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Bouzid W, Cantet C, Berard E, Mathieu C, Hermabessière S, Houles M, Krams T, Qassemi S, Cambon A, McCambridge C, Tavassoli N, Rolland Y. Exploring Predictive Factors for Potentially Avoidable Emergency Department Transfers: Findings From the FINE Study. J Am Med Dir Assoc 2024; 25:572-579.e1. [PMID: 38159914 DOI: 10.1016/j.jamda.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES To assess the prevalence of potentially avoidable transfers (PAT) and identify factors associated with these transfers to emergency departments (EDs) among nursing home (NH) residents. DESIGN This is a secondary outcome analysis of the FINE study, a multicenter observational study collecting data on NH residents, NH settings, and contextual factors of ED transfers. SETTINGS AND PARTICIPANTS NHs in the former Midi-Pyrénées region of the southwest of France (n = 312); a total of 1037 NH residents who experienced ED transfers (n = 1017) between January 2016 and December 2016. METHODS The analysis included resident baseline characteristics and NH and transfer decision-making characteristics. An expert group categorized the transfer status as either PAT or unavoidable. Multivariable analysis using a mixed logistic model, accounting for intra-NH correlation, was conducted to assess factors independently associated with PAT. RESULTS Among 1017 included transfers, 87.02% (n = 885) were identified as PAT and 12.98% (n = 132) unavoidable transfers. Multivariable analysis revealed that the following patient-related factors were associated with a likely high rate of PAT: usual behavior disturbances before transfer, including productive trouble (OR 2.04, 95% CI 1.25-3.33; P = .0044) and unusual symptom of falling during the week preceding the transfer (OR 4.55, 95% CI 1.76-11.82; P = .0019). On the other hand, distance between ED and NH (OR 0.98, 95% CI 0.97-0.998; P = .0231), NH staff trained in palliative care in the last 3 years (OR 0.52, 95% CI 0.29-0.95; P = .0324), the impossibility of direct hospitalization to an appropriate unit (OR 0.54, 95% CI 0.34-0.87; P = .0117), and the resident Charlson Comorbidity Index (OR 0.90, 95% CI 0.82-0.99; P = .0369) were associated with a lower probability of PAT. CONCLUSION AND IMPLICATIONS Transfers from NHs to hospital EDs were frequently potentially avoidable, meaning that there are still significant opportunities to reduce PAT. Our findings may help to specifically identify interventions that should be targeted at both NH and resident levels.
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Affiliation(s)
- Wafa Bouzid
- Gérontopôle, Toulouse University Hospital, Toulouse, France; Centre Hospitalier Universitaire de Toulouse, Service d'Epidémiologie, Toulouse, France; Regional Health Agency of Occitanie, Toulouse, France.
| | | | - Emilie Berard
- Centre Hospitalier Universitaire de Toulouse, Service d'Epidémiologie, Toulouse, France; UMR 1295 CERPOP, INSERM-Université de Toulouse III, Toulouse, France
| | - Celine Mathieu
- Gérontopôle, Toulouse University Hospital, Toulouse, France
| | | | - Mathieu Houles
- Gérontopôle, Toulouse University Hospital, Toulouse, France
| | - Thomas Krams
- Gérontopôle, Toulouse University Hospital, Toulouse, France
| | - Soraya Qassemi
- Gérontopôle, Toulouse University Hospital, Toulouse, France
| | | | | | - Neda Tavassoli
- Gérontopôle, Toulouse University Hospital, Toulouse, France
| | - Yves Rolland
- Gérontopôle, Toulouse University Hospital, Toulouse, France; Centre Hospitalier Universitaire de Toulouse, Service d'Epidémiologie, Toulouse, France
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Gettel CJ, Galske J, Sather AR, Haidous AK, Hwang U, Brackett AL, Venkatesh AK, Rising KL, Goldberg EM, van Oppen JD, Conroy SP, Carpenter CR. Patient-reported outcome measure use among older adults after emergency department care: A systematic review. Acad Emerg Med 2024; 31:273-287. [PMID: 38366698 DOI: 10.1111/acem.14850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/05/2023] [Accepted: 12/09/2023] [Indexed: 02/18/2024]
Abstract
BACKGROUND Patient-reported outcome measures (PROMs) are gaining favor in clinical and research settings given their ability to capture a patient's symptom burden, functional status, and quality of life. Our objective in this systematic review was to summarize studies including PROMs assessed among older adults (age ≥ 65 years) after seeking emergency care. METHODS With the assistance of a medical librarian, we searched Ovid MEDLINE, PubMed, Embase, CINAHL, Web of Science-Core Collection, and Cochrane CENTRAL from inception through June 2023 for studies in which older adult ED patients had PROMs assessed in the post-emergency care time period. Independent reviewers performed title/abstract review, full-text screening, data extraction, study characteristic summarization, and risk-of-bias (RoB) assessments. RESULTS Our search strategy yielded 5153 studies of which 56 met study inclusion criteria. Within included studies, 304 unique PROM assessments were performed at varying time points after the ED visit, including 61 unique PROMs. The most commonly measured domain was physical function, assessed within the majority of studies (47/56; 84%), with measures including PROMs such as Katz activities of daily living (ADLs), instrumental ADLs, and the Barthel Index. PROMs were most frequently assessed at 1-3 months after an ED visit (113/304; 37%), greater than 6 months (91/304; 30%), and 4-6 months (88/304; 29%), with very few PROMs assessed within 1 month of the ED visit (12/304; 4%). Of the 16 interventional studies, two were determined to have a low RoB, four had moderate RoB, nine had high RoB, and one had insufficient information. Of the 40 observational studies, 10 were determined to be of good quality, 20 of moderate quality, and 10 of poor quality. CONCLUSIONS PROM assessments among older adults following an ED visit frequently measured physical function, with very few assessments occurring within the first 1 month after an ED visit.
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Affiliation(s)
- Cameron J Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut, USA
| | - James Galske
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Ali K Haidous
- University of Michigan-Dearborn, Dearborn, Michigan, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New York, USA
| | - Alexandria L Brackett
- Harvey Cushing/John Hay Whitney Medical Library, Yale School of Medicine, New Haven, Connecticut, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kristin L Rising
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Center for Connected Care, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- College of Nursing, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Elizabeth M Goldberg
- Department of Emergency Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - James D van Oppen
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Simon P Conroy
- Medical Research Council Unit for Lifelong Health and Ageing, University College London, London, UK
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Ouchi K, Joshi C, Kaithamattam J, Gale SA, Marshall GA, Pietras A, Wang W, Boyer EW, Tulsky JA, Block SD, Rentz D, Schonberg MA. Refinement of an Emergency Department-Based, Advance Care Planning Intervention for Patients With Cognitive Impairment and Their Caregivers. THE GERONTOLOGIST 2024; 64:gnad020. [PMID: 36848220 PMCID: PMC10733123 DOI: 10.1093/geront/gnad020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Advance care planning (ACP) conversations are important to provide goal-concordant care (i.e., the care that matches the patient's previously stated goals) near end of life. While 31% of older adults presenting to the emergency department (ED) have dementia, only 39% have previously had ACP conversations. We refined and piloted an ED-based, motivational interview designed to stimulate ACP conversations (ED GOAL) for patients living with cognitive impairment and their caregivers. RESEARCH DESIGN AND METHODS We systematically refined ED GOAL and then conducted an acceptability study in an urban, academic medical center. We prospectively enrolled adults aged 50+ with cognitive impairment and their caregivers. Trained clinicians conducted the intervention. We measured acceptability after the intervention and participants' ACP engagement at baseline and 1-month follow-up. RESULTS Specific statements to address both the patient and caregiver were added to the ED GOAL script. Of 60 eligible patient/caregiver dyads approached, 26 participated, and 20 (77%) completed follow-up assessments. Patient mean age was 79 years (SD 8.5); 65% were female, 92.3% were White, 96.2% were non-Hispanic, and 69% had moderate dementia. Most patients/caregivers reported feeling completely heard and understood by the study clinician about their future medical care preferences (58%, 15/26). They also reported that the study clinician was very respectful (96%, 25/26) when eliciting those preferences. DISCUSSION AND IMPLICATIONS Patients living with cognitive impairment and their caregivers found our refined ED GOAL acceptable and respectful. Future studies need to examine the effect of ED GOAL on ACP engagement among these dyads in the ED.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher Joshi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jenson Kaithamattam
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Seth A Gale
- Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Center for Alzheimer Research and Treatment, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Gad A Marshall
- Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Center for Alzheimer Research and Treatment, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Alison Pietras
- Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Center for Alzheimer Research and Treatment, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Wei Wang
- Division of Circadian and Sleep Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Edward W Boyer
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Susan D Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Dorene Rentz
- Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Center for Alzheimer Research and Treatment, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Mara A Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Yusufov M, Adeyemi O, Flannery M, Bouillon-Minois JB, Van Allen K, Cuthel AM, Goldfeld KS, Ouchi K, Grudzen CR. Psychometric Properties of the Functional Assessment of Cancer Therapy-General for Evaluating Quality of Life in Patients With Life-Limiting Illness in the Emergency Department. J Palliat Med 2024; 27:63-74. [PMID: 37672598 PMCID: PMC11074445 DOI: 10.1089/jpm.2022.0270] [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] [Accepted: 07/20/2023] [Indexed: 09/08/2023] Open
Abstract
Background: The Functional Assessment of Cancer Therapy-General (FACT-G) is a widely used quality-of-life measure. However, no studies have examined the FACT-G among patients with life-limiting illnesses who present to emergency departments (EDs). Objective: The goal of this study was to examine the psychometric properties of the FACT-G among patients with life-limiting illnesses who present to EDs in the United States. Methods: This cross-sectional study pooled data from 12 EDs between April 2018 and January 2020 (n = 453). Patients enrolled in the study were adults with one or more of the four life-limiting illnesses: advanced cancer, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, or End-Stage Renal Disease. We conducted item, exploratory, and confirmatory analyses (exploratory factor analysis [EFA] and confirmatory factor analysis [CFA]) to determine the psychometric properties of the FACT-G. Results: The FACT-G had good internal consistency (Cronbach's alpha α = 0.88). The simplest EFA model was a six-factor structure. The CFA supported the six-factor structure, evidenced by the adequate fit indices (comparative fit index = 0.93, Tucker-Lewis index = 0.92, root-mean-square error of approximation = 0.05; 90% confidence interval: 0.04 - 0.06). The six-factor structure comprised the physical, emotional, work and daily activities-related functional well-being, and the family and friends-related social well-being domains. Conclusions: The FACT-G is a reliable measure of health-related quality of life among patients with life-limiting illnesses who present to the ED. Clinical Trial Registration: NCT03325985.
