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Munir Ehrlington S, Hörlin E, Toll John R, Wretborn J, Wilhelms D. Frailty is associated with 30-day mortality: a multicentre study of Swedish emergency departments. Emerg Med J 2024:emermed-2023-213444. [PMID: 39053972 DOI: 10.1136/emermed-2023-213444] [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: 06/22/2023] [Accepted: 07/09/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Older patients living with frailty have an increased risk for adverse events. The Clinical Frailty Scale (CFS) is a 9-point frailty assessment instrument that has shown promise to identify frail emergency department (ED) patients at increased risk of adverse outcomes. The aim of this study was to investigate the association between CFS scores and 30-day mortality in an ED setting when assessments are made by regular ED staff. METHOD This was a prospective multicentre observational study carried out between May and November 2021 at three EDs in Sweden, where frailty via CFS is routinely assessed by ED staff. All patients ≥65 years of age were eligible for inclusion. Mortality at 7, 30 and 90 days, admission rate, ED and hospital length of stay (LOS) were compared between patients living with frailty (CFS≥5) and robust patients. Logistic regression was used to adjust for confounders. RESULTS A total of 1840 ED visits of patients aged ≥65 years with CFS assessments done during the study period were analysed, of which 606 (32.9%) were patients living with frailty. Mortality after the index visit was higher in patients living with frailty at 7 days (2.6% vs 0.2%), 30 days (7.9% vs 0.9%) and 90 days (15.5% vs 2.4%). Adjusted ORs for mortality for those with frailty compared with more robust patients were 9.9 (95% CI 2.1 to 46.5) for 7-day, 6.0 (95% CI 3.0 to 12.2) for 30-day and 5.7 (95% CI 3.6 to 9.1) 90-day mortality. Patients living with frailty had higher admission rates, 58% versus 36%, a difference of 22% (95% CI 17% to 26%), longer ED LOS, 5 hours:08 min versus 4 hours:36 min, a difference of 31 min (95% CI 14 to 50), and longer in-hospital LOS, 4.8 days versus 2.7 days, a difference of 2.2 days (95% CI 1.2 to 3.0). CONCLUSION Patients living with frailty, had significantly higher mortality and admission rates as well as longer ED and in-hospital LOS compared with robust patients. The results confirm the capability of the CFS to risk stratify short-term mortality in older ED patients. TRIAL REGISTRATION NUMBER NCT04877028.
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Affiliation(s)
| | - Erika Hörlin
- Emergency Department, Linköping University Hospital, Linkoping, Östergötland, Sweden
| | - Rani Toll John
- Emergency Department, Linköping University Hospital, Linkoping, Östergötland, Sweden
| | - Jens Wretborn
- Emergency Department, Linköping University Hospital, Linkoping, Östergötland, Sweden
| | - Daniel Wilhelms
- Emergency Department, Linköping University Hospital, Linkoping, Östergötland, Sweden
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Zaboli A, Brigo F, Sibilio S, Brigiari G, Massar M, Magnarelli G, Parodi M, Mian M, Pfeifer N, Turcato G. Assessing the utility of frailty scores in triage: a comparative study of validated scales. Intern Emerg Med 2024:10.1007/s11739-024-03684-7. [PMID: 38900239 DOI: 10.1007/s11739-024-03684-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 06/14/2024] [Indexed: 06/21/2024]
Abstract
Currently, there is conflicting evidence regarding the efficacy of frailty scales and their ability to enhance or support triage operations. This study aimed to assess the utility of three common frailty scales (CFS, PRISMA-7, ISAR) and determine their utility in the triage setting. This prospective observational monocentric study was conducted at Merano Hospital's Emergency Department (ED) from June 1st to December 31st, 2023. All patients attending this ED during the 80-day study period were included, and frailty scores were correlated with three outcomes: hospitalization, 30-day mortality, and severity of condition as assessed by ED physicians. Patients were categorized by age, and analyses were performed for the entire study population, patients aged 18-64, and those aged 65 or older. Univariate analysis was followed by multivariable analysis to evaluate whether frailty scores were independently associated with the outcomes. In multivariable analysis, none of the frailty scores were found to be associated with the study outcomes, except for the CFS, which was associated with an increased risk of 30-day mortality, with an odds ratio of 1.752 (95% CI 1.148-2.674; p = 0.009) in the general population and 1.708 (95% CI 1.044-2.793; p = 0.033) in the population aged ≥ 65. Presently, available frailty scores do not appear to be useful in the triage context. Future research should consider developing new systems for accurate frailty assessment to support risk prediction in the triage assessment.
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Affiliation(s)
- Arian Zaboli
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Via A. Volta, 13°, Bolzano, Italy.
| | - Francesco Brigo
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Via A. Volta, 13°, Bolzano, Italy
| | - Serena Sibilio
- Department Public Health, Institute of Nursing Science, Universitat Basel, Basel, BS, Switzerland
| | - Gloria Brigiari
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Magdalena Massar
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Via A. Volta, 13°, Bolzano, Italy
| | - Gabriele Magnarelli
- Department of Emergency Medicine, Hospital of Merano-Meran (SABES-ASDAA), Merano-Meran, Italy
- Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, Salzburg, Austria
| | - Marta Parodi
- Department of Internal Medicine, Intermediate Care Unit, Hospital Alto Vicentino (AULSS-7), Santorso, Italy
| | - Michael Mian
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Via A. Volta, 13°, Bolzano, Italy
- College of Health Care-Professions Claudiana, Bozen, Italy
| | - Norbert Pfeifer
- Department of Emergency Medicine, Hospital of Merano-Meran (SABES-ASDAA), Merano-Meran, Italy
| | - Gianni Turcato
- Department of Internal Medicine, Intermediate Care Unit, Hospital Alto Vicentino (AULSS-7), Santorso, Italy
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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.
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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
| | - 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
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Källberg AS, Berg LM, Skogli S, Bjurbo C, Muntlin Å, Ehrenberg A. Prevalence of frailty and associated factors in older adults seeking care at Swedish emergency departments. BMC Geriatr 2023; 23:798. [PMID: 38049748 PMCID: PMC10694934 DOI: 10.1186/s12877-023-04545-2] [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: 06/13/2023] [Accepted: 11/30/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Internationally, prolonged length of stay for older adults in the emergency department (ED) is associated with increased risk of in-hospital adverse events. In Sweden patients 65 years and older account for 35% of emergency visits, and according to consensus from an international expert group, all persons over 70 should be screened for frailty. This is not routinely done in Swedish EDs, and therefore, knowledge about prevalence, characteristics and clinical outcomes associated with frailty is limited. AIM To describe the prevalence of frailty and associated factors in older adults seeking care at Swedish EDs. METHODS The study has a cross-sectional design. Data was collected at three hospital-based EDs, varying in level and size of setting, for one month. Patients age 70 and older presenting at the EDs and agreed to participate were screened for frailty using the FRail Elderly Support researcH group (FRESH) instrument. Data were analysed using descriptive statistics to assess the distribution of patient characteristics and clinical outcomes. Multivariate logistic regression was used to model the association between frailty and demographic characteristics, and Cox regression was used to model the association between frailty and clinical outcomes. RESULTS A total of 3101 patients were eligible for inclusion; of these, 984 (32%) were included and screened for frailty. Of the final sample, 57.3% were assessed as frail. Characteristics significantly associated with frailty were living in a residential care facility, age (> 80 years), being a woman and arriving with emergency medical service (EMS). There was a significant association between frailty and admittance to in-hospital care. CONCLUSION Our study shows a high prevalence of frailty in older people. Factors associated with frailty were living in a residential care facility, age ≥ 80 years, being a woman and arriving with EMS to the ED and being admitted to in-hospital care. Frailty screening should be incorporated in the triage system to identify frail patients who need tailored interventions. More studies using the FRESH instrument are needed to further confirm our findings and to develop the methods for screening for frailty in the ED.
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Affiliation(s)
- Ann-Sofie Källberg
- School of Health and Welfare, Dalarna University, Falun, SE-791 88, Sweden.
- Department of Emergency Medicine, Falun Hospital and Centre for Clinical Research Dalarna, Nissers väg 3, Falun, SE-791 82, Sweden.
| | - Lena M Berg
- School of Health and Welfare, Dalarna University, Falun, SE-791 88, Sweden
| | - Sara Skogli
- Department of Internal Medicine, Falun Hospital, Falun, SE-791 82, Sweden
| | - Charlotte Bjurbo
- Department of Emergency Care and Internal Medicine, Uppsala University Hospital, entrance 40, level 5, Uppsala, SE-751 85, Sweden
| | - Åsa Muntlin
- Department of Emergency Care and Internal Medicine, Uppsala University Hospital, entrance 40, level 5, Uppsala, SE-751 85, Sweden
- Department of Medical Sciences, Uppsala University, Uppsala University Hospital, entrance 40, level 5, Uppsala, SE-751 85, Sweden
| | - Anna Ehrenberg
- School of Health and Welfare, Dalarna University, Falun, SE-791 88, Sweden
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Nickel CH, Kellett J. Assessing Physiologic Reserve and Frailty in the Older Emergency Department Patient: Should the Paradigm Change? Clin Geriatr Med 2023; 39:475-489. [PMID: 37798060 DOI: 10.1016/j.cger.2023.05.004] [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] [Indexed: 10/07/2023]
Abstract
Older patients are more vulnerable to acute illness or injury because of reduced physiologic reserve associated with aging. Therefore, their assessment in the emergency department (ED) should include not only vital signs and their baseline values but also changes that reflect physiologic reserve, such as mobility, mental status, and frailty. Combining aggregated vitals sign scores and frailty might improve risk stratification in the ED. Implementing these changes in ED assessment may require the introduction of senior-friendly processes to ensure ED treatment is appropriate to the older patients' immediate discomfort, personal goals, and likely prognosis.
