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Qian XX, Chau PH, Fong DYT, Ho M, Woo J. Identifying factors associated with post-hospital falls in older patients: a territory-wide cohort study. Public Health 2024; 235:1-7. [PMID: 39032191 DOI: 10.1016/j.puhe.2024.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 05/07/2024] [Accepted: 06/15/2024] [Indexed: 07/22/2024]
Abstract
OBJECTIVES Post-hospital falls impose a substantial healthcare burden on older adults, yet contributing factors remain inadequately examined. This study aimed to investigate underinvestigated factors associated with post-hospital falls. STUDY DESIGN Retrospective territory-wide cohort study. METHODS We examined the electronic medical records of patients aged ≥65 who were discharged from public hospitals in Hong Kong (2007-2018). During the 12 months following discharge, participants were monitored to identify falls based on diagnosis codes or clinical notes from inpatient episodes, the emergency department (ED) visits, and death records. Falls were categorized into two groups: those only requiring ED visits and those requiring hospitalizations. Binary logistic and multinomial logistic regressions examined the associated factors for post-hospital falls and subcategories of falls, respectively. RESULTS Among 606,392 older patients, 28,593 (4.71%; 95% CI = 4.66%-4.77%) experienced falls within 12 months after discharge. Of those, 8438 (29.5%) only required ED visits, and 20,147 (70.5%) required hospitalizations. Discharge from non-surgical wards, length of stay over two weeks, receiving the Geriatric Day Hospital and Rehabilitation Day Program, advancing age, being female, having more comorbidities, taking more fall risk increasing drugs, previous admission for falls, and living in Hong Kong Island were associated with increased fall risk. Receiving allied health service or nurse service was associated with reduced risk. The same factors were more associated with falls requiring hospitalizations rather than falls only requiring ED visits. CONCLUSIONS Older patients with identified factors were particularly vulnerable to post-hospital falls leading to rehospitalizations. Fall risk assessment and tailored prevention should prioritize this group.
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Affiliation(s)
- X X Qian
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - P H Chau
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
| | - D Y T Fong
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - M Ho
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - J Woo
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
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2
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Lee S, Skains RM, Magidson PD, Qadoura N, Liu SW, Southerland LT. Enhancing healthcare access for an older population: The age-friendly emergency department. J Am Coll Emerg Physicians Open 2024; 5:e13182. [PMID: 38726466 PMCID: PMC11079440 DOI: 10.1002/emp2.13182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/29/2023] [Accepted: 01/24/2024] [Indexed: 05/12/2024] Open
Abstract
Healthcare systems face significant challenges in meeting the unique needs of older adults, particularly in the acute setting. Age-friendly healthcare is a comprehensive approach using the 4Ms framework-what matters, medications, mentation, and mobility-to ensure that healthcare settings are responsive to the needs of older patients. The Age-Friendly Emergency Department (AFED) is a crucial component of a holistic age-friendly health system. Our objective is to provide an overview of the AFED model, its core principles, and the benefits to older adults and healthcare clinicians. The AFED optimizes the delivery of emergency care by integrating age-specific considerations into various aspects of (1) ED physical infrastructure, (2) clinical care policies, and (3) care transitions. Physical infrastructure incorporates environmental modifications to enhance patient safety, including adequate lighting, nonslip flooring, and devices for sensory and ambulatory impairment. Clinical care policies address the physiological, cognitive, and psychosocial needs of older adults while preserving focus on emergency issues. Care transitions include communication and involving community partners and case management services. The AFED prioritizes collaboration between interdisciplinary team members (ED clinicians, geriatric specialists, nurses, physical/occupational therapists, and social workers). By adopting an age-friendly approach, EDs have the potential to improve patient-centered outcomes, reduce adverse events and hospitalizations, and enhance functional recovery. Moreover, healthcare clinicians benefit from the AFED model through increased satisfaction, multidisciplinary support, and enhanced training in geriatric care. Policymakers, healthcare administrators, and clinicians must collaborate to standardize guidelines, address barriers to AFEDs, and promote the adoption of age-friendly practices in the ED.