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Affiliation(s)
- Miryam Yusufov
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Oluwaseun Adeyemi
- Ronald O. Perelman Department of Emergency Medicine, Division of Supportive and Acute Care Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mara Flannery
- Ronald O. Perelman Department of Emergency Medicine, Division of Supportive and Acute Care Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Kaitlyn Van Allen
- Ronald O. Perelman Department of Emergency Medicine, Division of Supportive and Acute Care Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Allison M. Cuthel
- Ronald O. Perelman Department of Emergency Medicine, Division of Supportive and Acute Care Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Keith S. Goldfeld
- Department of Population Health, Division of Supportive and Acute Care Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
| | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine, Division of Supportive and Acute Care Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Population Health, Division of Supportive and Acute Care Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Rousseau G, Thummel S, Vannier C, Paul Louis M, Debacq C, Ridoux C, Deneau P, Laribi S. Evaluation of the appropriateness of nursing home residents' transfer to emergency departments. Int Emerg Nurs 2023; 69:101312. [PMID: 37348235 DOI: 10.1016/j.ienj.2023.101312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/14/2023] [Accepted: 05/25/2023] [Indexed: 06/24/2023]
Abstract
INTRODUCTION France is experiencing a steady increase in the number of residents living in nursing homes (NHs). Each year, 25% of these residents are hospitalized, half of them through emergency departments (EDs). A part of these transfers to EDs are unjustified and not without consequences. The first aim of our study is to evaluate the proportion of avoidable NHs resident transfer to EDs. METHODS An observational, prospective and multicentric study was conducted between January and August 2019 in the 6 EDs of a French county during 3 inclusion periods. A multidisciplinary expert panel determined the appropriateness of each ED transfer. The results were expressed in gross values and %. Expert agreement was assessed by Fleiss' kappa statistical measure. RESULTS Transfers were deemed avoidable in 12 to 35% of cases and appropriate in 53 to 81% of cases according to the experts. Fleiss' Kappa score on the concordance of the different experts' answers concerning the relevance of transfers was slight with k = 0.28 with a significant p-value (p < 0.0001). Infection could benefit of direct hospitalization whereas trauma/wound and acute heart/pulmonary failure are the most relevant reasons of presentation to the ED. CONCLUSIONS Too many ED transfers of NH residents remain avoidable. There is a disparity of results among the experts reflecting a limitation of this study related to the subjective nature of relevance. In a society where demographic projections predict a continuing aging population anywhere EDs are regularly crowded, it would be interesting to identify and prevent factors predisposing to ED transfer and consider alternative managements with a better geriatric and emergency physicians collaboration for this specific population.
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Affiliation(s)
| | - Simon Thummel
- Emergency Medicine Department, CHRU Tours, Tours, France; University of Tours, School of Medicine, Tours, France
| | - Clara Vannier
- Emergency Medicine Department, CHRU Tours, Tours, France; University of Tours, School of Medicine, Tours, France
| | | | - Camille Debacq
- Division of Geriatric Medicine, CHRU Tours, Tours, France
| | - Clément Ridoux
- Nursing home and Geriatric Medicine, CH Sainte-Maure de Touraine, Sainte Maure de Touraine, France
| | - Pierre Deneau
- Emergency Medicine Department, CHRU Tours, Tours, France
| | - Said Laribi
- Emergency Medicine Department, CHRU Tours, Tours, France; University of Tours, School of Medicine, Tours, France
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Ouchi K, Lee RS, Block SD, Aaronson EL, Hasdianda MA, Wang W, Rossmassler S, Lopez RP, Berry D, Sudore R, Schonberg MA, Tulsky JA. An emergency department nurse led intervention to facilitate serious illness conversations among seriously ill older adults: A feasibility study. Palliat Med 2023; 37:730-739. [PMID: 36380515 PMCID: PMC10183478 DOI: 10.1177/02692163221136641] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Serious illness conversations may lead to care consistent with patients' goals near the end of life. The emergency department could serve as an important time and location for these conversations. AIM To determine the feasibility of an emergency department-based, brief motivational interview to stimulate serious illness conversations among seriously ill older adults by trained nurses. DESIGN A pre-/post-intervention study. SETTINGS/PARTICIPANTS In an urban, tertiary care, academic medical center and a community hospital from January 2021 to January 2022, we prospectively enrolled adults ⩾50 years of age with serious illness and an expected prognosis <1 year. We measured feasibility outcomes using the standardized framework for feasibility studies. In addition, we also collected the validated 4-item Advance Care Planning Engagement Survey (a 5-point Likert scale) at baseline and 4-week follow-up and reviewing the electronic medical record for documentation related to newly completed serious illness conversations. RESULTS Among 116 eligible patients who were willing and able to participate, 76 enrolled (65% recruitment rate), and 68 completed the follow-up (91% retention rate). Mean patient age was 64.4 years (SD 8.4), 49% were female, and 58% had metastatic cancer. In all, 16 nurses conducted the intervention, and all participants completed the intervention with a median duration of 27 min. Self-reported Advance Care Planning Engagement increased from 2.78 pre to 3.31 post intervention (readiness to "talk to doctors about end-of-life wishes," p < 0.008). Documentation of health care proxy forms increased (62-70%) as did Medical Order for Life Sustaining Treatment (1-11%) during the 6 months after the emergency department visit. CONCLUSION A novel, emergency department-based, nurse-led brief motivational interview to stimulate serious illness conversations is feasible and may improve advance care planning engagement and documentation in seriously ill older adults.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Serious Illness Care Program, Ariadne Labs, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rachel S. Lee
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Susan D. Block
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Emily L. Aaronson
- Harvard Medical School, Boston, MA, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Mohammad A. Hasdianda
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Wei Wang
- Harvard Medical School, Boston, MA, USA
- Division of Circadian and Sleep Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Sarah Rossmassler
- Department of Nursing, MGH Institute on Health Professions, Boston, MA, USA
- Division of Geriatrics and Palliative Care, Baystate Medical Center, Springfield, MA, USA
| | - Ruth Palan Lopez
- Department of Nursing, MGH Institute on Health Professions, Boston, MA, USA
| | - Donna Berry
- Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle, WA, USA
| | - Rebecca Sudore
- Division of Geriatrics Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Mara A. Schonberg
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - James A. Tulsky
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
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7
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Prachanukool T, Block SD, Berry D, Lee RS, Rossmassler S, Hasdianda MA, Wang W, Sudore R, Schonberg MA, Tulsky JA, Ouchi K. Emergency department-based, nurse-initiated, serious illness conversation intervention for older adults: a protocol for a randomized controlled trial. Trials 2022; 23:866. [PMID: 36210436 PMCID: PMC9549655 DOI: 10.1186/s13063-022-06797-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 09/27/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Visits to the emergency department (ED) are inflection points in patients' illness trajectories and are an underutilized setting to engage seriously ill patients in conversations about their goals of care. We developed an intervention (ED GOAL) that primes seriously ill patients to discuss their goals of care with their outpatient clinicians after leaving the ED. The aims of this study are (i) to test the impact of ED GOAL administered by trained nurses on self-reported, advance care planning (ACP) engagement after leaving the ED and (ii) to evaluate whether ED GOAL increases self-reported completion of serious illness conversation and other patient-centered outcomes. METHODS This is a two-armed, parallel-design, single-blinded, randomized controlled trial of 120 seriously ill older adults in two academic and one community EDs in Boston, MA. Participants are English-speaking adults 50 years and older with a serious life-limiting illness with a recent ED visit. Patients with a valid MOLST (medical order for life-sustaining treatment) form or other documented goals of care within the last 3 months are excluded. We enroll the caregivers of patients with cognitive impairment. Patients are assigned to the intervention or control group using block randomization. A blinded research team member will perform outcome assessments. We will assess (i) changes in ACP engagement within 6 months and (ii) qualitative assessments of the effect of ED GOAL. DISCUSSION In seriously ill older adults arriving in the ED, this randomized controlled trial will test the effects of ED GOAL on patients' self-reported ACP engagement, EMR documentation of new serious illness conversations, and improving patient-centered outcomes. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT05209880.
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Affiliation(s)
- Thidathit Prachanukool
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Susan D Block
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Donna Berry
- Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle, WA, USA
| | - Rachel S Lee
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Sarah Rossmassler
- Department of Nursing, MGH Institute on Health Professions, Boston, MA, USA
- Division of Geriatrics and Palliative Care, Baystate Medical Center, Springfield, MA, USA
| | - Mohammad A Hasdianda
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Wei Wang
- Division of Circadian and Sleep Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Rebecca Sudore
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Mara A Schonberg
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - James A Tulsky
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
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8
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Hasdianda MA, Gray TF, Bello JL, Ballaron B, Egorova NA, Berry DL, Ouchi K. Nurses' Perceptions of Facilitating Advance Care Planning Conversations in the Emergency Department. Palliat Med Rep 2021; 2:65-70. [PMID: 34223506 PMCID: PMC8241390 DOI: 10.1089/pmr.2020.0116] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Nurses are well positioned to initiate advance care planning (ACP) conversations because of their unique strength in communication and central patient-facing role in the interdisciplinary team. Nurse-led ACP conversations have demonstrated promising results in settings outside of the emergency department (ED). Understanding ED nurses' perspectives regarding ACP conversations is needed before implementing similar practices in the ED. Objective: To explore ED nurses' perception of facilitating ACP conversations. Design: We conducted a cross-sectional survey to assess ED nurses' perceptions of facilitating ACP conversations in the ED. Setting: ED nurses at one academic hospital and one community hospital located within the northeastern region of the United States. Results: Seventy-seven (53.1%) out of 145 eligible ED nurses completed the survey. All participants perceived ACP conversations in the ED as at least somewhat important. Forty (51.9%) felt somewhat comfortable in facilitating these conversations. The majority of participants (77.9%) agreed that a specially trained nurse consultation model might be helpful in the ED. We found a correlation between total clinical experience and interest in facilitating ACP conversations in the ED (p = 0.045). Conclusion: ED nurses are well positioned to help patients clarify their goals-of-care and end-of-life care preferences. They perceived ACP conversations to be important and felt comfortable to facilitate them in the ED. Additional studies are needed to empirically test its implementation.
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Affiliation(s)
- Mohammad Adrian Hasdianda
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Tamryn F Gray
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Medicine, Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Josephine Lo Bello
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Brittany Ballaron
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Natasha A Egorova
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Donna L Berry
- Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
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9
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Nagurney JM, Han L, Leo‐Summers L, Allore HG, Gill TM. Risk Factors for Disability After Emergency Department Discharge in Older Adults. Acad Emerg Med 2020; 27:1270-1278. [PMID: 32673434 DOI: 10.1111/acem.14088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 06/30/2020] [Accepted: 07/12/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We have previously shown that older adults discharged from the emergency department (ED) experience an increased disability burden within a 6-month time period after ED discharge. The objective of this study was to identify risk factors associated with increased disability burden among older adults discharged from the ED. METHODS This study is part of an ongoing longitudinal study of 754 community-living persons aged ≥70 years. The analytic sample included 813 ED visits without hospitalization from 430 participants who had at least one visit to an ED during a 14-year follow-up period (1998-2012). Information on ED visits and disability burden in 13 functional activities was collected during monthly interviews. Twenty-nine candidate risk factors were evaluated for their independent associations with increased disability burden using a longitudinal multivariable model. RESULTS In the multivariable analyses, age ≥85 (adjusted risk ratio [aRR] = 1.14, 95% confidence interval [CI] = 1.05 to 1.24), being unmarried (aRR = 1.15, 95% CI = 1.05 to 1.27), lower-extremity weakness (aRR = 1.20, 95% CI = 1.07 to 1.34), and physical frailty (aRR = 1.25, 95% CI = 1.13 to 1.37) were associated with increased disability burden. As the number of risk factors increased, the predicted mean disability burden (on a scale of 0 to 13) also increased, ranging from a value of 1.80 (95% CI = 1.43 to 2.27) for 0 risk factors to a value of 8.59 (95% CI = 7.93 to 9.29) for four risk factors. CONCLUSIONS Among older adults discharged from the ED, several risk factors were associated with increased disability burden over the following 6 months, including age ≥85, being unmarried, lower-extremity weakness, and physical frailty. Further research is needed to evaluate whether risk stratification based on nonmodifiable factors or interventions targeting modifiable risk factors improve functional outcomes for older adults discharged from the ED.
