulnerability to poor resolution of homeostasis after a stressor event. This loss of reserve means that a minor illness can result in a disproportionate loss of functional ability. Improving acute care for frail older patients is now a national priority and an important aspect of the National Programme for Older People in Ireland. Evidence suggests that an interdisciplinary approach incorporating rapid comprehensive geriatric assessment and early intervention by an interdisciplinary team can reduces susceptibility to hospitalisation related functional decline. The aim of the Systematic Approach to Improving Care for Frail Older Patients (SAFE) is to develop and explore the process of implementing a model of excellence in the delivery of patient-centred integrated care within the context of frail older people’s acute admissions. Methods: The SAFE study will employ a mixed methodology approach, including a rapid realist review of the current literature alongside a review of baseline data for older people attending the emergency department. Semi-structured interviews will be undertaken to document the current pathway. The intervention processes and outcomes will be jointly co-designed by a patient and public involvement (PPI) group together with the interdisciplinary healthcare professionals from hospital, community and rehabilitation settings. Successive rounds of Plan-Do-Study-Act cycles will then be undertaken to test and refine the pathway for full implementation. Discussion: This research project will result in a plan for implementing an integrated, patient-centred pathway for acute care of the frail older people which has been tested in the Irish setting. During the process of development, each element of the new pathway will be tested in turn to ensure that patient centred outcomes are being realised. This will ensure the resulting model of care is ready for implementation in the context of the Irish health service.
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Affiliation(s)
- Éidín Ní Shé
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, D4, Ireland
| | - Mary McCarthy
- Older Person's Empowerment Network and Patient and Public Involvement Representative in Healthcare at the Health Service Executive, Dublin, D8, Ireland
| | - Deirdre O'Donnell
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, D4, Ireland
| | - Orla Collins
- St Vincent's University Hospital, Dublin, Dublin, D4, Ireland
| | - Graham Hughes
- St Vincent's University Hospital, Dublin, Dublin, D4, Ireland
| | - Nigel Salter
- St Vincent's University Hospital, Dublin, Dublin, D4, Ireland
| | - Lisa Cogan
- Royal Hospital Donnybrook, Dublin, D4, Ireland
| | | | - Emmet McGrath
- St Vincent's University Hospital, Dublin, Dublin, D4, Ireland
| | - John O'Donovan
- Health Service Executive , Dun Laoghaire, County Dublin, Ireland
| | - Andrew Patton
- St Vincent's University Hospital, Dublin, Dublin, D4, Ireland
| | - Eilish McAuliffe
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, D4, Ireland
| | - Diarmuid O'Shea
- St Vincent's University Hospital, Dublin, Dublin, D4, Ireland
| | - Marie Therese Cooney
- St Vincent's University Hospital, Dublin, Dublin, D4, Ireland.,School of Medicine, University College Dublin, Dublin, D4, Ireland
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Ní Shé É, McCarthy M, O'Donnell D, Collins O, Hughes G, Salter N, Cogan L, O'Donoghue C, McGrath E, O'Donovan J, Patton A, McAuliffe E, O'Shea D, Cooney MT. The systematic approach to improving care for Frail Older Patients (SAFE) study: A protocol for co-designing a frail older person’s pathway. HRB Open Res 2018. [DOI: 10.12688/hrbopenres.12804.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Frailty is the age-accelerated decline across multiple organ systems which leads to vulnerability to poor resolution of homeostasis after a stressor event. This loss of reserve means that a minor illness can result in a disproportionate loss of functional ability. Improving acute care for frail older patients is now a national priority and an important aspect of the National Programme for Older People in Ireland. Evidence suggests that an interdisciplinary approach incorporating rapid comprehensive geriatric assessment and early intervention by an interdisciplinary team can reduces susceptibility to hospitalisation related functional decline. The aim of the Systematic Approach to Improving Care for Frail Older Patients (SAFE) is to develop and explore the process of implementing a model of excellence in the delivery of patient-centred integrated care within the context of frail older people’s acute admissions. Methods: The SAFE study will employ a mixed methodology approach, including a rapid realist review of the current literature alongside a review of baseline data for older people attending the emergency department. Semi-structured interviews will be undertaken to document the current pathway. The intervention processes and outcomes will be jointly co-designed by a patient and public involvement (PPI) group together with the interdisciplinary healthcare professionals from hospital, community and rehabilitation settings. Successive rounds of Plan-Do-Study-Act cycles will then be undertaken to test and refine the pathway for full implementation. Discussion: This research project will result in a plan for implementing an integrated, patient-centred pathway for acute care of the frail older people which has been tested in the Irish setting. During the process of development, each element of the new pathway will be tested in turn to ensure that patient centred outcomes are being realised. This will ensure the resulting model of care is ready for implementation in the context of the Irish health service.
