1
|
Ranta M, Lönnroos E, Miettinen M, Kouvo A, Lammintakanen J. Emergency nurses' and physicians' perceptions and self-assessed competence in providing care to older patients. Int Emerg Nurs 2024; 74:101443. [PMID: 38677059 DOI: 10.1016/j.ienj.2024.101443] [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: 05/02/2023] [Revised: 01/26/2024] [Accepted: 03/23/2024] [Indexed: 04/29/2024]
Abstract
AIM This study examined emergency nurses' and physicians' perceptions and self-assessed competence in caring for older patients. METHODS Data were analyzed using a mixed methods approach and quantitative data were supplemented with qualitative responses. There were 451 nurses and physicians working at the two examined emergency departments, with 125 of them responding to the survey; the response rate was 27.7 %. RESULTS Physicians and nurses felt that acutely ill older patients are a responsibility of emergency services. Nurses were more critical than physicians (p = 0.000) of the failure to recognize older patients as a special group at the emergency department. Over half (51.8 %) of the physicians and 29.0 % of the nurses (p = 0.027) felt that older patients' special needs had been considered during facility planning. Nurses and physicians described the problems related to multimorbidity and aging relatively similarly. Both expressed a need for more knowledge in geriatrics and gerontology. CONCLUSION Future facility planning and care processes at the emergency department should better consider the specific needs of older patients. The results also emphasize a need to more effectively prioritize competence and educational needs of emergency staff and recognize caring for older patients as a specific competence area in the emergency department.
Collapse
Affiliation(s)
- Milja Ranta
- University of Eastern Finland, Yliopistonranta 1, Department of Health and Social Management, 70210 Kuopio, Finland.
| | - Eija Lönnroos
- University of Eastern Finland, Yliopistonranta 1, Department of Medicine, Public Health and Clinical Nutrition, 70210 Kuopio, Finland.
| | | | - Antti Kouvo
- University of Eastern Finland, Yliopistonranta 1, Faculty of Social Sciences and Business Studies, Department of Sociology, 70210 Kuopio, Finland.
| | - Johanna Lammintakanen
- University of Eastern Finland, Yliopistonranta 1, Faculty of Social Sciences and Business Studies, Department of Health and Social Management, 70210 Kuopio, Finland.
| |
Collapse
|
2
|
Aguirre NL, Gutiérrez SG, Miro O, Aguiló S, Jacob J, Alquézar-Arbé A, Burillo G, Fernandez C, Llorens P, Alonso CR, Lopez IT, Cañete M, Asensio PR, Díaz BP, Pizarro TP, Navarro RJDR, Viola NP, Hernández-Castells L, Soler AC, Sánchez Fernández-Linares E, Serrano JÁS, Ezponda P, Lorenzo AM, Liarte JVO, Ramón SS, Aranda AR, Martín-Sánchez FJ, del Castillo JG. Older Adult Patients in the Emergency Department: Which Patients should be Selected for a Different Approach? Ann Geriatr Med Res 2024; 28:9-19. [PMID: 37963716 PMCID: PMC10982447 DOI: 10.4235/agmr.23.0121] [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: 08/02/2023] [Revised: 10/05/2023] [Accepted: 11/08/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND While multidimensional and interdisciplinary assessment of older adult patients improves their short-term outcomes after evaluation in the emergency department (ED), this assessment is time-consuming and ill-suited for the busy environment. Thus, identifying patients who will benefit from this strategy is challenging. Therefore, this study aimed to identify older adult patients suitable for a different ED approach as well as independent variables associated with poor short-term clinical outcomes. METHODS We included all patients ≥65 years attending 52 EDs in Spain over 7 days. Sociodemographic, comorbidity, and baseline functional status data were collected. The outcomes were 30-day mortality, re-presentation, hospital readmission, and the composite of all outcomes. RESULTS During the study among 96,014 patients evaluated in the ED, we included 23,338 patients ≥65 years-mean age, 78.4±8.1 years; 12,626 (54.1%) women. During follow-up, 5,776 patients (24.75%) had poor outcomes after evaluation in the ED: 1,140 (4.88%) died, 4,640 (20.51) returned to the ED, and 1,739 (7.69%) were readmitted 30 days after discharge following the index visit. A model including male sex, age ≥75 years, arrival by ambulance, Charlson Comorbidity Index ≥3, and functional impairment had a C-index of 0.81 (95% confidence interval, 0.80-0.82) for 30-day mortality. CONCLUSION Male sex, age ≥75 years, arrival by ambulance, functional impairment, or severe comorbidity are features of patients who could benefit from approaches in the ED different from the common triage to improve the poor short-term outcomes of this population.