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Affiliation(s)
- Justine M. Nagurney
- From the Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston MAUSA
| | - Ling Han
- and the Department of Internal Medicine Section of Geriatrics Yale School of Medicine New Haven CTUSA
| | - Linda Leo‐Summers
- and the Department of Internal Medicine Section of Geriatrics Yale School of Medicine New Haven CTUSA
| | - Heather G. Allore
- and the Department of Internal Medicine Section of Geriatrics Yale School of Medicine New Haven CTUSA
| | - Thomas M. Gill
- and the Department of Internal Medicine Section of Geriatrics Yale School of Medicine New Haven CTUSA
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10
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Exercise Interventions for Community-Dwelling Older Adults Following an Emergency Department Consultation for a Minor Injury. J Aging Phys Act 2020; 29:267-279. [PMID: 33108761 DOI: 10.1123/japa.2019-0200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 07/05/2020] [Accepted: 07/05/2020] [Indexed: 11/18/2022]
Abstract
This study compared effects of exercise-based interventions with usual care on functional decline, physical performance, and health-related quality of life (12-item Short-Form health survey) at 3 and 6 months after minor injuries, in older adults discharged from emergency departments. Participants were randomized either to the intervention or control groups. The interventions consisted of 12-week exercise programs available in their communities. Groups were compared on cumulative incidences of functional decline, physical performances, and 12-item Short-Form health survey scores at all time points. Functional decline incidences were: intervention, 4.8% versus control, 15.4% (p = .11) at 3 months, and 5.3% versus 17.0% (p = .06) at 6 months. While the control group remained stable, the intervention group improved in Five Times Sit-To-Stand Test (3.0 ± 4.5 s, p < .01). The 12-item Short-Form health survey role physical score improvement was twice as high following intervention compared with control. Early exercises improved leg strength and reduced self-perceived limitations following a minor injury.
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11
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Managing Code Status Conversations for Seriously Ill Older Adults in Respiratory Failure. Ann Emerg Med 2020; 76:751-756. [PMID: 32747084 DOI: 10.1016/j.annemergmed.2020.05.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Indexed: 11/21/2022]
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12
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Pajka SE, Hasdianda MA, George N, Sudore R, Schonberg MA, Bernstein E, Tulsky JA, Block SD, Ouchi K. Feasibility of a Brief Intervention to Facilitate Advance Care Planning Conversations for Patients with Life-Limiting Illness in the Emergency Department. J Palliat Med 2020; 24:31-39. [PMID: 32471321 DOI: 10.1089/jpm.2020.0067] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Advance care planning (ACP) conversations are an important intervention to provide care consistent with patient goals near the end of life. The emergency department (ED) could serve as an important time and location for these conversations. Objectives: To determine the feasibility of an ED-based, brief negotiated interview (BNI) to stimulate ACP conversations among seriously ill older adults. Methods: We conducted a pre/postintervention study in the ED of an urban, tertiary care, academic medical center. From November 2017 to May 2019, we prospectively enrolled adults ≥65 years of age with serious illness. Trained clinicians conducted the intervention. We measured patients' ACP engagement at baseline and follow-up (3 ± 1 weeks) and reviewed electronic medical record documentation of ACP (e.g., medical order for life-sustaining treatment [MOLST]). Results: We enrolled 51 patients (mean age = 71; SD 12), 41% were female, and 51% of patients had metastatic cancer. Median duration of the intervention was 11.8 minutes; few (6%) of the interventions were interrupted. We completed follow-up for 61% of participants. Patients' self-reported ACP engagement increased from 3.0 to 3.7 out of 5 after the intervention (p < 0.01). Electronic documentation of health care proxy forms increased (75%-94%, n = 48) as did MOLST (0%-19%, n = 48) during the six months after the ED visit. Conclusion: A novel, ED-based, BNI intervention to stimulate ACP conversations for seriously ill older adults is feasible and may improve ACP engagement and documentation.
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Affiliation(s)
- Sarah E Pajka
- Department of Emergency Medicine and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mohammad Adrian Hasdianda
- Department of Emergency Medicine and Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Naomi George
- Department of Emergency Medicine, Center for Adult Critical Care, University of New Mexico, School of Medicine, Albuquerque, New Mexico, USA
| | - Rebecca Sudore
- Department of Medicine, University of California, San Francisco, California, USA
| | - Mara A Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Edward Bernstein
- The Brief Negotiated Interview Active Referral to Treatment Institute, Boston University School of Public Health, Boston, Massachusetts, USA.,Department of Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Susan D Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
| | - Kei Ouchi
- Department of Emergency Medicine and Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
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13
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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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14
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Southerland LT, Stephens JA, Carpenter CR, Mion LC, Moffatt-Bruce SD, Zachman A, Hill M, Caterino JM. Study protocol for IMAGE: implementing multidisciplinary assessments for geriatric patients in an emergency department observation unit, a hybrid effectiveness/implementation study using the Consolidated Framework for Implementation Research. Implement Sci Commun 2020; 1:28. [PMID: 32885187 PMCID: PMC7427917 DOI: 10.1186/s43058-020-00015-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 01/27/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Older adults in the emergency department (ED) are at high risk for functional decline, unrecognized delirium, falls, and medication interactions. Holistic assessment by a multidisciplinary team in the ED decreases these adverse outcomes and decreases admissions, but there are many barriers to incorporating this type of care during the ED visit. METHODS This is a hybrid type II effectiveness-implementation study using a pre-/post-cohort design (n = 380) at a tertiary care academic ED with an ED observation unit (Obs Unit). The intervention is a two-step protocol of (step 1) ED nurses screening adult patients ≥ 65 years old for geriatric needs using the Delirium Triage Screen, 4-Stage Balance Test, and the Identifying Seniors at Risk score. Patients who have geriatric needs identified by this screening but who do not meet hospital admission criteria will (step 2) be placed in the Obs Unit for multidisciplinary geriatric assessment by the hospital's geriatric consultation team, physical therapists, occupational therapists, pharmacists, and/or case managers. Not all patients may require all elements of the multidisciplinary geriatric assessment. The Consolidated Framework for Implementation Research: Care Transitions Framework was used to identify barriers to implementation. Lean Six Sigma processes will be used to overcome these identified barriers with the goal of achieving geriatric screening rates of > 80%. Implementation success and associated factors will be reported. For the effectiveness aim, pre-/post-cohorts of adults ≥ 65 years old cared for in the Obs Unit will be followed for 90 days post-ED visit (n = 150 pre and 230 post). The primary outcome is the prevention of functional decline. Secondary outcomes include health-related quality of life, new geriatric syndromes identified, new services provided, and Obs Unit metrics such as length of stay and admission rates. DISCUSSION A protocol for implementing integrated multidisciplinary geriatric assessment into the ED setting has the potential to improve patient functional status by identifying and addressing geriatric issues and needs prior to discharge from the ED. Using validated frameworks and implementation strategies will increase our understanding of how to improve the quality of ED care for older adults in the acute care setting. TRIAL REGISTRATION ClinicalTrials.gov Identifier, NCT04068311, registered 28 August 2019.
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Affiliation(s)
- Lauren T. Southerland
- Department of Emergency Medicine, The Ohio State Wexner Medical Center, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210 USA
| | - Julie A. Stephens
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State College of Medicine, Columbus, OH USA
| | | | - Lorraine C. Mion
- College of Nursing, The Ohio State Wexner Medical Center, Columbus, OH USA
| | | | - Angela Zachman
- Department of Emergency Medicine, The Ohio State Wexner Medical Center, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210 USA
| | - Michael Hill
- Department of Emergency Medicine, The Ohio State Wexner Medical Center, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210 USA
| | - Jeffrey M. Caterino
- Department of Emergency Medicine, The Ohio State Wexner Medical Center, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210 USA
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15
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Ouchi K, Strout T, Haydar S, Baker O, Wang W, Bernacki R, Sudore R, Schuur JD, Schonberg MA, Block SD, Tulsky JA. Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital. JAMA Netw Open 2019; 2:e1911139. [PMID: 31517962 PMCID: PMC6745053 DOI: 10.1001/jamanetworkopen.2019.11139] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE The accuracy of mortality assessment by emergency clinicians is unknown and may affect subsequent medical decision-making. OBJECTIVE To determine the association of the question, "Would you be surprised if your patient died in the next one month?" (known as the surprise question) asked of emergency clinicians with actual 1-month mortality among undifferentiated older adults who visited the emergency department (ED). DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study at a single academic medical center in Portland, Maine, included consecutive patients 65 years or older who received care in the ED and were subsequently admitted to the hospital from January 1, 2014, to December 31, 2015. Data analyses were conducted from January 2018 to March 2019. EXPOSURES Treating emergency clinicians were required to answer the surprise question, "Would you be surprised if your patient died in the next one month?" in the electronic medical record when placing a bed request for all patients who were being admitted to the hospital. MAIN OUTCOMES AND MEASURES The primary outcome was mortality at 1 month, assessed from the National Death Index. The secondary outcomes included accuracies of responses by both emergency clinicians and admitting internal medicine clinicians to the surprise question in identifying older patients with high 6-month and 12-month mortality. RESULTS The full cohort included 10 737 older adults (mean [SD] age, 75.9 [8.8] years; 5532 [52%] women; 10 157 [94.6%] white) in 16 223 visits treated in the ED and admitted to the hospital. There were 5132 patients (31.6%) with a Charlson Comorbidity Index score of 2 or more. Mortality rates were 8.3% at 1 month, 17.2% at 6 months, and 22.5% at 12 months. Emergency clinicians stated that they would not be surprised if the patient died in the next month for 2104 patients (19.6%). In multivariable analysis controlling for age, sex, race, admission diagnosis, and comorbid conditions, the odds of death at 1 month were higher in patients for whom clinicians answered that they would not be surprised if the patient died in the next 1 month compared with patients for whom clinicians answered that they would be surprised if the patient died in the next 1 month (odds ratio, 2.4 [95% CI, 2.2-2.7]; P < .001). However, the diagnostic test characteristics of the surprise question were poor (sensitivity, 20%; specificity, 93%; positive predictive value, 43%; negative predictive value, 82%; accuracy, 78%; area under the receiver operating curve of the multivariable model, 0.73 [95% CI, 0.72-0.74; P < .001]). CONCLUSIONS AND RELEVANCE This study found that asking the surprise question of emergency clinicians may be a valuable tool to identify older patients in the ED with a high risk of 1-month mortality. The effect of implementing the surprise question to improve population-level health care for older adults in the ED who are seriously ill remains to be seen.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
| | - Tania Strout
- Department of Emergency Medicine, Maine Medical Center, Portland, Maine
| | - Samir Haydar
- Department of Emergency Medicine, Maine Medical Center, Portland, Maine
| | - Olesya Baker
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Wei Wang
- Division of Sleep Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Rachelle Bernacki
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Rebecca Sudore
- Department of Medicine, University of California, San Francisco
| | - Jeremiah D. Schuur
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Mara A. Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Susan D. Block
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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16
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Ouchi K, George N, Schuur JD, Aaronson EL, Lindvall C, Bernstein E, Sudore RL, Schonberg MA, Block SD, Tulsky JA. Goals-of-Care Conversations for Older Adults With Serious Illness in the Emergency Department: Challenges and Opportunities. Ann Emerg Med 2019; 74:276-284. [PMID: 30770207 PMCID: PMC6714052 DOI: 10.1016/j.annemergmed.2019.01.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 12/20/2018] [Accepted: 12/31/2018] [Indexed: 12/13/2022]
Abstract
During the last 6 months of life, 75% of older adults with preexisting serious illness, such as advanced heart failure, lung disease, and cancer, visit the emergency department (ED). ED visits often mark an inflection point in these patients' illness trajectories, signaling a more rapid rate of decline. Although most patients are there seeking care for acute issues, many of them have priorities other than to simply live as long as possible; yet without discussion of preferences for treatment, they are at risk of receiving care not aligned with their goals. An ED visit may offer a unique "teachable moment" to empower patients to consider their ability to influence future medical care decisions. However, the constraints of the ED setting pose specific challenges, and little research exists to guide clinicians treating patients in this setting. We describe the current state of goals-of-care conversations in the ED, outline the challenges to conducting these conversations, and recommend a research agenda to better equip emergency physicians to guide shared decisionmaking for end-of-life care. Applying best practices for serious illness communication may help emergency physicians empower such patients to align their future medical care with their values and goals.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA; Serious Illness Care Program, Ariadne Labs, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA.
