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Heeren P, Islam F, Desruelles D, Flamaing J, Sabbe M, Milisen K. A consensus statement on minimum operational standards for geriatric emergency care in Belgium: a modified Delphi study. BMC Geriatr 2023; 23:768. [PMID: 37993796 PMCID: PMC10666396 DOI: 10.1186/s12877-023-04474-0] [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: 07/15/2022] [Accepted: 11/09/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND As emergency department (ED) leaders started integrating geriatric emergency guidelines on a facultative basis, important variations have emerged between EDs in care for older patients. The aim of this study was to establish a consensus on minimum operational standards for Geriatric ED care in Belgium. METHODS A two-stage modified Delphi study was conducted. Twenty panellists were recruited from Dutch and French speaking regions in Belgium to join an interdisciplinary expert panel. In the first stage, an online survey was conducted to identify and define all possible elements of geriatric emergency care. In the second stage, an online survey and online expert panel meeting were organized consecutively to determine which elements should be recognized as minimum operational standards. RESULTS Between March 2020 and February 2021, the expert panel developed a broad consensus including ten statements focusing on the target population, specific goals, availability of geriatric practitioners and quality assurance. Additionally, the expert panel also determined which protocols, materials and accommodation criteria should be available in conventional EDs (39 standards) and in observational EDs (57 standards). CONCLUSIONS This study presents a consensus on minimum operational standards for geriatric emergency care in two ED types: the conventional ED and the observational ED. These findings may serve as a starting point towards broadly supported minimum standards of care stipulated by legislation in Belgium or other countries.
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Affiliation(s)
- Pieter Heeren
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, Leuven, 3000, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Research Foundation Flanders, Egmontstraat 5, 1000, Brussels, Belgium
| | - Farah Islam
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, Leuven, 3000, Belgium
- Department of Public Health, Institute of Nursing Science, University of Basel, Bernoullistrasse 38, 4056, Basel, Switzerland
| | - Didier Desruelles
- Department of Emergency Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, Emergency Medicine, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium
| | - Johan Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Marc Sabbe
- Department of Emergency Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, Emergency Medicine, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, Leuven, 3000, Belgium.
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Mowbray FI, Ellis B, Schumacher C, Heckman G, de Wit K, Strum RP, Jones A, Correia RH, Mercier E, Costa AP. The Association Between Frailty and a Nurse-Identified Need for Comprehensive Geriatric Assessment Referral from the Emergency Department. Can J Nurs Res 2023; 55:404-412. [PMID: 36632010 PMCID: PMC10416548 DOI: 10.1177/08445621221144667] [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: 01/13/2023] Open
Abstract
BACKGROUND Emergency nurses commonly conduct geriatric assessments in the emergency department (ED). However, little is known about what geriatric syndromes or clinical presentations prompt a nurse to document an identified need for comprehensive geriatric assessment (CGA). OBJECTIVES To examine the association between geriatric syndromes, like frailty, and a nurse-identified need for a CGA following emergency care. METHODS We conducted a secondary analysis of a multi-province Canadian cohort from the InterRAI Multinational Cohort Study. We collected data at ED registration from patients 75 years of age and older (n = 2,274) from eight ED sites across Canada between November 2009 and April 2012. Geriatric syndromes were assessed by trained emergency nurses using the interRAI ED Contact Assessment; and we retrospectively calculated the ED frailty index. We employed binary logistic regression to determine the adjusted associations between geriatric syndromes and a nurse-identified need for a CGA. RESULTS Approximately one-quarter (28%) of older adults were identified to need a CGA following emergency care. A 0.1 unit increase in the ED frailty index increased the likelihood of a nurse identify a need for CGA (RD: 6.6; 95% CI = 5.5-7.9). Most geriatric syndromes increased the probability of a nurse documenting the need for a CGA. CONCLUSION When assessed by emergency nurses, the identified need for CGA is strongly linked to the presence of geriatric syndromes, including frailty. We provide face validity for the continued use of emergency nurses for screening and assessing older ED patients.
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Affiliation(s)
- Fabrice I. Mowbray
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Brittany Ellis
- Department of Emergency Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Connie Schumacher
- School of Nursing, Faculty of Applied Health Sciences, Brock University, St. Catherine's, Ontario, Canada
| | - George Heckman
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Kerstin de Wit
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Ryan P. Strum
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Aaron Jones
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca H. Correia
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Eric Mercier
- Centre de recherche du CHU de Québec, Université Laval, Québec City, Québec, Canada
- Centre de recherche sur les soins et les services de première ligne, Université Laval, Québec City, Québec, Canada
| | - Andrew P. Costa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Stoltenberg MJ, Kennedy M, Rico J, Russell M, Petrillo LA, Engel KG, Kamdar M, Ouchi K, Wang DH, Bernacki RH, Biese K, Aaronson E. Developing a novel integrated geriatric palliative care consultation program for the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12860. [PMCID: PMC9742608 DOI: 10.1002/emp2.12860] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 10/27/2022] [Accepted: 11/01/2022] [Indexed: 12/14/2022] Open
Abstract
With the aging of our population, older adults are living longer with multiple chronic conditions, frailty, and life‐limiting illnesses, which creates specific challenges for emergency departments (EDs). Older adults and those with serious illnesses have high rates of ED use and hospitalization, and the emergency care they receive may be discordant with their goals and values. In response, new models of care delivery have begun to emerge to address both geriatric and palliative care needs in the ED. However, these programs are typically siloed from one another despite significant overlap. To develop a new combined model, we assembled stakeholders and thought leaders at the intersection of emergency medicine, palliative care, and geriatrics and used a consensus process to define elements of an ideal model of a combined palliative care and geriatric intervention in the ED. This article provides a brief history of geriatric and palliative care integration in EDs and presents the integrated geriatric and palliative care model developed.
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Affiliation(s)
- Mark J. Stoltenberg
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Maura Kennedy
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Janet Rico
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Matthew Russell
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Laura A. Petrillo
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Kirsten G. Engel
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Mihir Kamdar
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Kei Ouchi
- Harvard Medical SchoolBostonMassachusettsUSA,Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA,Department of Psychosocial Oncology and Palliative CareDana‐Farber Cancer InstituteBostonMassachusettsUSA
| | - David H. Wang
- Division of Palliative MedicineScripps HealthSan DiegoCaliforniaUSA
| | - Rachelle H. Bernacki
- Harvard Medical SchoolBostonMassachusettsUSA,Ariadne LabsBrigham and Women's Hospital & Harvard T. H. Chan School of Public HealthBostonMassachusettsUSA,Department of Psychosocial Oncology and Palliative CareDana‐Farber Cancer InstituteBostonMassachusettsUSA
| | - Kevin Biese
- West Health InstituteLa JollaCaliforniaUSA,Department of Emergency MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Emily Aaronson
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
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4
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Hwang U, Carpenter C, Dresden S, Dussetschleger J, Gifford A, Hoang L, Leggett J, Nowroozpoor A, Taylor Z, Shah M. The Geriatric Emergency Care Applied Research (GEAR) network approach: a protocol to advance stakeholder consensus and research priorities in geriatrics and dementia care in the emergency department. BMJ Open 2022; 12:e060974. [PMID: 35459682 PMCID: PMC9036447 DOI: 10.1136/bmjopen-2022-060974] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/25/2022] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Increasingly, older adults are turning to emergency departments (EDs) to address healthcare needs. To achieve these research demands, infrastructure is needed to both generate evidence of intervention impact and advance the development of implementation science, pragmatic trials evaluation and dissemination of findings from studies addressing the emergency care needs of older adults. The Geriatric Emergency Care Applied Research Network (https://gearnetwork.org) has been created in response to these scientific needs-to build a transdisciplinary infrastructure to support the research that will optimise emergency care for older adults and persons living with dementia. METHODS AND ANALYSIS In this paper, we describe our approach to developing the GEAR Network infrastructure, the scoping reviews to identify research and clinical gaps and its use of consensus-driven research priorities with a transdisciplinary taskforce of stakeholders that includes patients and care partners. We describe how priority topic areas are ascertained, the process of conducting scoping reviews with integrated academic librarians performing standardised searches and providing quality control on reviews, input and support from the taskforce and conducting a large-scale consensus workshop to prioritise future research topics. The GEAR Network approach provides a framework and systematic approach to develop a research agenda and support research in geriatric emergency care. ETHICS AND DISSEMINATION This is a systematic review of previously conducted research; accordingly, it does not constitute human subjects research needing ethics review. These reviews will be prepared as manuscripts and submitted for publication to peer-reviewed journals, and the results will be presented at conferences.Open Science Framework registered DOI: 10.17605/OSF.IO/6QRYX, 10.17605/OSF.IO/AKVZ8, 10.17605/OSF.IO/EPVR5, 10.17605/OSF.IO/VXPRS.