Collapse
Affiliation(s)
- Nere Larrea Aguirre
- Research Unit, Galdakao-Usansolo University Hospital, Vizcaya, Spain. Kronikgune Institute for Health Services Research, Barakaldo, Spain
| | - Susana García Gutiérrez
- Research Unit, Galdakao-Usansolo University Hospital, Vizcaya, Spain. Kronikgune Institute for Health Services Research, Barakaldo, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud (RICAPPS), Faculty of Health Sciences, Medicine Department, University of Deusto, Bilbo, Spain
| | - Oscar Miro
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Sira Aguiló
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Javier Jacob
- Emergency Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Catalonia, Spain
| | - Aitor Alquézar-Arbé
- Emergency Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Guillermo Burillo
- Emergency Department, Hospital Universitario de Canarias, University of La Laguna, Tenerife, Spain
| | - Cesáreo Fernandez
- Emergency Department, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Pere Llorens
- Emergency Department, Hospital General Universitario Dr. Balmis de Alicante, Alicante, Spain
| | | | | | - Mónica Cañete
- Emergency Department, Hospital Nuestra Señora del Prado de Talavera de la Reina, Toledo, Spain
| | | | | | | | | | | | | | | | | | | | - Patxi Ezponda
- Emergency Department, Hospital De Zumarraga, Guipuzcoa, Spain
| | | | | | | | | | | | | | - on behalf of the members of the SIESTA Network
- Research Unit, Galdakao-Usansolo University Hospital, Vizcaya, Spain. Kronikgune Institute for Health Services Research, Barakaldo, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud (RICAPPS), Faculty of Health Sciences, Medicine Department, University of Deusto, Bilbo, Spain
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
- Emergency Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Catalonia, Spain
- Emergency Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Catalonia, Spain
- Emergency Department, Hospital Universitario de Canarias, University of La Laguna, Tenerife, Spain
- Emergency Department, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
- Emergency Department, Hospital General Universitario Dr. Balmis de Alicante, Alicante, Spain
- Emergency Department, Hospital del Nalón, Langreo, Asturias, Spain
- Emergency Department, Hospital Virgen de Altagracia, Ciudad Real, Spain
- Emergency Department, Hospital Nuestra Señora del Prado de Talavera de la Reina, Toledo, Spain
- Emergency Department, Hospital Universitario Vinalopó, Alicante, Spain
- Emergency Department, Hospital Universitario de Móstoles, Madrid, Spain
- Emergency Department, Hospital Virgen del Rocio, Sevilla, Spain
- Emergency Department, Hospital General Universitario Dr. Peset, Valencia, Spain
- Emergency Department, Hospital Universitario Son Espases, Mallorca, Spain
- Emergency Department, Clinica Universitaria Navarra, Madrid, Spain
- Emergency Department, Clinico Universitario de Valencia, Valencia, Spain
- Emergency Department, Hospital Alvaro Cunqueiro, Pontevedra, Spain
- Emergency Department, Hospital Universitario de Salamanca, Salamanca, Spain
- Emergency Department, Hospital De Zumarraga, Guipuzcoa, Spain
- Emergency Department, Hospital Virxe Da Xunqueira, A Coruña, Spain
- Emergency Department, Hospital Universitario Los Arcos del Mar Menor, San Javier, Murcia, Spain
- Emergency Department, Hospital Universitario Río Ortega, Valladolid, Spain
- Emergency Department, Hospital Juan Ramón Jiménez, Huelva, Spain
| |
Collapse
|
3
|
O’Shaughnessy Í, Robinson K, Whiston A, Barry L, Corey G, Devlin C, Hartigan D, Synnott A, McCarthy A, Moriarty E, Jones B, Carroll I, Shchetkovsky D, O’Connor M, Steed F, Carey L, Conneely M, Leahy A, Quinn C, Shanahan E, Ryan D, Galvin R. Comprehensive Geriatric Assessment in the Emergency Department: A Prospective Cohort Study of Process, Clinical, and Patient-Reported Outcomes. Clin Interv Aging 2024; 19:189-201. [PMID: 38343726 PMCID: PMC10859053 DOI: 10.2147/cia.s434641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/01/2023] [Indexed: 02/15/2024] Open
Abstract
Background This study aimed to explore the process, clinical, and patient-reported outcomes of older adults who received an interdisciplinary Comprehensive Geriatric Assessment (CGA) in the emergency department (ED) over a six-month period after their initial ED attendance. Patients and Methods A prospective cohort study recruited older adults aged ≥65 years who presented to the ED of a university teaching hospital in Ireland. Baseline assessment data comprising a battery of demographic variables and validated indices were obtained at the index ED attendance. Telephone interviews were completed with participants at 30- and 180-day follow-up. The primary outcome was incidence of hospital admission following the index ED attendance. Secondary outcomes included participant satisfaction, incidence of functional decline, health-related quality of life, incidence of unscheduled ED re-attendance(s), hospital (re)admission(s), nursing home admission, and death. Results A total of 133 participants (mean age 82.43 years, standard deviation = 6.89 years; 71.4% female) were recruited; 21.8% of the cohort were admitted to hospital following the index ED attendance with a significant decline in function reported at hospital discharge (Z = 2.97, p = 0.003). Incidence of 30- and 180-day unscheduled ED re-attendance was 10.5% and 24.8%, respectively. The outcome at the index ED attendance was a significant predictor of adverse outcomes whereby those who were discharged home had significantly lower odds of multiple adverse process outcomes at 30- and 180-day follow-up, and significantly higher function and health-related quality of life at 30-day follow-up. Conclusion While this study was observational in nature, findings suggest CGA in the ED may improve outcomes by mitigating against the adverse effects of potentially avoidable hospital admissions and focusing on a longitudinal approach to healthcare delivery at the primary-secondary care interface. Future research should be underpinned by an experimental study design to address key limitations in this study.
Collapse
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
| | - Aoife Whiston
- 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
| | - Gillian Corey
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Collette Devlin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Deirdre Hartigan
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Aoife Synnott
- Department of Physiotherapy, University Hospital Limerick, Limerick, Ireland
| | - Aoife McCarthy
- Department of Occupational Therapy, University Hospital Limerick, Limerick, Ireland
| | - Eoin Moriarty
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Bryan Jones
- Department of Medical Social Work, University Hospital Limerick, Limerick, Ireland
| | - Ida Carroll
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Denys Shchetkovsky
- Limerick EM Education Research Training (ALERT), Emergency Department, University Hospital 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, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Fiona Steed
- Department of Health, Government of Ireland, Dublin, Ireland
| | - Leonora Carey
- Department of Occupational Therapy, University Hospital 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
| | - Aoife Leahy
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Colin Quinn
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Elaine Shanahan
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Damien Ryan
- Limerick EM Education Research Training (ALERT), Emergency Department, University Hospital Limerick, Limerick, Ireland
- School of Medicine, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, 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
| |
Collapse
|
4
|
Jomard N, Vincent A, Chammem R, Gilbert T, Rouze H, Comte B, Haesebaert J, Schott AM. Emergency calls concerning older patients: Are the appropriate questions asked? Geriatr Gerontol Int 2023; 23:54-59. [PMID: 36461775 DOI: 10.1111/ggi.14509] [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: 04/26/2022] [Revised: 10/10/2022] [Accepted: 10/17/2022] [Indexed: 12/04/2022]
Abstract
AIM In the present study, we evaluated the triage process particularly for older patients after calls to Emergency Medical Call Centers (ECC), according to the geriatric assessment tool. METHODS In this observational population-based cross-sectional study in the Rhône (France), we analyzed the audiotapes of all calls received by ECC concerning patients aged ≥75 years, during seven randomly selected days, over a period of 1 year. We analyzed whether information about seven key items, predefined by a panel of experts as essential for quality telephone triage of seniors, was actually collected. RESULTS Among 4168 calls, 712 (17.1%) concerned patients >75 years (mean ± SD, age 84.6 ± 5.6 years). The mean duration of calls was 3 min 28 s. Information about living arrangements (alone or not), dependency, multiple pathologies, polymedication, ability to walk independently or with help, and hospitalization in the previous 3 months was not collected in 20%, 42%, 40%, 45%, 58% and 61% of calls, respectively. All seven geriatric items were collected for only 54 (7.8%) calls, and only three criteria collected for 277 (40%) calls. Nurse-managed calls were significantly associated with the collection of less geriatric items compared with physician-managed calls. CONCLUSION Key information is particularly important to guide the orientation, and further management of older patients may be lacking during the telephone triage of patients in ECCs. This may represent an important level of improvement of the triage process, to address the needs of older patients better and avoid inappropriate emergency department visits. Geriatr Gerontol Int 2023; 23: 54-59.