| | - Naomi George
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Emily L Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Charlotta Lindvall
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA; Department of Medicine, Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA
| | - Edward Bernstein
- The Brief Negotiated Interview Active Referral to Treatment Institute, Boston University School of Public Health, and the Department of Emergency Medicine, Boston University School of Medicine, Boston, MA
| | - Rebecca L Sudore
- Department of Medicine, University of California, San Francisco, CA
| | - Mara A Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Susan D Block
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Serious Illness Care Program, Ariadne Labs, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA; Department of Psychiatry, Brigham and Women's Hospital, Boston, MA
| | - James A Tulsky
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA; Department of Medicine, Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA
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17
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Chang AK, Bijur PE, Ata A, Campbell C, Pearlman S, White D, Chertoff A, Restivo A, Gallagher EJ. Randomized Clinical Trial of Intravenous Acetaminophen as an Analgesic Adjunct for Older Adults With Acute Severe Pain. Acad Emerg Med 2019; 26:402-409. [PMID: 30118582 DOI: 10.1111/acem.13556] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/06/2018] [Accepted: 08/13/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Older adults are at risk for undertreatment of pain. We examined intravenous (IV) acetaminophen as an analgesic adjunct to IV opioids in the care of older emergency department (ED) patients with acute severe pain. METHODS This was a randomized clinical trial conducted in two EDs in the Bronx, New York. Eligible adults aged 65 years and older with acute severe pain were randomized to 0.5 mg of IV hydromorphone and 1 g of IV acetaminophen or 0.5 mg of IV hydromorphone and 100 mL of normal saline placebo. The primary outcome was the between group difference in improvement of numerical rating scale (NRS) pain scores at 60 minutes. Secondary outcomes were the between-group differences in the proportion of patients who chose to forgo additional pain medications at 60 minutes; the proportion who developed side effects; the proportion who required rescue analgesia; and between-group differences in NRS pain scores at 5, 15, 30, and 45 minutes. RESULTS Eighty-one patients were allocated to each arm. Eighty patients in the IV acetaminophen arm and 79 patients in the placebo arm had sufficient data for analysis. At 60 minutes, patients in the hydromorphone + IV acetaminophen group improved by 5.7 NRS units while those in the hydromorphone + placebo group improved by 5.2 NRS units, for a difference of 0.6 NRS units (95% confidence interval [CI] = -0.4 to 1.5). A total of 28.7% of patients in the hydromorphone + IV acetaminophen group wanted more analgesia at 60 minutes versus 29.1% in the hydromorphone + placebo group, for a difference of -0.4% (95% CI = -14.3% to 13.5%). These differences were neither clinically nor statistically significant. Safety profiles were similar in both groups. CONCLUSION In this randomized clinical trial, the addition of IV acetaminophen to IV hydromorphone as an adjunctive analgesic for acute, severe, pain in older adults provided neither clinically nor statistically superior pain relief when compared to hydromorphone alone within the first hour of treatment.
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Affiliation(s)
- Andrew K. Chang
- Department of Emergency Medicine Albany Medical College AlbanyNY
| | - Polly E. Bijur
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
| | - Ashar Ata
- Department of Emergency Medicine Albany Medical College AlbanyNY
| | - Caron Campbell
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
| | - Scott Pearlman
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
| | - Deborah White
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
| | - Andrew Chertoff
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
| | - Andrew Restivo
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
| | - E. John Gallagher
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
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18
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Ouchi K, George N, Revette AC, Hasdianda MA, Fellion L, Reust A, Powell LH, Sudore R, Schuur JD, Schonberg MA, Bernstein E, Tulsky JA, Block SD. Empower Seriously Ill Older Adults to Formulate Their Goals for Medical Care in the Emergency Department. J Palliat Med 2018; 22:267-273. [PMID: 30418094 DOI: 10.1089/jpm.2018.0360] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Most seriously ill older adults visit the emergency department (ED) near the end of life, yet no feasible method exists to empower them to formulate their care goals in this setting. OBJECTIVE To develop an intervention to empower seriously ill older adults to formulate their future care goals in the ED. DESIGN Prospective intervention development study. SETTING In a single, urban, academic ED, we refined the prototype intervention with ED clinicians and patient advisors. We tested the intervention for its acceptability in English-speaking patients ≥65 years old with serious illness or patients whose treating ED clinician answered "No" to the "surprise question" ("would not be surprised if died in the next 12 months"). We excluded patients with advance directives or whose treating ED clinician determined the patient to be inappropriate. MEASUREMENTS Our primary outcome was perceived acceptability of our intervention. Secondary outcomes included perceived main intent and stated attitude toward future care planning. RESULTS We refined the intervention with 16 mock clinical encounters of ED clinicians and patient advisors. Then, we administered the refined intervention to 23 patients and conducted semistructured interviews afterward. Mean age of patients was 76 years, 65% were women, and 43% of patients had metastatic cancer. Most participants (n = 17) positively assessed our intervention, identified questions for their doctors, and reflected on how they feel about their future care. CONCLUSION An intervention to empower seriously ill older adults to understand the importance of future care planning in the ED was developed, and they found it acceptable.
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Affiliation(s)
- Kei Ouchi
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts.,3 Serious Illness Care Program, Ariadne Labs , Boston, Massachusetts.,4 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Naomi George
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Anna C Revette
- 5 Survey and Data Management Core for Qualitative and Quantitative Research, Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Mohammad Adrian Hasdianda
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Lauren Fellion
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Audrey Reust
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Lynda H Powell
- 6 Department of Preventive Medicine, Rush Medical College , Chicago, Illinois
| | - Rebecca Sudore
- 7 Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Jeremiah D Schuur
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Mara A Schonberg
- 8 Department of Medicine, Beth Israel Deaconess Medical Center , Boston, Massachusetts
| | - Edward Bernstein
- 9 The Brief Negotiated Interview Active Referral to Treatment Institute, Boston University School of Public Health , Boston, Massachusetts.,10 Department of Emergency Medicine, Boston University School of Medicine , Boston, Massachusetts
| | - James A Tulsky
- 4 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,11 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital , Boston, Massachusetts
| | - Susan D Block
- 3 Serious Illness Care Program, Ariadne Labs , Boston, Massachusetts.,4 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,10 Department of Emergency Medicine, Boston University School of Medicine , Boston, Massachusetts.,11 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,12 Department of Psychiatry, Brigham and Women's Hospital , Boston, Massachusetts
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19
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Hwang U, Hastings SN, Ramos K. Improving Emergency Department Discharge Care with Telephone Follow-Up. Does It Connect? J Am Geriatr Soc 2017; 66:436-438. [PMID: 29272032 DOI: 10.1111/jgs.15218] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Ula Hwang
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.,Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.,Geriatric Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY
| | - S Nicole Hastings
- Division of Geriatrics, Department of Medicine, School of Medicine, Duke University, Durham, NC.,Center for the Study of Aging and Human Development, Duke University, Durham, NC.,Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC.,Geriatric Research, Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, NC
| | - Katherine Ramos
- Center for the Study of Aging and Human Development, Duke University, Durham, NC.,Geriatric Research, Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, NC
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20
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Ouchi K, Jambaulikar G, George NR, Xu W, Obermeyer Z, Aaronson EL, Schuur JD, Schonberg MA, Tulsky JA, Block SD. The "Surprise Question" Asked of Emergency Physicians May Predict 12-Month Mortality among Older Emergency Department Patients. J Palliat Med 2017; 21:236-240. [PMID: 28846475 DOI: 10.1089/jpm.2017.0192] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Identification of older adults with serious illness (life expectancy less than one year) who may benefit from serious illness conversations or other palliative care interventions in the emergency department (ED) is difficult. OBJECTIVES To assess the performance of the "surprise question (SQ)" asked of emergency physicians to predict 12-month mortality. DESIGN We asked attending emergency physician "Would you be surprised whether this patient died in the next 12 months?" regarding patients ≥65 years old that they had cared for that shift. We prospectively obtained death records from Massachusetts Department of Health Vital Records. SETTING An urban, university-affiliated ED. MEASUREMENT Twelve-month mortality. RESULTS We approached 38 physicians to answer the SQ, and 86% participated. The mean age of our cohort was 76 years, 51% were male, and 45% had at least one serious illness. Out of 207 patients, the physicians stated that they "would not be surprised" if the patient died in the next 12 months for 102 of the patients (49%); 44 of the 207 patients (21%) died within 12 months. The SQ demonstrated sensitivity of 77%, specificity of 56%, positive predictive value of 32%, and negative predictive value of 90%. When combined with other predictors, the model sorted the patient who lived from the patient who died correctly 72% of the time (c-statistic = 0.72). CONCLUSION Use of the SQ by emergency physicians may predict 12-month mortality in older ED patients and may help emergency physicians identify older adults in need of palliative care interventions.