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Affiliation(s)
- Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, Basel CH-4031, Switzerland.
| | - John Kellett
- Department of Emergency Medicine, Odense University Hospital, University of Southern Denmark, Denmark
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Sokhal BS, Matetić A, Abhishek A, Banerjee A, Partington R, Roddy E, Rashid M, Mallen CD, Mamas MA. Impact of Frailty on Emergency Department Encounters for Cardiovascular Disease: A Retrospective Cohort Study. Am J Cardiol 2023; 206:210-218. [PMID: 37708753 DOI: 10.1016/j.amjcard.2023.08.138] [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: 07/30/2023] [Revised: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 09/16/2023]
Abstract
Data are limited on whether the causes of emergency department (ED) encounters for cardiovascular diseases (CVDs) and associated clinical outcomes vary by frailty status. Using the United States Nationwide ED Sample, selected CVD encounters (acute myocardial infarction [AMI], ischemic stroke, atrial fibrillation [AF], heart failure [HF], pulmonary embolism, cardiac arrest, and hemorrhagic stroke) were stratified by hospital frailty risk score (HFRS). Logistic regression was used to determine the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of ED mortality among the different frailty groups. A total of 8,577,028 selected CVD ED encounters were included. A total of 5,120,843 (59.7%) had a low HFRS (<5), 3,041,699 (35.5%) had an intermediate HFRS (5 to 15), and 414,485 (4.8%) had a high HFRS (>15). Ischemic stroke was the most common reason for the encounter in the high HFRS group (66.9%), followed by hemorrhagic stroke (11.7%) and AMI (7.2%). For the low HFRS group, AF was the most common reason for the encounter (30.2%), followed by AMI (23.6%) and HF (16.8%). Compared with the low-risk group, high-risk patients had a decreased ED mortality and an increased overall mortality across most CVD encounters (p <0.001). The strongest association with overall mortality was observed among patients with a high HFRS admitted for AF (aOR 27.14, 95% CI 25.03 to 29.43) and HF (aOR 13.71, 95% CI 12.95 to 14.51) compared with their low-risk counterparts. In conclusion, patients presenting to the ED with acute CVD have a significant frailty burden, with different patterns of CVD according to frailty status. Frailty is associated with an increased all-cause mortality in patients for most CVD encounters.
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Affiliation(s)
- Balamrit Singh Sokhal
- School of Medicine; Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, United Kingdom
| | - Andrija Matetić
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, United Kingdom; Department of Cardiology, University Hospital of Split, Split, Croatia
| | - Abhishek Abhishek
- Academic Rheumatology, University of Nottingham, Nottingham, United Kingdom
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, United Kingdom
| | | | - Edward Roddy
- School of Medicine; Haywood Academic Rheumatology Centre, Midland Partnership Foundation Trust, Stoke-on-Trent, United Kingdom
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, United Kingdom
| | | | - Mamas Andreas Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, United Kingdom.
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Hörlin E, Munir Ehrlington S, Toll John R, Henricson J, Wilhelms D. Is the clinical frailty scale feasible to use in an emergency department setting? A mixed methods study. BMC Emerg Med 2023; 23:124. [PMID: 37880591 PMCID: PMC10601295 DOI: 10.1186/s12873-023-00894-8] [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: 10/14/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND The Clinical Frailty Scale (CFS) is a frailty assessment tool used to identify frailty in older patients visiting the emergency department (ED). However, the current understanding of how it is used and accepted in ED clinical practice is limited. This study aimed to assess the feasibility of CFS in an ED setting. METHODS This was a prospective, mixed methods study conducted in three Swedish EDs where CFS had recently been introduced. We examined the completion rate of CFS assessments in relation to patient- and organisational factors. A survey on staff experience of using CFS was also conducted. All quantitative data were analysed descriptively, while free text comments underwent a qualitative content analysis. RESULTS A total of 4235 visits were analysed, and CFS assessments were performed in 47%. The completion rate exceeded 50% for patients over the age of 80. Patients with low triage priority were assessed to a low degree (24%). There was a diurnal variation with the highest completion rates seen for arrivals between 6 and 12 a.m. (58%). The survey response rate was 48%. The respondents rated the perceived relevance and the ease of use of the CFS with a median of 5 (IQR 2) on a scale with 7 being the highest. High workload, forgetfulness and critical illness were ranked as the top three barriers to assessment. The qualitative analysis showed that CFS assessments benefit from a clear routine and a sense of apparent relevance to emergency care. CONCLUSION Most emergency staff perceived CFS as relevant and easy to use, yet far from all older ED patients were assessed. The most common barrier to assessment was high workload. Measures to facilitate use may include clarifying the purpose of the assessment with explicit follow-up actions, as well as formulating a clear routine for the assessment. REGISTRATION The study was registered on ClinicalTrials.gov 2021-06-18 (identifier: NCT04931472).
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Affiliation(s)
- Erika Hörlin
- Department of Emergency Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Samia Munir Ehrlington
- Department of Emergency Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Rani Toll John
- Department of Emergency Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Joakim Henricson
- Department of Emergency Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Daniel Wilhelms
- Department of Emergency Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Garcia-Pérez D, Vena-Martínez A, Robles-Perea L, Roselló-Padullés T, Espaulella-Panicot J, Arnau A. Prognostic Value of a New Tool (the 3D/3D+) for Predicting 30-Day Mortality in Emergency Department Patients Aged 75 Years and Older. J Clin Med 2023; 12:6469. [PMID: 37892606 PMCID: PMC10607455 DOI: 10.3390/jcm12206469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023] Open
Abstract
The 3D/3D+ multidimensional geriatric assessment tool provides an optimal model of emergency care for patients aged 75 and over who attend the Emergency Department (ED). The baseline, or static, component (3D) stratifies the degree of frailty prior to the acute illness, while the current, or dynamic, component (3D+) assesses the multidimensional impact caused by the acute illness and helps to guide the choice of care facility for patients upon their discharge from the ED. The objective of this study was to evaluate the prognostic value of the 3D/3D+ to predict short- and long-term adverse outcomes in ED patients aged 75 years and older. Multivariable logistic regression models were used to identify the predictors of mortality 30 days after 3D/3D+ assessment. Two hundred and seventy-eight patients (59.7% women) with a median age of 86 years (interquartile range: 83-90) were analyzed. According to the baseline component (3D), 83.1% (95% CI: 78.2-87.3) presented some degree of frailty. The current component (3D+) presented alterations in 60.1% (95% CI: 54.1-65.9). The choice of care facility at ED discharge indicated by the 3D/3D+ was considered appropriate in 96.4% (95% CI: 93.0-98.0). Thirty-day all-cause mortality was 19.4%. Delirium and functional decline were the dimensions on the 3D/3D+ that were independently associated with 30-day mortality. These two dimensions had an area under receiver operating characteristic of 0.80 (95% CI: 0.73-0.86) for predicting 30-day mortality. The 3D/3D+ tool enhances the provision of comprehensive care by ED professionals, guides them in the choice of patients' discharge destination, and has a prognostic validity that serves to establish future therapeutic objectives.
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Affiliation(s)
- Dolors Garcia-Pérez
- Emergency Service, Althaia Xarxa Assistencial Universitària de Manresa, 08243 Manresa, Spain
- Doctoral Program in Medicine and Biomedical Sciences, Universitat de Vic-Universitat Central de Catalunya (UVIC-UCC), 08500 Vic, Spain
- Faculty of Medicine, Universitat de Vic-Central de Catalunya (UVIC-UCC), 08500 Vic, Spain; (J.E.-P.); (A.A.)
- Central Catalonia Chronicity Research Group (C3RG), Institut de Recerca i Innovació en Ciències de la Vida i de la Salut a la Catalunya Central (IRIS-CC), 08500 Vic, Spain
| | - Anabelén Vena-Martínez
- UFISS Geriatric Emergncy Service, Hospital Universitari de Santa Maria de Lleida, 25008 Lleida, Spain;
| | - Laura Robles-Perea
- Emergency Service, Hospital de Figueres (Fundació Salut Empordà), 17600 Figueres, Spain;
| | | | - Joan Espaulella-Panicot
- Faculty of Medicine, Universitat de Vic-Central de Catalunya (UVIC-UCC), 08500 Vic, Spain; (J.E.-P.); (A.A.)
- Central Catalonia Chronicity Research Group (C3RG), Institut de Recerca i Innovació en Ciències de la Vida i de la Salut a la Catalunya Central (IRIS-CC), 08500 Vic, Spain
- Geriatric and Palliative Care Service, Consorci Hospitalari Vic, Fundació Hospital de la Santa Creu de Vic, 08500 Vic, Spain
| | - Anna Arnau
- Faculty of Medicine, Universitat de Vic-Central de Catalunya (UVIC-UCC), 08500 Vic, Spain; (J.E.-P.); (A.A.)
- Central Catalonia Chronicity Research Group (C3RG), Institut de Recerca i Innovació en Ciències de la Vida i de la Salut a la Catalunya Central (IRIS-CC), 08500 Vic, Spain
- Research and Innovation Unit, Althaia Xarxa Assistencial Universitària de Manresa, 08243 Manresa, Spain
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Uit Het Broek LG, Ort BBA, Vermeulen H, Pelgrim T, Vloet LCM, Berben SAA. Risk stratification tools for patients with syncope in emergency medical services and emergency departments: a scoping review. Scand J Trauma Resusc Emerg Med 2023; 31:48. [PMID: 37723535 PMCID: PMC10508018 DOI: 10.1186/s13049-023-01102-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 07/16/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Patients with a syncope constitute a challenge for risk stratification in (prehospital) emergency care. Professionals in EMS and ED need to differentiate the high-risk from the low-risk syncope patient, with limited time and resources. Clinical decision rules (CDRs) are designed to support professionals in risk stratification and clinical decision-making. Current CDRs seem unable to meet the standards to be used in the chain of emergency care. However, the need for a structured approach for syncope patients remains. We aimed to generate a broad overview of the available risk stratification tools and identify key elements, scoring systems and measurement properties of these tools. METHODS We performed a scoping review with a literature search in MEDLINE, CINAHL, Pubmed, Embase, Cochrane and Web of Science from January 2010 to May 2022. Study selection was done by two researchers independently and was supervised by a third researcher. Data extraction was performed through a data extraction form, and data were summarised through descriptive synthesis. A quality assessment of included studies was performed using a generic quality assessment tool for quantitative research and the AMSTAR-2 for systematic reviews. RESULTS The literature search identified 5385 unique studies; 38 were included in the review. We discovered 19 risk stratification tools, one of which was established in EMS patient care. One-third of risk stratification tools have been validated. Two main approaches for the application of the tools were identified. Elements of the tools were categorised in history taking, physical examination, electrocardiogram, additional examinations and other variables. Evaluation of measurement properties showed that negative and positive predictive value was used in half of the studies to assess the accuracy of tools. CONCLUSION A total of 19 risk stratification tools for syncope patients were identified. They were primarily established in ED patient care; most are not validated properly. Key elements in the risk stratification related to a potential cardiac problem as cause for the syncope. These insights provide directions for the key elements of a risk stratification tool and for a more advanced process to validate risk stratification tools.