Collapse
Affiliation(s)
- Nathalie Jomard
- Hospices Civils de Lyon, Hôpital des Charpennes, Geriatric Medical Team, Lyon, France
| | - Adélaïde Vincent
- Hospices Civils de Lyon, Hôpital E. Herriot, Acute Medical Geriatric Unit, Lyon, France
| | - Rita Chammem
- Université Claude Bernard Lyon 1, Laboratoire HESPER, Lyon, France
| | - Thomas Gilbert
- Université Claude Bernard Lyon 1, Laboratoire HESPER, Lyon, France.,Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Geriatric Deparment, Lyon, France
| | - Heloïse Rouze
- Université Claude Bernard Lyon 1, Laboratoire HESPER, Lyon, France.,Hospices Civils de Lyon, Pôle de santé publique, Lyon, France
| | - Brigitte Comte
- Hospices Civils de Lyon, Hôpital E. Herriot, Short Stay Geriatric Unit, Lyon, France
| | - Julie Haesebaert
- Université Claude Bernard Lyon 1, Laboratoire HESPER, Lyon, France.,Hospices Civils de Lyon, Pôle de santé publique, Lyon, France
| | - Anne-Marie Schott
- Université Claude Bernard Lyon 1, Laboratoire HESPER, Lyon, France.,Hospices Civils de Lyon, Pôle de santé publique, Lyon, France
| |
Collapse
|
5
|
Cen Z, Li J, Hu H, Lei KC, Loi CI, Liang Z, Chan TF, Ung COL. Exploring the implementation of an outreach specialist program for nursing home residents in Macao: A multisite, qualitative study. Front Public Health 2022; 10:950704. [PMID: 36249183 PMCID: PMC9558699 DOI: 10.3389/fpubh.2022.950704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/25/2022] [Indexed: 01/22/2023] Open
Abstract
Background The "Specialist Medical Outreach Project (SMOP)" involving inter-disciplinary hospital-based healthcare professionals is a government initiative that aims to provide integrative specialist care to high-risk residents at the nursing homes. However, research exploring the implementation and impact of SMOP is lacking. This study aimed to evidence the impact of SMOP on the quality of care at the nursing home and the key contextual determinants influencing SMOP outcomes. Method Semi-structured key informant audio-recorded face-to-face interviews were conducted with eight managers, six doctors, 28 nursing staff, and seven pharmacy staff at the nursing homes participating in the SMOP to collect insights about how SMOP was operated and performed, and the impact of SMOP as observed and expected. Participants were recruited with purposive sampling. A thematic analysis approach was employed and key themes were identified using open coding, grouping, and categorizing. Results Forty-nine interviews were conducted. Thematic analysis identified three principal themes: the overall perception about SMOP, the benefits as observed; and the areas of improvement. Together with the 10 subthemes, the results highlighted the expectations for SMOP to address the unmet needs and promote patient-centered care, and the benefits of SMOP in supporting effective use of resources for the nursing home, reducing the risks of adverse events for the residents, promoting communication and capacity building for the healthcare providers and facilitating efficient use of healthcare resources for the health system. Requests for more frequent visits by a larger inter-disciplinary specialist team were raised. Careful staff and workflow planning, and mechanisms for data-sharing and communication across care settings were deemed the most important actions for improvement. Conclusion It is a general perception that the SMOP is beneficial in enhancing the quality of care for high-risk residents in the nursing home in Macao. Cross-sector inter-disciplinary collaboration and efficient data-sharing and communication mechanism play a crucial role in ensuring the success of the program. A robust assessment framework to monitor and evaluate the cost-effectiveness of the program is yet to be developed.
Collapse
Affiliation(s)
- Zhifeng Cen
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao SAR, China
| | - Junlei Li
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao SAR, China
| | - Hao Hu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao SAR, China,Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Taipa, Macao SAR, China
| | - Ka Cheng Lei
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao SAR, China
| | - Cheng I Loi
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao SAR, China
| | - Zuanji Liang
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao SAR, China
| | - Tek Fai Chan
- Macao Society for Medicinal Administration, Taipa, Macao SAR, China
| | - Carolina Oi Lam Ung
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao SAR, China,Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Taipa, Macao SAR, China,*Correspondence: Carolina Oi Lam Ung
| |
Collapse
|
6
|
Somagutta MR, Uday U, Bathula NR, Pendyala S, Mahadevaiah A, Jain MS, Mahmutaj G, Gad M, Jean Baptiste J. Diagnosing Frailty in Primary Care Practice. Cureus 2022; 14:e23329. [PMID: 35464517 PMCID: PMC9015073 DOI: 10.7759/cureus.23329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/19/2022] [Indexed: 11/11/2022] Open
Abstract
Frailty is a complex age-related clinical condition with increased vulnerability to negative health outcomes that manifest as a multidimensional syndrome and hence, a challenge to identify at-risk populations. We aim to summarize the implementation of strategies to diagnose fragility in family practice using current evidence. We searched the PubMed and Google Scholar databases for relevant articles, using the Medical Subject Headings (MeSH) terms "Frailty," "Frailty Scales," and "Primary Health Care." All original research articles on the elderly population (65 years of age or older) published in English and the last five years were included. Frailty diagnosis has resulted in positive outcomes in the overall literature. Recent hospital admission may indicate a health problem that can end up in a negative outcome and has been often described as associated with frailty. It was also shown to affect the intensive care units' mortality, in-hospital mortality, and long-term mortality. However, multiple screening instruments have been developed and validated to improve feasibility in clinical practice. The frequent lack of agreement between frailty instruments has slowed the broad implementation of these tools. The impacts of frailty warrant an upstream, proactive, holistic, interprofessional primary care approach to its identification, assessment, and management. It is a preventable disorder; identifying elderly patients at risk in primary care can help shape appropriate care processes tailored to their needs. This literature review aims to demonstrate the importance and strategies in identifying frailty in primary care settings and assess its impact on several outcomes.