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Affiliation(s)
- Kei Ouchi
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts.,3 Serious Illness Care Program , Ariadne Labs, Boston, Massachusetts
| | - Guru Jambaulikar
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Naomi R George
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Wanlu Xu
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts
| | - Ziad Obermeyer
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts.,3 Serious Illness Care Program , Ariadne Labs, Boston, Massachusetts
| | - Emily L Aaronson
- 2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts.,4 Department of Emergency Medicine, Massachusetts General Hospital , Boston, Massachusetts
| | - Jeremiah D Schuur
- 1 Department of Emergency Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Emergency Medicine, Harvard Medical School , Boston, Massachusetts
| | - Mara A Schonberg
- 5 Department of Medicine, Beth Israel Deaconess Medical Center , Boston, Massachusetts
| | - James A Tulsky
- 6 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,7 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital , Boston, Massachusetts
| | - Susan D Block
- 3 Serious Illness Care Program , Ariadne Labs, Boston, Massachusetts.,6 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,7 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,8 Department of Psychiatry, Brigham and Women's Hospital , Boston, Massachusetts
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21
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Perrin A, Tavassoli N, Mathieu C, Hermabessière S, Houles M, McCambridge C, Magre E, Fernandez S, Caquelard A, Charpentier S, Lauque D, Azema O, Bismuth S, Chicoulaa B, Oustric S, Costa N, Molinier L, Vellas B, Bérard E, Rolland Y. Factors predisposing nursing home resident to inappropriate transfer to emergency department. The FINE study protocol. Contemp Clin Trials Commun 2017; 7:217-223. [PMID: 29696189 PMCID: PMC5898573 DOI: 10.1016/j.conctc.2017.07.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 07/18/2017] [Accepted: 07/20/2017] [Indexed: 11/19/2022] Open
Abstract
Background Each year, around one out of two nursing home (NH) residents are hospitalized in France, and about half to the emergency department (ED). These transfers are frequently inappropriate. This paper describes the protocol of the FINE study. The first aim of this study is to identify the factors associated with inappropriate transfers to ED. Methods/design FINE is a case-control observational study. Sixteen hospitals participate. Inclusion period lasts 7 days per season in each center for a total period of inclusion of one year. All the NH residents admitted in ED during these periods are included. Data are collected in 4 times: before transfer in the NH, at the ED, in hospital wards in case of patient's hospitalization and at the patient's return to NH. The appropriateness of ED transfers (i.e. case versus control NH residents) is determined by a multidisciplinary team of experts. Results Our primary objective is to determine the factors predisposing NH residents to inappropriate transfer to ED. Our secondary objectives are to assess the cost of the transfers to ED; study the evolution of NH residents' functional status and the psychotropic and inappropriate drugs prescription between before and after the transfer; calculate the prevalence of potentially avoidable transfers to ED; and identify the factors predisposing NH residents to potentially avoidable transfer to ED. Discussion A better understanding of the determinant factors of inappropriate transfers to ED of NH residents may lead to proposals of recommendations of better practice in NH and would allow implementing quality improvement programs in the health organization.
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Affiliation(s)
- Amélie Perrin
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Neda Tavassoli
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Équipe Régionale Vieillissement et Prévention de La Dépendance (ERVPD), Toulouse, France
- Corresponding author. La Cité de la Santé - Équipe Régionale Vieillissement et Prévention de la Dépendance, 20 rue du Pont Saint Pierre – TSA 60033, 31059, Toulouse Cedex 9, France.
| | - Céline Mathieu
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Observatoire Régional de La Santé de Midi-Pyrénées (ORSMIP), Toulouse, France
| | | | - Mathieu Houles
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Cécile McCambridge
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Équipe Régionale Vieillissement et Prévention de La Dépendance (ERVPD), Toulouse, France
- Pôle Pharmacie, Centre Hospitalo-Universitaire de Toulouse, Toulouse, France
| | - Elodie Magre
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Pôle Pharmacie, Centre Hospitalo-Universitaire de Toulouse, Toulouse, France
| | - Sophie Fernandez
- Pôle Médecine D’Urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Anne Caquelard
- Pôle Médecine D’Urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Sandrine Charpentier
- Pôle Médecine D’Urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- UMR 1027, INSERM - Université de Toulouse III, Toulouse, France
| | - Dominique Lauque
- Pôle Médecine D’Urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- UFR Sciences Médicales, Université de Toulouse III, Toulouse, France
| | - Olivier Azema
- Observatoire Régional des Urgences de Midi-Pyrénées (ORU-MiP), Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Serge Bismuth
- Département Universitaire de Médecine Générale (DUMG), Université de Toulouse III, Toulouse, France
| | - Bruno Chicoulaa
- Département Universitaire de Médecine Générale (DUMG), Université de Toulouse III, Toulouse, France
| | - Stéphane Oustric
- UMR 1027, INSERM - Université de Toulouse III, Toulouse, France
- Département Universitaire de Médecine Générale (DUMG), Université de Toulouse III, Toulouse, France
| | - Nadège Costa
- UMR 1027, INSERM - Université de Toulouse III, Toulouse, France
- Département D’Information Médicale (DIM), Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Laurent Molinier
- UMR 1027, INSERM - Université de Toulouse III, Toulouse, France
- Département D’Information Médicale (DIM), Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Département D’Epidémiologie, D’Economie de La Santé et de Santé Publique, Université Toulouse III, Toulouse, France
| | - Bruno Vellas
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Équipe Régionale Vieillissement et Prévention de La Dépendance (ERVPD), Toulouse, France
- UMR 1027, INSERM - Université de Toulouse III, Toulouse, France
| | - Emilie Bérard
- UMR 1027, INSERM - Université de Toulouse III, Toulouse, France
- Service D'Epidémiologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Yves Rolland
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Équipe Régionale Vieillissement et Prévention de La Dépendance (ERVPD), Toulouse, France
- UMR 1027, INSERM - Université de Toulouse III, Toulouse, France
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22
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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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23
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Nagurney JM, Fleischman W, Han L, Leo-Summers L, Allore HG, Gill TM. Emergency Department Visits Without Hospitalization Are Associated With Functional Decline in Older Persons. Ann Emerg Med 2017; 69:426-433. [PMID: 28069299 DOI: 10.1016/j.annemergmed.2016.09.018] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/29/2016] [Accepted: 09/12/2016] [Indexed: 12/17/2022]
Abstract
STUDY OBJECTIVE Among older persons, disability and functional decline are associated with increased mortality, institutionalization, and costs. The aim of the study was to determine whether illnesses and injuries leading to an emergency department (ED) visit but not hospitalization are associated with functional decline among community-living older persons. METHODS From a cohort of 754 community-living older persons who have been followed with monthly interviews for up to 14 years, we matched 813 ED visits without hospitalization (ED only) to 813 observations without an ED visit or hospitalization (control). We compared the course of disability during the following 6 months between the 2 matched groups. To establish a frame of reference, we also compared the ED-only group with an unmatched group who were hospitalized after an ED visit (ED-hospitalized). Disability scores (range 0 [lowest] to 13 [highest]) were compared using generalized linear models adjusted for relevant covariates. Admission to a nursing home and mortality were evaluated as secondary outcomes. RESULTS The ED-only and control groups were well matched. For both groups, the mean age was 84 years, and 69% were women. The baseline disability scores were 3.4 and 3.6 in the ED-only and control groups, respectively. During the 6-month follow-up period, the ED-only group had significantly higher disability scores than the control group, with an adjusted risk ratio of 1.14 (95% confidence interval [CI] 1.09 to 1.19). Compared with participants in the ED-only group, those who were hospitalized after an ED visit had disability scores that were significantly higher (risk ratio 1.17; 95% CI 1.12 to 1.22). Both nursing home admissions (hazard ratio 3.11; 95% CI 2.05 to 4.72) and mortality (hazard ratio 1.93; 95% CI 1.07 to 3.49) were higher in the ED-only group versus control group during the 6-month follow-up period. CONCLUSION Although not as debilitating as an acute hospitalization, illnesses and injuries leading to an ED visit without hospitalization were associated with a clinically meaningful decline in functional status during the following 6 months, suggesting that the period after an ED visit represents a vulnerable time for community-living older persons.
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Affiliation(s)
- Justine M Nagurney
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
| | - William Fleischman
- Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine, New Haven, CT
| | - Ling Han
- Department of Internal Medicine, Section of Geriatrics, Yale School of Medicine, New Haven, CT
| | - Linda Leo-Summers
- Department of Internal Medicine, Section of Geriatrics, Yale School of Medicine, New Haven, CT
| | - Heather G Allore
- Department of Internal Medicine, Section of Geriatrics, Yale School of Medicine, New Haven, CT; Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Thomas M Gill
- Department of Internal Medicine, Section of Geriatrics, Yale School of Medicine, New Haven, CT; Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
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24
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Brown CJ, Kennedy RE, Lo AX, Williams CP, Sawyer P. Impact of Emergency Department Visits and Hospitalization on Mobility Among Community-Dwelling Older Adults. Am J Med 2016; 129:1124.e9-1124.e15. [PMID: 27288857 PMCID: PMC5039061 DOI: 10.1016/j.amjmed.2016.05.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 05/22/2016] [Accepted: 05/23/2016] [Indexed: 01/16/2023]
Abstract
PURPOSE The study purpose was to assess the effects of emergency department visits on mobility as measured by Life-Space Assessment (LSA) scores and to compare life-space trajectories associated with emergency department visit only, hospitalization, and no event. METHODS A total of 410 community-dwelling adults aged ≥75 years who were living in the community, were able to communicate by telephone, could schedule an in-home interview, and could answer questions independently were followed from June 2010 to August 2014. In-home baseline and monthly telephone follow-up interviews collected data on LSA scores, emergency department use, and hospitalizations. Life-space is measured using a validated patient-reported tool reflecting community mobility and quality of life. Trajectories of LSA before and after an emergency department visit or hospitalization were compared with no event occurrence. RESULTS Mean age of participants was 81.7 years (standard deviation, 4.8); 57% were female, and 35% were African American. During 3 years of follow-up, 83 persons (20%) had an emergency department visit without subsequent hospitalization and 164 persons (40%) were hospitalized. Although baseline LSA scores were similar, in the month after an emergency department visit, adjusted LSA scores decreased by 6.1 points (P = .01) in comparison with hospitalized participants who experienced an average decrease of 18.0 points (P < .0001). Neither those with an emergency department visit only nor those with hospitalization recovered to their prior level of community mobility. Moreover, those with an emergency department visit showed no significant improvement in LSA scores up to 1 year later. CONCLUSIONS Older adults who experienced an emergency department visit or hospitalization had an associated decrease in community mobility without significant recovery.
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Affiliation(s)
- Cynthia J Brown
- Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Ala; Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham.
| | - Richard E Kennedy
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham
| | - Alexander X Lo
- Department of Emergency Medicine, University of Alabama at Birmingham
| | - Courtney P Williams
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham
| | - Patricia Sawyer
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham
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25
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Southerland LT, Stephens JA, Robinson S, Falk J, Phieffer L, Rosenthal JA, Caterino JM. Head Trauma from Falling Increases Subsequent Emergency Department Visits More Than Other Fall-Related Injuries in Older Adults. J Am Geriatr Soc 2016; 64:870-4. [PMID: 27100582 DOI: 10.1111/jgs.14041] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To determine whether fall-related injuries affect return to the ED after the initial visit. DESIGN Retrospective chart review. SETTING Academic Level 1 trauma center ED. PARTICIPANTS Individuals aged 65 and older evaluated for a fall from standing height or less and discharged (N = 263, average age 77, 70% female). MEASUREMENTS After institutional review board approval, electronic medical record data were queried. Univariate and multivariable logistic regression models were used to determine factors associated with risk of returning to the ED within 90 days. RESULTS Injuries included fractures (45%, n = 117); head trauma (22%, n = 58); abrasions, lacerations, or contusions (34%, n = 88); and none (22%, n = 57). Emergency care was frequently required, with 13 (5%, 95% confidence interval (CI) = 2.3-7.6%) returning within 72 hours, 35 (13%, 95% CI = 9.2-17%] within 30 days, and 57 (22%, 95% CI = 17-27%) within 90 days. Univariately, the odds of returning to the ED within 90 days was more than two times as high for those with head trauma as for those without (odds ratio = 2.66). This remained significant in the multivariable model, which controlled for Charlson Comorbidity Index, fractures, soft tissue injuries, and ED observation unit use. CONCLUSION More than one-third of older adults with minor head trauma from a fall will need to return to the ED in the following 90 days. These individuals should receive close attention from primary care providers. The link between minor head trauma and ED recidivism is a new finding.