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Affiliation(s)
- Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Geriatric Research, Education and Clinical Center, James J Peters VA Medical Center, Bronx, New York, USA
| | - Christopher Carpenter
- Department of Emergency Medicine and Emergency Care Research Core, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Scott Dresden
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Angela Gifford
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Ly Hoang
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Jesseca Leggett
- Department of Emergency Medicine and Emergency Care Research Core, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Armin Nowroozpoor
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Zachary Taylor
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Manish Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Kennedy M, Lesser A, Israni J, Liu SW, Santangelo I, Tidwell N, Southerland LT, Carpenter CR, Biese K, Ahmad S, Hwang U. Reach and Adoption of a Geriatric Emergency Department Accreditation Program in the United States. Ann Emerg Med 2022; 79:367-373. [PMID: 34389196 PMCID: PMC10015385 DOI: 10.1016/j.annemergmed.2021.06.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 06/10/2021] [Accepted: 06/14/2021] [Indexed: 02/03/2023]
Abstract
STUDY OBJECTIVE The objectives of this study were to describe the reach and adoption of Geriatric Emergency Department Accreditation (GEDA) program and care processes instituted at accredited geriatric emergency departments (EDs). METHODS We analyzed a cross-section of a cohort of US EDs that received GEDA from May 2018 to March 2021. We obtained data from the American College of Emergency Physicians and publicly available sources. Data included GEDA level, geographic location, urban/rural designation, and care processes instituted. Frequencies and proportions and median and interquartile ranges were used to summarize categorical and continuous data, respectively. RESULTS Over the study period, 225 US geriatric ED accreditations were issued and included in our analysis-14 Level 1, 21 Level 2, and 190 Level 3 geriatric EDs; 5 geriatric EDs reapplied and received higher-level accreditation after initial accreditation at a lower level. Only 9 geriatric EDs were in rural regions. There was significant heterogeneity in protocols enacted at geriatric EDs; minimizing urinary catheter use and fall prevention were the most common. CONCLUSION There has been rapid growth in geriatric EDs, driven by Level 3 accreditation. Most geriatric EDs are in urban areas, indicating the potential need for expansion beyond these areas. Future research evaluating the impact of GEDA on health care utilization and patient-oriented outcomes is needed.
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Affiliation(s)
- Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA.
| | | | | | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Ilianna Santangelo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | | | | | - Christopher R Carpenter
- Department of Emergency Medicine and Emergency Care Research Core, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Kevin Biese
- West Health Institute, La Jolla, CA; Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC
| | - Surriya Ahmad
- Department of Emergency Medicine, SUNY Downstate, Kings County Hospital Center, Brooklyn, NY
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT; Geriatrics Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY
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6
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Flaherty JH, Rodin MB, Morley JE. Changing Hospital Care For Older Adults: The Case for Geriatric Hospitals in the United States. Gerontol Geriatr Med 2022; 8:23337214221109005. [PMID: 35813982 PMCID: PMC9260589 DOI: 10.1177/23337214221109005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hospital care of frail older adults is far from optimal. Although some geriatric models of care have been shown to improve outcomes, the effect size is small and models are difficult to fully implement, sustain and replicate. The two root causes for these shortcomings are competing interests (high revenue generating diseases, procedures and surgeries) and current hospital cultures (for example a culture of safety that emphasizes bed alarms and immobility rather than frequent ambulation). Geriatric hospitals would be hospitals completely dedicated to the care of frail older patients, a group which is most vulnerable to the negative consequences of a hospitalization. They would differ from a typical adult hospital because they could implement evidence based principles of successful geriatric models of care on a hospital wide basis, which would make them sustainable and allow for scaling up of proven outcomes. Innovative structural designs, unachievable in a typical adult hospital, would enhance mobility while maintaining safety. Financial viability and stability would be a challenge but should be feasible, likely through affiliation with larger health care systems with other hospitals because of cost savings associated with geriatric models of care (decreased length of stay, increased likelihood of discharge home, without increasing costs).
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Affiliation(s)
- Joseph H. Flaherty
- Regional Medical Director of Geriatrics,
Envision Physician Services, Dallas, Texas, Division of Geriatrics, University of Texas Southwestern, Dallas, Texas, USA
| | - Miriam B. Rodin
- Division of Geriatrics, Department of
Internal Medicine, Saint Louis University, St Louis, Missouri
| | - John E. Morley
- Division of Geriatrics, Department of
Internal Medicine, Saint Louis University, St Louis, Missouri
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7
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Bapat S, Washburn M, Tata V, Fleming M, Abughosh SM, Essien EJ, Thornton D. Barriers and Facilitators to DATA Waivered Providers Prescribing Buprenorphine: A Qualitative Analysis Applying the Theory of Planned Behavior. Subst Use Misuse 2022; 57:1761-1771. [PMID: 35993387 DOI: 10.1080/10826084.2022.2112226] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Background: Provider beliefs about the treatment of people with addiction may influence their prescribing behavior. Objective: This study applied the Theory of Planned Behavior (TPB), to identify the salient beliefs of Drug Addiction Treatment Act of 2000 (DATA 2000) waivered providers, concerning prescribing buprenorphine to patients with Opioid Use Disorder (OUD). Methods: Texas buprenorphine providers participated in one of four online focus group discussions conducted in fall 2019. The focus group discussion were audio recorded and the total length was between 60-90 minutes. Thematic analysis was conducted to identify emerging themes and to categorize the behavioral, normative, and control beliefs related to buprenorphine prescribing. Results: Of the 14 total participants, 57% of the participants were male and annually treated between zero to sixty patients with buprenorphine. The codes generated were represented in thematic maps, specifying the positive or negative aspects of buprenorphine prescribing. Results indicate that providers' primary motivation to prescribe buprenorphine was, implementation of a whole-patient approach through collaboration with behavioral health providers, in the provision of medications for opioid use disorder (MOUD). Providers primary normative belief was the recognition of key members of the medical community and patients' families and friends as influential groups. Providers' control beliefs focused on their ability to use buprenorphine in different practice settings. Conclusion: These results indicate that buprenorphine access may be expanded by increasing support for DATA waivered providers from other parts of the healthcare system such as behavioral health providers and pharmacists. Implications for clinical practice and future research will be discussed.
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Affiliation(s)
- Shweta Bapat
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, Houston, Texas, USA
| | - Micki Washburn
- Arlington School of Social Work, University of Texas at Arlington, Arlington, Texas, USA
| | - Vaishnavi Tata
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, Houston, Texas, USA
| | - Marc Fleming
- Department of Pharmaceutical Economics and Policy, Chapman University School of Pharmacy, Irvine, California, USA
| | - Susan M Abughosh
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, Houston, Texas, USA
| | - E James Essien
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, Houston, Texas, USA
| | - Douglas Thornton
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, Houston, Texas, USA
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Kaeley N, Kumar J, Kumar M, Vempalli N, Dhar M, Bhardwaj BB, Kumar S, Kabi A, Arora P. Prevalence and pattern of geriatric emergencies in a teaching hospital of North India. J Family Med Prim Care 2021; 10:3899-3903. [PMID: 34934699 PMCID: PMC8653474 DOI: 10.4103/jfmpc.jfmpc_2450_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/21/2021] [Accepted: 05/20/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction Changing demographic patterns worldwide and improvement in healthcarehas contributed to increasing visits to the emergency department byelderly patients. Geriatric patients usually have multiple co-morbidities and declining physiological functional status. This complex interplay of various factors requires a specific and curated approach from the emergency physicians. Our aim was to study the pattern and prevalence of geriatric emergencies and the profile of infectious and non-infectious causes of fever in geriatric population in our tertiary care center. Materials and Methods This retrospective descriptive study was carried out at a tertiary care hospital of north India and included all patients aged more than 18 years who visited the emergency department over a period of six months (July 2018 to December 2018). Detailed data regarding demographic, clinical and diagnosis was obtained retrospectively from the hospital records system. The patients were divided into two groups, age less than 60 years and elderly patients more than 60 years of age for comparison. Results A total of 24768 patients above the age of 18 years visited the emergency department over a period of six months. Out of which 5399 (27.5%) patients belonged to the geriatric age group more than 60 years of age. 2474 (45.8%) geriatric age group patientswere triaged to critical areas level one and level two as compared to 4668 (24.1%) patients aged less than 60 years. Ninety (1.8%) geriatric patients succumbed to death as compared to 77 (0.4%) patients aged less than 60 years. 651 (21.9%) geriatric patients were shifted to intensive care unit as opposed to 1038 (14.8%) patients of the younger age group.226 (4.2%) geriatric patients presented with fever in the emergency department.116 (73.4%) patients having underlying co-morbidities , had fever due to infectious causes whereas 42 ( 26.5%) patients had fever due to non-infectious causes. Conclusion The clinical presentation mortality and morbidity pattern of geriatric patients differs significantly from that of younger population and requires a customized approach and dedicated emergency setups.
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Affiliation(s)
- Nidhi Kaeley
- Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Jainendra Kumar
- Department of Medicine, Government Doon Medical College, Dehradun, Uttarakhand, India
| | - Manish Kumar
- Department of Medicine, Government Doon Medical College, Dehradun, Uttarakhand, India
| | - Nagasubramanyam Vempalli
- Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Mridul Dhar
- Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Bharat B Bhardwaj
- Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Subodh Kumar
- Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Ankita Kabi
- Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Poonam Arora
- Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Kelekar U, Das Gupta D, Shepherd J, Sule A. Risk Factors of Fall-Related Emergency Department Visits by Fall Location of Older Adults in the US. West J Emerg Med 2021; 22:988-999. [PMID: 35354005 PMCID: PMC8328180 DOI: 10.5811/westjem.2021.2.49307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 02/24/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction: Prior evidence indicates that predictors of older adult falls vary by indoor-outdoor location of the falls. While a subset of United States’ studies reports this finding using primary data from a single geographic area, other secondary analyses of falls across the country do not distinguish between the two fall locations. Consequently, evidence at the national level on risk factors specific to indoor vs outdoor falls is lacking.
Methods: Using the 2017 Nationwide Emergency Department Sample (NEDS) data, we conducted a multivariable analysis of fall-related emergency department (ED) visits disaggregated by indoor vs outdoor fall locations of adults 65 years and older (N = 6,720,937) in the US.