Collapse
|
7
|
Conneely M, Leahy A, O'Connor M, Barry L, Corey G, Griffin A, O'Shaughnessy Í, O'Carroll I, Leahy S, Trépel D, Ryan D, Robinson K, Galvin R. A physiotherapy-led transition to home intervention for older adults following emergency department discharge: protocol for a pilot feasibility randomised controlled trial. Pilot Feasibility Stud 2022; 8:3. [PMID: 34980285 PMCID: PMC8720939 DOI: 10.1186/s40814-021-00954-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/28/2021] [Indexed: 12/12/2022] Open
Abstract
Background Older adults frequently attend the emergency department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. This paper reports a protocol designed to evaluate the feasibility of conducting a three arm randomised controlled trial (RCT) within the ED setting and in the patient’s home. The interventions are comprehensive geriatric assessment (CGA), ED PLUS and usual care. Methods The ED PLUS pilot trial is designed as a feasibility RCT conducted in the ED and Acute Medical Assessment Unit of a university teaching hospital in the mid-west region of Ireland. We aim to recruit 30 patients, aged 65 years and over presenting to the ED with undifferentiated medical complaints and discharged within 72 h of index visit. Patients will be randomised by a computer in a ratio of 1:1:1 to deliver usual care, CGA or ED PLUS during a 6-month study period. A randomised algorithm is used to perform randomization. CGA will include a medical assessment, medication review, nursing assessment, falls assessment, assessment of mobility and stairs, transfers, personal care, activities of daily living (ADLs), social supports and baseline cognition. ED PLUS, a physiotherapist led, multidisciplinary intervention, aims to bridge the transition of care between the index visit to the ED and the community by initiating a CGA intervention in the ED and implementing a 6-week follow-up self-management programme in the patient’s own home following discharge from the ED. The outcomes will be parameters of the feasibility of the intervention and trial methods and will be assessed quantitatively and qualitatively. Discussion Rising ED visits and an ageing population with chronic health issues render ED interventions to reduce adverse outcomes in older adults a research priority. This feasibility RCT will generate data and experience to inform the conduct and delivery of a definite RCT. Trial registration The trial was registered in Clinical Trials Protocols and Results System as of 21st July 2021, with registration number NCT049836020. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-021-00954-5.
Collapse
Affiliation(s)
- Mairéad Conneely
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland.
| | - Aoife Leahy
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland.,Department of Ageing and Therapeutics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Margaret O'Connor
- Department of Ageing and Therapeutics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Louise Barry
- School of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Gillian Corey
- School of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Anne Griffin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Íde O'Shaughnessy
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland.,Department of Ageing and Therapeutics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Ida O'Carroll
- Department of Ageing and Therapeutics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Siobhán Leahy
- Department of Sport, Exercise & Nutrition, School of Science & Computing, Galway-Mayo Institute of Technology, Dublin Road, Galway, Ireland
| | - Dominic Trépel
- Trinity Institute of Neurosciences, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Damian Ryan
- Limerick EM Education Research Training (ALERT), Emergency Department, University Hospital Limerick, Dooradoyle, 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
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| |
Collapse
|
8
|
Alakare J, Kemp K, Strandberg T, Castrén M, Jakovljević D, Tolonen J, Harjola VP. Systematic geriatric assessment for older patients with frailty in the emergency department: a randomised controlled trial. BMC Geriatr 2021; 21:408. [PMID: 34215193 PMCID: PMC8252275 DOI: 10.1186/s12877-021-02351-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/13/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Comprehensive geriatric assessment provided in hospital wards in frail patients admitted to hospital has been shown to reduce mortality and increase the likelihood of living at home later. Systematic geriatric assessment provided in emergency departments (ED) may be effective for reducing days in hospital and unnecessary hospital admissions, but this has not yet been proven in randomised trials. METHODS We conducted a single-centre, randomised controlled trial with a parallel-group, superiority design in an academic hospital ED. ED patients aged ≥ 75 years who were frail, or at risk of frailty, as defined by the Clinical Frailty Scale, were included in the trial. Patients were recruited during the period between December 11, 2018 and June 7, 2019, and followed up for 365 days. For the intervention group, systematic geriatric assessment was added to their standard care in the ED, whereas the control group received standard care only. The primary outcome was cumulative hospital stay during 365-day follow-up. The secondary outcomes included: admission rate from the index visit, total hospital admissions, ED-readmissions, proportion of patients living at home at 365 days, 365-day mortality, and fall-related ED-visits. RESULTS A total of 432 patients, 63 % female, with median age of 85 years, formed the analytic sample of 213 patients in the intervention group and 219 patients in the control group. Cumulative hospital stay during one-year follow-up as rate per 100 person-years for the intervention and control groups were: 3470 and 3149 days, respectively, with rate ratio of 1.10 (95 % confidence interval, 0.55-2.19, P = .78). Admission rates to hospital wards from the index ED visit for the intervention and control groups were: 62 and 70 %, respectively (P = .10). No significant differences were observed between the groups for any outcomes. CONCLUSION Systematic geriatric assessment for older adults with frailty in the ED did not reduce hospital stay during one-year follow-up. No statistically significant difference was observed for any secondary outcomes. More coordinated, continuous interventions should be tested for potential benefits in long-term outcomes. TRIAL REGISTRATION The trial was registered in the ClinicalTrials.gov (registration number and date NCT03751319 23/11/2018).
Collapse
Affiliation(s)
- Janne Alakare
- Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, PL 340
- Haartmaninkatu 4, 00029 HUS, Helsinki, Finland.
| | - Kirsi Kemp
- Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, PL 340
- Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
| | - Timo Strandberg
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Centre for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Maaret Castrén
- Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, PL 340
- Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
| | - Dimitrije Jakovljević
- Päijät-Häme Joint Authority for Health and Wellbeing, Services for Older People, Lahti, Finland
| | - Jukka Tolonen
- Department of Internal Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Veli-Pekka Harjola
- Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, PL 340
- Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
| |
Collapse
|
9
|
Comprehensive Geriatric Assessment and Clinical Outcomes in the Older People at the Emergency Department. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18116164. [PMID: 34200317 PMCID: PMC8201329 DOI: 10.3390/ijerph18116164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 11/17/2022]
Abstract
Visits by older people to the Emergency Department (ED) have increased in recent decades with higher revisiting and admission rates after discharge, particularly for those with frailties. This study used a before-after design aimed at evaluating Comprehensive Geriatric Assessment (CGA) screening in older ED patients (aged ≥ 75 years) during the 12-month preintervention period. Additionally, a CGA-based structured follow-up program after ED discharge was executed during the next 12-month intervention period. Amongst the 358 participants (median age 82 years), involving 122 in the preintervention period and 236 in the intervention period, 77 participants (21.5%) were identified as pre-frailty, while 274 (76.5%) were identified as frail using the Fried frailty phenotype. One-hundred ten (110) (30.7%) patients revisited the ED with 73 (20.4%) being admitted and 20 (5.6%) dying within three months after ED discharge. Compared with preintervention and intervention period, it was shown that the rates of admission at the index ED visit (50.8% vs. 23.1%), and mortality (10.7% vs. 3.0%), were both were significantly reduced. Using multivariate regression analysis, it was shown frailty was significantly associated with three-month mortality after adjusting for potential confounders. On the contrary, the program significantly decreased admission and death rate. It is suggested that frailty was prevalent amongst the older ED patients, and should be screened for in order to decrease revisits/admissions after ED discharge.