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Affiliation(s)
| | - Julie A Stephens
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio
| | - Shari Robinson
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio
| | - James Falk
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio
| | - Laura Phieffer
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio
| | - Joseph A Rosenthal
- Department of Physical Medicine and Rehabilitation, The Ohio State University, Columbus, Ohio
| | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio
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26
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Abdulaziz KE, Brehaut J, Taljaard M, Émond M, Sirois MJ, Lee JS, Wilding L, Perry JJ. National survey of family physicians to define functional decline in elderly patients with minor trauma. BMC FAMILY PRACTICE 2016; 17:117. [PMID: 27550226 PMCID: PMC4994293 DOI: 10.1186/s12875-016-0520-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 08/16/2016] [Indexed: 01/01/2023]
Abstract
Background Failing to assess elderly patients for functional decline at the time around a minor injury may result in adverse health outcomes. This study was conducted to define what constitutes clinically significant functional decline and the sensitivity required for a clinical decision instrument to identify such functional decline after an injury in previously independent elderly patients. Methods After a thorough development process, a survey questionnaire was administered to a random sample of 178 family physicians. The surveys were distributed using a modified Dillman technique. Results From 143 eligible surveys, we received 67 completed surveys (response rate, 46.9 %). Respondents indicated that a drop of at least 3 points on the 28-point Older Americans Resources and Services (OARS) ADL Scale was considered clinically significant by 90 % of physicians. Ninety percent (90 %) of physicians would be satisfied with a sensitivity of 90 % or more for a clinical decision instrument to detect patients at risk of functional decline at 6 months following an injury. The majority of family physicians do not routinely assess the majority of the tasks on the OARS scale for injured elderly patients. Conclusions A high proportion of physicians (90 %) would consider a drop of 3 points on the OARS ADL Scale as significant to define functional decline and would be satisfied with a sensitivity of 90 % for a clinical decision instrument to detect such a decline. Any instrument to identify patients at elevated risk for subsequent decline should consider these outcome measures to be clinically useful. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0520-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kasim E Abdulaziz
- Department of Epidemiology and Community Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Clinical Epidemiology Program, University of Ottawa, Ottawa, ON, Canada
| | - Jamie Brehaut
- Department of Epidemiology and Community Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Clinical Epidemiology Program, University of Ottawa, Ottawa, ON, Canada
| | - Monica Taljaard
- Department of Epidemiology and Community Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Clinical Epidemiology Program, University of Ottawa, Ottawa, ON, Canada
| | - Marcel Émond
- Department of Family and Emergency Medicine, Université Laval, Laval, QC, Canada.,Unité de recherche en traumatologie-urgence-soins intensifs du Centre de recherche FRQ-S du CHA de Québec, Laval, QC, Canada
| | - Marie-Josée Sirois
- Département de réadaptation, Université Laval, Laval, QC, Canada.,Unité de recherche en traumatologie-urgence-soins intensifs du Centre de recherche FRQ-S du CHA de Québec, Laval, QC, Canada
| | - Jacques S Lee
- Department of Emergency Medicine, University of Toronto, Clinical Epidemiology Unit, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Laura Wilding
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey J Perry
- Department of Epidemiology and Community Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada. .,Clinical Epidemiology Program, University of Ottawa, Ottawa, ON, Canada. .,Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada. .,Epidemiology Program, F6, The Ottawa Hospital, Civic Campus 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
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27
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Manavi N, Abedi H. Investigating the effect of an empowerment program on physical activity of the elderly in Rezaeian Health Center, Iran, in 2014. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2016; 21:345-50. [PMID: 27563315 PMCID: PMC4979255 DOI: 10.4103/1735-9066.185570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 12/13/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Reaching geriatric period is one of the greatest successes in human Beings. The older adults are predisposed to risk of many diseases and disabilities, and physical activity is one of the most efficient methods to prevent geriatric period disorders. Therefore, the present study aimed define the effect of an empowerment program on physical activity of the elderly residing in Shahid Rezaian health care center in 2014. MATERIALS AND METHODS This quasi-experimental study was conducted on 70 older adults, age 65 years and over, selected through convenient sampling and assigned to groups of study and control. Study group was divided into 5 seven-member subgroups and a one-hour session of physical exercises was administrated for them once a week for eight sequential weeks. All subjects evaluated before and after intervention by International Physical Activity Questionnaire. Subjects' physical activity was scored, based on the personal activity protocol,and the results were compared. Significance level was considered as P<0.05. RESULTS Frequency distributions of the female subjects were 29 (82%) and 28 (80%) in study and control groups respectively. Mean (SD) scores of physical activity were 347.8 (174.1) and 321.7 (119.2) before intervention, and 641.3 (240.6) and 331.3 (101.5) after intervention in study and control groups respectively. Independent t-test showed a significant increase in physical activity score in study group, compared to control (t=4.06, P<0.001). CONCLUSIONS The level of physical activity can be improved in the elderly through application of an empowerment program so as to take steps toward solving their immobility related problems and promoting their health through application of an empowerment program at this period of their life.
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Affiliation(s)
- Narges Manavi
- Nursing Department, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran
| | - Heidarali Abedi
- Nursing Department, Faculty of Nursing and Midwifery, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran
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28
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Abdulaziz K, Perry JJ, Taljaard M, Émond M, Lee JS, Wilding L, Sirois MJ, Brehaut J. National Survey of Geriatricians to Define Functional Decline in Elderly People with Minor Trauma. Can Geriatr J 2016; 19:2-8. [PMID: 27076859 PMCID: PMC4815935 DOI: 10.5770/cgj.19.192] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background This study was designed to determine a clinically significant point drop in function to define functional decline and the required sensitivity for a clinical decision tool to identify elderly patients at high risk of functional decline following a minor injury. Methods After a rigorous development process, a survey questionnaire was administered to a random sample of 178 geriatricians selected from those registered in a national medical directory. The surveys were distributed using a modified Dillman technique. Results We obtained a satisfactory response rate of 70.5%. Ninety percent of the geriatricians required a sensitivity of 90% or less for a clinical decision tool to identify injured seniors at high risk of functional decline 6 months post injury. Our results indicate that 90% of the respondents considered a drop in function of at least 2 points in activities of daily living (ADL) as clinically significant when considering all 14 ADL items. Considering only the 7 basic ADL items, 90% of physicians considered a 1 point drop as clinically significant. Conclusions A tool with a sensitivity of 90% to detect patients at risk of functional decline at 6 months post minor injury would meet or exceed the sensitivity required by 90% of geriatric specialists. These findings clearly define what is a clinically significant decline following a “minor injury.”
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Affiliation(s)
- Kasim Abdulaziz
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON;; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
| | - Jeffrey J Perry
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON;; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON;; Department of Emergency Medicine, University of Ottawa, Ottawa, ON
| | - Monica Taljaard
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON;; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
| | - Marcel Émond
- Department of Family and Emergency Medicine, Université Laval, Laval, QC;; Unité de recherche en traumatologie-urgence-soins intensifs du Centre de recherche FRQ-S du CHA de Québec, Laval, QC
| | - Jacques S Lee
- Department of Emergency Medicine, University of Toronto, Clinical Epidemiology Unit, Sunnybrook Health Sciences Center, Toronto
| | - Laura Wilding
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON
| | - Marie-Josée Sirois
- Département de réadaptation, Université Laval, Laval, QC;; Unité de recherche en traumatologie-urgence-soins intensifs du Centre de recherche FRQ-S du CHA de Québec, Laval, QC
| | - Jamie Brehaut
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON;; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
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Provencher V, Sirois MJ, Émond M, Perry JJ, Daoust R, Lee JS, Griffith LE, Batomen Kuimi BL, Despeignes LR, Wilding L, Allain-Boulé N, Lebon J. Frail older adults with minor fractures show lower health-related quality of life (SF-12) scores up to six months following emergency department discharge. Health Qual Life Outcomes 2016; 14:40. [PMID: 26956158 PMCID: PMC4782387 DOI: 10.1186/s12955-016-0441-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 02/29/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Minor fractures (e.g. wrist, ankle) are risk factors for lower physical health-related quality of life (HRQoL) in seniors. Recent studies found that measures of frailty were associated with decreased physical and mental HRQoL in older people. As most people with minor fractures go to emergency departments (EDs) for treatment, measuring their frailty status in EDs may help stratify their level of HRQoL post-injury and provide them with appropriate health care and services after discharge. This study thus examines the HRQoL of seniors visiting EDs for minor fractures at 3 and 6 months after discharge, according to their frailty status. METHODS This prospective sub-study was conducted within the larger Canadian Emergency Team Initiative (CETI) cohort. Independent seniors (≥65 years) were recruited in 7 Canadian EDs after treatment for various minor fractures. Frailty status in the ED phase was assessed by the Canadian Study of Health and Aging--Clinical Frailty Scale (CSHA-CFS). The SF-12 questionnaire was completed at 3 and 6 months after ED discharge to ascertain HRQoL. Demographic and clinical data were collected. Linear mixed models were used to test for differences between frailty levels and HRQoL outcomes, controlling for confounding variables and repeated measures over time. RESULTS The sample comprised 334 participants with minor fractures. Prevalence of frailty was as follows: 56.6 % very fit-well; 32.3 % well with treated comorbidities-apparently vulnerable; and 11.1 % mildly-moderately frail. After adjusting for confounding variables, the frailest group showed significantly lower mean HRQoL scores than the fittest group on the physical scale at 3 months (49.3 ± 3.7 vs 60.9 ± 2.0) and 6 months (48.7 ± 3.8 vs 61.1 ± 1.8), as well as on the mental scale at 3 months (59.5 ± 4.4 vs 69.6 ± 1.9). Analyses exploring differences in proportion of patients with HRQoL < 50/100 between the three groups produced similar results. CONCLUSIONS Older adults with minor fractures who were frail had lower physical and mental HRQoL scores at 3 and 6 months after ED discharge than their fittest counterparts. Measuring the frailty status of older adults who suffered a minor fracture in ED might help clinical decision-making at the time of discharge by providing them with appropriate health care and services to improve their HRQoL in the following months.
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Affiliation(s)
- Véronique Provencher
- Université de Sherbrooke, and Centre de recherche sur le vieillissement, Sherbrooke, QC, Canada.
| | - Marie-Josée Sirois
- Université Laval, and Centre de Recherche du CHU de Québec, Quebec, QC, Canada.
| | - Marcel Émond
- Université Laval, and Centre de Recherche du CHU de Québec, Quebec, QC, Canada.
| | - Jeffrey J Perry
- University of Ottawa, and Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Raoul Daoust
- Université de Montréal, and Research Center, Hôpital du Sacré-Cœur de Montréal , Montréal, QC, Canada.
| | - Jacques S Lee
- University of Toronto, and Sunnybrook Health Science Center, Toronto, ON, Canada.
| | | | | | | | - Laura Wilding
- University of Ottawa, and Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Nadine Allain-Boulé
- Université Laval, and Centre de Recherche du CHU de Québec, Quebec, QC, Canada.
| | - Johan Lebon
- Université Laval, and Centre de Recherche du CHU de Québec, Quebec, QC, Canada.