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Affiliation(s)
- Lucia G Uit Het Broek
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands.
| | - B Bastiaan A Ort
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Hester Vermeulen
- Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Thomas Pelgrim
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Lilian C M Vloet
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Sivera A A Berben
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
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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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11
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Alshibani A, Alharbi M, Conroy S. Frailty Identification in Prehospital Care: A Scoping Review of the Literature. Open Access Emerg Med 2023; 15:227-239. [PMID: 37337614 PMCID: PMC10276993 DOI: 10.2147/oaem.s409083] [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] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/22/2023] [Indexed: 06/21/2023] Open
Abstract
The proportion of older adults is increasing worldwide. Frailty assessment in prehospital care was suggested to improve triage decisions and paramedics' judgment. This study aimed to assess the scope and nature of available evidence around frailty identification in prehospital care. A systematic search of the literature was performed using MEDLINE, SCOPUS, CINHAL, and Web of Science to identify relevant articles published from January 2022 downwards. A list of indexed terms and their associated alternatives were pre-determined. Of the 71 identified and reviewed articles after removing duplicates, six articles were included in the review. Due to the heterogeneity of the included articles, the findings were described narratively. The findings of this review showed that the available evidence is limited and heterogenic. Two themes emerged from the findings of the included articles: 1) Paramedics' Perceptions about Frailty Assessment in Prehospital Care and 2) Frailty Scores for Application in Prehospital Care. Paramedics recognised frailty assessment in pre-hospital care to be feasible and important. They highlighted the need for a simple and clear frailty score that could be used and mentioned to other healthcare professionals when handing over patients. Six frailty scores were reported to be used in prehospital care. The evidence around each frailty score is very limited. Overall, frailty assessment in prehospital care was shown to be important and feasible. Different frailty scores have been assessed for use in prehospital care. Further research investigating frailty identification in prehospital care is needed.
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Affiliation(s)
- Abdullah Alshibani
- Emergency Medical Services Department, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Meshal Alharbi
- Emergency Medical Services Department, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Simon Conroy
- MRC Lifelong Health & Ageing Unit, University College London, London, UK
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12
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Prognostic Association Between Frailty and Post-Arrest Health Outcomes in Patients Receiving Home Care: A Population-Based Retrospective Cohort Study. Resuscitation 2023; 187:109766. [PMID: 36931455 DOI: 10.1016/j.resuscitation.2023.109766] [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: 11/04/2022] [Revised: 02/22/2023] [Accepted: 03/02/2023] [Indexed: 03/17/2023]
Abstract
AIM To evaluate the association between frailty and post-cardiac arrest survival, functional decline, and cognitive decline, among patients receiving home care METHODS: Frailty was measured using the Clinical Frailty Scale (CFS) and a valid frailty index. We used multivariable logistic regression to measure the association between frailty and post-arrest outcomes after adjusting for age, sex, and arrest setting. Functional independence and cognitive performance were measured using the interRAI ADL Long-Form and Cognitive Performance Scale, respectively. We conducted sub-group analytics of in-hospital and out-of-hospital arrests RESULTS: Our cohort consisted of 7,901 home care clients; most patients arrested out-of-hospital (55.4%) and were 75 years or older (66.3%). Most of the cohort was classified as frail (94.2%), with a CFS score of 5 or greater. The 30-day survival rate was higher for in-hospital (26.6%) than out-of-hospital cardiac arrests (5.2%). Most patients who survived to discharge had declines in post-arrest functional independence (65.8%) and cognitive performance (46.5%). A one-point increase in the CFS decreased the odds of 30-day survival by 8% (aOR=0.92; 95%CI = 0.87-0.97). A 0.1 unit increase in the frailty index reduced 30-day survival odds by 9% (aOR = 0.91; 95%CI = 0.86-0.96). The frailty index was associated with declines in functional independence (OR = 1.16; 95%CI = 1.02-1.31) and cognitive performance (OR = 1.24; 95%CI = 1.09-1.42), while the CFS was not. CONCLUSION Frailty is associated with cardiac arrest survival and post-arrest cognitive and functional status in patients receiving home care. Post-cardiac arrest cognitive and functional status are best predicted using more comprehensive frailty indices.
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13
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O’Caoimh R. Validation of the Risk Instrument for Screening in the Community ( RISC) among Older Adults in the Emergency Department. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3734. [PMID: 36834429 PMCID: PMC9966437 DOI: 10.3390/ijerph20043734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 06/18/2023]
Abstract
Although several short-risk-prediction instruments are used in the emergency department (ED), there remains insufficient evidence to guide healthcare professionals on their use. The Risk Instrument for Screening in the Community (RISC) is an established screen comprising three Likert scales examining the risk of three adverse outcomes among community-dwelling older adults at one-year: institutionalisation, hospitalisation, and death, which are scored from one (rare/minimal) to five (certain/extreme) and combined into an Overall RISC score. In the present study, the RISC was externally validated by comparing it with different frailty screens to predict risk of hospitalisation (30-day readmission), prolonged length of stay (LOS), one-year mortality, and institutionalisation among 193 consecutive patients aged ≥70 attending a large university hospital ED in Western Ireland, assessed for frailty, determined by comprehensive geriatric assessment. The median LOS was 8 ± 9 days; 20% were re-admitted <30 days; 13.5% were institutionalised; 17% had died; and 60% (116/193) were frail. Based on the area under the ROC curve scores (AUC), the Overall RISC score had the greatest diagnostic accuracy for predicting one-year mortality and institutionalisation: AUC 0.77 (95% CI: 0.68-0.87) and 0.73 (95% CI: 0.64-0.82), respectively. None of the instruments were accurate in predicting 30-day readmission (AUC all <0.70). The Overall RISC score had good accuracy for identifying frailty (AUC 0.84). These results indicate that the RISC is an accurate risk-prediction instrument and frailty measure in the ED.
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Affiliation(s)
- Rónán O’Caoimh
- Department of Geriatric Medicine, Mercy University Hospital, Grenville Place, T12 WE28 Cork, Ireland; ; Tel.: +353-21-420-5976
- Clinical Research Facility Cork, Mercy University Hospital, University College Cork, T12 WE28 Cork, Ireland
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14
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O’Caoimh R, McGauran J, O’Donovan MR, Gillman C, O’Hea A, Hayes M, O’Connor K, Moloney E, Alcock M. Frailty Screening in the Emergency Department: Comparing the Variable Indicative of Placement Risk, Clinical Frailty Scale and PRISMA-7. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:290. [PMID: 36612612 PMCID: PMC9819173 DOI: 10.3390/ijerph20010290] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/13/2022] [Accepted: 12/19/2022] [Indexed: 06/17/2023]
Abstract
Prompt recognition of frailty in the emergency department (ED) is important to identify patients at higher risk of adverse outcomes. Despite this, few studies examine the diagnostic accuracy of screening instruments for frailty, instead focusing on predictive validity. We compared three commonly used, short frailty screens to an independent comprehensive geriatric assessment (CGA) in an urban University Hospital ED. Consecutive attendees aged ≥70 years were screened by trained raters, blind to the CGA, with the Variable Indicative of Placement risk (VIP), 3 and 4-item versions, Clinical Frailty Scale (CFS) and PRISMA-7. Accuracy was measured from the area under the ROC curve (AUROC). In total, 197 patients were included, median age 79 (±10); 46% were female. Half (49%) were confirmed as frail after CGA. All instruments differentiated frail from non-frail states, although the CFS (AUROC: 0.91) and PRISMA-7 (AUROC: 0.90) had higher accuracy compared to the VIP-4 (AUROC: 0.84) and VIP-3 (AUROC: 0.84). The CFS was significantly more accurate than the VIP-3 (p = 0.026) or VIP-4 (p = 0.047). There was no significant difference between the CFS and PRISMA-7 (p = 0.90). The CFS and PRISMA-7 were more accurate and should be considered in preference to the VIP (3 or 4-item versions) to identify frailty in EDs.
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Affiliation(s)
- Rónán O’Caoimh
- Mercy University Hospital, Grenville Place, T12 WE28 Cork, Ireland
- Clinical Research Facility Cork, University College Cork, Mercy University Hospital, T12 WE28 Cork, Ireland
| | - Jane McGauran
- Mercy University Hospital, Grenville Place, T12 WE28 Cork, Ireland
| | - Mark R. O’Donovan
- Clinical Research Facility Cork, University College Cork, Mercy University Hospital, T12 WE28 Cork, Ireland
| | - Ciara Gillman
- Mercy University Hospital, Grenville Place, T12 WE28 Cork, Ireland
| | - Anne O’Hea
- Mercy University Hospital, Grenville Place, T12 WE28 Cork, Ireland
| | - Mary Hayes
- Mercy University Hospital, Grenville Place, T12 WE28 Cork, Ireland
| | - Kieran O’Connor
- Mercy University Hospital, Grenville Place, T12 WE28 Cork, Ireland
| | - Elizabeth Moloney
- Clinical Research Facility Cork, University College Cork, Mercy University Hospital, T12 WE28 Cork, Ireland
| | - Megan Alcock
- Mercy University Hospital, Grenville Place, T12 WE28 Cork, Ireland
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15
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Affiliation(s)
- Liang-Kung Chen
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan; Center for Healthy Longevity and Aging Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan; Taipei Municipal Gan-Dau Hospital (Managed by Taipei Veterans General Hospital), Taipei, Taiwan.