Collapse
|
10
|
Liu J, Palmgren T, Ponzer S, Masiello I, Farrokhnia N. Can dedicated emergency team and area for older people reduce the hospital admission rate? - An observational pre- and post-intervention study. BMC Geriatr 2021; 21:115. [PMID: 33568087 PMCID: PMC7877031 DOI: 10.1186/s12877-021-02044-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 01/20/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Emergency department (ED) care of older patients is often complex. Geriatric ED guidelines can help to meet this challenge. However, training requirements, the use of time-consuming tools for comprehensive geriatric assessment (CGA), a lack of golden standard to identify the frail patients, and the weak evidence of positive outcomes of using CGA in EDs pose barriers to introduce the guidelines. Dedicating an interprofessional team of regular ED medical and nursing staff and an older-friendly ED area can be another approach. Previous studies of geriatrician-led CGA in EDs have reported a reduced hospital admission rate. The aim of this study was to investigate whether a dedicated interprofessional emergency team also can reduce the hospital admission rate without the resources required by the formal use of CGA. METHODS An observational pre-post study at a large adult ED, where all patients 80 years or older arriving on weekdays in the intervention period from 2016.09.26 to 2016.11.28 and the corresponding weekdays in the previous year from 2015.09.28 to 2015.11.30 were included. In the intervention period, older patients either received care in the geriatric module by the dedicated team or in the regular team modules for patients of mixed ages. In 2015, all patients received care in regular team modules. The primary outcome measure was the total hospital admission rate and the ED length of stay was the secondary outcome measure. RESULTS We included 2377 arrivals in the intervention period, when 26.7% (N = 634) received care in the geriatric module, and 2207 arrivals in the 2015 period. The total hospital admission rate was 61.7% (N = 1466/2377) in the intervention period compared to 64.8% (N = 1431/2207) in 2015 (p = 0.03). The difference was larger for patients treated in the geriatric module, 51.1% compared to 62.1% (95% CI: 56.3 to 68.0%) for patients who would have been eligible in 2015. The ED length of stay was longer in the intervention period. CONCLUSIONS An interprofessional team and area dedicated to older patients was associated to a lower hospital admission rate. Further studies are needed to confirm the results.
Collapse
Affiliation(s)
- Jenny Liu
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden.
| | - Therese Palmgren
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden
| | - Sari Ponzer
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden
| | - Italo Masiello
- Department of Computer Science and Media Technology, Linnaeus University, Växjö, Sweden
| | - Nasim Farrokhnia
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden
| |
Collapse
|
11
|
Huang YL, McGonagle M, Shaw R, Eastham J, Alsaba N, Crilly J. Models of care for frail older persons who present to the emergency department: a scoping review protocol. Syst Rev 2020; 9:280. [PMID: 33278903 PMCID: PMC7719249 DOI: 10.1186/s13643-020-01534-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 11/16/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND People aged ≥ 65 years comprise around 1 in 5 emergency department (ED) presentations. Many of these presentations occur due to complications associated with chronic diseases and frailty. This review aims to provide a comprehensive understanding of available research regarding models of care for frail older people presenting to the ED. METHODS The Joanna Briggs Institute scoping review framework will be used to guide this review. Literature searches will be conducted in the following electronic databases (from January 2009 onwards): CINAHL via EBSCOhost, Ovid MEDLINE, Embase, SocINDEX. Grey literature will be identified through searching Google Scholar. This review will consider primary research studies (including observational and interventional studies) published in English on models of care for frail older people (aged ≥ 65) presenting to the ED. Two researchers will independently screen all citations, full-text articles, and abstract data. Potential disagreements will be resolved through discussion with a third researcher. Data extracted from included studies will include the following: author(s), year of publication, country, research design and aim, time frame of the study, study population and sample size, data collection methods, definition of frailty, model of care, and key findings that pertain to the ability to inform this review. The strength of the body of evidence will be assessed using the National Health and Medical Research Council level of evidence hierarchy body of evidence matrix. Data will be presented in a tabular format and accompanied by a narrative that describes the characteristics of the body of literature. DISCUSSION Despite the increased number of ED presentations for frail older people, there has been no synthesis of the sources of evidence of model of care for frail older people in the setting of emergency care. The results of this scoping review will provide an overview of different models of care and help inform future research in the development of models of care for frail older persons, tailored to the healthcare system in the emergency context. SYSTEMATIC REVIEW REGISTRATION This scoping review has been registered in the Open Science Framework (osf.io/h2t94).
Collapse
Affiliation(s)
- Ya-Ling Huang
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, 1 Hospital Blvd, Southport, QLD 4215, Australia.