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Platts-Mills TF, Flannigan SA, Bortsov AV, Smith S, Domeier RM, Swor RA, Hendry PL, Peak DA, Rathlev NK, Jones JS, Lee DC, Keefe FJ, Sloane PD, McLean SA. Persistent Pain Among Older Adults Discharged Home From the Emergency Department After Motor Vehicle Crash: A Prospective Cohort Study. Ann Emerg Med 2015; 67:166-176.e1. [PMID: 26092559 DOI: 10.1016/j.annemergmed.2015.05.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 04/28/2015] [Accepted: 05/04/2015] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE Motor vehicle crashes are the second most common form of trauma among older adults. We seek to describe the incidence, risk factors, and consequences of persistent pain among older adults evaluated in the emergency department (ED) after a motor vehicle crash. METHODS We conducted a prospective longitudinal study of patients aged 65 years or older who presented to one of 8 EDs after motor vehicle crash between June 2011 and June 2014 and were discharged home after evaluation. ED evaluation was done through in-person interview; follow-up data were obtained through mail-in survey or telephone call. Pain severity (0 to 10 scale) overall and for 15 parts of the body were assessed at each follow-up point. Principal component analysis was used to assess the dimensionality of the locations of pain data. Participants reporting pain severity greater than or equal to 4 attributed to the motor vehicle crash at 6 months were defined as having persistent pain. RESULTS Of the 161 participants, 72% reported moderate to severe pain at the ED evaluation. At 6 months, 26% of participants reported moderate to severe motor vehicle crash-related pain. ED characteristics associated with persistent pain included acute pain severity; pain located in the head, neck, and jaw or lower back and legs; poor self-rated health; less formal education; pre-motor vehicle crash depressive symptoms; and patient's expected time to physical recovery more than 30 days. Compared with individuals without persistent pain, those with persistent pain were substantially more likely at 6-month follow-up to have also experienced a decline in their capacity for physical function (73% versus 36%; difference=37%; 95% confidence interval [CI] 19% to 52%), a new difficulty with activities of daily living (42% versus 17%; difference=26%; 95% CI 10% to 43%), a 1-point or more reduction in overall self-rated health on a 5-point scale (54% versus 30%; difference=24%; 95% CI 6% to 41%), and a change in their living situation to obtain additional help (23% versus 8%; difference=15%; 95% CI 2% to 31%). CONCLUSION Among older adults discharged home from the ED post-evaluation after a motor vehicle crash, persistent pain is common and frequently associated with functional decline and disability.
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Affiliation(s)
- Timothy F Platts-Mills
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC; Department of Anesthesiology, University of North Carolina, Chapel Hill, NC.
| | - Sean A Flannigan
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC
| | - Andrey V Bortsov
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC
| | - Samantha Smith
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC
| | - Robert M Domeier
- Department of Emergency Medicine, St Joseph Mercy Hospital, Ypsilanti, MI
| | - Robert A Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Phyllis L Hendry
- Department of Emergency Medicine, University of Florida Health, Jacksonville, FL
| | - David A Peak
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Niels K Rathlev
- Department of Emergency Medicine, Baystate Medical Center, Springfield, MA
| | | | - David C Lee
- Department of Emergency Medicine, North Shore Hospital System, Manhasset, NY
| | - Francis J Keefe
- Department of Psychology and Neuroscience, Duke University, Durham, NC
| | - Philip D Sloane
- Department of Family Medicine, University of North Carolina, Chapel Hill, NC
| | - Samuel A McLean
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC; Department of Anesthesiology, University of North Carolina, Chapel Hill, NC
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National Survey of Emergency Physicians to Define Functional Decline in Elderly Patients with Minor Trauma. CAN J EMERG MED 2015; 17:639-47. [PMID: 26063056 DOI: 10.1017/cem.2015.37] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND There are a number of screening tools to predict return to the emergency department (ED) in elderly trauma patients, but none exist to specifically screen for functional decline after a minor injury. The objective of this study was to identify outcome measures for a possible future clinical decision rule to be used in the ED to identify previously independent patients at high risk of functional decline at six months post minor injury. METHODS After a rigorous development process, a survey instrument was administered to a random sample of 178 emergency physicians using the Dillman's Tailored Design Method. RESULTS Of 156 eligible surveys, we received 81 completed surveys (response rate 51.9%). Considering all 14 activities of daily living (ADL) items, 90% of physicians deemed a minimal clinically important difference (MCID) in function to be at least three points on the 28-point Older Americans Resources and Services (OARS) ADL Scale as clinically significant. A tool with a sensitivity of 93% to detect patients at risk of functional decline at six months post injury would meet or exceed the sensitivity deemed to be required by 90% of physicians. The majority of emergency physicians do not assess elderly injured patients for the majority of the tasks. CONCLUSIONS A drop of three points on the 28-point OARS ADL Scale would be deemed clinically important by the vast majority of emergency physicians. Further, a sensitivity of 93% for a clinical decision tool would satisfy the MCID requirements of the vast majority of emergency physicians. There appears to be a gap between physician knowledge and actual practice. We intend to use these findings in the development of a clinical decision rule to identify high-risk elderly trauma patients.
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Provencher V, Sirois MJ, Ouellet MC, Camden S, Neveu X, Allain-Boulé N, Emond M. Decline in Activities of Daily Living After a Visit to a Canadian Emergency Department for Minor Injuries in Independent Older Adults: Are Frail Older Adults with Cognitive Impairment at Greater Risk? J Am Geriatr Soc 2015; 63:860-8. [DOI: 10.1111/jgs.13389] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Véronique Provencher
- Department of Rehabilitation; Université Laval; Québec Québec Canada
- Centre de recherche du CHU de Québec; Axe Santé des Populations-Pratiques Optimales en Santé; Québec Québec Canada
| | - Marie-Josée Sirois
- Department of Rehabilitation; Université Laval; Québec Québec Canada
- Centre de recherche du CHU de Québec; Axe Santé des Populations-Pratiques Optimales en Santé; Québec Québec Canada
| | - Marie-Christine Ouellet
- Centre de recherche du CHU de Québec; Axe Santé des Populations-Pratiques Optimales en Santé; Québec Québec Canada
- Centre Interdisciplinaire de Recherche en Réadaptation et Intégration Sociale; Institut de Réadaptation en Déficience Physique de Québec; Québec Québec Canada
| | - Stéphanie Camden
- Centre de recherche du CHU de Québec; Axe Santé des Populations-Pratiques Optimales en Santé; Québec Québec Canada
| | - Xavier Neveu
- Centre de recherche du CHU de Québec; Axe Santé des Populations-Pratiques Optimales en Santé; Québec Québec Canada
| | - Nadine Allain-Boulé
- Centre de recherche du CHU de Québec; Axe Santé des Populations-Pratiques Optimales en Santé; Québec Québec Canada
| | - Marcel Emond
- Centre de recherche du CHU de Québec; Axe Santé des Populations-Pratiques Optimales en Santé; Québec Québec Canada
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Pereira GF, McLean SA, Tkacik TJ, Swor RA, Jones JS, Lee DC, Peak DA, Domeier RM, Rathlev NK, Hendry PL, Platts-Mills TF. Pain, distress, and anticipated recovery for older versus younger emergency department patients after motor vehicle collision. BMC Emerg Med 2014; 14:25. [PMID: 25547869 PMCID: PMC4307167 DOI: 10.1186/s12873-014-0025-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 12/09/2014] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Motor vehicle collisions (MVCs) are the second most common injury mechanism resulting in emergency department (ED) visits by older adults. MVCs result in substantial pain and psychological distress among younger individuals, but little is known about the occurrence of these symptoms in older individuals. We describe the frequency of and characteristics associated with pain, distress, and anticipated time for physical and emotional recovery for older adults presenting to the ED after MVC in comparison to younger adults. METHODS In-person interviews were conducted for adults presenting to one of eight EDs after MVC without an obvious fracture or injury requiring admission as part of two prospective studies. Pain severity was assessed using a 0-10 verbal scale. Distress was assessed using the Peritraumatic Distress Inventory (range 0-52). Patients were asked to estimate their expected time for physical and emotional recovery; these responses were dichotomized to <30 or ≥30 days. ED pain and distress and associations between patient and collision characteristics and ED pain and distress were examined for patients age 65 years and older and patients age 18 to 64. RESULTS Older (n = 96) and younger (n = 943) adults had the same mean pain scores (5.5, SD 2.5 vs. 5.5, SD 2.4). Distress scores were lower in older than in younger adults (15.5, SD 9 vs. 19.2, SD 10). A higher percentage of older adults than younger adults had an anticipated time to physical recovery ≥30 days (41%, 95% confidence interval [CI] 28%-55% vs. 11%, 95% CI 9%-13%). Similarly, older adults were more likely to have an anticipated time for emotional recovery ≥30 days (45%, 95% CI 35%-55% vs. 17%, 95% CI 15%-20%). Older adults were less likely than younger adults to have moderate or severe neck pain (score ≥4) (25%, 95% CI 23% to 41% vs. 54%, 95% CI 48% to 60%) or back pain (31%, 95% CI 23% to 46% vs. 56%, 95% CI 51 to 62%) but more likely to have moderate or severe chest pain (42%, 95% CI 32% to 50% vs. 20%, 95% CI 16 to 23%). Pre-MVC depressive symptoms and pain catastrophizing were positively associated with pain and distress in both older and younger adults. CONCLUSIONS In our cohort, older adults who presented to the ED after MVC experienced similar pain severity as younger patients and less distress but were more likely to estimate their times for physical and emotional recovery to be 30 days or more. Increased emergency provider awareness of acute pain and distress symptoms among older patients experiencing MVC may improve outcomes for these patients.
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Affiliation(s)
- Gregory F Pereira
- School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Samuel A McLean
- Department of Anesthesiology, University of North Carolina, 101 Manning Drive, CB #7010, Chapel Hill, NC, 27599-7010, USA.
- Departments of Emergency Medicine and Anesthesiology, University of North Carolina, 101 Manning Drive, CB #7010, Chapel Hill, NC, 27599-7010, USA.
| | - Thomas J Tkacik
- Department of Anesthesiology, University of North Carolina, 101 Manning Drive, CB #7010, Chapel Hill, NC, 27599-7010, USA.
| | - Robert A Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI, USA.
| | - Jeffrey S Jones
- Department of Emergency Medicine, Spectrum Health - Butterworth Campus, Grand Rapids, MI, USA.
| | - David C Lee
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, USA.
| | - David A Peak
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Robert M Domeier
- Department of Emergency Medicine, St. Joseph Mercy Hospital, Ann Arbor, MI, USA.
| | - Niels K Rathlev
- Department of Emergency Medicine, Baystate Medical Center, Springfield, MA, USA.
| | - Phyllis L Hendry
- Department of Emergency Medicine and Pediatrics, University of Florida-Jacksonville, Jacksonville, FL, USA.
| | - Timothy F Platts-Mills
- Department of Anesthesiology, University of North Carolina, 101 Manning Drive, CB #7010, Chapel Hill, NC, 27599-7010, USA.
