Demography is destiny: an agenda for geriatric emergency medicine in Australasia

Societal vulnerability in the context of population aging-Perceptions of healthcare students' in Saudi Arabia

Background and objective

Healthcare professionals have an important role in increasing awareness and protecting populations from natural disasters. This study aimed to assess the perception of healthcare students toward societal vulnerability in the context of population aging.

Methods

This is a cross-sectional questionnaire-based study conducted among students from two different health colleges over 4 months from February to May 2021. Descriptive analysis was used to assess the perception, and inferential testing was used to assess the various association of knowledge toward societal vulnerability using SPSS.

Results

The majority of respondents were male (69.2%), between 20 and 24 years of age (91.2%), and studying for a nursing degree (76.6%). Only 4.7% had previously completed a previous degree. The mean score of perceptions on the Aging and Disaster Vulnerability Scale among nursing students was 42.5 ± 10.3 (0-65) while for paramedicine 48.1 ± 9.7 (0-65). Similarly, the mean score among male students was 44.1 ±10.5. The mean PADVS total score for the cohort was 43.8 (SD = 10.5). The mean PADVS total score for nursing students was significantly lower than paramedic students (42.5 vs. 48.1; p < 0.001). There was no correlation between PADVS total score and gender, age, area of residence, or previous degree.

Conclusion

Our results indicate that Saudi healthcare students perceive older adults are somewhat vulnerable to disasters with significant differences between nursing and paramedic students. Furthermore, we suggest informing emergency services disaster response planning processes about educational intervention to overcome disasters in Saudi Arabia and other countries.

Prioritising models of healthcare service delivery for a more sustainable health system: a Delphi study of Australian health policy, clinical practice and management, academic and consumer stakeholders

Objectives Healthcare expenditure is growing at an unsustainable rate in developed countries. A recent scoping review identified several alternative healthcare delivery models with the potential to improve health system sustainability. Our objective was to obtain input and consensus from an expert Delphi panel about which alternative models they considered most promising for increasing value in healthcare delivery in Australia and to contribute to shaping a research agenda in the field. Methods The panel first reviewed a list of 84 models obtained through the preceding scoping review and contributed additional ideas in an open round. In a subsequent scoring round, the panel rated the priority of each model in terms of its potential to improve health care sustainability in Australia. Consensus was assumed when ≥50% of the panel rated a model as (very) high priority (consensus on high priority) or as not a priority or low priority (consensus on low priority). Results Eighty-two of 149 invited participants (55%) representing all Australian states/territories and wide expertise completed round one; 71 completed round two. Consensus on high priority was achieved for 59 alternative models; 14 were rated as (very) high priority by ≥70% of the panel. Top priorities included improving medical service provision in aged care facilities, providing single-point-access multidisciplinary care for people with chronic conditions and providing tailored early discharge and hospital at home instead of in-patient care. No consensus was reached on 47 models, but no model was deemed low priority. Conclusions Input from an expert stakeholder panel identified healthcare delivery models not previously synthesised in systematic reviews that are a priority to investigate. Strong consensus exists among stakeholders regarding which models require the most urgent attention in terms of (cost-)effectiveness research. These findings contribute to shaping a research agenda on healthcare delivery models and where stakeholder engagement in Australia is likely to be high. What is known about the topic? Healthcare expenditure is growing at an unsustainable rate in high-income countries worldwide. A recent scoping review of systematic reviews identified a substantial body of evidence about the effects of a wide range of models of healthcare service delivery that can inform health system improvements. Given the large number of systematic reviews available on numerous models of care, a method for gaining consensus on the models of highest priority for implementation (where evidence demonstrates this will lead to beneficial effects and resource savings) or for further research (where evidence about effects is uncertain) in the Australian context is warranted. What does this paper add? This paper describes a method for reaching consensus on high-priority alternative models of service delivery in Australia. Stakeholders with leadership roles in health policy and government organisations, hospital and primary care networks, academic institutions and consumer advocacy organisations were asked to identify and rate alternative models based on their knowledge of the healthcare system. We reached consensus among ≥70% of stakeholders that improving medical care in residential aged care facilities, providing single-point-access multidisciplinary care for patients with a range of chronic conditions and providing early discharge and hospital at home instead of in-patient stay for people with a range of conditions are of highest priority for further investigation. What are the implications for practitioners? Decision makers seeking to optimise the efficiency and sustainability of healthcare service delivery in Australia could consider the alternative models rated as high priority by the expert stakeholder panel in this Delphi study. These models reflect the most promising alternatives for increasing value in the delivery of health care in Australia based on stakeholders' knowledge of the health system. Although they indicate areas where stakeholder engagement is likely to be high, further research is needed to demonstrate the effectiveness and cost-effectiveness of some of these models.