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16
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Fehlmann CA, Nickel CH, Cino E, Al-Najjar Z, Langlois N, Eagles D. Frailty assessment in emergency medicine using the Clinical Frailty Scale: a scoping review. Intern Emerg Med 2022; 17:2407-2418. [PMID: 35864373 PMCID: PMC9302874 DOI: 10.1007/s11739-022-03042-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 06/20/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Frailty is a common condition present in older Emergency Department (ED) patients that is associated with poor health outcomes. The Clinical Frailty Scale (CFS) is a tool that measures frailty on a scale from 1 (very fit) to 9 (terminally ill). The goal of this scoping review was to describe current use of the CFS in emergency medicine and to identify gaps in research. METHODS We performed a systemic literature search to identify original research that used the CFS in emergency medicine. Several databases were searched from January 2005 to July 2021. Two independent reviewers completed screening, full text review and data abstraction, with a focus on study characteristics, CFS assessment (evaluators, timing and purpose), study outcomes and statistical methods. RESULTS A total of 4818 unique citations were identified; 34 studies were included in the final analysis. Among them, 76% were published after 2018, mainly in Europe or North America (79%). Only two assessed CFS in the pre-hospital setting. The nine-point scale was used in 74% of the studies, and patient consent was required in 69% of them. The main reason to use CFS was as a main exposure (44%), a potential predictor (15%) or an outcome (15%). The most frequently studied outcomes were mortality and hospital admission. CONCLUSION The use of CFS in emergency medicine research is drastically increasing. However, the reporting is not optimal and should be more standardized. Studies evaluating the impact of frailty assessment in the ED are needed. REGISTRATION https://doi.org/10.17605/OSF.IO/W2F8N.
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Affiliation(s)
- Christophe Alain Fehlmann
- Division of Emergency Medicine, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Christian Hans Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Emily Cino
- Faculty of Medicine, University of Ottawa, Ottawa, ON Canada
| | | | - Nigèle Langlois
- Health Sciences Library, University of Ottawa, Ottawa, Canada
| | - Debra Eagles
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Ottawa Hospital Research Institute, Ottawa, ON Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON Canada
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Phelps K, Regen E, van Oppen JD, Riley P, Lalseta J, Martin G, Mason S, Conroy S. What are the goals of care for older people living with frailty when they access urgent care? Are those goals attained? A qualitative view of patient and carer perspectives. Int Emerg Nurs 2022; 63:101189. [DOI: 10.1016/j.ienj.2022.101189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/04/2022] [Accepted: 05/25/2022] [Indexed: 11/05/2022]
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Wallis M, Craswell A, Marsden E, Taylor A. Establishing the Geriatric Emergency Department Intervention in Queensland emergency departments: a qualitative implementation study using the i-PARIHS model. BMC Health Serv Res 2022; 22:692. [PMID: 35606808 PMCID: PMC9128293 DOI: 10.1186/s12913-022-08081-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 05/13/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Frail older adults require specific, targeted care and expedited shared decision making in the emergency department (ED) to prevent poor outcomes and minimise time spent in this chaotic environment. The Geriatric Emergency Department Intervention (GEDI) model was developed to help limit these undesirable consequences. This qualitative study aimed to explore the ways in which two hospital implementation sites implemented the structures and processes of the GEDI model and to examine the ways in which the i-PARIHS (innovation-Promoting Action on Research Implementation in Health Services) framework influenced the implementation. METHODS Using the i-PARIHS approach to implementation, the GEDI model was disseminated into two hospitals using a detailed implementation toolkit, external and internal facilitators and a structured program of support. Following implementation, interviews were conducted with a range of staff involved in the implementation at both sites to explore the implementation process used. Transcribed interviews were analysed for themes and sub-themes. RESULTS There were 31 interviews with clinicians involved in the implementation, conducted across two hospitals, including interviews with the two external facilitators. Major themes identified included: (i) elements of the GEDI model adopted or (ii) adapted by implementation sites and (iii) factors that affected the implementation of the GEDI model. Both sites adopted the model of care and there was general support for the GEDI approach to the management of frail older people in the ED. Both sites adapted the structure of the GEDI team and the expertise of the team members to suit their needs and resources. Elements such as service focus, funding, staff development and service evaluation were initially adopted but adaptation occurred over time. Resourcing and cost shifting issues at the implementation sites and at the site providing the external facilitators negatively impacted the facilitation process. CONCLUSIONS The i-PARIHS framework provided a pragmatic approach to the implementation of the evidenced-based GEDI model. Passionate, driven clinicians ensured that successful implementation occurred despite unanticipated changes in context at both the implementation and host facilitator sites as well as the absence of sustained facilitation support.
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Affiliation(s)
- Marianne Wallis
- Faculty of Health, Southern Cross University, Southern Cross Drive, Bilinga, Queensland Australia
- Sunshine Coast Health Institute, Birtinya, Queensland Australia
| | - Alison Craswell
- School of Nursing, Midwifery and Paramedicine, University of Sunshine Coast, Sippy Downs, Queensland Australia
| | - Elizabeth Marsden
- Sunshine Coast Health Institute, Birtinya, Queensland Australia
- School of Nursing, Midwifery and Paramedicine, University of Sunshine Coast, Sippy Downs, Queensland Australia
| | - Andrea Taylor
- Sunshine Coast Health Institute, Birtinya, Queensland Australia
- School of Nursing, Midwifery and Paramedicine, University of Sunshine Coast, Sippy Downs, Queensland Australia
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The Diagnostic Accuracy and Clinimetric Properties of Screening Instruments to Identify Frail Older Adults Attending Emergency Departments: A Protocol for a Mixed Methods Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031380. [PMID: 35162397 PMCID: PMC8834939 DOI: 10.3390/ijerph19031380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 01/23/2023]
Abstract
Background: Prompt and efficient identification and stratification of patients who are frail is important, as this cohort are at high risk of adverse healthcare outcomes. Numerous frailty screening tools have been developed to support their identification across different settings, yet relatively few have emerged for use in emergency departments (EDs). This protocol provides details for a systematic review aiming to synthesize the accumulated evidence regarding the diagnostic accuracy and clinimetric properties of frailty screening instruments to identify frail older adults in EDs. Methods: Six electronic databases will be searched from January 2000 to March 2021. Eligible studies will include adults aged ≥60 years screened in EDs with any available screening instrument to identify frailty (even if not originally designed for this purpose). Studies, including case-control, longitudinal, and cohort studies, will be included, where instruments are compared to a reference standard to explore diagnostic accuracy. Predictive accuracy for a selection of outcomes, including mortality, institutionalization, and readmission, will be assessed. Clinical and methodological heterogeneity will be examined, and a random effects meta-analysis performed if appropriate. Conclusion: Understanding whether frailty screening on presentation to EDs is accurate in identifying frailty, and predicting these outcomes is important for decision-making and targeting appropriate management.
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Beauchet O, Cooper-Brown LA, Lubov J, Allali G, Afilalo M, Launay CP. "Emergency Room Evaluation and Recommendations" (ER2) Tool for the Screening of Older Emergency Department Visitors With Major Neurocognitive Disorders: Results From the ER 2 Database. Front Neurol 2022; 12:767285. [PMID: 35069410 PMCID: PMC8770802 DOI: 10.3389/fneur.2021.767285] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/13/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: The Emergency Room Evaluation and Recommendation (ER2) is an application in the electronic medical file of patients visiting the Emergency Department (ED) of the Jewish General Hospital (JGH; Montreal, Quebec, Canada). It screens for older ED visitors at high risk of undesirable events. The aim of this study is to examine the performance criteria (i.e., sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV], positive likelihood ratio [LR+], negative likelihood ratio [LR-] and area under the receiver operating characteristic curve [AUROC]) of the ER2 high-risk level and its "temporal disorientation" item alone to screen for major neurocognitive disorders in older ED visitors at the JGH. Methods: Based on a cross-sectional design, 999 older adults (age 84.9 ± 5.6, 65.1% female) visiting the ED of the JGH were selected from the ER2 database. ER2 was completed upon the patients' arrival at the ED. The outcomes were ER2's high-risk level, the answer to ER2's temporal disorientation item (present vs. absent), and the diagnosis of major neurocognitive disorders (yes vs. no) which was confirmed when it was present in a letter or other files signed by a physician. Results: The sensitivities of both ER2's high-risk level and temporal disorientation item were high (≥0.91). Specificity, the PPV, LR+, and AROC were higher for the temporal disorientation item compared to ER2's high-risk level, whereas a highest sensitivity, LR-, and NPV were obtained with the ER2 high-risk level. Both area under the receiver operating characteristic curves were high (0.71 for ER2's high-risk level and 0.82 for ER2 temporal disorientation item). The odds ratios (OR) of ER2's high-risk level and of temporal disorientation item for the diagnosis of major neurocognitive disorders were positive and significant with all OR above 18, the highest OR being reported for the temporal disorientation item in the unadjusted model [OR = 26.4 with 95% confidence interval (CI) = 17.7-39.3]. Conclusion: Our results suggest that ER2 and especially its temporal disorientation item may be used to screen for major neurocognitive disorders in older ED users.
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Affiliation(s)
- Olivier Beauchet
- Department of Medicine, University of Montreal, Montreal, QC, Canada.,Research Center of the Geriatric University Institute of Montreal, Montreal, QC, Canada.,Division of Geriatric Medicine, Department of Medicine, Sir Mortimer B. Davis Jewish General Hospital, Lady Davis Institute for Medical Research, McGill University, Montreal, QC, Canada.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | | | - Joshua Lubov
- Division of Geriatric Medicine, Department of Medicine, Sir Mortimer B. Davis Jewish General Hospital, Lady Davis Institute for Medical Research, McGill University, Montreal, QC, Canada
| | - Gilles Allali
- Division of Neurology, Department of Neurosciences, Geneva University Hospitals, Geneva, Switzerland.,Leenaards Memory Center, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Marc Afilalo
- Emergency Department, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Cyrille P Launay
- Division of Geriatric Medicine, Department of Medicine, Sir Mortimer B. Davis Jewish General Hospital, Lady Davis Institute for Medical Research, McGill University, Montreal, QC, Canada
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21
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Conroy S, Thomas M. Urgent care for older people. Age Ageing 2022; 51:6146885. [PMID: 33620421 DOI: 10.1093/ageing/afab019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Geriatric medicine is the clinical specialty that focuses upon the care of older people-especially those with frailty (a state of increased vulnerability). In hospital, older people living with frailty are at high risk of developing a range of unpleasant outcomes such as delirium, falls, fractures, pressure sores and death. Comprehensive geriatric assessment is a form of holistic care that incorporates a specific set of clinical competencies that are able to reduce these adverse outcomes. Over the years, geriatric medicine has moved from being more of a community-based service towards a more acute specialty-encroaching now upon emergency department care. The challenge now is to work out how best to deliver geriatric care across the whole hospital (older people with frailty are not just cared for in geriatric wards!). The themed collection published on the Age & Ageing journal website outlines key articles that are attempting to develop solutions to this challenging conundrum. We hope that you enjoy reading them.