- Departments of Emergency Medicine and Anesthesiology, University of North Carolina, 101 Manning Drive, CB #7010, Chapel Hill, NC, 27599-7010, USA.
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Betz ME, Ginde AA, Southerland LT, Caterino JM. Emergency department and outpatient treatment of acute injuries in older adults in the United States: 2009-2010. J Am Geriatr Soc 2014; 62:1317-23. [PMID: 24890363 DOI: 10.1111/jgs.12877] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We sought to describe epidemiological patterns of acute injuries treated in emergency department (ED) and outpatient primary care settings in the United States. DESIGN Retrospective cross-sectional analysis of data from the 2009 and 2010 National Health Care Surveys. SETTING Emergency departments and outpatient primary care clinics. PARTICIPANTS Older adults (≥ 65) with initial visits for acute injuries. MEASUREMENTS Frequencies and incidence rates of medically attended injury according to participant characteristics and care setting. RESULTS Of the 19.7 million medically attended acute injuries in older adults in 2009-10, 50% were treated at EDs and 50% at outpatient primary care clinics. The annual incidence rate of medically attended injuries rose with age, from 20.8 (95% confidence interval (CI) = 17.0-24.6) per 100 in those aged 65 to 74 to 41.5 (95% CI = 33.5-49.4) per 100 for those aged 85 and older. Of injury-related ED visits, 60% occurred outside standard business hours, 36% were triaged as low acuity, and 25% resulted in admission. Only 9% of injury-related primary care visits had injury prevention counseling documented. CONCLUSION Medically attended injuries area common in older adults, and their incidence increases with advancing age. Half of all initial visits for acute injuries in older adults are to primary care clinics. Most injured individuals are discharged home, and injury prevention counseling is rarely documented. To inform injury prevention efforts appropriately and to avoid underestimating the burden of injury, future injury studies should include a range of outpatient and inpatient care settings.
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Affiliation(s)
- Marian E Betz
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, Colorado
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Southerland LT, Richardson DS, Caterino JM, Essenmacher AC, Swor RA. Emergency department recidivism in adults older than 65 years treated for fractures. Am J Emerg Med 2014; 32:1089-92. [PMID: 24929775 DOI: 10.1016/j.ajem.2014.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 04/07/2014] [Accepted: 05/01/2014] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Fractures in older adults are a commonly diagnosed injury in the emergency department (ED). We performed a retrospective medical record review to determine the rate of return to the same ED within 72 hours (returns) and the risk factors associated with returning. METHODS A retrospective medical record review of patients at least 65 years old discharged from a large, academic ED with a new diagnosis of upper extremity, lower extremity, or rib fractures was performed. Risk factors analyzed included demographic data, type of fracture, analgesic prescriptions, assistive devices provided, other concurrent injuries, and comorbidities (Charlson Comorbidity Index). Our primary outcome was return to the ED within 72 hours. RESULTS Three hundred fifteen patients qualified. Most fractures were in the upper extremity (64% [95% confidence interval {CI}, 58%-69%]). Twenty patients (6.3% [95% CI, 3.9%-9.6%]) returned within 72 hours. Most returns (15/20, 75%) were for reasons associated with the fracture itself, such as cast problems and inadequate pain control. Only 3 (<1% of all patients) patients returned for cardiac etiologies. Patients with distal forearm fractures had higher return rates (10.7% vs 4.5%, P = .03), and most commonly returned for cast or splint problems. Age, sex, other injuries, assistive devices, and Charlson Comorbidity Index score (median, 1 [interquartile range, 1-2] for both groups) did not predict 72-hour returns. CONCLUSION Older adults with distal forearm fractures may have more unscheduled health care usage in the first 3 days after fracture diagnosis than older adults with other fracture types. Overall, revisits for cardiac reasons or repeat falls were rare (<1%).
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Affiliation(s)
| | - Daniel S Richardson
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan
| | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio
| | | | - Robert A Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan
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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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Platts-Mills TF, Owens ST, McBride JM. A modern-day purgatory: older adults in the emergency department with nonoperative injuries. J Am Geriatr Soc 2014; 62:525-8. [PMID: 24617946 DOI: 10.1111/jgs.12699] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Older adults frequently present to the emergency department (ED) with injuries that do not require operative treatment but are sufficiently severe to make it unsafe for them to return home. These individuals typically do not meet criteria for hospital admission, but because of limited reimbursement for observation, admitting physicians are often reluctant to accept these individuals for observation. Admission to a skilled nursing or assisted living facility from the ED or rapid access to additional in-home care is also often difficult or impossible. As a result, older adults with nonoperative injuries often spend a long time in the ED waiting for an appropriate disposition. The challenges of identifying an appropriate disposition for these individuals, the consequences for patients, and some potential solutions to this commonly encountered problem are described.
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Affiliation(s)
- Timothy F Platts-Mills
- Department of Emergency Medicine, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
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Carpenter CR. Deteriorating Functional Status in Older Adults After Emergency Department Evaluation of Minor Trauma-Opportunities and Pragmatic Challenges. J Am Geriatr Soc 2013; 61:1806-7. [DOI: 10.1111/jgs.12478] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sirois MJ, Émond M, Ouellet MC, Perry J, Daoust R, Morin J, Dionne C, Camden S, Moore L, Allain-Boulé N. Cumulative Incidence of Functional Decline After Minor Injuries in Previously Independent Older Canadian Individuals in the Emergency Department. J Am Geriatr Soc 2013; 61:1661-8. [DOI: 10.1111/jgs.12482] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Marie-Josée Sirois
- Department of Rehabilitation; Université Laval; Québec Canada
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
| | - Marcel Émond
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
- Hôpital Enfant-Jésus; Centre Hospitalier Universitaire de Québec; Québec Canada
| | - Marie-Christine Ouellet
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
- Centre Interdisciplinaire de Recherche en Réadaptation et Intégration Sociale; Institut de Réadaptation en Déficience Physique de Québec; Québec Canada
| | | | - Raoul Daoust
- Hôpital du Sacré-Cœur de Montréal; Montreal Canada
| | - Jacques Morin
- Hôpital Enfant-Jésus; Centre Hospitalier Universitaire de Québec; Québec Canada
| | - Clermont Dionne
- Department of Rehabilitation; Université Laval; Québec Canada
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
| | - Stéphanie Camden
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
| | - Lynne Moore
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
| | - Nadine Allain-Boulé
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
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Arendts G, Fitzhardinge S, Pronk K, Hutton M. Outcomes in older patients requiring comprehensive allied health care prior to discharge from the emergency department. Emerg Med Australas 2013; 25:127-31. [DOI: 10.1111/1742-6723.12049] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2012] [Indexed: 11/29/2022]
Affiliation(s)
| | | | | | - Marani Hutton
- South Metropolitan Health Service; Western Australian Department of Health; Fremantle; Western Australia; Australia
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Stiffler KA, Finley A, Midha S, Wilber ST. Frailty assessment in the emergency department. J Emerg Med 2013; 45:291-8. [PMID: 23419211 DOI: 10.1016/j.jemermed.2012.11.047] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 05/31/2012] [Accepted: 11/06/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Frailty (defined as weakness, slowness, weight loss, exhaustion, and physical inactivity) is characterized by increased vulnerability to stressors. Frail older patients are at increased risk of Emergency Department (ED) visits, hospitalization, disability, and death. OBJECTIVES Our aims were to determine the prevalence of frailty (and assess the feasibility of measuring frailty) in older ED patients. We also assessed the correlation of self-reported speed and weakness to measured values and the association between frailty and function. METHODS We performed a study of discharged ED patients aged ≥ 65 years. We used Fried's frailty definition and a validated activities-of-daily-living (ADL) scale. We measured self-reported and objective weakness and slowness. Data were reported as means and proportions with 95% confidence interval (CI); associations were measured using 95% CI for the differences. Ninety patients provided a 95% CI of ± 10%. RESULTS The mean age of the 90 patients was 76 ± 6.4 SD years; 51% were male. Mean assessment time was 7.4 min (95% CI 6.9-7.9). Twenty percent of patients were frail (18/90, 95% CI 12-30%). Self-report was 18% sensitive and 90% specific for objective weakness; self-report was 42% sensitive and 86% specific for objective slowness. Frail and weak patients were more likely dependent in one or more ADLs (26% difference, 95% CI 1-51% and 20% difference, 95% CI 1-41%, respectively). CONCLUSIONS Frailty is common in discharged older ED patients. Self-reported weakness and slowness are poor predictors of their objective counterparts. Frailty was associated with ADL dependence. These two domains may be reliable markers for elderly ED patients at high risk for adverse outcomes.
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Affiliation(s)
- Kirk A Stiffler
- Department of Emergency Medicine, Summa Akron City Hospital, Akron, Ohio 44304, USA
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Platts-Mills TF, Hunold KM, Esserman DA, Sloane PD, McLean SA. Motor vehicle collision-related emergency department visits by older adults in the United States. Acad Emerg Med 2012; 19:821-7. [PMID: 22724382 DOI: 10.1111/j.1553-2712.2012.01383.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Motor vehicle collisions (MVCs) are the second most common cause of nonfatal injury among U.S. adults age 65 years and older. However, the frequency of emergency department (ED) visits, disposition, pain locations, and pain severity for older adults experiencing MVCs have not previously been described. The authors sought to determine these characteristics using information from two nationally representative data sets. METHODS Data from the 2008 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample (NEDS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) were used to estimate MVC-related ED visits and ED disposition for patients 65 years and older. NHAMCS data from 2004 through 2008 were used to further characterize MVC-related ED visits. RESULTS In 2008, the NEDS contained 28,445,564 patient visits, of which 760,356 (2.7%) were due to MVCs. The NHAMCS contained 34,134 patient visits, of which 1,038 (3.0%) were due to MVCs. National estimates of MVC-related ED visits by patients 65 years and older in 2008 are 226,000 (95% confidence interval [CI]=210,000 to 240,000) for NEDS and 270,000 (95% CI=185,000 to 355,000) for NHAMCS. Most older adults with MVC-related ED visits were sent home from the ED (proportion discharged NEDS 78%, 95% CI=78% to 79%; NHAMCS 77%, 95% CI=66% to 86%). During the years 2004 through 2008, of MVC-related ED visits by older adults not resulting in hospital admission, moderate or severe pain was reported in 61% (95% CI=52% to 70%) of those with recorded pain scores. Older patients sent home after MVC-related ED visits were less likely than younger patients to receive analgesics (35%, 95% CI=26% to 43% vs. 47%, 95% CI=44% to 50%) during their ED evaluations or as discharge prescriptions (52%, 95% CI=41% to 62% vs. 65%, 95% CI=61% to 68%). CONCLUSIONS In 2008, adults age 65 years or older made more than 200,000 MVC-related ED visits. Approximately 80% of these visits were discharged home from the ED, but the majority of discharged patients reported moderate or severe pain. Further studies of pain and functional outcomes in this population are needed.
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Affiliation(s)
- Timothy F Platts-Mills
- Department of Emergency Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC, USA.
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Oyetunji TA, Ong’uti SK, Bolorunduro OB, Gonzalez DO, Cornwell EE, Haider AH. Epidemiologic Trend in Elderly Domestic Injury. J Surg Res 2012; 173:206-11. [DOI: 10.1016/j.jss.2011.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2011] [Revised: 04/18/2011] [Accepted: 05/03/2011] [Indexed: 11/27/2022]
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