Care of frail and older adults: A content analysis of paramedic operational clinical practice guidelines

INTRODUCTION

Frailty rates are increasing with population ageing. In paramedicine, Clinical Practice Guidelines (CPGs) are essential documents that support decision making, yet little evidence exists regarding the support CPGs provide paramedics in the care of frail and older adults.

AIM

To investigate how CPGs support paramedics' care of frail and older adults.

METHODS

CPGs from nine Australasian paramedic services were collected in 2019. Content analysis was used to explore two hundred and thirty-seven individual CPGs for decision support information regarding frail and older adults.

RESULTS

Evidence-based content relating to older adults was sparse compared to paediatric content. Two overarching decision support domains were identified, patient assessment and management. Inconsistent age descriptors were widespread, particularly in pharmacological guidelines. Five service providers' CPGs contained validated assessment instruments for use with older adults.

CONCLUSION

Decision support documentation regarding frail and older adults varies across Australasian paramedic services. Frailty and older adult specific CPGs, and validated assessment instruments suitable to the paramedicine environment could improve paramedic decision making and minimise patient risk. A collaborative approach encompassing service providers and educational institutions is crucial to develop consistent, evidence-based CPGs relevant to older adults.

Patients in need of comprehensive geriatric assessment: The utility of the InterRAI emergency department screener

INTRODUCTION

The interRAI Emergency Department-Screener (ED-screener) is a risk stratification instrument incorporating functional and social aspects to identify older adults in EDs. The aim was to assess the construct validity and utility of the ED-screener in comparison with more established instruments.

METHODS

The ED-screener, Triage Risk Screening Tool (TRST) and Identification of Seniors at Risk (ISAR) were administered to older ED-patients. Construct validity was assessed by correlation with TRST and ISAR. The ED-screener scores that corresponded to the established cut-offs for ISAR and TRST were assessed with linear regression. The sensitivity and specificity of the ED-screener for mortality at 4-months were calculated.

RESULTS

Two hundred patients were included (mean age 78.5 years, 44% male). Majority (85%) lived at home, 43% lived alone and 53% received home care. The scores of 3.02 and 3.01 on ED-screener corresponded to the cut-off score of 2 on the other instruments. The correlation of the ED-screener with ISAR and TRST was 0.56 and 0.41 respectively. A score of 3 on the ED-screener was 100% sensitive and 28% specific for 4-month mortality.

CONCLUSION

These findings provide support for the construct validity of the ED-screener and its ability to predict outcomes in its intended setting.

Here one year, gone the next? Investigating persistence of frequent emergency department attendance: a retrospective study in Australia

OBJECTIVES

Patients are presenting to emergency departments (EDs) with increasing complexity at rates beyond population growth and ageing. Intervention studies target patients with 12 months or less of frequent attendance. However, these interventions are not well targeted since most patients do not remain frequent attenders. This paper quantifies temporary and ongoing frequent attendance and contrasts risk factors for each group.

DESIGN

Retrospective population-based study using 10 years of longitudinal data.

SETTING

An Australian geographic region that includes metropolitan and rural EDs.

PARTICIPANTS

332 100 residents visited any ED during the study period.

MAIN OUTCOME MEASURE

Frequent attendance was defined as seven or more visits to any ED in the region within a 12-month period. Temporary frequent attendance was defined as meeting this threshold only once, and ongoing more than once. Risk factors for temporary and ongoing frequent attenders were identified using logistic regression models for adults and children.

RESULTS

Of 8577 frequent attenders, 80.1% were temporary and 19.9% ongoing (12.9% repeat, 7.1% persistent). Among adults, ongoing were more likely than temporary frequent attenders to be young to middle aged (aged 25-64 years), and less likely to be from a high socioeconomic area or be admitted. Ongoing frequent attenders had higher rates of non-injury presentations, in particular substance-related (OR=2.5, 99% CI 1.1 to 5.6) and psychiatric illness (OR=2.9, 99% CI 1.8 to 4.6). In comparison, children who were ongoing were more likely than temporary frequent attenders to be aged 5-15 years, and were not more likely to be admitted (OR=2.7, 99% CI 0.7 to 10.9).

CONCLUSIONS

Future intervention studies should distinguish between temporary and ongoing frequent attenders, develop specific interventions for each group and include rigorous evaluation.