Results: Results are compatible with findings from previous primary studies. While women (relative risk [RR] = 1.43, 95% confidence interval [CI], 1.42-1.44) were more likely to report indoor falls, men were more likely to present with an outdoor fall. Visits for indoor falls were highest among those 85 years and older (RR = 2.35, 95% CI, 2.33-2.37) with outdoor fall visits highest among those 84 years and younger. Additionally, the probabilities associated with an indoor fall in the presence of chronic conditions were consistently much higher when compared to an outdoor fall. We also found that residence in metropolitan areas increased the likelihood of an indoor elderly fall compared to higher outdoor fall visits from seniors in non-core rural areas, but both indoor and outdoor fall visits were higher among older adults in higher income ZIP codes.
Conclusion: Our findings highlight the contrasting risk profile for elderly ED patients who report indoor vs outdoor falls when compared to the elderly reporting no falls. In conjunction, we highlight implications from three perspectives: a population health standpoint for EDs working with their primary care and community care colleagues; an ED administrative vantage point; and from an individual emergency clinician’s point of view.
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Affiliation(s)
- Uma Kelekar
- Marymount University, College of Business, Innovation, Leadership and Technology, Division of Health Care Management, Arlington, Virginia
| | - Debasree Das Gupta
- Utah State University, Department of Kinesiology and Health Science, Logan, Utah
| | - Jewel Shepherd
- University of South Dakota, Beacom School of Business, Vermillion, South Dakota
| | - Anupam Sule
- St. Joseph Mercy Oakland, Department of Informatics and Outcomes, Pontiac, Michigan
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10
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Adapting and validating the Autism Diagnostic Observation Schedule Version 2 for use with deaf children and young people. J Autism Dev Disord 2021; 52:553-568. [PMID: 33761060 PMCID: PMC8813800 DOI: 10.1007/s10803-021-04931-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 12/14/2022]
Abstract
We report a Delphi Consensus modification and first validation study of the Autism Diagnostic Observation Schedule - 2 with deaf children and young people (ADOS-2 Deaf adaptation). Validation included 122 deaf participants (aged 2-18 years), 63 with an Autism Spectrum Disorder (ASD). This was compared to a National Institute for Health and Clinical Excellence (NICE) guideline standard clinical assessment by blinded independent specialist clinicians. Results showed overall sensitivity 73% (95%CI 60%, 83%); specificity 71% (95%CI 58%, 82%), and for the more common modules 1-3 (combined as in previous studies) sensitivity 79% (95% CI 65-89%); specificity 79% (95% CI 66-89%) suggesting this instrument will be a helpful addition for use with deaf children and young people.
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Abstract
Geriatric emergency medicine has emerged as a subspecialty of emergency medicine over the past 25 years. This emergence has seen the development of increases in training opportunities, care delivery strategies, collaborative best practice guidelines, and formal geriatric emergency department accreditation. This multidisciplinary field remains ripe for continued development in the coming decades as the aging US population parallels a call from patients, health care providers, and health systems to improve the delivery of high-value care. This article educates emergency medicine practitioners and highlights high-value care practice trends to inform and prioritize decision-making for this unique patient population.
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Abstract
Editor's note: This is the third article in a series on clinical research by nurses. The series is designed to give nurses the knowledge and skills they need to participate in research, step by step. Each column will present the concepts that underpin evidence-based practice-from research design to data interpretation. The articles will be accompanied by a podcast offering more insight and context from the author.
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Affiliation(s)
- Alexa Colgrove Curtis
- Alexa Colgrove Curtis is assistant dean of graduate nursing and director of the MPH-DNP dual degree program and Courtney Keeler is an associate professor, both at the University of San Francisco School of Nursing and Health Professions. Contact author: Alexa Colgrove Curtis, . Nursing Research, Step by Step is coordinated by Bernadette Capili, PhD, NP-C: . The authors have disclosed no potential conflicts of interest, financial or otherwise. A podcast with the authors is available at www.ajnonline.com
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Liu J, Palmgren T, Ponzer S, Masiello I, Farrokhnia N. Can dedicated emergency team and area for older people reduce the hospital admission rate? - An observational pre- and post-intervention study. BMC Geriatr 2021; 21:115. [PMID: 33568087 PMCID: PMC7877031 DOI: 10.1186/s12877-021-02044-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 01/20/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Emergency department (ED) care of older patients is often complex. Geriatric ED guidelines can help to meet this challenge. However, training requirements, the use of time-consuming tools for comprehensive geriatric assessment (CGA), a lack of golden standard to identify the frail patients, and the weak evidence of positive outcomes of using CGA in EDs pose barriers to introduce the guidelines. Dedicating an interprofessional team of regular ED medical and nursing staff and an older-friendly ED area can be another approach. Previous studies of geriatrician-led CGA in EDs have reported a reduced hospital admission rate. The aim of this study was to investigate whether a dedicated interprofessional emergency team also can reduce the hospital admission rate without the resources required by the formal use of CGA. METHODS An observational pre-post study at a large adult ED, where all patients 80 years or older arriving on weekdays in the intervention period from 2016.09.26 to 2016.11.28 and the corresponding weekdays in the previous year from 2015.09.28 to 2015.11.30 were included. In the intervention period, older patients either received care in the geriatric module by the dedicated team or in the regular team modules for patients of mixed ages. In 2015, all patients received care in regular team modules. The primary outcome measure was the total hospital admission rate and the ED length of stay was the secondary outcome measure. RESULTS We included 2377 arrivals in the intervention period, when 26.7% (N = 634) received care in the geriatric module, and 2207 arrivals in the 2015 period. The total hospital admission rate was 61.7% (N = 1466/2377) in the intervention period compared to 64.8% (N = 1431/2207) in 2015 (p = 0.03). The difference was larger for patients treated in the geriatric module, 51.1% compared to 62.1% (95% CI: 56.3 to 68.0%) for patients who would have been eligible in 2015. The ED length of stay was longer in the intervention period. CONCLUSIONS An interprofessional team and area dedicated to older patients was associated to a lower hospital admission rate. Further studies are needed to confirm the results.
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Affiliation(s)
- Jenny Liu
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden.
| | - Therese Palmgren
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden
| | - Sari Ponzer
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden
| | - Italo Masiello
- Department of Computer Science and Media Technology, Linnaeus University, Växjö, Sweden
| | - Nasim Farrokhnia
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden
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14
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Forcino RC, Meinders MJ, Engel JA, O'Malley AJ, Elwyn G. Routine patient-reported experience measurement of shared decision-making in the USA: a qualitative study of the current state according to frontrunners. BMJ Open 2020; 10:e037087. [PMID: 32513894 PMCID: PMC7282390 DOI: 10.1136/bmjopen-2020-037087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/27/2020] [Accepted: 05/20/2020] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES To identify and describe instances of routine patient-reported shared decision-making (SDM) measurement in the USA, and to explore barriers and facilitators of routine patient-reported SDM measurement for quality improvement. SETTING Payer and provider healthcare organisations in the USA. PARTICIPANTS Current or former adult employees of healthcare organisations with prior SDM activity and that may be conducting routine SDM measurement (n=21). OUTCOMES Qualitative interview and survey data collected through snowball sampling recruitment strategy to inform barriers and facilitators of routine patient-reported SDM measurement. RESULTS Three participating sites routinely measured SDM from patients' perspectives, including one payer organisation and two provider organisations-with the largest measurement effort taking place in the payer organisation. Facilitators of SDM measurement included SDM as a core organisational value or strategic priority, trialability of SDM measurement programmes, flexibility in how measures can be administered and existing momentum from payer-mandated measurement programmes. Barriers included competing organisational priorities with regard to patient-reported measurement and lack of perceived comparative advantage of patient-reported SDM measurement. CONCLUSIONS Payers have a unique opportunity to encourage emphasis on SDM within healthcare organisations, including routine patient-reported measurement of SDM; however, provider organisations are currently best placed to make effective use of this type of data.