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Undertaking a Collaborative Rapid Realist Review to Investigate What Works in the Successful Implementation of a Frail Older Person's Pathway. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15020199. [PMID: 29370094 PMCID: PMC5858268 DOI: 10.3390/ijerph15020199] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 01/15/2018] [Accepted: 01/17/2018] [Indexed: 11/17/2022]
Abstract
We addressed the research question “what factors enable the successful development and implementation of a frail older person’s pathway within the acute setting”. A rapid realist review (RRR) was conducted by adopting the RAMESES standards. We began with a sample of 232 articles via database searches supplemented with 94 additional records including inputs from a twitter chat and a hospital site visit. Our final sample consisted of 18 documents. Following review and consensus by an expert panel we identified a conceptual model of context-mechanism-(resources)-outcomes. There was overall agreement frailty should be identified at the front door of the acute hospital. Significant challenges identified related to organisational boundaries both within the acute setting and externally, the need to shift outcomes to patient orientated ones, to support staff to sustain the pathway by providing ongoing education and by providing role clarity. RRRs can support research such as the systematic approach to improving care for frail older adults (SAFE) study by producing accounts of what works based on a wide range of sources and innovative engagement with stakeholders. It is evident from our provisional model that numerous factors need to combine and interact to enable and sustain a successful frail older person’s pathway.
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Åberg AC, Ehrenberg A. Inpatient geriatric care in Sweden-Important factors from an inter-disciplinary team perspective. Arch Gerontol Geriatr 2017. [PMID: 28623800 DOI: 10.1016/j.archger.2017.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to describe factors of importance for the quality of inpatient geriatric care from an inter-disciplinary team perspective, an area that has not been previously studied to our knowledge. The study design was qualitative descriptive with data being collected from focus-group interviews with members of geriatric care teams. The data collection was conducted at a Swedish university hospital with 69 beds for geriatric care. It comprised five group interviews with a total of 32 staff members, including representatives of all the seven professions working with geriatric care. Data was analysed using qualitative content analysis and a thematic framework approach. Three main themes were identified as being perceived as characterising important factors essential for quality geriatric care: Interactive assessment processes, A holistic care approach, and Proactive non-hierarchical interaction. Aspects of Time and Goal-Orientation were additionally running like common threads through these themes and informed them. Accessibility, open communication, and staff continuity were experienced as prerequisites for well-functioning teamwork. Including patients and relatives in care planning and implementation was seen as essential for good care, but was at risk due to budget cuts that imposed shortened hospital stays. To meet the care demands of the growing population of older frail people, more specialised team-based care according to the concept of Comprehensive Geriatric Assessment - which is possibly best provided by older-friendly hospitals - appears as a constructive solution for reaching high degrees of both staff and patient satisfaction in geriatric care. More research is needed in this area.
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Affiliation(s)
- Anna Cristina Åberg
- School of Education, Health and Social Studies, Dalarna University, Sweden; Department of Public Health and Caring Sciences/Geriatrics, Uppsala University, Uppsala, Sweden.
| | - Anna Ehrenberg
- School of Education, Health and Social Studies, Dalarna University, Sweden; School of Health Sciences, Örebro University, Örebro, Sweden
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