A randomized-controlled trial of a patient-centred intervention in high-risk discharged older patients

BACKGROUND

The risk of early reattendance after discharge has been proposed as a performance indicator for emergency departments (EDs), but is not uniform in all patients. Those individuals at the highest risk of reattendance may benefit from an intense intervention to reduce this risk, and our objective was to test this hypothesis in a clinical trial.

METHODS

A randomized-controlled trial was conducted in the EDs of two hospitals. Very high-risk adults aged 65 years and older, identified using a validated risk-prediction nomogram and being discharged from ED, were randomized to receive a postdischarge patient-centred intervention or standard care. The intervention focused on identifying and supporting patients to address risk factors for future hospital presentation. The primary outcome measure was any unplanned ED reattendance within 28 days. Secondary outcomes included 28-day and 1-year hospital usage, institutionalization and death.

RESULTS

We enrolled 164 patients, 82 in each study arm. There was an 8% absolute (95% confidence interval: -7%-20%) and a 20% relative risk reduction for an intervention patient making an unplanned ED reattendance within 28 days. This difference was not statistically significant (P=0.26).

CONCLUSION

This postdischarge intervention was associated with only small and nonsignificant reductions in ED reattendance.

Health Care Student Perceptions of Societal Vulnerability to Disasters in the Context of Population Aging

OBJECTIVE

This paper reports on undergraduate health care students' perception of societal vulnerability to disasters in the context of population aging. Forecast increases in extreme weather events are likely to have a particularly devastating effect on older members of the community.

METHODS

Undergraduate paramedicine and nursing students were surveyed using the Perceptions of Ageing and Disaster Vulnerability Scale (PADVS) to determine their views on the risks posed to older members of the community by disasters. Data analysis included a comparison of subscales relating to isolation, health system readiness, declining function, and community inclusiveness.

RESULTS

Students reported a moderate level of concern about disaster vulnerability. Students who had previously completed another university degree reported significantly higher levels of concern than those without a prior degree. Australian students reported lower concern about societal vulnerability compared to a previously reported cohort of Japanese students.

CONCLUSION

Our study suggests current education of future health care students does not promote adequate levels of awareness of the health-related challenges posed by disasters, particularly among older members of the community. Without addressing this gap in education, the risk of negative outcomes for both unprepared first responders and older members of the community is significant. (Disaster Med Public Health Prep. 2019;13:449-455).

Australian recommendations for the integration of emergency care for older people: Consensus Statement

OBJECTIVES

Management of older patients during acute illness or injury does not occur in isolation in emergency departments. We aimed to develop a collaborative Consensus Statement to enunciate principles of integrated emergency care.

METHODS

Briefing notes, informed by research and evidence reviews, were developed and evaluated by a Consensus Working Party comprising cross-specialty representation from clinical experts, service providers, consumers and policymakers. The Consensus Working Party then convened to discuss and develop the statement's content. A subcommittee produced a draft, which was reviewed and edited by the Consensus Working Party.

RESULTS

Consensus was reached after three rounds of discussion, with 12 principles and six recommendations for how to follow these principles, including an integrated care framework for action.

CONCLUSION

Dissemination will encourage stakeholders and associated policy bodies to embrace the principles and priorities for action, potentially leading to collaborative work practices and improvement of care during and after acute illness or injury.

Factors influencing decision-making processes for unwell residents in residential aged care: Hospital transfer or Residential InReach referral?

OBJECTIVE

To investigate decision-making around hospital transfer and/or referral of residents to a Residential InReach (RiR) service in north-eastern metropolitan Melbourne, Australia, from the perspectives of residential aged care facility (RACF) staff, general practitioners (GPs) and RiR registered nurses (RNs).

METHODS

Thirty-one staff from eight RACFs, five GPs and four RiR RNs participated in individual or group interviews.

RESULTS

Residential aged care facility staff and GPs valued and relied upon RiR to manage unwell residents. Thematic analysis identified RiR utilisation was driven by the following: (i) complexity of decision-making processes in RACFs; (ii) variability in facility-based medical and nursing care; and (iii) impact of RiR service outcomes on patients and referrers.

CONCLUSION

Availability of timely and appropriate medical and nursing care in RACFs was reported to influence transfers to the hospital and/or referrals to RiR. RiR was used to complement or substitute usual care available to residents. Further research and improvements in RACF and RiR resources are required.

Emergency nurses' knowledge and self-rated practice skills when caring for older patients in the Emergency Department

BACKGROUND

Older adults are high users of emergency department services and their care requirements can present challenges for emergency nurses. Although clinical outcomes for older patients improve when they are cared for by nurses with specialist training, emergency nurses' knowledge and self-assessment of care for older patients is poorly understood.