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Affiliation(s)
- Rachel C Forcino
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA
| | - Marjan J Meinders
- Scientific Center for Quality of Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jaclyn A Engel
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA
- Department of Biomedical Data Science, Dartmouth College, Lebanon, New Hampshire, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA
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Heeren P, Devriendt E, Wellens NI, Deschodt M, Flamaing J, Sabbe M, Milisen K. Old and New Geriatric Screening Tools in a Belgian Emergency Department: A Diagnostic Accuracy Study. J Am Geriatr Soc 2020; 68:1454-1461. [DOI: 10.1111/jgs.16503] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 02/07/2020] [Accepted: 02/09/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Pieter Heeren
- Department of Public Health and Primary CareAcademic Centre for Nursing and Midwifery, KU Leuven Leuven Belgium
- Department of Geriatric MedicineUniversity Hospitals Leuven Leuven Belgium
- Research Foundation Flanders Brussels Belgium
| | - Els Devriendt
- Department of Public Health and Primary CareAcademic Centre for Nursing and Midwifery, KU Leuven Leuven Belgium
- Department of Geriatric MedicineUniversity Hospitals Leuven Leuven Belgium
| | - Nathalie I.H. Wellens
- Department of Public Health and Primary CareAcademic Centre for Nursing and Midwifery, KU Leuven Leuven Belgium
- Department of Public Health and Social Affairs (DSAS)Direction Générale de la Santé Canton Vaud, Etat de Vaud Lausanne Switzerland
| | - Mieke Deschodt
- Department of Public Health and Primary CareGerontology and Geriatrics, KU Leuven Leuven Belgium
- Department of Public HealthNursing Science, University of Basel Basel Switzerland
| | - Johan Flamaing
- Department of Geriatric MedicineUniversity Hospitals Leuven Leuven Belgium
- Department of Public Health and Primary CareGerontology and Geriatrics, KU Leuven Leuven Belgium
| | - Marc Sabbe
- Department of Emergency MedicineUniversity Hospitals Leuven Leuven Belgium
- Department of Public Health and Primary CareEmergency Medicine, KU Leuven Leuven Belgium
| | - Koen Milisen
- Department of Public Health and Primary CareAcademic Centre for Nursing and Midwifery, KU Leuven Leuven Belgium
- Department of Geriatric MedicineUniversity Hospitals Leuven Leuven Belgium
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Berning MJ, Oliveira J E Silva L, Suarez NE, Walker LE, Erwin P, Carpenter CR, Bellolio F. Interventions to improve older adults' Emergency Department patient experience: A systematic review. Am J Emerg Med 2020; 38:1257-1269. [PMID: 32222314 DOI: 10.1016/j.ajem.2020.03.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/26/2020] [Accepted: 03/08/2020] [Indexed: 01/17/2023] Open
Abstract
STUDY OBJECTIVE To summarize interventions that impact the experience of older adults in the emergency department (ED) as measured by patient experience instruments. METHODS This is a systematic review to evaluate interventions aimed to improve geriatric patient experience in the ED. We searched Ovid CENTRAL, Ovid EMBASE, Ovid MEDLINE and PsycINFO from inception to January 2019. The main outcome was patient experience measured through instruments to assess patient experience or satisfaction. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the confidence in the evidence available. RESULTS The search strategy identified 992 studies through comprehensive literature search and hand-search of reference lists. A total of 21 studies and 3163 older adults receiving an intervention strategy aimed at improve patient experience in the ED were included. Department-wide interventions, including geriatric ED and comprehensive geriatric assessment unit, focused care coordination with discharge planning and referral for community services, were associated with improved patient experience. Providing an assistive listening device to those with hearing loss and having a pharmacist reviewing the medication list showed an improved patient perception of quality of care provided. The confidence in the evidence available for the outcome of patient experience was deemed to be very low. CONCLUSION While all studies reported an outcome of patient experience, there was significant heterogeneity in the tools used to measure it. The very low certainty in the evidence available highlights the need for more reliable tools to measure patient experience and studies designed to measure the effect of the interventions.
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Affiliation(s)
- Michelle J Berning
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States of America
| | | | | | - Laura E Walker
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Patricia Erwin
- Mayo Clinic Libraries, Rochester, MN, United States of America
| | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, MO, United States of America
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States of America; Department of Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, United States of America.
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Goldberg EM, Marks SJ, Ilegbusi A, Resnik L, Strauss DH, Merchant RC. GAPcare: The Geriatric Acute and Post-Acute Fall Prevention Intervention in the Emergency Department: Preliminary Data. J Am Geriatr Soc 2020; 68:198-206. [PMID: 31621901 PMCID: PMC7001768 DOI: 10.1111/jgs.16210] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/25/2019] [Accepted: 09/07/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVES We aimed to describe a new multidisciplinary team fall prevention intervention for older adults who seek care in the emergency department (ED) after having a fall, assess its feasibility and acceptability, and review lessons learned during its initiation. DESIGN Single-blind randomized controlled pilot study. SETTING Two urban academic EDs PARTICIPANTS: Adults 65 years old or older (n = 110) who presented to the ED within 7 days of a fall. INTERVENTION Participants were randomized to a usual care (UC) and an intervention (INT) arm. Participants in the INT arm received a brief medication therapy management session delivered by a pharmacist and a fall risk assessment and plan by a physical therapist (PT). INT participants received referrals to outpatient services (eg, home safety evaluation, outpatient PT). MEASUREMENTS We used participant, caregiver, and clinician surveys, as well as electronic health record review, to assess the feasibility and acceptability of the intervention. RESULTS Of the 110 participants, the median participant age was 81 years old, 67% were female, 94% were white, and 16.3% had cognitive impairment. Of the 55 in the INT arm, all but one participant received the pharmacy consult (98.2%); the PT consult was delivered to 83.6%. Median consult time was 20 minutes for pharmacy and 20 minutes for PT. ED length of stay was not increased in the INT arm: UC 5.25 hours vs INT 5.0 hours (P < .94). After receiving the Geriatric Acute and Post-acute Fall Prevention Intervention (GAPcare), 100% of participants and 97.6% of clinicians recommended the pharmacy consult, and 95% of participants and 95.8% of clinicians recommended the PT consult. CONCLUSION These findings support the feasibility and acceptability of the GAPcare model in the ED. A future larger randomized controlled trial is planned to determine whether GAPcare can reduce recurrent falls and healthcare visits in older adults. J Am Geriatr Soc 68:198-206, 2019.
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Affiliation(s)
- Elizabeth M Goldberg
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Health Services, Practice and Policy, Brown University School of Public Health, Providence, Rhode Island
| | - Sarah J Marks
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - Aderonke Ilegbusi
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Linda Resnik
- Department of Health Services, Practice and Policy, Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
| | - Daniel H Strauss
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Roland C Merchant
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
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Dresden SM, McCarthy DM, Engel KG, Courtney DM. Perceptions and expectations of health-related quality of life among geriatric patients seeking emergency care: a qualitative study. BMC Geriatr 2019; 19:209. [PMID: 31382886 PMCID: PMC6683497 DOI: 10.1186/s12877-019-1228-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 07/26/2019] [Indexed: 01/23/2023] Open
Abstract
Background Health-related quality of life (HRQoL), encompassing social, emotional, and physical wellbeing is an important clinical outcome of medical care, especially among geriatric patients. It is unclear which domains of HRQoL are most important to geriatric patients and which domains they hope to address when using the Emergency Department (ED). The objective of this study was to understand which aspects of HRQoL are most valued by geriatric patients in the ED and what expectations patients have for addressing or improving HRQoL during an ED visit. Methods This was a qualitative focus group study of geriatric ED patients from an urban, academic ED in the United States with > 16,500 annual geriatric visits. Patients were eligible if they were age > =65 years and discharged from the ED within 45 days of recruitment. Semi-structured pilot interviews and focus groups were conducted several weeks after the ED visit. Participants shared their ED experiences and to discuss their perceptions of the subsequent impact on their quality of life, focusing on the domains of physical, mental, and social health. Latent content and constant comparative methods were used to code focus group transcripts and analyze for emergent themes. Results Three individuals participated in pilot interviews and 31 participated in six focus groups. Twelve codes across five main themes relating to HRQoL were identified. Patients recalled: (1) A strong desire to regain physical function, and (2) anxiety elicited by the emotional experience of seeking care in the emergency department, due to uncertainty in diagnosis, treatment, and prognosis. In addition, patients noted both (3) interpersonal impacts of health on quality of life, primarily mediated primarily by social interaction, and (4) an individual experience of health and quality of life mediated primarily by mental health. Finally, (5) patients questioned if the ED was the right place to attempt to address HRQoL. Conclusions Patients expressed anxiety around the time of their ED visit related to uncertainty, they desired functional recovery, and identified both interpersonal effects of health on quality of life mediated by social health, and an individual experience of health and quality of life mediated by mental health.
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Affiliation(s)
- Scott M Dresden
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, 211 E. Ontario St., Suite 200, Chicago, IL, 60611, USA.
| | - Danielle M McCarthy
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, 211 E. Ontario St., Suite 200, Chicago, IL, 60611, USA
| | - Kirsten G Engel
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, 211 E. Ontario St., Suite 200, Chicago, IL, 60611, USA
| | - D Mark Courtney
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, 211 E. Ontario St., Suite 200, Chicago, IL, 60611, USA
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Lee JS, Tong T, Tierney MC, Kiss A, Chignell M. Predictive Ability of a Serious Game to Identify Emergency Patients With Unrecognized Delirium. J Am Geriatr Soc 2019; 67:2370-2375. [PMID: 31355442 DOI: 10.1111/jgs.16095] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 06/24/2019] [Accepted: 06/30/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Recognition of delirium in the emergency department (ED) is poor. Our objectives were to assess: (1) the diagnostic accuracy of the Predicting Emergency department Delirium with an Interactive Computer Tablet (PrEDICT) "serious game" to identify older ED patients with delirium compared to clinical recognition and (2) the feasibility of the PrEDICT application compared to existing tests of attention. DESIGN Prospective observational study. SETTING ED of a Canadian tertiary care center. PARTICIPANTS We included ED patients, aged 70 years and older, with a minimum 4-hour stay. We excluded anyone with critical illness, communication barriers, and visual impairment or those unable to use a computer tablet. None had prevalent delirium by ED clinicians' routine clinical assessment. MEASUREMENTS Participants were asked to tap targets on a tablet at four difficulty levels. Time and accuracy were automatically recorded. Other measures included the Confusion Assessment Method, the Delirium Severity Index, the Digit Vigilance Test (DVT), and the Choice Reaction Test (CRT). RESULTS We enrolled 203 patients. Their average age was 80.6 years, 49.8% were female, and their average ED length of stay was 15.9 hours. Sixteen subjects had clinically unrecognized delirium, and 14 of them completed the PrEDICT game (87.5%). We developed a threshold score with 100% sensitivity (95% confidence interval [CI] = 76.8%-100.0%) and 59.7% specificity (95% CI = 52.3%-66.6%) to identify patients with clinically unrecognized delirium. The area under the curve was 0.86 (95% CI = 0.77-0.94). Completion rates were 196/203 (96.6%) for the PrEDICT serious game compared to 128/203 (63.1%) for the CRT and 51/203 (25.1%) for the DVT. CONCLUSION Older ED patients were able to use our serious game, including 87.5% of those with clinically unrecognized delirium. The PrEDICT application has potential to act as a sensitive screening tool to identify older ED patients with clinically unrecognized delirium. J Am Geriatr Soc 67:2370-2375, 2019.