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Affiliation(s)
- Simon Conroy
- Department of Health Sciences, University of Leicester, Leicester LE1 7RH, UK
| | - Matt Thomas
- Department of Medicine for Older People, Poole Hospital, Poole BH15 2JB, UK
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22
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Boreskie KF, Hay JL, Boreskie PE, Arora RC, Duhamel TA. Frailty-aware care: giving value to frailty assessment across different healthcare settings. BMC Geriatr 2022; 22:13. [PMID: 34979966 PMCID: PMC8722007 DOI: 10.1186/s12877-021-02722-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 12/15/2021] [Indexed: 12/14/2022] Open
Abstract
Healthcare systems need to adapt to better serve an aging population with complex presentations. Frailty assessments are a potential means to address this heterogeneity in aging to identify individuals at increased risk for adverse health outcomes. Furthermore, frailty assessments offer an opportunity to optimize patient care in various healthcare settings. While the vast number of frailty assessment tools available can be a source of confusion for clinicians, each tool has features adaptable to the constraints and goals of different healthcare settings. This review discusses and compares barriers, facilitators, and the application of frailty assessments in primary care, the emergency department/intensive care unit and surgical care to cover a breadth of settings with different frailty assessment considerations. The implementation of frailty-aware care across healthcare settings potentiates better healthcare outcomes for older adults.
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Affiliation(s)
- Kevin F Boreskie
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada.
- Institute of Cardiovascular Sciences, St. Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada.
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Jacqueline L Hay
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
- Institute of Cardiovascular Sciences, St. Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
| | - Patrick E Boreskie
- Department of Emergency Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rakesh C Arora
- Institute of Cardiovascular Sciences, St. Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
- Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Todd A Duhamel
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
- Institute of Cardiovascular Sciences, St. Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
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23
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Frailty assessment and acute frailty service provision in the UK: results of a national 'day of care' survey. BMC Geriatr 2022; 22:19. [PMID: 34979956 PMCID: PMC8721940 DOI: 10.1186/s12877-021-02679-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 11/05/2021] [Indexed: 11/18/2022] Open
Abstract
Background The incorporation of acute frailty services into the acute care pathway is increasingly common. The prevalence and impact of acute frailty services in the UK are currently unclear. Methods The Society for Acute Medicine Benchmarking Audit (SAMBA) is a day of care survey undertaken annually within the UK. SAMBA 2019 (SAMBA19) took place on Thursday 27th June 2019. A questionnaire was used to collect hospital and patient-level data on the structure and organisation of acute care delivery. SAMBA19 sought to establish the frequency of frailty assessment tool use and describe acute frailty services nationally. Hospitals were classified based on the presence of acute frailty services and metrics of performance compared. Results A total of 3218 patients aged ≥70 admitted to 129 hospitals were recorded in SAMBA19. The use of frailty assessment tools was reported in 80 (62.0%) hospitals. The proportion of patients assessed for the presence of frailty in individual hospitals ranged from 2.2 to 100%. Bedded Acute Frailty Units were reported in 65 (50.3%) hospitals. There was significant variation in admission rates between hospitals. This was not explained by the presence of a frailty screening policy or presence of a dedicated frailty unit. Conclusion Two fifths of participating UK hospitals did not have a routine frailty screening policy: where this existed, rates of assessment for frailty were variable and most at-risk patients were not assessed. Responses to positive results were poorly defined. The provision of acute frailty services is variable throughout the UK. Improvement is needed for the aspirations of national policy to be fully realised.
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24
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Ticinesi A, Nouvenne A, Cerundolo N, Prati B, Parise A, Tana C, Rendo M, Guerra A, Meschi T. Accounting for frailty and multimorbidity when interpreting high-sensitivity troponin I tests in oldest old. J Am Geriatr Soc 2021; 70:549-559. [PMID: 34792185 PMCID: PMC9299120 DOI: 10.1111/jgs.17566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 12/17/2022]
Abstract
Background Older patients evaluated in Emergency Departments (ED) for suspect Myocardial Infarction (MI) frequently exhibit unspecific elevations of serum high‐sensitivity troponin I (hs‐TnI), making interpretation particularly challenging for emergency physicians. The aim of this longitudinal study was to identify the interaction of multimorbidity and frailty with hs‐TnI levels in older patients seeking emergency care. Methods A group of patients aged≥75 with suspected MI was enrolled in our acute geriatric ward immediately after ED visit. Multimorbidity and frailty were measured with Cumulative Illness Rating Scale (CIRS) and Clinical Frailty Scale (CFS), respectively. The association of hs‐TnI with MI (main endpoint) was assessed by calculation of the Area Under the Receiver‐Operating Characteristic Curve (AUROC), deriving population‐specific cut‐offs with Youden test. The factors associated with hs‐TnI categories, including MI, CFS and CIRS, were determined with stepwise multinomial logistic regression. The association of hs‐TnI with 3‐month mortality (secondary endpoint) was also investigated with stepwise logistic regression. Results Among 268 participants (147 F, median age 85, IQR 80–89), hs‐TnI elevation was found in 191 cases (71%, median 23 ng/L, IQR 11–65), but MI was present in only 12 cases (4.5%). hs‐TnI was significantly associated with MI (AUROC 0.751, 95% CI 0.580–0.922, p = 0.003), with an optimal cut‐off of 141 ng/L. hs‐TnI levels ≥141 ng/L were significantly associated with CFS (OR 1.58, 95% CI 1.15–2.18, p = 0.005), while levels <141 ng/L were associated with the cardiac subscore of CIRS (OR 1.36, 95% CI 1.07–1.71, p = 0.011). CFS, but not hs‐TnI levels, predicted 3‐month mortality. Conclusions In geriatric patients with suspected MI, frailty and cardiovascular multimorbidity should be carefully considered when interpreting emergency hs‐TnI testing.
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Affiliation(s)
- Andrea Ticinesi
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Antonio Nouvenne
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Nicoletta Cerundolo
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Beatrice Prati
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Alberto Parise
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Claudio Tana
- Internal Medicine Unit and Geriatrics Clinic, SS Annunziata Hospital, Chieti, Italy
| | - Martina Rendo
- Primary Care Department, Parma District, Azienda Unità Sanitaria Locale di Parma, Parma, Italy
| | - Angela Guerra
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Tiziana Meschi
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
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25
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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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26
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Gentili S, Emberti Gialloreti L, Riccardi F, Scarcella P, Liotta G. Predictors of Emergency Room Access and Not Urgent Emergency Room Access by the Frail Older Adults. Front Public Health 2021; 9:721634. [PMID: 34540791 PMCID: PMC8446358 DOI: 10.3389/fpubh.2021.721634] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Emergency rooms (ERs) overcrowded by older adults have been the focus of public health policies during the recent COVID-19 outbreak too. This phenomenon needed a change in the nursing care of older frail people. Health policies have tried to mitigate the frequent use of ER by implementing community care to meet the care demands of older adults. The present study aimed to investigate the predictors of emergency room access (ERA) and not-urgent emergency room access (NUERA) of community-dwelling frail older adults in order to provide an indication for out-of-hospital care services. Method: Secondary analysis of an observational longitudinal cohort study was carried out. The cohort consisted of 1,246 community-dwelling frail older adults (over 65 years) in the Latium region in Italy. The ER admission rate was assessed over 3 years from the administration of the functional geriatric evaluation (FGE) questionnaire. The ordinal regression model was used to identify the predictors of ERA and NUERA. Moreover, the ERA and NUERA rate per 100 observations/year was analyzed. Results: The mean age was 73.6 (SD ± 7.1) years, and 53.4% were women. NUERAs were the 39.2% of the ERAs; robust and pre-frail individuals (79.3% of the sample) generated more than two-third of ERAs (68.17%), even if frails and very frails showed the higher ER rates per observation/year. The ordinal logistic regression model highlighted a predictive role on ERAs of comorbidity (OR = 1.13, p < 0.001) and frailty level (OR = 1.29; p < 0.001). Concerning NUERAs, social network (OR 0.54, P = 0.015) and a medium score of pulmo-cardio-vascular function (OR 1.50, P = 0.006) were the predictors. Conclusion: Comorbidity, lack of social support, and functional limitations increase both ERA and NUERA rates generated by the older adult population. Overall, bio-psycho-social frailty represents an indicator of the frequency of ERAs. However, to reduce the number of ERAs, intervention should focus mainly on the robust and pre-frail needs for prevention and care.
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Affiliation(s)
- Susanna Gentili
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata,"Rome, Italy
| | | | - Fabio Riccardi
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata,"Rome, Italy
| | - Paola Scarcella
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata,"Rome, Italy
| | - Giuseppe Liotta
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata,"Rome, Italy
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27
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Risk for short-term undesirable outcomes in older emergency department users: Results of the ER2 observational cohort study. PLoS One 2021; 16:e0249882. [PMID: 34379629 PMCID: PMC8357090 DOI: 10.1371/journal.pone.0249882] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 03/26/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The "Emergency Room Evaluation and Recommendations" (ER2) is a clinical tool designed to determine prognosis for the short-term Emergency Department (ED) undesirable outcomes including long length of stay (LOS) in ED and in hospital, as well as the likelihood of hospital admission during an index ED visit. It is also designed to guide appropriate and timely tailor-made geriatric interventions. This study aimed to examine whether ER2 assessment part was: 1) usable by ED healthcare workers (e.g. nurses) and 2) scoring system associated with long LOS in ED and in hospital, as well as hospital admission in older ED users on stretchers. METHODS Based on an observational, prospective and longitudinal cohort study 1,800 participants visiting the ED of the Jewish General Hospital (Montreal, Quebec, Canada) were recruited between September and December 2017. ER2 assessment determined three risk-levels (i.e., low, medium and high) for short-term ED undesirable outcomes. The rate of ER2 digital form completed, the time to fill ER2 items and obtain ER2 risk-levels, the LOS in ED and in hospital, and hospital admission were used as outcomes. RESULTS ER2 was usable by ED nurses in charge of older ED users. High-risk group was associated with both increased ED stay (coefficient of regression β = 3.81 with P≤0.001) and hospital stay (coefficient of regression β = 4.60 with P = 0.002) as well as with hospital admission (HR = 1.32 with P≤0.001) when low ER2 risk level was used as referent level. Kaplan-Meier distributions showed that the three risk groups of participants differed significantly (P = 0.001). Those with high-risk level (P≤0.001) were discharged later from hospital to a non-hospital location compared to those with low risk. There was no significant difference between those classified in low-risk and in medium-risk groups (P = 0.985) and those in medium and high-risk groups (P = 0.096). CONCLUSION The ER2 assessment part is usable in daily practice of ED care and its risk stratifications may be used to predict adverse outcomes including prolonged LOS in ED and in hospital as well as hospital admission. TRIAL REGISTRATION NCT03964311.