AIM

To assess emergency nurses' knowledge and self-rating of practice when caring for older patients.

METHODS

A cross-sectional self-report survey of emergency nurses (n=101) in Melbourne, Australia.

RESULTS

Mean scores were 12.7 (SD 2.66) for the 25-item knowledge of older persons questionnaire, and 9.04 (SD 1.80) for the 15-item gerontic health related questions. Scores were unaffected by years of experience as a registered nurse or emergency nurse. More than 80% of nurses rated themselves as 'very good' or 'good' in assessing pain (94.9%), identifying delirium (87.8%), and identifying dementia (82.8%). Areas with a 'poor' ratings were identifying depression (46.5%), assessing polypharmacy (46.5%) and assessing nutrition (37.8%).

CONCLUSIONS

There was variation in knowledge and self-rating of practice related to care of older patients. The relationship between knowledge and self-ratings of practice in relation to actual emergency nursing care of older people and patient outcomes warrants further exploration.

Differences in emergency ambulance demand between older adults living in residential aged care facilities and those living in the community in Melbourne, Australia

OBJECTIVE

To describe the clinical presentation and temporal variation in ambulance service cases involving patients aged 65 years or older (older adults) from residential aged care facilities and those who are community dwelling (CD).

METHODS

This study used four years of electronic case records from Ambulance Victoria in Melbourne, Australia. Trigonometric regression was used to analyse demand patterns.

RESULTS

Residential aged care facility cases included proportionally more falls and infection-related problems and fewer circulatory-related incidents than CD cases. Community dwelling demand patterns differed between weekdays and weekends and peaked late morning. Residential aged care facility cases peaked late morning, with a secondary peak early evening, but with no significant difference between days.

CONCLUSIONS

Older adult ambulance demand has distinct temporal patterns that differ by place of residence and are associated with different clinical presentations. These results provide a basis for informing ambulance planning and the identification of alternate health services.

Emergency department utilisation among older people with acute and/or chronic conditions: A multi-centre retrospective study

INTRODUCTION

Older persons aged over 65years represent up to 41% of Australian Emergency Department (ED) presentations. Older persons present with acute and/or chronic conditions, have more Emergency Department visits, hospital admissions and readmissions than other age groups. However, little is known about the characteristics and trends of acute illness and chronic presentations and whether frailty changes these dimensions within this cohort.

METHODS

A 12-month retrospective medical record audit of persons over 65years presenting to four EDs.

RESULTS

Data from 44,774 (26.6%) patients aged 65years and over were analysed. Patients with acute conditions presented more frequently (n=30,373; 67.8%), received more urgent triage categories (n=13,471; 30.1%) and had higher admission rates (n=18,332; 61%). Chronic conditions presented less frequently (n=14,396; 32.1%) and had higher discharge rates (n=9302; 65%). Patients over 80years were allocated more urgent triage categories and commonly presented with falls (n=3814; 8.5%). Patients between 65 and79years had a higher discharge rate (n=10,397; 46.1%).

CONCLUSION

Older persons with acute illnesses were more likely to be admitted than those with chronic conditions and who were more likely to be discharged home. There is scope for further investigation of new models of care to better manage older persons with chronic conditions and ED discharge practices.

Non-medical needs of older patients in the emergency department

AIM

To determine the non-medical needs of older patients in the emergency department (ED).

METHODS

We undertook a cross-sectional survey of three age groups (50-64, 65-79, 80+ years) using a self-administered questionnaire with five response options (strongly agree-strongly disagree) for 31 items.

RESULTS

There were 548 patients enrolled. Significantly fewer older patients knew how to call for assistance (P < 0.01), knew how the ED works (P < 0.01), felt frightened by their illness (P < 0.01) or felt that the ED lights were too bright (P < 0.03). A substantial proportion of all patients did not agree that their illness and/or treatment had been well explained.

CONCLUSION

Older patients appear resilient but need to be told to call for assistance when needed, to know how to call for this assistance and how the ED works. Clear information regarding their illness and treatment should be provided, particularly to younger patients who may be anxious.

Community-based palliative care is associated with reduced emergency department use by people with dementia in their last year of life: A retrospective cohort study

OBJECTIVE

To describe patterns in the use of hospital emergency departments in the last year of life by people who died with dementia and whether this was modified by use of community-based palliative care.

DESIGN

Retrospective population-based cohort study of people in their last year of life. Time-to-event analyses were performed using cumulative hazard functions and flexible parametric proportional hazards regression models.