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Affiliation(s)
- Jacques S Lee
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Emergency Services, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Division of Emergency Services, Schwartz-Reisman Emergency Medicine Institute, Toronto, Ontario, Canada
| | - Tiffany Tong
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Mary C Tierney
- Division of Emergency Services, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Primary Care Research Unit, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Alex Kiss
- Division of Emergency Services, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Mark Chignell
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
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Schumacher JG, Hirshon JM, Magidson P, Chrisman M, Hogan T. Tracking the Rise of Geriatric Emergency Departments in the United States. J Appl Gerontol 2018; 39:871-879. [PMID: 30451060 DOI: 10.1177/0733464818813030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The traditional model of emergency care no longer fits the growing needs of the over 20 million older adults annually seeking emergency department care. In 2007 a tailored "geriatric emergency department" model was introduced and rapidly replicated among hospitals, rising steeply over the past 5 years. This survey examined all U.S. emergency departments self-identifying themselves as Geriatric Emergency Departments (GEDs) and providing enhanced geriatric emergency care services. It was guided by the recently adopted Geriatric Emergency Department Guidelines and examined domains including, GED identity, staffing, and administration; education, equipment, and supplies; policies, procedures, and protocols; follow-up and transitions of care; and quality improvement. Results reveal a heterogeneous mix of GED staffing, procedures, physical environments and that GEDs' familiarity with the GED Guidelines is low. Findings will inform emergency departments and gerontologists nationwide about key GED model elements and will help hospitals to improve ED services for their older adult patients.
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The Value of Urgent and Emergent Care in Otolaryngology. CURRENT OTORHINOLARYNGOLOGY REPORTS 2018. [DOI: 10.1007/s40136-018-0207-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Affiliation(s)
- Tim A Lash
- West Health Policy Center, 10350 North Torrey Pines Road, La Jolla, CA 92037, USA.
| | - Marcus R Escobedo
- The John A. Hartford Foundation, 55 East 59th Street, New York, NY 10022, USA.
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Abstract
This article reviews 10 best practices that integrate geriatric principles into emergency department processes of care. These best practices are grouped around ten words: complexity; clinician education; geriatric-specific; atypical; medication; variability; cognitive impairment; psychosocial issues; end-of-life care; and interdisciplinary.
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Bending the Curve of Health Trajectories for Older Adults Discharged From the Emergency Department. Ann Emerg Med 2017; 69:434-436. [DOI: 10.1016/j.annemergmed.2016.10.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Indexed: 11/22/2022]
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McCusker J, Vadeboncoeur A, Cossette S, Veillette N, Ducharme F, Minh Vu TT, Ciampi A, Cetin‐Sahin D, Belzile E. Changes in Emergency Department Geriatric Services in Quebec and Correlates of These Changes. J Am Geriatr Soc 2017; 65:1448-1454. [DOI: 10.1111/jgs.14818] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 11/21/2016] [Accepted: 12/06/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Jane McCusker
- St. Mary's Research Centre Montreal Canada
- McGill University Montreal Canada
| | - Alain Vadeboncoeur
- Université de Montréal Montreal Canada
- Emergency Medicine Services Montreal Heart Institute Montreal Canada
| | - Sylvie Cossette
- Université de Montréal Montreal Canada
- Montreal Heart Institute Research Center Montreal Canada
| | - Nathalie Veillette
- Université de Montréal Montreal Canada
- Centre de recherche de l'Institut universitaire de gériatrie de Montréal Montreal Canada
| | - Francine Ducharme
- Université de Montréal Montreal Canada
- Centre de recherche de l'Institut universitaire de gériatrie de Montréal Montreal Canada
| | - Thien Tuong Minh Vu
- Université de Montréal Montreal Canada
- Centre de recherche de l'Institut universitaire de gériatrie de Montréal Montreal Canada
- Centre hospitalier de l'Université de Montréal Montreal Canada
| | - Antonio Ciampi
- St. Mary's Research Centre Montreal Canada
- McGill University Montreal Canada
| | - Deniz Cetin‐Sahin
- St. Mary's Research Centre Montreal Canada
- Center for Research in Aging Donald Berman Maimonides Geriatric Centre Montreal Canada
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28
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Beach SR, Carpenter CR, Rosen T, Sharps P, Gelles R. Screening and detection of elder abuse: Research opportunities and lessons learned from emergency geriatric care, intimate partner violence, and child abuse. J Elder Abuse Negl 2016; 28:185-216. [PMID: 27593945 PMCID: PMC7339956 DOI: 10.1080/08946566.2016.1229241] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This article provides an overview of elder abuse screening and detection methods for community-dwelling and institutionalized older adults, including general issues and challenges for the field. Then, discussions of applications in emergency geriatric care, intimate partner violence (IPV), and child abuse are presented to inform research opportunities in elder abuse screening. The article provides descriptions of emerging screening and detection methods and technologies from the emergency geriatric care and IPV fields. We also discuss the variety of potential barriers to effective screening and detection from the viewpoint of the older adult, caregivers, providers, and the health care system, and we highlight the potential harms and unintended negative consequences of increased screening and mandatory reporting. We argue that research should continue on the development of valid screening methods and tools, but that studies of perceived barriers and potential harms of elder abuse screening among key stakeholders should also be conducted.
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Affiliation(s)
- Scott R. Beach
- University Center for Social and Urban Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher R. Carpenter
- Emergency Medicine, Washington University School of Medicine-St. Louis, St. Louis, Missouri, USA
| | - Tony Rosen
- Weill Cornell Medical College, New York, New York, USA
| | - Phyllis Sharps
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Richard Gelles
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Campbell L, Evans Y, Pumper M, Moreno MA. Social media use by physicians: a qualitative study of the new frontier of medicine. BMC Med Inform Decis Mak 2016; 16:91. [PMID: 27418201 PMCID: PMC4946237 DOI: 10.1186/s12911-016-0327-y] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 07/03/2016] [Indexed: 12/05/2022] Open
Abstract
Background A growing number of physicians are using social media as a professional platform for health communication. The purpose of this study was to understand perspectives and experiences of these “early adopter” physician bloggers and social media users. Methods This was an exploratory qualitative study involving in-depth semi-structured telephone interviews of physicians who were early adopters, defined as physicians who used social media to distribute health information. Participants were recruited through snowball sampling. Interview transcripts were manually analyzed for common themes by three separate investigators who came to common conclusions via the constant comparative method. Results Seventeen physicians participated in this study, including 35 % females, 76 % pediatricians and 76 % bloggers. Participants identified multiple perceived benefits and barriers to social media use by physicians; further, four major themes were identified. First, participants often saw themselves as rugged individualists who set their own rules for social media health communications. Second, participants expressed uncertainty about boundaries or strategies for social media use. Third, participants described using social media much like traditional media, as a one-way communication platform, rather than as an interactive forum. Finally, participants expressed disparate views regarding the time involved in participating in social media; some felt that time spent on social media was unproblematic to fit into their day while others felt that it was an impediment to patient care. Conclusions Uncertainty remains regarding roles and responsibilities of physicians providing medical content within social media forums and few providers appeared to be using the platform to its full potential. Future studies may inform best practices to optimize social media health communication to benefit patients.
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Affiliation(s)
- Lauren Campbell
- University of Washington School of Public Health, Seattle, USA.,University of Washington School of Medicine, Seattle, WA, USA
| | - Yolanda Evans
- University of Washington School of Medicine, Seattle, WA, USA.,Seattle Children's Research Institute, Seattle, WA, USA
| | - Megan Pumper
- Seattle Children's Research Institute, Seattle, WA, USA
| | - Megan A Moreno
- University of Washington School of Public Health, Seattle, USA. .,University of Washington School of Medicine, Seattle, WA, USA. .,Seattle Children's Research Institute, Seattle, WA, USA.
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Abstract
Purpose
This is the first study to compile statistical data to describe the functions and responsibilities of physicians in formal and informal leadership roles in the Canadian health system. This mixed-methods research study offers baseline data relative to this purpose, and also describes physician leaders’ views on fundamental aspects of their leadership responsibility.
Design/methodology/approach
A survey with both quantitative and qualitative fields yielded 689 valid responses from physician leaders. Data from the survey were utilized in the development of a semi-structured interview guide; 15 physician leaders were interviewed.
Findings
A profile of Canadian physician leadership has been compiled, including demographics; an outline of roles, responsibilities, time commitments and related compensation; and personal factors that support, engage and deter physicians when considering taking on leadership roles. The role of health-care organizations in encouraging and supporting physician leadership is explicated.
Practical implications
The baseline data on Canadian physician leaders create the opportunity to determine potential steps for improving the state of physician leadership in Canada; and health-care organizations are provided with a wealth of information on how to encourage and support physician leaders. Using the data as a benchmark, comparisons can also be made with physician leadership as practiced in other nations.
Originality/value
There are no other research studies available that provide the depth and breadth of detail on Canadian physician leadership, and the embedded recommendations to health-care organizations are informed by this in-depth knowledge.