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A narrative review of frailty assessment in older patients at the emergency department. Eur J Emerg Med 2021; 28:266-276. [PMID: 33883392 DOI: 10.1097/mej.0000000000000811] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Optimizing emergency care for the aging population is an important future challenge, as the proportion of older patients at the emergency department (ED) rapidly increases. Older patients, particularly those who are frail, have a high risk of adverse outcomes after an ED visit, such as functional decline, institutionalization, and death. The ED can have a key position in identifying frail older patients who benefit most from comprehensive geriatric care [including delirium preventive measures, early evaluation of after-discharge care, and a comprehensive geriatric assessment (CGA)]. However, performing extensive frailty assessment is not suitable at the ED. Therefore, quick and easy-to-use instruments are needed to identify older patients at risk for adverse outcomes. This narrative review outlines the importance and complexity of frailty assessment at the ED. It aligns the available screening instruments, including clinical judgment as frailty assessment, and summarizes arguments for and against frailty assessment at the ED.
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29
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The Accuracy of Four Frequently Used Frailty Instruments for the Prediction of Adverse Health Outcomes Among Older Adults at Two Dutch Emergency Departments: Findings of the AmsterGEM Study. Ann Emerg Med 2021; 78:538-548. [PMID: 34304915 DOI: 10.1016/j.annemergmed.2021.04.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Older adults presenting to the emergency department (ED) are at high risk of adverse health outcomes. This study aimed to evaluate the accuracy of 4 frequently used screening instruments for the prediction of adverse health outcomes among older adults in the ED. METHODS This was a prospective cohort study in patients ≥70 years of age presenting to the ED in 2 hospitals in the Netherlands. Screening instruments included the acutely presenting older patient screening program (APOP) (providing 2 risk scores-functional decline [APOP1] and mortality [APOP2]), the International Resident Assessment Instrument Emergendy Department screener (InterRAI ED), the Identification of Seniors At Risk-Hospitalized Patients (ISAR-HP), and the safety management system (VMS). The primary outcome measure was a composite outcome encompassing functional decline, institutionalization, and mortality at 3 months after ED presentation. Other follow-up time points were 1 and 6 months. Analyses were performed to assess prognostic accuracy. RESULTS In total, 889 patients were included. After 3 months, 267 (31%) patients experienced at least 1 adverse outcome. The positive likelihood ratio ranged from 1.67 (VMS) to 3.33 (APOP1), and the negative likelihood ratio ranged from 0.41 (ISAR-HP) to 0.88 (APOP2). Sensitivity ranged from 17% (APOP2) to 74% (ISAR-HP), and specificity ranged from 63% (ISAR-HP) to 94% (APOP2). The area under the curve ranged from 0.62 (APOP2) to 0.72 (APOP1 and ISAR-HP). Calibration was reasonable for APOP1 and VMS. The prognostic accuracy was comparable across all outcomes and at all follow-up time points. CONCLUSION The frailty screening instruments assessed in this study showed poor to moderate prognostic accuracy, which brings into question their usability in the prediction of adverse health outcomes among older adults who present to the ED.
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30
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Hollinghurst J, Housley G, Watkins A, Clegg A, Gilbert T, Conroy SP. A comparison of two national frailty scoring systems. Age Ageing 2021; 50:1208-1214. [PMID: 33252680 DOI: 10.1093/ageing/afaa252] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The electronic Frailty Index (eFI) has been developed in primary care settings. The Hospital Frailty Risk Score (HFRS) was derived using secondary care data. OBJECTIVE Compare the two different tools for identifying frailty in older people admitted to hospital. DESIGN AND SETTING Retrospective cohort study using the Secure Anonymised Information Linkage Databank, comprising 126,600 people aged 65+ who were admitted as an emergency to hospital in Wales from January 2013 up until December 2017. METHODS Pearson's correlation coefficient and weighted kappa were used to assess the correlation between the tools. Cox and logistic regression were used to estimate hazard ratios (HRs) and odds ratios (ORs). The Concordance statistic and area under the receiver operating curves (AUROC) were estimated to determine discrimination. RESULTS Pearson's correlation coefficient was 0.26 and the weighted kappa was 0.23. Comparing the highest to the least frail categories in the two scores the HRs for 90-day mortality, 90-day emergency readmission and care home admissions within 1-year using the HFRS were 1.41, 1.69 and 4.15 for the eFI 1.16, 1.63 and 1.47. Similarly, the ORs for inpatient death, length of stay greater than 10 days and readmission within 30-days were 1.44, 2.07 and 1.52 for the HFRS, and 1.21, 1.21 and 1.44 for the eFI. AUROC was determined as having no clinically relevant difference between the tools. CONCLUSIONS The eFI and HFRS have a low correlation between their scores. The HRs and ORs were higher for the increasing frailty categories for both the HFRS and eFI.
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Affiliation(s)
- Joe Hollinghurst
- Health Data Research UK (HDR-UK), Data Science Building, Swansea University, Swansea SA2 8PP, UK
| | - Gemma Housley
- East Midlands Academic Science Health Network, Nottingham, UK
| | - Alan Watkins
- Health Data Research UK (HDR-UK), Data Science Building, Swansea University, Swansea SA2 8PP, UK
| | | | - Thomas Gilbert
- Department Geriatric Medicine, Lyon University Teaching Hospital, Lyon, France
| | - Simon P Conroy
- Department of Health Sciences, University of Leicester, University Road, Leicester, LE1 7RH
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31
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Jarman H, Crouch R, Baxter M, Wang C, Peck G, Sivapathasuntharam D, Jennings C, Cole E. Feasibility and accuracy of ED frailty identification in older trauma patients: a prospective multi-centre study. Scand J Trauma Resusc Emerg Med 2021; 29:54. [PMID: 33785031 PMCID: PMC8011126 DOI: 10.1186/s13049-021-00868-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/15/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The burden of frailty on older people is identifiable by its adverse effect on mortality, morbidity and long term functional and health outcomes. In patients suffering from a traumatic injury there is increasing evidence that it is frailty rather than age that impacts greatest on these outcomes and that early identification can guide frailty specific care. The aim of this study was to evaluate the feasibility of nurse-led assessment of frailty in older trauma patients in the ED in patients admitted to major trauma centres. METHODS Patients age 65 years and over attending the Emergency Departments (ED) of five Major Trauma Centres following traumatic injury were enrolled between June 2019 and March 2020. Patients were assessed for frailty whilst in the ED using three different screening tools (Clinical Frailty Scale [CFS], Program of Research to Integrate Services for the Maintenance of Autonomy 7 [PRIMSA7], and the Trauma Specific Frailty Index [TSFI]) to compare feasibility and accuracy. Accuracy was determined by agreement with geriatrician assessment of frailty. The primary outcome was identification of frailty in the ED using three different assessment tools. RESULTS We included 372 patients whose median age was 80, 53.8% of whom were female. The most common mechanism of injury was fall from less than 2 m followed by falls greater than 2 m. Completion rates for the tools were variable, 31.9% for TSFI, compared to 93% with PRISMA7 and 98.9% with the CFS. There was substantial agreement when using CFS between nurse defined frailty and geriatrician defined frailty. Agreement was moderate using PRISMA7 and slight using TSFI. CONCLUSIONS This prospective study has demonstrated that screening for frailty in older major trauma patients within the Emergency Department is feasible and accurate using CFS. TRIAL REGISTRATION ISRCTN, ISRCTN10671514 . Registered 22 October 2019.
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Affiliation(s)
- Heather Jarman
- Emergency Department Clinical Research Unit, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.
| | - Robert Crouch
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mark Baxter
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Chao Wang
- Faculty of Health, Social Care and Education, Kingston University and St George's, University of London, London, UK
| | - George Peck
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Cara Jennings
- King's College Hospital NHS Foundation Trust, London, UK
| | - Elaine Cole
- Blizard Institute, Queen Mary's, University of London, London, UK
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Blomaard LC, de Groot B, Lucke JA, de Gelder J, Booijen AM, Gussekloo J, Mooijaart SP. Implementation of the acutely presenting older patient (APOP) screening program in routine emergency department care : A before-after study. Z Gerontol Geriatr 2021; 54:113-121. [PMID: 33471176 PMCID: PMC7946672 DOI: 10.1007/s00391-020-01837-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/16/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the effects of implementation of the acutely presenting older patient (APOP) screening program for older patients in routine emergency department (ED) care shortly after implementation. METHODS We conducted an implementation study with before-after design, using the plan-do-study-act (PDSA) model for quality improvement, in the ED of a Dutch academic hospital. All consecutive patients ≥ 70 years during 2 months before and after implementation were included. The APOP program comprises screening for risk of functional decline, mortality and cognitive impairment, targeted interventions for high-risk patients and education of professionals. Outcome measures were compliance with interventions and impact on ED process, length of stay (LOS) and hospital admission rate. RESULTS Two comparable groups of patients (median age 77 years) were included before (n = 920) and after (n = 953) implementation. After implementation 560 (59%) patients were screened of which 190 (34%) were high-risk patients. Some of the program interventions for high-risk patients in the ED were adhered to, some were not. More hospitalized patients received comprehensive geriatric assessment (CGA) after implementation (21% before vs. 31% after; p = 0.002). In 89% of high-risk patients who were discharged to home, telephone follow-up was initiated. Implementation did not influence median ED LOS (202 min before vs. 196 min after; p = 0.152) or hospital admission rate (40% before vs. 39% after; p = 0.410). CONCLUSION Implementation of the APOP screening program in routine ED care did not negatively impact the ED process and resulted in an increase of CGA and telephone follow-up in older patients. Future studies should investigate whether sustainable changes in management and patient outcomes occur after more PDSA cycles.