| | - Megan McGonagle
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, 1 Hospital Blvd, Southport, QLD 4215, Australia
| | - Rebecca Shaw
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, 1 Hospital Blvd, Southport, QLD 4215, Australia
| | - Julie Eastham
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, 1 Hospital Blvd, Southport, QLD 4215, Australia
| | - Nemat Alsaba
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, 1 Hospital Blvd, Southport, QLD 4215, Australia.,Bond University, 14 University Dr, Robina, QLD 4226, Australia
| | - Julia Crilly
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, 1 Hospital Blvd, Southport, QLD 4215, Australia.,School of Nursing and Midwifery, Griffith University, 1 Parklands Dr, Southport, QLD 4215, Australia.,Menzies Health Institute Queensland, Griffith University, G40 Griffith Health Centre, Level 8.86 Gold Coast Campus, Griffith University, QLD 4222, Australia
| |
Collapse
|
12
|
Dawson S, Kunonga P, Beyer F, Spiers G, Booker M, McDonald R, Cameron A, Craig D, Hanratty B, Salisbury C, Huntley A. Does health and social care provision for the community dwelling older population help to reduce unplanned secondary care, support timely discharge and improve patient well-being? A mixed method meta-review of systematic reviews. F1000Res 2020; 9:857. [PMID: 34621521 PMCID: PMC8482050 DOI: 10.12688/f1000research.25277.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2020] [Indexed: 11/20/2022] Open
Abstract
Background: This study aimed to identify and examine systematic review evidence of health and social care interventions for the community-dwelling older population regarding unplanned hospital admissions, timely hospital discharge and patient well-being. Methods: A meta-review was conducted using Joanna Briggs and PRISMA guidance. A search strategy was developed: eight bibliographic medical and social science databases were searched, and references of included studies checked. Searches were restricted to OECD countries and to systematic reviews published between January 2013-March 2018. Data extraction and quality appraisal was undertaken by one reviewer with a random sample screened independently by two others. Results: Searches retrieved 21,233 records; using data mining techniques, we identified 8,720 reviews. Following title and abstract and full-paper screening, 71 systematic reviews were included: 62 quantitative, seven qualitative and two mixed methods reviews. There were 52 reviews concerned with healthcare interventions and 19 reviews concerned with social care interventions. This meta-review summarises the evidence and evidence gaps of nine broad types of health and social care interventions. It scrutinises the presence of research in combined health and social care provision, finding it lacking in both definition and detail given. This meta-review debates the overlap of some of the person-centred support provided by community health and social care provision. Research recommendations have been generated by this process for both primary and secondary research. Finally, it proposes that research recommendations can be delivered on an ongoing basis if meta-reviews are conducted as living systematic reviews. Conclusions: This meta-review provides evidence of the effect of health and social care interventions for the community-dwelling older population and identification of evidence gaps. It highlights the lack of evidence for combined health and social care interventions and for the impact of social care interventions on health care outcomes. Registration: PROSPERO ID CRD42018087534; registered on 15 March 2018.
Collapse
Affiliation(s)
- Shoba Dawson
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Patience Kunonga
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, UK, Newcastle, UK
| | - Fiona Beyer
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, UK, Newcastle, UK
| | - Gemma Spiers
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, UK, Newcastle, UK
| | - Matthew Booker
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Ruth McDonald
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Ailsa Cameron
- School for Policy Studies, University of Bristol, Bristol, UK
| | - Dawn Craig
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, UK, Newcastle, UK
| | - Barbara Hanratty
- Population Health Sciences Institute, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle University, UK, Newcastle, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Alyson Huntley
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| |
Collapse
|
13
|
Southerland LT, Stephens JA, Carpenter CR, Mion LC, Moffatt-Bruce SD, Zachman A, Hill M, Caterino JM. Study protocol for IMAGE: implementing multidisciplinary assessments for geriatric patients in an emergency department observation unit, a hybrid effectiveness/implementation study using the Consolidated Framework for Implementation Research. Implement Sci Commun 2020; 1:28. [PMID: 32885187 PMCID: PMC7427917 DOI: 10.1186/s43058-020-00015-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 01/27/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Older adults in the emergency department (ED) are at high risk for functional decline, unrecognized delirium, falls, and medication interactions. Holistic assessment by a multidisciplinary team in the ED decreases these adverse outcomes and decreases admissions, but there are many barriers to incorporating this type of care during the ED visit. METHODS This is a hybrid type II effectiveness-implementation study using a pre-/post-cohort design (n = 380) at a tertiary care academic ED with an ED observation unit (Obs Unit). The intervention is a two-step protocol of (step 1) ED nurses screening adult patients ≥ 65 years old for geriatric needs using the Delirium Triage Screen, 4-Stage Balance Test, and the Identifying Seniors at Risk score. Patients who have geriatric needs identified by this screening but who do not meet hospital admission criteria will (step 2) be placed in the Obs Unit for multidisciplinary geriatric assessment by the hospital's geriatric consultation team, physical therapists, occupational therapists, pharmacists, and/or case managers. Not all patients may require all elements of the multidisciplinary geriatric assessment. The Consolidated Framework for Implementation Research: Care Transitions Framework was used to identify barriers to implementation. Lean Six Sigma processes will be used to overcome these identified barriers with the goal of achieving geriatric screening rates of > 80%. Implementation success and associated factors will be reported. For the effectiveness aim, pre-/post-cohorts of adults ≥ 65 years old cared for in the Obs Unit will be followed for 90 days post-ED visit (n = 150 pre and 230 post). The primary outcome is the prevention of functional decline. Secondary outcomes include health-related quality of life, new geriatric syndromes identified, new services provided, and Obs Unit metrics such as length of stay and admission rates. DISCUSSION A protocol for implementing integrated multidisciplinary geriatric assessment into the ED setting has the potential to improve patient functional status by identifying and addressing geriatric issues and needs prior to discharge from the ED. Using validated frameworks and implementation strategies will increase our understanding of how to improve the quality of ED care for older adults in the acute care setting. TRIAL REGISTRATION ClinicalTrials.gov Identifier, NCT04068311, registered 28 August 2019.
Collapse
Affiliation(s)
- Lauren T. Southerland
- Department of Emergency Medicine, The Ohio State Wexner Medical Center, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210 USA
| | - Julie A. Stephens
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State College of Medicine, Columbus, OH USA
| | | | - Lorraine C. Mion
- College of Nursing, The Ohio State Wexner Medical Center, Columbus, OH USA
| | | | - Angela Zachman
- Department of Emergency Medicine, The Ohio State Wexner Medical Center, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210 USA
| | - Michael Hill
- Department of Emergency Medicine, The Ohio State Wexner Medical Center, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210 USA
| | - Jeffrey M. Caterino
- Department of Emergency Medicine, The Ohio State Wexner Medical Center, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210 USA
| |
Collapse
|
14
|
Nouvenne A, Caminiti C, Diodati F, Iezzi E, Prati B, Lucertini S, Schianchi P, Pascale F, Starcich B, Manotti P, Brianti E, Fabi M, Ticinesi A, Meschi T. Implementation of a strategy involving a multidisciplinary mobile unit team to prevent hospital admission in nursing home residents: protocol of a quasi-experimental study (MMU-1 study). BMJ Open 2020; 10:e034742. [PMID: 32071189 PMCID: PMC7045229 DOI: 10.1136/bmjopen-2019-034742] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Nursing home residents represent a particularly vulnerable population experiencing high risk of unplanned hospital admissions, but few interventions have proved effective in reducing this risk. The aim of this research will be to verify the effects of a hospital-based multidisciplinary mobile unit (MMU) team intervention delivering urgent care to nursing home residents directly at their bedside. METHODS AND ANALYSIS Four nursing homes based in the Parma province, in Northern Italy, will be involved in this prospective, pragmatic, multicentre, 18-month quasiexperimental study (sequential design with two cohorts). The residents of two nursing homes will receive the MMU team care intervention. In case of urgent care needs, the nursing home physician will contact the hospital physician responsible for the MMU team by phone. The case will be triaged as (a) manageable by phone advice, (b) requiring urgent assessment by the MMU team or (c) requiring immediate emergency department (ED) referral. MMU team is composed of one senior physician and one emergency-medicine resident chosen within the staff of Internal Medicine and Critical Subacute Care Unit of Parma University-Hospital, usually with different specialty background, and equipped with portable ultrasound, set of drugs and devices useful in urgency. The MMU visits patients in nursing homes, with the mission to stabilise clinical conditions and avoid hospital admission. Residents of the other two nursing homes will receive usual care, that is, ED referral in every case of urgency. Study endpoints include unplanned hospital admissions (primary), crude all-cause mortality, hospital mortality, length of stay and healthcare-related costs (secondary). ETHICS AND DISSEMINATION The study protocol was approved by the Ethics Committee of Area Vasta Emilia Nord (Emilia-Romagna region). Informed consent will be collected from patients or legal representatives. The results will be actively disseminated through peer-reviewed journals and conference presentations, in compliance with the Italian law. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT04085679); Pre-results.