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Mubang RN, Stoltzfus JC, Cohen MS, Hoey BA, Stehly CD, Evans DC, Jones C, Papadimos TJ, Grell J, Hoff WS, Thomas P, Cipolla J, Stawicki SP. Comorbidity-Polypharmacy Score as Predictor of Outcomes in Older Trauma Patients: A Retrospective Validation Study. World J Surg 2016; 39:2068-75. [PMID: 25809063 DOI: 10.1007/s00268-015-3041-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Traditional injury severity assessment is insufficient in estimating the morbidity and mortality risk for older (≥45 years) trauma patients. Commonly used tools involve complex calculations or tables, do not consider all comorbidities, and often rely on data that are not available early in the trauma patient's hospitalization. The comorbidity-polypharmacy score (CPS), a sum of all pre-injury medications and comorbidities, was found in previous studies to independently predict morbidity and mortality in this older patient population. However, these studies are limited by relatively small sample sizes. Consequently, we sought to validate previous research findings in a large, administrative dataset. METHODS A retrospective study of patients ages≥45 years was performed using an administrative trauma database from St. Luke's University Hospital's Level I Trauma Center. The study period was from 1 January 2008 to 31 December 2013. Abstracted data included patient demographics, injury mechanism and severity [injury characteristics and severity score (ISS)], Glasgow coma scale (GCS), hospital and intensive care unit lengths of stay (HLOS and ILOS, respectively), morbidity, post-discharge destination, and in-hospital mortality. Univariate analyses were conducted with mortality, all-cause morbidity, and discharge destination as primary end-points. Variables reaching statistical significance (p≤0.20) were included in a multivariate logistic regression model. Data are presented as adjusted odds ratios (AORs), with p<0.05 denoting statistical significance. RESULTS A total of 5863 patient records were analyzed. Average patient age was 68.5±15.3 years (52% male, 89% blunt mechanism, mean GCS 14.3). Mean HLOS and ILOS increased significantly with increasing CPS (p<0.01). Independent predictors of mortality included age (AOR 1.05, p<0.01), CPS (per-unit AOR 1.08, p<0.02), GCS (AOR 1.43 per-unit decrease, p<0.01), and ISS (per-unit 1.08, p<0.01). Independent predictors of all-cause morbidity included age (AOR 1.02, p<0.01), GCS (AOR per-unit decrease 1.08, p<0.01), ISS (per-unit AOR 1.09, p<0.01), and CPS (per-unit AOR 1.04, p<0.01). CPS did not independently predict need for discharge to a facility. CONCLUSIONS This study confirms that CPS is an independent predictor of all-cause morbidity and mortality in older trauma patients. However, CPS was not independently associated with need for discharge to a facility. Prospective multicenter studies are needed to evaluate the use of CPS as a predictive and interventional tool, with special focus on correlations between specific pre-existing conditions, pharmacologic interactions, and morbidity/mortality patterns.
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Affiliation(s)
- Ronnie N Mubang
- Department of Surgery, St Luke's University Health Network, 801 Ostrum Street, NW2 Administration, Bethlehem, PA, 18015, USA
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Risk Factors for Emergency Department Short Time Readmission in Stratified Population. BIOMED RESEARCH INTERNATIONAL 2015; 2015:685067. [PMID: 26682222 PMCID: PMC4664798 DOI: 10.1155/2015/685067] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 10/07/2015] [Accepted: 10/11/2015] [Indexed: 01/05/2023]
Abstract
Background. Emergency department (ED) readmissions are considered an indicator of healthcare quality that is particularly relevant in older adults. The primary objective of this study was to identify key factors for predicting patients returning to the ED within 30 days of being discharged. Methods. We analysed patients who attended our ED in June 2014, stratified into four groups based on the Kaiser pyramid. We collected data on more than 100 variables per case including demographic and clinical characteristics and drug treatments. We identified the variables with the highest discriminating power to predict ED readmission and constructed classifiers using machine learning methods to provide predictions. Results. Classifier performance distinguishing between patients who were and were not readmitted (within 30 days), in terms of average accuracy (AC). The variables with the greatest discriminating power were age, comorbidity, reasons for consultation, social factors, and drug treatments. Conclusions. It is possible to predict readmissions in stratified groups with high accuracy and to identify the most important factors influencing the event. Therefore, it will be possible to develop interventions to improve the quality of care provided to ED patients.
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Hwang U, Carpenter C. Assessing geriatric vulnerability for post emergency department adverse outcomes: challenges abound while progress is slow. Emerg Med J 2015; 33:2-3. [DOI: 10.1136/emermed-2015-204983] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2015] [Indexed: 11/04/2022]
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Shaw PB, Delate T, Lyman A, Adams J, Kreutz H, Sanchez JK, Dowd MB, Gozansky W. Impact of a Clinical Pharmacy Specialist in an Emergency Department for Seniors. Ann Emerg Med 2015. [PMID: 26211427 DOI: 10.1016/j.annemergmed.2015.06.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE This study assesses outcomes associated with the implementation of an emergency department (ED) for seniors in which a clinical pharmacy specialist, with specialized geriatric training that included medication management training, is a key member of the ED care team. METHODS This was a retrospective cohort analysis of patients aged 65 years or older who presented at an ED between November 1, 2012, and May 31, 2013. Three groups of seniors were assessed: treated by the clinical pharmacy specialist in the ED for seniors, treated in the ED for seniors but not by the clinical pharmacy specialist, and not treated in the ED for seniors. Outcomes included rates of an ED return visit, mortality and hospital admissions, and follow-up total health care costs. Multivariable regression modeling was used to adjust for any potential confounders in the associations between groups and outcomes. RESULTS A total of 4,103 patients were included, with 872 (21%) treated in the ED for seniors and 342 (39%) of these treated by the clinical pharmacy specialist. Groups were well matched overall in patient characteristics. Patients who received medication review and management by the clinical pharmacy specialist did not experience a reduction in ED return visits, mortality, cost of follow-up care, or hospital admissions compared with the other groups. Of the patients treated by the clinical pharmacy specialist, 154 (45.0%) were identified as having at least 1 medication-related problem. CONCLUSION Although at least 1 medication-related problem was identified in almost half of patients treated by the clinical pharmacy specialist in the ED for seniors, incorporation of a clinical pharmacy specialist into the ED staff did not improve clinical outcomes.
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Affiliation(s)
- Paul B Shaw
- Pharmacy Department, Kaiser Permanente Colorado, Lafayette, CO.
| | - Thomas Delate
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO
| | - Alfred Lyman
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO
| | - Jody Adams
- Pharmacy Department, Lutheran Medical Center, Wheat Ridge, CO
| | - Heather Kreutz
- Pharmacy Department, Kaiser Permanente Colorado, Denver, CO
| | - Julia K Sanchez
- Pharmacy Department, Kaiser Permanente Colorado, Englewood, CO
| | - Mary Beth Dowd
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO
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Callinan SM, Brandt NJ. Tackling Communication Barriers Between Long-Term Care Facility and Emergency Department Transfers to Improve Medication Safety in Older Adults. J Gerontol Nurs 2015; 41:8-13. [DOI: 10.3928/00989134-20150616-04] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Mota FRDN, Victor JF, Silva MJD, Bessa MEP, Amorim VLD, Cavalcante MLSN, Moreira ACA, Barbosa TM. Cross-cultural adaptation of the Caregiver Reaction Assessment for use in Brazil with informal caregivers of the elderly. Rev Esc Enferm USP 2015; 49:426-34. [DOI: 10.1590/s0080-623420150000300010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 03/06/2015] [Indexed: 11/22/2022] Open
Abstract
This study aimed to carry out the cross-cultural adaptation of the Caregiver Reaction Assessment CRA for use in Brazil with informal caregivers of dependent elderly METHOD A methodological study, of five steps: initial translation, synthesis of translations, retro-translation, evaluation by a judge committee and a pre-test, with 30 informal caregivers of older persons in Fortaleza, Brazil. Content validity was assessed by five experts in gerontology and geriatrics. The cross-cultural adaptation was rigorously conducted, allowing for inferring credibility. RESULTS The Brazilian version of the CRA had a simple and fast application (ten minutes), easily understood by the target audience. It is semantically, idiomatically, experimentally and conceptually equivalent to the original version, with valid content to assess the burden of informal caregivers for the elderly (Content Validity Index = 0.883). CONCLUSION It is necessary that other psychometric properties of validity and reliability are tested before using in care practice and research.
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Schnitker LM, Martin-Khan M, Burkett E, Brand CA, Beattie ERA, Jones RN, Gray LC. Structural quality indicators to support quality of care for older people with cognitive impairment in emergency departments. Acad Emerg Med 2015; 22:273-84. [PMID: 25754936 DOI: 10.1111/acem.12617] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 08/25/2014] [Accepted: 10/15/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The purpose of this study was to identify the structural quality of care domains and to establish a set of structural quality indicators (SQIs) for the assessment of care of older people with cognitive impairment in emergency departments (EDs). METHODS A structured approach to SQI development was undertaken including: 1) a comprehensive search of peer-reviewed and gray literature focusing on identification of evidence-based interventions targeting structure of care of older patients with cognitive impairment and existing SQIs; 2) a consultative process engaging experts in the care of older people and epidemiologic methods (i.e., advisory panel) leading to development of a draft set of SQIs; 3) field testing of drafted SQIs in eight EDs, leading to refinement of the SQI set; and 4) an independent voting process among the panelists for SQI inclusion in a final set, using preestablished inclusion and exclusion criteria. RESULTS At the conclusion of the process, five SQIs targeting the management of older ED patients with cognitive impairment were developed: 1) the ED has a policy outlining the management of older people with cognitive impairment during the ED episode of care; 2) the ED has a policy outlining issues relevant to carers of older people with cognitive impairment, encompassing the need to include the (family) carer in the ED episode of care; 3) the ED has a policy outlining the assessment and management of behavioral symptoms, with specific reference to older people with cognitive impairment; 4) the ED has a policy outlining delirium prevention strategies, including the assessment of patients' delirium risk factors; and 5) the ED has a policy outlining pain assessment and management for older people with cognitive impairment. CONCLUSIONS This article presents a set of SQIs for the evaluation of performance in caring for older people with cognitive impairment in EDs.
