Emergency demand, repeat and frequent presentations by older patients in metropolitan Melbourne: A retrospective cohort study using routinely collected hospital data

Impact of a peer-support programme to improve loneliness and social isolation due to COVID-19: does adding a secure, user friendly video-conference solution work better than telephone support alone? Protocol for a three-arm randomised clinical trial

INTRODUCTION

The COVID-19 pandemic has forced the implementation of physical distancing and self-isolation strategies worldwide. However, these measures have significant potential to increase social isolation and loneliness. Among older people, loneliness has increased from 40% to 70% during COVID-19. Previous research indicates loneliness is strongly associated with increased mortality. Thus, strategies to mitigate the unintended consequences of social isolation and loneliness are urgently needed. Following the Obesity-Related Behavioural Intervention Trials model for complex behavioural interventions, we describe a protocol for a three-arm randomised clinical trial to reduce social isolation and loneliness.

METHODS AND ANALYSIS

A multicentre, outcome assessor blinded, three-arm randomised controlled trial comparing 12 weeks of: (1) the HOspitals WoRking in Unity ('HOW R U?') weekly volunteer-peer support telephone intervention; (2) 'HOW R U?' deliver using a video-conferencing solution and (3) a standard care group. The study will follow Consolidated Standard of Reporting Trials guidelines.We will recruit 24-26 volunteers who will receive a previously tested half day lay-training session that emphasises a strength-based approach and safety procedures. We will recruit 141 participants ≥70 years of age discharged from two participating emergency departments or referred from hospital family medicine, geriatric or geriatric psychiatry clinics. Eligible participants will have probable baseline loneliness (score ≥2 on the de Jong six-item loneliness scale). We will measure change in loneliness, social isolation (Lubben social network scale), mood (Geriatric Depression Score) and quality of life (EQ-5D-5L) at 12-14 weeks postintervention initiation and again at 24-26 weeks.

ETHICS AND DISSEMINATION

Approval has been granted by the participating research ethics boards. Participants randomised to standard care will be offered their choice of telephone or video-conferencing interventions after 12 weeks. Results will be disseminated through journal publications, conference presentations, social media and through the International Federation of Emergency Medicine.

TRIAL REGISTRATION NUMBER

NCT05228782.

Prevalence and characteristics of frequent presenters to Auburn Hospital emergency department

OBJECTIVES

Frequent presenters (FPs) to the ED are common and contribute to ED overcrowding. Our aim was to identify the proportion of FPs over a 12-month period and to investigate the sociodemographic, clinical and attendance characteristics of FPs.

METHODS

A retrospective cohort study of adult patients (≥18 years) presenting to Auburn Hospital ED between 1 January 2018 to 31 December 2018. Patients with ≥4 presentations in 12 months were classified as FP. Multivariable logistic regression was used to assess associations between sociodemographic characteristics and FP.

RESULTS

During the study period, there were 22 679 presentations to the ED from 16 624 adult patients. FPs represented 5.1% (95% confidence interval [CI] 4.8-5.5) of the total population, but 15.8% of the total ED visits. Median age of FPs was 46 years (interquartile range 29-72), 51.9% were males. Age over 65 was the strongest determinant of FP (odds ratio [OR] 2.33; 95% CI 2.01-2.72 adjusted for sex). FP was more likely for Arabic speakers compared to English speakers (OR 1.54; 95% CI 1.28-1.86 adjusted for age and sex) and least likely for Mandarin speakers (adjusted OR 0.40; 95% CI 0.27-0.59).

CONCLUSIONS

FPs represent a significant proportion of ED visits, yet a small proportion of ED patients. Our findings suggest that identifying ways to provide targeted services to older FPs may reduce the overall rates. The differences between language groups and FP highlights the importance of social context and culture when developing targeted interventions.