Collapse
Affiliation(s)
- Antonio Nouvenne
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Caterina Caminiti
- Research and Innovation Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Francesca Diodati
- Research and Innovation Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Elisa Iezzi
- Research and Innovation Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Beatrice Prati
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Stefano Lucertini
- Primary Care Department, Azienda Unità Sanitaria Locale di Parma, Parma, Emilia-Romagna, Italy
| | - Paolo Schianchi
- Primary Care Department, Azienda Unità Sanitaria Locale di Parma, Parma, Emilia-Romagna, Italy
| | - Federica Pascale
- Primary Care Department, Azienda Unità Sanitaria Locale di Parma, Parma, Emilia-Romagna, Italy
| | - Bruno Starcich
- Primary Care Department, Azienda Unità Sanitaria Locale di Parma, Parma, Emilia-Romagna, Italy
| | - Pietro Manotti
- Medical Direction, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Ettore Brianti
- Medical Direction, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Massimo Fabi
- General Management, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Andrea Ticinesi
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Tiziana Meschi
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
- Department of Medicine and Surgery, Università degli studi di Parma, Parma, Italy
| |
Collapse
|
15
|
Southerland LT, Lo AX, Biese K, Arendts G, Banerjee J, Hwang U, Dresden S, Argento V, Kennedy M, Shenvi CL, Carpenter CR. Concepts in Practice: Geriatric Emergency Departments. Ann Emerg Med 2019; 75:162-170. [PMID: 31732374 DOI: 10.1016/j.annemergmed.2019.08.430] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/16/2019] [Accepted: 08/19/2019] [Indexed: 01/02/2023]
Abstract
In 2018, the American College of Emergency Physicians (ACEP) began accrediting facilities as "geriatric emergency departments" (EDs) according to adherence to the multiorganizational guidelines published in 2014. The guidelines were developed to help every ED improve its care of older adults. The geriatric ED guideline recommendations span the care continuum from out-of-hospital care, ED staffing, protocols, infrastructure, and transitions to outpatient care. Hospitals interested in making their EDs more geriatric friendly thus face the challenge of adopting, adapting, and implementing extensive guideline recommendations in a cost-effective manner and within the capabilities of their facilities and staff. Because all innovation is at heart local and must function within the constraints of local resources, different hospital systems have developed implementation processes for the geriatric ED guidelines according to their differing institutional capabilities and resources. This article describes 4 geriatric ED models of care to provide practical examples and guidance for institutions considering developing geriatric EDs: a geriatric ED-specific unit, geriatrics practitioner models, geriatric champions, and geriatric-focused observation units. The advantages and limitations of each model are compared and examples of specific institutions and their operational metrics are provided.
Collapse
Affiliation(s)
- Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Alexander X Lo
- Department of Emergency Medicine, Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kevin Biese
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Glenn Arendts
- Emergency Medicine, School of Medicine, University of Western Australia, Perth, Australia
| | - Jay Banerjee
- College of Life Sciences, University of Leicester and Department of Emergency Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Ula Hwang
- Department of Emergency Medicine, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, NY
| | - Scott Dresden
- Department of Emergency Medicine, Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Vivian Argento
- Geriatric Services, Bridgeport Hospital, Yale University School of Medicine, New Haven, CT
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Christina L Shenvi
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | |
Collapse
|
16
|
Hesselink G, Demirbas M, Rikkert MO, Schoon Y. Geriatric Education Programs for Emergency Department Professionals: A Systematic Review. J Am Geriatr Soc 2019; 67:2402-2409. [PMID: 31335964 PMCID: PMC6900059 DOI: 10.1111/jgs.16067] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 06/05/2019] [Accepted: 06/08/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate geriatric education programs for emergency department (ED) professionals based on: content and teaching methods and learning outcome effects and factors promoting or hindering program implementation. DESIGN Systematic review. SETTING ED. PARTICIPANTS Physicians, nurses, and medical residents working in the ED. METHODS AND MEASUREMENT Five major biomedical databases were searched for (quasi) experimental studies, published between 1990 and April 2018, evaluating geriatric education programs for ED professionals. Data were synthesized around study quality, learning participants, teaching content and methods, and Kirkpatrick learning outcomes. RESULTS Nine before‐after studies were included. Learners were mostly ED residents and, to a smaller extent, ED nurses and physicians. Study quality was moderate, with the lowest scores on sampling and instrument validity. Programs varied from a 1‐day workshop to a 2‐year curriculum, mostly combining didactic lectures with active and experiential learning formats. Topics commonly addressed included managing: geriatric syndromes, trauma and falls, medication, atypical presentations, and care transitions. Statistically significant improvements were mostly found in learners' knowledge acquisition (six studies). Significant improvements were also found in single studies on: self‐reported geriatric screening, documentation of geriatric care, and appropriate urinary catheter placement. Factors promoting program implementation included: solving competing educational demands and busy work schedules, embedding the program in preexisting curricula, and close collaboration between emergency and geriatric medicine faculties. CONCLUSIONS Various geriatric education programs improve the geriatric knowledge of ED professionals and seem to positively impact their clinical practice. However, more program evaluations with larger study samples, and use of valid and reliable outcome measures, are needed to provide robust evidence on the effectiveness of such programs. J Am Geriatr Soc, 1–8, 2019. J Am Geriatr Soc 67:2402–2409, 2019
Collapse
Affiliation(s)
- Gijs Hesselink
- Emergency Department, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,IQ Health Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Mehmet Demirbas
- Department of Geriatric Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Marcel Olde Rikkert
- Department of Geriatric Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Yvonne Schoon
- Emergency Department, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Department of Geriatric Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| |