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Affiliation(s)
- Laura C Blomaard
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, 9600, 2300 RC, Leiden, The Netherlands.
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacinta A Lucke
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Emergency Medicine, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Jelle de Gelder
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, 9600, 2300 RC, Leiden, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Anja M Booijen
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, 9600, 2300 RC, Leiden, The Netherlands
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacobijn Gussekloo
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, 9600, 2300 RC, Leiden, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Simon P Mooijaart
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, 9600, 2300 RC, Leiden, The Netherlands
- Institute of Evidence-Based Medicine in Old Age | IEMO, Leiden, The Netherlands
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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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Beauchet O, Galery K, Vilcocq C, Maubert É, Afilalo M, Launay CP. PRISMA-7 and Risk for Short-Term Adverse Events in Older Patients Visiting the Emergency Department: Results of a Large Observational and Prospective Cohort Study. J Nutr Health Aging 2021; 25:94-99. [PMID: 33367468 DOI: 10.1007/s12603-020-1463-8] [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] [Indexed: 10/23/2022]
Abstract
BACKGROUND The "Program of Research on the Integration of Services for the Maintenance of Autonomy" (PRISMA-7) is the reference tool for the assessment of older patients visiting the emergency departments (EDs) in the province of Quebec (Canada). This study aimed to examine 1) whether the PRISMA-7 high-risk level for disabilities was associated with the length of stay in ED and in hospital, and hospital admission; and 2) performance criteria (i.e., sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV], likelihood ratios [LR]) of the PRISMA-7 high-risk level for the length of stay in ED and hospital, and hospital admission in older ED users. METHODS A total of 12,983 older ED users of the Jewish General Hospital (Montreal, Quebec, Canada) were recruited in this observational and prospective cohort study. All enrolled participants had a PRISMA-7 assessment upon their arrival at ED. The length of stay in ED and hospital, and hospital admission were used as outcomes. RESULTS A PRISMA-7 high-risk level was associated with an increased length of stay in ED and hospital (β ≥2.1 with P≤0.001 and Hazard ratio (HR)= ≥1.2 with P≤0.001) as well as in hospital (HR=1.27 with P≤0.001) in patients on a stretcher. All performance criteria were low (i.e., <0.78). Patients with a PRISMA-7 high-risk level were discharged significantly later from ED and hospital compared to those with low-risk level (P=0.001). INTERPRETATION A PRISMA-7 high-risk level was associated with a long length of stay in ED and hospital, and hospital admission in patients on a stretcher but had poor performance criteria for these adverse events, suggesting that it cannot be used as a prognostic tool in older ED users.
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Affiliation(s)
- O Beauchet
- Olivier Beauchet, MD, PhD; Department of Medicine, Division of Geriatric Medicine, Sir Mortimer B. Davis - Jewish General Hospital, McGill University, 3755 chemin de la Côte Sainte-Catherine, Montréal, QC H3T 1E2, Canada; E-mail: ; Phone: (+1) 514-340-8222, # 24741; Fax: (+1) 514-340-7547
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Abstract
BACKGROUND Early Warning Score systems are used to monitor patients at risk of deterioration. How comorbidities impact Early Warning Score's ability to predict short-term mortality in the emergency department is not fully elucidated. The aim of the study was to investigate how comorbidities impact Early Warning Score as predictor of 7-day mortality. METHODS This is an observational cohort study of adult emergency department patients attending one of the five emergency departments in Central Region Denmark from 1 March 2015 to 31 May 2015. Charlson Comorbidity Index was used as a measure of comorbidities. Logistic regression was used to calculate the odds ratio for 7-day mortality. Patients were compared in three groups: Charlson Comorbidity Index: 0, 1-2, 3+. RESULTS A total of 30 060 adult patients attended one of the five emergency departments. Nineteen thousand one hundred twenty-three patients were included. Charlson Comorbidity Index 3+ patients presenting with Early Warning Score 0, 1-2 or 3-4 had significantly higher odds ratio of 7-day mortality compared to Charlson Comorbidity Index 0 patients with equal Early Warning Score. For patients with Early Warning Score 5+, Charlson Comorbidity Index -status had no significant impact on 7-day mortality after adjusting for age. CONCLUSION In patients presenting with lower acuity (Early Warning Score 0-4) Charlson Comorbidity Index has a significant impact on 7-day mortality regardless of Early Warning Score. Including Charlson Comorbidity Index status in Early Warning Score or adjusting for Charlson Comorbidity Index -status could increase the predictive value of Early Warning Score in predicting 7-day mortality.
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Serina P, Lo AX, Kocherginsky M, Gray E, Lindquist LA, Post LA, Heinemann AW, Cruz D, Dresden SM. The Clinical Frailty Scale and Health Services Use for Older Adults in the Emergency Department. J Am Geriatr Soc 2020; 69:837-839. [PMID: 33205408 DOI: 10.1111/jgs.16937] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/20/2020] [Accepted: 10/24/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Peter Serina
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alexander X Lo
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Masha Kocherginsky
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Elizabeth Gray
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lee A Lindquist
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lori A Post
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Allen W Heinemann
- Center for Rehabilitation Outcomes Research, Shirley Ryan AbilityLab, Chicago, Illinois, USA.,Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois, USA
| | - Daniel Cruz
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Scott M Dresden
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Blomaard LC, Mooijaart SP, Bolt S, Lucke JA, de Gelder J, Booijen AM, Gussekloo J, de Groot B. Feasibility and acceptability of the 'Acutely Presenting Older Patient' screener in routine emergency department care. Age Ageing 2020; 49:1034-1041. [PMID: 32428199 PMCID: PMC7583525 DOI: 10.1093/ageing/afaa078] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Indexed: 11/12/2022] Open
Abstract
Background risk stratification tools for older patients in the emergency department (ED) have rarely been implemented successfully in routine care. Objective to evaluate the feasibility and acceptability of the ‘Acutely Presenting Older Patient’ (APOP) screener, which identifies older ED patients at the highest risk of adverse outcomes within 2 minutes at presentation. Design and setting 2-month prospective cohort study, after the implementation of the APOP screener in ED routine care in the Leiden University Medical Center. Subjects all consecutive ED patients aged ≥70 years. Methods feasibility of screening was assessed by measuring the screening rate and by identifying patient- and organisation-related determinants of screening completion. Acceptability was assessed by collecting experienced barriers of screening completion from triage-nurses. Results we included 953 patients with a median age of 77 (IQR 72–82) years, of which 560 (59%) patients were screened. Patients had a higher probability of being screened when they had a higher age (OR 1.03 (95%CI 1.01–1.06), P = 0.017). Patients had a lower probability of being screened when they were triaged very urgent (OR 0.55 (0.39–0.78), P = 0.001) or when the number of patients upon arrival was high (OR 0.63 (0.47–0.86), P = 0.003). Experienced barriers of screening completion were patient-related (‘patient was too sick’), organisation-related (‘ED was too busy’) and personnel-related (‘forgot to complete screening’). Conclusion with more than half of all older patients screened, feasibility and acceptability of screening in routine ED care is very promising. To further improve screening completion, solutions are needed for patients who present with high urgency and during ED rush hours.
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Affiliation(s)
- Laura C Blomaard
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Simon P Mooijaart
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
- Institute of Evidence-Based Medicine in Old Age
- IEMO, Leiden, The Netherlands
| | - Shanti Bolt
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacinta A Lucke
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Emergency Medicine, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Jelle de Gelder
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Anja M Booijen
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacobijn Gussekloo
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Clinical impression for identification of vulnerable older patients in the emergency department. Eur J Emerg Med 2020; 27:137-141. [DOI: 10.1097/mej.0000000000000632] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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: 56] [Impact Index Per Article: 11.2] [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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Beauchet O, Fung S, Launay CP, Cooper-Brown LA, Afilalo J, Herbert P, Afilalo M, Chabot J. Screening for older inpatients at risk for long length of stay: which clinical tool to use? BMC Geriatr 2019; 19:156. [PMID: 31170929 PMCID: PMC6555010 DOI: 10.1186/s12877-019-1165-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 05/21/2019] [Indexed: 11/23/2022] Open
Abstract
Background Screening for inpatients at risk for long length of stay (LOS) is the first step of an effective hospital care plan for older inpatients. This study aims, in older adults admitted to a geriatric acute care ward, to examine and compare the 6-item brief geriatric assessment (BGA) and the “Programme de Recherche sur l’Intégration des Services pour le Maintien de l’Autonomie” (PRISMA-7) risk levels with long LOS, and to establish their performance criteria (i.e., sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios) for LOS. Methods Based on an observational, retrospective, cohort design, 166 inpatients aged ≥75 admitted to a geriatric acute care ward of a McGill University-affiliated hospital (Montreal, Quebec, Canada) were recruited. The risk levels of the 6-item BGA (low, moderate and high) and the PRISMA-7 (low versus high) were calculated from a baseline assessment. The LOS was subsequently calculated in number of days. Results Only the 6-item BGA high risk level was associated with a long LOS (Odds ratio = 1.1 with P = 0.028 and Hazard ratio = 2.1 with P = 0.004). Kaplan-Meier distributions showed that there was no significant difference in the delay of hospital discharge between the low and high-risk level reported by the PRISMA-7 (P = 0.381), whereas the 6-item BGA three risk levels differed significantly (P = 0.008), with individuals at high risk levels being discharged later when compared to those with low (P = 0.001) and moderate (P = 0.019) risk levels. Both tools’ performance criteria were poor (i.e., < 0.70), except for PRISMA-7’s sensitivity which was 100%. Conclusion The 6-item BGA risk levels were associated with LOS, low risk-level being associated with short LOS and high-risk level with long LOS, but no association was reported with the PRISMA-7 risk levels. Both tools had poor performance criteria for long LOS, suggesting that they cannot be used as prognostic tools with current scientific knowledge.