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Affiliation(s)
- Linda M. Schnitker
- The Centre for Research in Geriatric Medicine; The University of Queensland; Brisbane Australia
| | - Melinda Martin-Khan
- The Centre for Research in Geriatric Medicine; The University of Queensland; Brisbane Australia
- Centre for Online Health; The University of Queensland; Brisbane Australia
| | - Ellen Burkett
- The Department of Emergency Medicine; Princess Alexandra Hospital; Brisbane Australia
| | - Caroline A. Brand
- The Centre for Research Excellence in Patient Safety; Monash University; Melbourne Australia
| | - Elizabeth R. A. Beattie
- The School of Nursing and Midwifery; Queensland University of Technology; Brisbane Australia
| | - Richard N. Jones
- Hebrew SeniorLife; Institute for Aging Research; Harvard Medical School; Boston MA
| | - Len C. Gray
- The Centre for Research in Geriatric Medicine; The University of Queensland; Brisbane Australia
- Centre for Online Health; The University of Queensland; Brisbane Australia
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Schnitker LM, Martin-Khan M, Burkett E, Beattie ERA, Jones RN, Gray LC. Process quality indicators targeting cognitive impairment to support quality of care for older people with cognitive impairment in emergency departments. Acad Emerg Med 2015; 22:285-98. [PMID: 25754937 DOI: 10.1111/acem.12616] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 08/25/2014] [Accepted: 10/15/2014] [Indexed: 01/05/2023]
Abstract
OBJECTIVES The objective of this study was to develop process quality indicators (PQIs) to support the improvement of care services for older people with cognitive impairment in emergency departments (ED). METHODS A structured research approach was taken for the development of PQIs for the care of older people with cognitive impairment in EDs, including combining available evidence with expert opinion (phase 1), a field study (phase 2), and formal voting (phase 3). A systematic review of the literature identified ED processes targeting the specific care needs of older people with cognitive impairment. Existing relevant PQIs were also included. By integrating the scientific evidence and clinical expertise, new PQIs were drafted and, along with the existing PQIs, extensively discussed by an advisory panel. These indicators were field tested in eight hospitals using a cohort of older persons aged 70 years and older. After analysis of the field study data (indicator prevalence, variability across sites), in a second meeting, the advisory panel further defined the PQIs. The advisory panel formally voted for selection of those PQIs that were most appropriate for care evaluation. RESULTS In addition to seven previously published PQIs relevant to the care of older persons, 15 new indicators were created. These 22 PQIs were then field tested. PQIs designed specifically for the older ED population with cognitive impairment were only scored for patients with identified cognitive impairment. Following formal voting, a total of 11 PQIs were included in the set. These PQIs targeted cognitive screening, delirium screening, delirium risk assessment, evaluation of acute change in mental status, delirium etiology, proxy notification, collateral history, involvement of a nominated support person, pain assessment, postdischarge follow-up, and ED length of stay. CONCLUSIONS This article presents a set of PQIs for the evaluation of the care for older people with cognitive impairment in EDs. The variation in indicator triggering across different ED sites suggests that there are opportunities for quality improvement in care for this vulnerable group. Applied PQIs will identify an emergency services' implementation of care strategies for cognitively impaired older ED patients. Awareness of the PQI triggers at an ED level enables implementation of targeted interventions to improve any suboptimal processes of care. Further validation and utility of the indicators in a wider population is now indicated.
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Affiliation(s)
- Linda M. Schnitker
- The Centre for Research in Geriatric Medicine; University of Queensland; Brisbane Australia
| | - Melinda Martin-Khan
- The Centre for Research in Geriatric Medicine; University of Queensland; Brisbane Australia
- The Centre for Online Health; University of Queensland; Brisbane Australia
| | - Ellen Burkett
- The Department of Emergency Medicine; Princess Alexandra Hospital; Brisbane Australia
| | - Elizabeth R. A. Beattie
- The School of Nursing and Midwifery; Queensland University of Technology; Brisbane Australia
| | - Richard N. Jones
- Hebrew SeniorLife; Institute for Aging Research; Harvard Medical School; Boston, MA
| | - Len C. Gray
- The Centre for Online Health; University of Queensland; Brisbane Australia
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Carpenter CR, Shelton E, Fowler S, Suffoletto B, Platts-Mills TF, Rothman RE, Hogan TM. Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: a systematic review and meta-analysis. Acad Emerg Med 2015; 22:1-21. [PMID: 25565487 DOI: 10.1111/acem.12569] [Citation(s) in RCA: 215] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 07/21/2014] [Accepted: 08/24/2014] [Indexed: 12/20/2022]
Abstract
OBJECTIVES A significant proportion of geriatric patients experience suboptimal outcomes following episodes of emergency department (ED) care. Risk stratification screening instruments exist to distinguish vulnerable subsets, but their prognostic accuracy varies. This systematic review quantifies the prognostic accuracy of individual risk factors and ED-validated screening instruments to distinguish patients more or less likely to experience short-term adverse outcomes like unanticipated ED returns, hospital readmissions, functional decline, or death. METHODS A medical librarian and two emergency physicians conducted a medical literature search of PubMed, EMBASE, SCOPUS, CENTRAL, and ClinicalTrials.gov using numerous combinations of search terms, including emergency medical services, risk stratification, geriatric, and multiple related MeSH terms in hundreds of combinations. Two authors hand-searched relevant specialty society research abstracts. Two physicians independently reviewed all abstracts and used the revised Quality Assessment of Diagnostic Accuracy Studies instrument to assess individual study quality. When two or more qualitatively similar studies were identified, meta-analysis was conducted using Meta-DiSc software. Primary outcomes were sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for predictors of adverse outcomes at 1 to 12 months after the ED encounters. A hypothetical test-treatment threshold analysis was constructed based on the meta-analytic summary estimate of prognostic accuracy for one outcome. RESULTS A total of 7,940 unique citations were identified yielding 34 studies for inclusion in this systematic review. Studies were significantly heterogeneous in terms of country, outcomes assessed, and the timing of post-ED outcome assessments. All studies occurred in ED settings and none used published clinical decision rule derivation methodology. Individual risk factors assessed included dementia, delirium, age, dependency, malnutrition, pressure sore risk, and self-rated health. None of these risk factors significantly increased the risk of adverse outcome (LR+ range = 0.78 to 2.84). The absence of dependency reduces the risk of 1-year mortality (LR- = 0.27) and nursing home placement (LR- = 0.27). Five constructs of frailty were evaluated, but none increased or decreased the risk of adverse outcome. Three instruments were evaluated in the meta-analysis: Identification of Seniors at Risk, Triage Risk Screening Tool, and Variables Indicative of Placement Risk. None of these instruments significantly increased (LR+ range for various outcomes = 0.98 to 1.40) or decreased (LR- range = 0.53 to 1.11) the risk of adverse outcomes. The test threshold for 3-month functional decline based on the most accurate instrument was 42%, and the treatment threshold was 61%. CONCLUSIONS Risk stratification of geriatric adults following ED care is limited by the lack of pragmatic, accurate, and reliable instruments. Although absence of dependency reduces the risk of 1-year mortality, no individual risk factor, frailty construct, or risk assessment instrument accurately predicts risk of adverse outcomes in older ED patients. Existing instruments designed to risk stratify older ED patients do not accurately distinguish high- or low-risk subsets. Clinicians, educators, and policy-makers should not use these instruments as valid predictors of post-ED adverse outcomes. Future research to derive and validate feasible ED instruments to distinguish vulnerable elders should employ published decision instrument methods and examine the contributions of alternative variables, such as health literacy and dementia, which often remain clinically occult.
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Affiliation(s)
- Christopher R. Carpenter
- The Department of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Erica Shelton
- The Department of Emergency Medicine; Johns Hopkins University; Baltimore MD
| | - Susan Fowler
- The Department of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Brian Suffoletto
- The Department of Emergency Medicine; University of Pittsburgh Medical Center; Pittsburgh PA
| | - Timothy F. Platts-Mills
- The Department of Emergency Medicine; University of North Carolina-Chapel Hill; Chapel Hill NC
| | - Richard E. Rothman
- The Department of Emergency Medicine; Johns Hopkins University; Baltimore MD
| | - Teresita M. Hogan
- The Department of Emergency Medicine; University of Chicago; Chicago IL
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Abstract
Changing global demography is resulting in older people presenting to emergency departments (EDs) in greater numbers than ever before. They present with greater urgency and are more likely to be admitted to hospital or re-attend and utilize greater resources. They experience longer waits for care and are less likely to be satisfied with their experiences. Not only that, but older people suffer poorer health outcomes after ED attendance, with higher mortality rates and greater dependence in activities of daily living or rates of admission to nursing homes. Older people's assessment and management in the ED can be complex, time consuming, and require specialist skills. The interplay of multiple comorbidities and functional decline result in the complex state of frailty that can predispose to poor health outcomes and greater care needs. Older people with frailty may present to services in an atypical fashion requiring detailed, multidimensional, and increasingly multidisciplinary care to provide the correct diagnosis and management as well as appropriate placement for ongoing care or admission avoidance. Specific challenges such as delirium, functional decline, or carer strain need to be screened for and managed appropriately. Identifying patients with specific frailty syndromes can be critical to identifying those at highest risk of poor outcomes and most likely to benefit from further specialist interventions. Models of care are evolving that aim to deliver multidimensional assessment and management by multidisciplinary specialist care teams (comprehensive geriatric assessment). Increasingly, these models are demonstrating improved outcomes, including admission avoidance or reduced death and dependence. Delivering this in the ED is an evolving area of practice that adapts the principles of geriatric medicine for the urgent-care environment.