Collapse
|
17
|
Hughes JM, Freiermuth CE, Shepherd-Banigan M, Ragsdale L, Eucker SA, Goldstein K, Hastings SN, Rodriguez RL, Fulton J, Ramos K, Tabriz AA, Gordon AM, Gierisch JM, Kosinski A, Williams JW. Emergency Department Interventions for Older Adults: A Systematic Review. J Am Geriatr Soc 2019; 67:1516-1525. [PMID: 30875098 PMCID: PMC6677239 DOI: 10.1111/jgs.15854] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/21/2019] [Accepted: 02/02/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To evaluate the effect of emergency department (ED) interventions on clinical, utilization, and care experience outcomes for older adults. DESIGN A conceptual model informed, protocol-based systematic review. SETTING Emergency Department (ED). PARTICIPANTS Older adults 65 years of age and older. METHODS AND MEASUREMENT Medline, Embase, CINAHL, and PsycINFO were searched for English-language studies published through December 2017. Studies evaluating the use of one or more eligible intervention strategies (discharge planning, case management, medication safety or management, and geriatric EDs including those that cited the 2014 Geriatric ED Guidelines) with adults 65 years of age and older were included. Studies were classified by the number of intervention strategies used (ie, single strategy or multi-strategy) and key intervention components present (ie, assessment, referral plus follow-up, and contact both before and after ED discharge ["bridge"]). The effect of ED interventions on clinical (functional status, quality of life [QOL]), patient experience, and utilization (hospitalization, ED return visit) outcomes was evaluated. RESULTS A total of 2000 citations were identified; 17 articles describing 15 unique studies (9 randomized and 6 nonrandomized) met eligibility criteria and were included in analyses. ED interventions showed a mixed pattern of effects. Overall, there was a small positive effect of ED interventions on functional status but no effects on QOL, patient experience, hospitalization at or after the initial ED index visit, or ED return visit. CONCLUSION Studies using two or more intervention strategies may be associated with the greatest effects on clinical and utilization outcomes. More comprehensive interventions, defined as those with all three key intervention components present, may be associated with some positive outcomes.
Collapse
Affiliation(s)
- Jaime M. Hughes
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina
| | - Caroline E. Freiermuth
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Megan Shepherd-Banigan
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Luna Ragsdale
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Stephanie A. Eucker
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Karen Goldstein
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - S. Nicole Hastings
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, North Carolina
| | | | - Jessica Fulton
- Psychology Service, Durham VA Health Care System, Durham, North Carolina
| | - Katherine Ramos
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, North Carolina
| | - Amir Alishahi Tabriz
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Adelaide M. Gordon
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
| | - Jennifer M. Gierisch
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Andrzej Kosinski
- Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina
| | - John W. Williams
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
18
|
Ukkonen M, Jämsen E, Zeitlin R, Pauniaho SL. Emergency department visits in older patients: a population-based survey. BMC Emerg Med 2019; 19:20. [PMID: 30813898 PMCID: PMC6391758 DOI: 10.1186/s12873-019-0236-3] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 02/20/2019] [Indexed: 11/23/2022] Open
Abstract
Background Given the higher incidence of emergency conditions in older inhabitants, the global increase in aged population will pose a challenge for emergency services. In this study we examined the burden caused to emergency health care by the aged population. Methods Consecutive patients aged 80 years or over visiting a high-volume, collaborative emergency department (ED) between 2015 and 2016 were included. The key factors under analysis were the incidence of emergency conditions and costs associated with emergency care. Results A total of 6944 patients (median age 85 years, range 80–104 years; 67% female) aged ≥80 years representing 1.5% of the local population, made 17,769 ED visits during the two-year observation period accounting for 15% of all ED visits. Forty-two percent (n = 2884) of patients had a single ED visit, whereas 8.2% (n = 570) made ≥5 ED visits/year for a total of 1400 visits (7.9%). Thirty-two percent of those aged ≥80 years required ED services each year. The number of ED visits increased with age (p < 0.001); and was 768/1000 person-years among octogenarians and 1007/1000 among nonagenarians, in comparison to 233/1000 among those aged < 80 years. One in five of the study population were discharged with non-specific diagnoses. Typical diagnoses included pneumonia (4.8%), malaise and fatigue (4.5%) and heart failure (4.3%). Non-specific diagnoses were frequent, and examination of patients with non-specific diagnoses incurred costs similar to or higher than those of other patients. The mean cost per ED visit in older patients was 422 €. Conclusions We demonstrated a high incidence of emergency department visits in older patients. While our aim was not to solve how the growing demand should be met, it seems unlikely that increasing ED resources is feasible. Instead, the focus should be on chronic care of the aged and prevention of potentially avoidable ED visits.
Collapse
Affiliation(s)
- Mika Ukkonen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland.,Emergency Division of Pirkanmaa Hospital District, Tampere University Hospital, Teiskontie 35, 33521, Tampere, Finland
| | - Esa Jämsen
- Centre of Geriatrics, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Rainer Zeitlin
- Department of General Administration, Tampere University Hospital, Tampere, Finland
| | - Satu-Liisa Pauniaho
- Emergency Division of Pirkanmaa Hospital District, Tampere University Hospital, Teiskontie 35, 33521, Tampere, Finland.
| |
Collapse
|
19
|
Theou O, Searle SD. Using frailty tools as prognostic markers in patients who are acutely ill. CMAJ 2018; 190:E182-E183. [PMID: 29565017 PMCID: PMC5828888 DOI: 10.1503/cmaj.170902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Olga Theou
- Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, NS
| | - Samuel D Searle
- Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, NS
| |
Collapse
|
20
|
Arendts G. How comprehensive is comprehensive enough? Emergency Department assessment of older people. Age Ageing 2017; 46:340-341. [PMID: 28104600 DOI: 10.1093/ageing/afw258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Indexed: 11/13/2022] Open
Affiliation(s)
- Glenn Arendts
- Emergency Medicine, University of Western Australia, Crawley, Western Australia, Australia
| |
Collapse
|