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Affiliation(s)
- Olivier Beauchet
- Department of Medicine, Division of Geriatric Medicine, Sir Mortimer B. Davis - Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, 3755 chemin de la Côte-Sainte-Catherine, Montréal, QC, H3T 1E2, Canada. .,Dr. Joseph Kaufmann Chair in Geriatric Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada. .,Centre of Excellence on longevity of McGill integrated University Health Network, Montreal, Quebec, Canada. .,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
| | - Shek Fung
- Department of Medicine, Division of Geriatric Medicine, St. Mary's Hospital Center, McGill University, Montreal, Quebec, Canada
| | - Cyrille P Launay
- Geriatric Medicine and Geriatric Rehabilitation ServiceDepartment of Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Liam Anders Cooper-Brown
- Centre of Excellence on longevity of McGill integrated University Health Network, Montreal, Quebec, Canada
| | - Jonathan Afilalo
- Division of Cardiology and Centre for Clinical Epidemiology, Jewish General Hospital and McGill University, Montreal, Quebec, Canada
| | - Paul Herbert
- Department of medicine, Montreal university Hospital and University of Montreal, Montreal, Quebec, Canada
| | - Marc Afilalo
- Emergency Department, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Julia Chabot
- Department of Medicine, Division of Geriatric Medicine, Sir Mortimer B. Davis - Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, 3755 chemin de la Côte-Sainte-Catherine, Montréal, QC, H3T 1E2, Canada.,Department of Medicine, Division of Geriatric Medicine, St. Mary's Hospital Center, McGill University, Montreal, Quebec, Canada
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Affiliation(s)
- Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Simon P Mooijaart
- Institute for Evidence Based Medicine in Old Age, Leiden University Medical Centre, Leiden, Netherlands
| | - Katie Gallacher
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Jennifer K Burton
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Lewis ET, Dent E, Alkhouri H, Kellett J, Williamson M, Asha S, Holdgate A, Mackenzie J, Winoto L, Fajardo-Pulido D, Ticehurst M, Hillman K, McCarthy S, Elcombe E, Rogers K, Cardona M. Which frailty scale for patients admitted via Emergency Department? A cohort study. Arch Gerontol Geriatr 2018; 80:104-114. [PMID: 30448693 DOI: 10.1016/j.archger.2018.11.002] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/23/2018] [Accepted: 11/05/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To determine the prevalence of frailty in Emergency Departments (EDs); examine the ability of frailty to predict poor outcomes post-discharge; and identify the most appropriate instrument for routine ED use. METHODS In this prospective study we simultaneously assessed adults 65+yrs admitted and/or spent one night in the ED using Fried, the Clinical Frailty Scale (CFS), and SUHB (Stable, Unstable, Help to walk, Bedbound) scales in four Australian EDs for rapid recognition of frailty between June 2015 and March 2016. RESULTS 899 adults with complete follow-up data (mean (SD) age 80.0 (8.3) years; female 51.4%) were screened for frailty. Although different scales yielded vastly different frailty prevalence (SUHB 9.7%, Fried 30.4%, CFS 43.7%), predictive discrimination of poor discharge outcomes (death, poor self-reported health/quality of life, need for community services post-discharge, or reattendance to ED after the index hospitalization) for all identical final models was equivalent across all scales (AUROC 0.735 for Fried, 0.730 for CFS and 0.720 for SUHB). CONCLUSION This study confirms that screening for frailty in older ED patients can inform prognosis and target discharge planning including community services required. The CFS was as accurate as the Fried and SUHB in predicting poor outcomes, but more practical for use in busy clinical environments with lower level of disruption. Given the limitations of objectively measuring frailty parameters, self-report and clinical judgment can reliably substitute the assessment in EDs. We propose that in a busy ED environment, frailty scores could be used as a red flag for poor follow-up outcome.
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Affiliation(s)
- Ebony T Lewis
- The University of New South Wales, School of Public Health and Community Medicine, Gate 11, Botany Street, Randwick, NSW, 2052, Australia.
| | - Elsa Dent
- Torrens University Australia, 220 Victoria Square, Adelaide, SA, 5000, Australia; Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne VIC 3004, Australia.
| | - Hatem Alkhouri
- Agency for Clinical Innovation, Emergency Care Institute, PO Box 699, Chatswood, NSW, 2057, Australia; The University of New South Wales, Faculty of Medicine, High St, Kensington, NSW 2052, Australia.
| | - John Kellett
- Hospital of South West Jutland, Department of Emergency Medicine, Esbjerg, Denmark.
| | - Margaret Williamson
- The University of New South Wales, The Simpson Centre for Health Services Research, South Western Sydney Clinical School, 1 Campbell Street, Liverpool, NSW, 2170, Australia.
| | - Stephen Asha
- St George Hospital Emergency Department, Gray St, Kogarah, Sydney, NSW, 2217, Australia.
| | - Anna Holdgate
- Liverpool Hospital Emergency Department, Corner of Elizabeth and Goulburn Streets, Liverpool, Sydney, NSW, 2170, Australia.
| | - John Mackenzie
- Prince of Wales Hospital Emergency Department, Barker St, Randwick, Sydney, NSW, 2031, Australia.
| | - Luis Winoto
- Sutherland Hospital Emergency Department, The Kingsway, Caringbah, Sydney, NSW, 2229, Australia.
| | - Diana Fajardo-Pulido
- The University of New South Wales, The Simpson Centre for Health Services Research, South Western Sydney Clinical School, 1 Campbell Street, Liverpool, NSW, 2170, Australia.
| | - Maree Ticehurst
- The University of New South Wales, The Simpson Centre for Health Services Research, South Western Sydney Clinical School, 1 Campbell Street, Liverpool, NSW, 2170, Australia.
| | - Ken Hillman
- The University of New South Wales, The Simpson Centre for Health Services Research, South Western Sydney Clinical School, 1 Campbell Street, Liverpool, NSW, 2170, Australia; Liverpool Hospital Intensive Care Unit, Corner of Elizabeth and Goulburn Streets, Liverpool, NSW, 2170, Australia.
| | - Sally McCarthy
- Prince of Wales Hospital Emergency Department, Barker St, Randwick, Sydney, NSW, 2031, Australia.
| | - Emma Elcombe
- The Ingham Institute for Applied Medical Research, Western Sydney University, 1 Campbell St, Liverpool, NSW, 2170, Australia.
| | - Kris Rogers
- The George Institute for Global Health, Level 5, 1 King Street, Newtown, NSW, 2042, Australia.
| | - Magnolia Cardona
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, 14 University Drive, Robina, QLD, 4226, Australia; Gold Coast Hospital and Health Service, 1 Hospital Blvd, Southport, QLD, 4215, Australia.
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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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Theou O, Campbell S, Malone ML, Rockwood K. Older Adults in the Emergency Department with Frailty. Clin Geriatr Med 2018; 34:369-386. [DOI: 10.1016/j.cger.2018.04.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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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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Fallon A, Kilbane L, Briggs R, Dyer A, Nabeel S, McElwaine P, Collins R, Coughlan T, O'Neill D, Ryan D, Kennelly SP. Screening for frailty in older emergency department patients: the utility of the Survey of Health, Ageing and Retirement in Europe Frailty Instrument. QJM 2018; 111:151-154. [PMID: 29237068 DOI: 10.1093/qjmed/hcx242] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Greater numbers of older patients are accessing hospital services. Specialist geriatric input at presentation may improve outcomes for at-risk patients. The Survey of Health, Ageing and Retirement in Europe Frailty Instrument (SHARE-FI) frailty measure, developed for use in the community, has also been used in the emergency department (ED). AIM To measure frailty, review its prevalence in older patients presenting to ED and compare characteristics and outcomes of frail patients with their non-frail counterparts. DESIGN Patient characteristics were recorded using symphony® electronic data systems. SHARE-FI assessed frailty. Cognition, delirium and 6 and 12 months outcomes were reviewed. METHODS A prospective cohort study was completed of those aged ≥70 presenting to ED over 24 h, 7 days a week. RESULTS Almost half of 198 participants (46.7%, 93/198) were classified as frail, but this was not associated with a significant difference in mortality rates (OR 0.89, 95% CI 0.58-1.38, P = 0.614) or being alive at home at 12 months (OR 1.07, 95% CI 0.72-1.57, P = 0.745). Older patients were more likely to die (OR 2.34, 95% CI 1.30-4.21, P = 0.004) and less likely to be alive at home at 12 months (OR 0.49, 95% CI 0.23-0.83, P = 0.009). Patients with dementia (OR 0.24, P = 0.005) and on ≥5 medications (OR 0.37, 95% CI 0.16-0.87, P = 0.022) had a lower likelihood of being alive at home at 12 months. CONCLUSIONS Almost half of the sample cohort was frail. Older age was a better predictor of adverse outcomes than frailty as categorized by the SHARE-FI. SHARE-FI has limited predictability when used as a frailty screening instrument in the ED.
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Affiliation(s)
- A Fallon
- Department of Age-Related Health Care, Tallaght Hospital, Dublin 24, Ireland
| | - L Kilbane
- Department of Age-Related Health Care, Tallaght Hospital, Dublin 24, Ireland
| | - R Briggs
- Department of Age-Related Health Care, Tallaght Hospital, Dublin 24, Ireland
| | - A Dyer
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Ireland
| | - S Nabeel
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Ireland
| | - P McElwaine
- Acute Medical Assessment Unit, Tallaght Hospital, Dublin 24, Ireland
| | - R Collins
- Department of Age-Related Health Care, Tallaght Hospital, Dublin 24, Ireland
| | - T Coughlan
- Department of Age-Related Health Care, Tallaght Hospital, Dublin 24, Ireland
| | - D O'Neill
- Department of Age-Related Health Care, Tallaght Hospital, Dublin 24, Ireland
| | - D Ryan
- Department of Age-Related Health Care, Tallaght Hospital, Dublin 24, Ireland
| | - S P Kennelly
- Department of Age-Related Health Care, Tallaght Hospital, Dublin 24, Ireland
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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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