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Affiliation(s)
- Graham Ellis
- Medicine for the Elderly, Monklands Hospital, Airdrie, Scotland, UK
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Carpenter CR, Avidan MS, Wildes T, Stark S, Fowler SA, Lo AX. Predicting geriatric falls following an episode of emergency department care: a systematic review. Acad Emerg Med 2014; 21:1069-82. [PMID: 25293956 DOI: 10.1111/acem.12488] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 06/19/2014] [Accepted: 06/21/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Falls are the leading cause of traumatic mortality in geriatric adults. Despite recent multispecialty guideline recommendations that advocate for proactive fall prevention protocols in the emergency department (ED), the ability of risk factors or risk stratification instruments to identify subsets of geriatric patients at increased risk for short-term falls is largely unexplored. OBJECTIVES This was a systematic review and meta-analysis of ED-based history, physical examination, and fall risk stratification instruments with the primary objective of providing a quantitative estimate for each risk factor's accuracy to predict future falls. A secondary objective was to quantify ED fall risk assessment test and treatment thresholds using derived estimates of sensitivity and specificity. METHODS A medical librarian and two emergency physicians (EPs) conducted a medical literature search of PUBMED, EMBASE, CINAHL, CENTRAL, DARE, the Cochrane Registry, and Clinical Trials. Unpublished research was located by a hand search of emergency medicine (EM) research abstracts from national meetings. Inclusion criteria for original studies included ED-based assessment of pre-ED or post-ED fall risk in patients 65 years and older with sufficient detail to reproduce contingency tables for meta-analysis. Original study authors were contacted for additional details when necessary. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to assess individual study quality for those studies that met inclusion criteria. When more than one qualitatively similar study assessed the same risk factor for falls at the same interval following an ED evaluation, then meta-analysis was performed using Meta-DiSc software. The primary outcomes were sensitivity, specificity, and likelihood ratios for fall risk factors or risk stratification instruments. Secondary outcomes included estimates of test and treatment thresholds using the Pauker method based on accuracy, screening risk, and the projected benefits or harms of fall prevention interventions in the ED. RESULTS A total of 608 unique and potentially relevant studies were identified, but only three met our inclusion criteria. Two studies that included 660 patients assessed 29 risk factors and two risk stratification instruments for falls in geriatric patients in the 6 months following an ED evaluation, while one study of 107 patients assessed the risk of falls in the preceding 12 months. A self-report of depression was associated with the highest positive likelihood ratio (LR) of 6.55 (95% confidence interval [CI] = 1.41 to 30.48). Six fall predictors were identified in more than one study (past falls, living alone, use of walking aid, depression, cognitive deficit, and more than six medications) and meta-analysis was performed for these risk factors. One screening instrument was sufficiently accurate to identify a subset of geriatric ED patients at low risk for falls with a negative LR of 0.11 (95% CI = 0.06 to 0.20). The test threshold was 6.6% and the treatment threshold was 27.5%. CONCLUSIONS This study demonstrates the paucity of evidence in the literature regarding ED-based screening for risk of future falls among older adults. The screening tools and individual characteristics identified in this study provide an evidentiary basis on which to develop screening protocols for geriatrics adults in the ED to reduce fall risk.
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Affiliation(s)
| | | | - Tanya Wildes
- The Department of Medicine Division of Medical Oncology; St. Louis MO
| | - Susan Stark
- The Department of Occupational Therapy; St. Louis MO
- The Department of Neurology; St. Louis MO
| | - Susan A. Fowler
- Washington University in St. Louis School of Medicine; St. Louis MO
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Carpenter CR, Bromley M, Caterino JM, Chun A, Gerson LW, Greenspan J, Hwang U, John DP, Lyons WL, Platts-Mills TF, Mortensen B, Ragsdale L, Rosenberg M, Wilber S. Optimal older adult emergency care: introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine. Acad Emerg Med 2014; 21:806-9. [PMID: 25117158 DOI: 10.1111/acem.12415] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 02/25/2014] [Accepted: 02/26/2014] [Indexed: 02/03/2023]
Abstract
In the United States and around the world, effective, efficient, and reliable strategies to provide emergency care to aging adults is challenging crowded emergency departments (EDs) and a strained health care system. In response, geriatric emergency medicine (EM) clinicians, educators, and researchers collaborated with the American College of Emergency Physicians (ACEP), American Geriatrics Society (AGS), Emergency Nurses Association (ENA), and the Society for Academic Emergency Medicine (SAEM) to develop guidelines intended to improve ED geriatric care by enhancing expertise, educational, and quality improvement expectations; equipment; policies; and protocols. These "Geriatric Emergency Department Guidelines" represent the first formal society-led attempt to characterize the essential attribute of the geriatric ED and received formal approval from the boards of directors for each of the four societies in 2013 and 2014. This article is intended to introduce EM and geriatric health care providers to the guidelines, while providing proposals for educational dissemination, refinement via formal effectiveness evaluations and cost-effectiveness studies, and institutional credentialing.
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Affiliation(s)
- Christopher R. Carpenter
- Department of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Marilyn Bromley
- American College of Emergency Physicians' Geriatric Section; Irving TX
| | - Jeffrey M. Caterino
- Department of Emergency Medicine; The Ohio State University; Columbus OH
- Department of Internal Medicine; The Ohio State University; Columbus OH
| | - Audrey Chun
- Department of Geriatric and Palliative Medicine; Icahn School of Medicine at Mount Sinai; New York NY
| | - Lowell W. Gerson
- Professor Emeritus of Family and Community Medicine; Northeast Ohio Medical University Summa Health System-Akron City Hospital; Akron OH
| | | | - Ula Hwang
- Department of Emergency Medicine; Icahn School of Medicine at Mount Sinai; New York NY
| | - David P. John
- Department of Emergency Medicine; Johnson Memorial Medical Center; Northeast Emergency Medicine Specialists; Stafford CT
| | - William L. Lyons
- Department of Internal Medicine, Geriatrics; University of Nebraska Medical Center; Omaha NE
| | - Timothy F. Platts-Mills
- Department of Emergency Medicine; University of North Carolina at Chapel Hill School of Medicine; Chapel Hill NC
| | - Betty Mortensen
- Emergency Nurses Association; Des Plaines IL
- Duke University School of Medicine; Durham NC
| | - Luna Ragsdale
- Wake Forest University School of Medicine; Winston-Salem NC
| | - Mark Rosenberg
- Department of Emergency Medicine; New York Medical College; St. Joseph's Healthcare System; Paterson NJ
| | - Scott Wilber
- Department of Emergency Medicine; Summa Akron City and St. Thomas Hospitals; Northeast Ohio Medical University; Rootstown OH
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Optimal older adult emergency care: Introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine. Ann Emerg Med 2014; 63:e1-3. [PMID: 24746436 DOI: 10.1016/j.annemergmed.2014.03.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Carpenter CR, Bromley M, Caterino JM, Chun A, Gerson LW, Greenspan J, Hwang U, John DP, Lyons WL, Platts-Mills TF, Mortensen B, Ragsdale L, Rosenberg M, Wilber S. Optimal Older Adult Emergency Care: Introducing Multidisciplinary Geriatric Emergency Department Guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Me. J Am Geriatr Soc 2014; 62:1360-3. [DOI: 10.1111/jgs.12883] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | - Marilyn Bromley
- Geriatric Section; American College of Emergency Physicians; Dallas Texas
| | - Jeffrey M. Caterino
- Department of Emergency Medicine and Internal Medicine; The Ohio State University; Columbus Ohio
| | - Audrey Chun
- Department of Geriatric and Palliative Medicine; Icahn School of Medicine at Mount Sinai; New York New York
| | - Lowell W. Gerson
- Northeast Ohio Medical University; Rootstown Ohio
- Summa Health System-Akron City Hospital; Akron Ohio
| | | | - Ula Hwang
- Emergency Medicine; Icahn School of Medicine at Mount Sinai; New York New York
| | - David P. John
- Johnson Memorial Medical Center; Stafford Connecticut
- Northeast Emergency Medicine Specialists; Stafford Connecticut
| | - William L. Lyons
- Department of Internal Medicine and Geriatrics; University of Nebraska Medical Center; Omaha Nebraska
| | - Timothy F. Platts-Mills
- Department of Emergency Medicine; School of Medicine; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
| | | | - Luna Ragsdale
- School of Medicine; Duke University; Durham North Carolina
- School of Medicine; Wake Forest University; Winston-Salem North Carolina
| | - Mark Rosenberg
- Department of Clinical Emergency Medicine; New York Medical College; Valhalla New York
- St Joseph's Healthcare System; Paterson New Jersey
| | - Scott Wilber
- Summa Akron City and St. Thomas Hospitals; Akron Ohio
- Department of Emergency Medicine; Northeast Ohio Medical University; Rootstown Ohio
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Geriatric Emergency Department Guidelines. Ann Emerg Med 2014; 63:e7-25. [DOI: 10.1016/j.annemergmed.2014.02.008] [Citation(s) in RCA: 172] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 02/06/2014] [Accepted: 02/06/2014] [Indexed: 12/16/2022]
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