SETTING/PARTICIPANTS

All people living in Western Australia who died with dementia in the 2-year period 1 January 2009 to 31 December 2010 (dementia cohort; N = 5261). A comparative cohort of decedents without dementia who died from other conditions amenable to palliative care (N = 2685).

RESULTS

More than 70% of both the dementia and comparative cohorts attended hospital emergency departments in the last year of life. Only 6% of the dementia cohort used community-based palliative care compared to 26% of the comparative cohort. Decedents with dementia who were not receiving community-based palliative care attended hospital emergency departments more frequently than people receiving community-based palliative care. The magnitude of the increased rate of emergency department visits varied over the last year of life from 1.4 (95% confidence interval: 1.1-1.9) times more often in the first 3 months of follow-up to 6.7 (95% confidence interval: 4.7-9.6) times more frequently in the weeks immediately preceding death.

CONCLUSIONS

Community-based palliative care of people who die with or of dementia is relatively infrequent but associated with significant reductions in hospital emergency department use in the last year of life.

Use of a risk nomogram to predict emergency department reattendance in older people after discharge: a validation study

In older people, revisit to the emergency department (ED) in the short period after discharge is not entirely avoidable, but in a proportion of cases is preventable, and should ideally be minimised. We have previously derived a risk probability nomogram to predict the likelihood of revisit. In this study, we sought to validate the nomogram for use as a general risk stratification tool for use in older people being discharged from ED. We conducted a prospective cohort study, applying the nomogram to consecutive community dwelling discharged patients aged 65 and over. Patients were followed up at 28 days post-discharge to determine whether there had been any unplanned ED revisit in that period. We cross tabulated predicted risk versus revisit rates. In 1143 study subjects, we find the odds of revisit increases progressively with increasing strata of predicted risk, culminating in an OR of 9.7 (95% CI 4.7-19.9) in the highest risk group. The 28-day revisit rates across strata range from 16% through 65%, with the difference between strata being statistically highly significant (p < 0.001). The area under the ROC curve is 0.65. We conclude that the risk nomogram can classify older people discharged from ED into risk strata, and has modest overall predictive value.

Emergency surgery in the elderly: the balance between function, frailty, fatality and futility

Becoming old is considered a privilege and results from the socioeconomic progress and improvements in health care systems worldwide. However, morbidity and mortality increases with age, and even more so in acute onset disease. With the current prospects of longevity, a considerable number of elderly patients will continue to live with good function and excellent quality of life after emergency surgical care. However, mortality in emergency surgery may be reported at 15-30%, doubled if associated with complications, and notably higher in patients over 75 years. A number of risks associated with death are reported, and a number of scores proposed for prediction of risk. Frailty, a decline in the physiological reserves that may make the person vulnerable to even the most minor of stressful event, appears to be a valid indicator and predictor of risk and poor outcome, but how to best address and measure frailty in the emergency setting is not clear. Futility may sometimes be clearly defined, but most often becomes a borderline decision between ethics, clinical predictions and patient communication for which no solid evidence currently exists. The number and severity of other underlying condition(s), as well as the treatment alternatives and their consequences, is a complex picture to interpret. Add in the onset of the acute surgical disease as a further potential detrimental factor on function and quality of life – and you have a perfect storm to handle. In this brief review, some of the challenging aspects related to emergency surgery in the elderly will be discussed. More research, including registries and trials, are needed for improved knowledge to a growing health care challenge.

Age before acuity: the drivers of demand for emergency department services in the Greater Sydney Area

OBJECTIVE

To contrast long-term population-based trends in general practice (GP) presentations and acute inpatient admissions from the emergency department (ED) in the elderly population within the Greater Sydney Area.

METHODS

This was a retrospective analysis of population-based ED presentation data over 11 years, between January 2001 and December 2011, conducted within the Greater Sydney Area in Australia. De-identified data were obtained from the New South Wales Emergency Department Data Collection database on all patients presenting to 30 public hospital EDs located within the Greater Sydney Area. The outcomes of interest were GP presentations to ED (triage category 4 or 5, self-referred and discharged from ED) and of acute inpatient admissions from ED per 1000 population.

RESULTS

Over 11 million presentations were identified. Around 40% of presentations were classified as a GP presentation and 23% were classified as acute inpatient admissions. There was a 2.9% per annum increase in acute inpatient admissions per 1000 population in those ≥80 years of age and no appreciable change in other age groups. Rates of GP presentations were higher in those <65 years of age. GP presentations increased 1.9% per annum in those aged <65 years of age.

CONCLUSIONS

The increase in ED demand appears to be driven by the elderly presenting with acute problems requiring inpatient admission. There has been a modest increase in the rate of GP presentations to ED.