Frailty screening among older adults receiving home care packages: a study of feasibility and prevalence

Home care packages (HCPs) aim to support older people to remain in their homes for as long as possible. Early detection and management of frailty in community-dwelling older people may prevent or delay transfer to residential aged care. This suggests that it is important to establish mechanisms for identifying frailty among older adults. This study examined the feasibility of obtaining self-reported level of frailty from a sample of older adults receiving HCPs from an Australian aged care provider. The prevalence of frailty and sociodemographic and clinical correlates were assessed. Customers aged ≥65 years receiving an HCP from an aged care and disability service provider in New South Wales (n=158; 53.5% consent rate) completed a survey during their scheduled visit. The mean (±s.d.) total score on the Edmonton Frail Scale was 7.3±2.4 (range 1-13). The prevalence of frailty was 45% (5% 'severe frailty', 14% 'moderate frailty', 26% 'mild frailty'). Clients who had fallen in the past year had, on average, a 1.0-point higher frailty score (95% confidence interval 0.16-1.90) than those who had not. Given the high proportion of adults in our sample who were identified as frail, regular standardised assessments of frailty may assist community aged care providers to provide early intervention to reduce the risk of falls within this group of clients.

Frailty and hospital outcomes within a low socioeconomic population

BACKGROUND

Clinical frailty scales (CFS) predict hospital-related outcomes. Frailty is more common in areas of higher socioeconomic disadvantage, but no studies exclusively report on the impact of CFS on hospital-related outcomes in areas of known socioeconomic disadvantage.

AIMS

To evaluate the association of the CFS with hospital-related outcomes.

DESIGN

Retrospective observational study in a community hospital within a disadvantaged area in Australia (Social Economic Index for Areas = 0.1%).

METHODS

The CFS was used in the emergency department (ED) for people aged ≥ 75 years. Frailty was defined as a score of ≥4. Associations between the CFS and mortality, admission rates, ED presentations and length of stay (LOS) were analysed using regression analyses.

RESULTS

Between 11 July 2017 and 31 March 2018, there were 5151 ED presentations involving 3258 patients aged ≥ 75 years. Frail persons were significantly more likely to be older, represent to the ED and have delirium compared with non-frail persons. CFS was independently associated with 28-day mortality, with odds of mortality increasing by 1.5 times per unit increase in CFS (95% CI: 1.3-1.7). Frail persons with CFS 4-6 were more likely to be admitted (OR: 1.2; 95% CI: 1.0-1.5), have higher geometric mean LOS (1.43; 95% CI 1.15-1.77 days) and higher rates of ED presentations (IRR: 1.12; 95% CI 1.04-1.21) compared with non-frail persons.

CONCLUSIONS

The CFS predicts community hospital-related outcomes in frail persons within a socioeconomic disadvantage area. Future intervention and allocation of resources could consider focusing on CFS 4-6 as a priority for frail persons within a community hospital setting.

Patients with life-limiting illness presenting to the emergency department

OBJECTIVE

To examine characteristics, outcomes and flow for patients over the age of 45 years with a life-limiting illness (LLI) presenting to a regional ED.

METHODS

Retrospective, observational cohort study of patients with LLI in an Australian regional ED over a 15-day period. Eligible patients were 45 years of age or older who fulfilled criteria for having an LLI. Data included demographics, diagnosis for current presentation, presence of advance care documentation, LLI category, admission and discharge destination from ED, ED and hospital length of stay and outcome for patients admitted to the acute hospital.

RESULTS

A total of 152 (12%) patients had an LLI. The LLI group were older, had a significantly longer median length of stay in the ED (5.9 [interquartile range 4.0-8.4] vs 3.9 h [interquartile range 2.5-6.3], P < 0.0001) and were less likely to leave the ED within 4 h (26% vs 51.5%, P < 0.0001). Forty-six percent of patients with an LLI had some form of advanced care documentation. Patients with an LLI were more likely to require hospital admission. In relation to illness trajectory, the frailty/dementia trajectory group had comparatively the longest ED length of stay with less than 10% leaving the ED within 4 h. This group were more likely to be discharged to a residential care facility.

CONCLUSION

A significant proportion of patients 45 years or older had an LLI which had implications for their length of ED stay and discharge destination.