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Affiliation(s)
- Sangil Lee
- Department of Emergency MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Rachel M. Skains
- University of Alabama at BirminghamBirminghamAlabamaUSA
- Geriatric Research, Education, and Clinical CenterBirmingham VA Medical CenterBirminghamAlabamaUSA
| | | | - Nadine Qadoura
- Department of Emergency MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Shan W. Liu
- Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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García-Martínez A, García-Rosa S, Gil-Rodrigo A, Machado VT, Pérez-Fonseca C, Nickel CH, Artajona L, Jacob J, Llorens P, Herrero P, Canadell N, Rangel C, Martín-Sánchez FJ, Del Nogal ML, Miró Ò. Prevalence and outcomes of fear of falling in older adults with falls at the emergency department: a multicentric observational study. Eur Geriatr Med 2024:10.1007/s41999-024-00992-1. [PMID: 38809489 DOI: 10.1007/s41999-024-00992-1] [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: 02/17/2024] [Accepted: 05/08/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE Fear of falling (FOF) may result in activity restriction and deconditioning. The aim of the study was to identify factors associated with FOF in older patients and to investigate if FOF influenced long-term outcomes. METHODS Multicentric, observational, prospective study including patients 65 years or older attending the emergency department (ED) after a fall. Demographical, patient- and fall-related features were recorded at the ED. FOF was assessed using a single question. The primary outcome was all-cause death. Secondary outcomes included new fall-related visit, fall-related hospitalisation, and admission to residential care. Logistic regression and Cox regression models were used for statistical analyses. RESULTS Overall, 1464 patients were included (47.1% with FOF), followed for a median of 6.2 years (2.2-7.9). Seven variables (age, female sex, living alone, previous falls, sedative medications, urinary incontinence, and intrinsic cause of the fall) were directly associated with FOF whereas use of walking aids and living in residential care were inversely associated. After the index episode, 748 patients (51%) died (median 3.2 years), 677 (46.2%) had a new fall-related ED visit (median 1.7 years), 251 (17.1%) were hospitalised (median 2.8 years), and 197 (19.4%) were admitted to care (median 2.1 years). FOF was associated with death (HR 1.239, 95% CI 1.073-1.431), hospitalisation (HR 1.407, 95% CI 1.097-1.806) and institutionalisation (HR 1.578, 95% CI 1.192-2.088), but significance was lost after adjustment. CONCLUSION FOF is a prevalent condition in older patients presenting to the ED after a fall. However, it was not associated with long-term outcomes. Future research is needed to understand the influence of FOF in maintenance of functional capacity or quality of life.
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Affiliation(s)
- Ana García-Martínez
- Emergency Department, IDIBAPS, Hospital Clínic, University of Barcelona, Villarroel, 170, 08036, Barcelona, Spain.
| | | | - Adriana Gil-Rodrigo
- Emergency Department, Short Stay Unit and Hospitalization at Home Unit, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Hospital General de Alicante, Universidad Miguel Hernández, Alicante, Spain
| | - Victoria Torres Machado
- Emergency Department, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | | | | | - Lourdes Artajona
- Emergency Department, IDIBAPS, Hospital Clínic, University of Barcelona, Villarroel, 170, 08036, Barcelona, Spain
| | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Pere Llorens
- Emergency Department, Short Stay Unit and Hospitalization at Home Unit, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Hospital General de Alicante, Universidad Miguel Hernández, Alicante, Spain
| | - Pablo Herrero
- Emergency Department, Hospital Central de Asturias, Oviedo, Spain
| | - Naila Canadell
- Emergency Department, IDIBAPS, Hospital Clínic, University of Barcelona, Villarroel, 170, 08036, Barcelona, Spain
| | - Carolina Rangel
- Emergency Department, IDIBAPS, Hospital Clínic, University of Barcelona, Villarroel, 170, 08036, Barcelona, Spain
| | | | | | - Òscar Miró
- Emergency Department, IDIBAPS, Hospital Clínic, University of Barcelona, Villarroel, 170, 08036, Barcelona, Spain
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Blandin M, Gallet M, Volteau C, Le Conte P, Rulleau T, Le Sant G. Effects of the delivery of physiotherapy on the treatment course of elderly fallers presenting to the emergency department: Protocol for a randomized clinical trial. PLoS One 2024; 19:e0303362. [PMID: 38718002 PMCID: PMC11078381 DOI: 10.1371/journal.pone.0303362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/23/2024] [Indexed: 05/12/2024] Open
Abstract
The use of physiotherapy (PT) in the hospital emergency department (ED) has shown positive results including improvements in patient waiting time, treatment initiation, discharge type, patient outcomes, safety and acceptability of the intervention by medical staffs. These findings originate from studies that primarily focus on musculoskeletal and orthopaedic conditions. Despite a significant number of people visiting the ED, there is a shortage of literature evaluating PT in the ED for elderly populations. The objective of this study is the evaluate the effect of delivering PT in the ED (versus no delivery) in patients aged 75 and over with 'falls' complaints. The main objective is the evaluate the effect on the discharge disposition (discharge home, hospitalization). Secondarily, we will evaluate the effect delivering PT on patient-length of stay, the number of falls at 7 days after admission to the ED, changes between the initial and final medical decision regarding patient orientation, and medical staff satisfaction. This study will follow a prospective longitudinal design involving participants aged 75 years and over. We plan to recruit a total n = 336 patients admitted to the ED with a 'fall' chief complaint. After consent, participants will be randomized into either the 'PT-group' (receiving a prescription and execution of PT within the ED), or to the 'no-PT group' (no delivery of PT within the ED). The PT intervention will involve a standardized assessment of motor capacities using validated clinical examinations, and the delivery of rehabilitative exercises based on individual needs. Outcomes will be recorded from the patient's medical record, and a phone call at 7 days. A questionnaire will be sent to medical staff. The results of this study will help to determine whether PT might be beneficial for the management of this increasing proportion of individuals who come to the ED. Trial registration: (Trial registration number: ClinicalTrials.gov NCT05753319). https://classic.clinicaltrials.gov/ct2/show/NCT05753319.
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Affiliation(s)
- Marie Blandin
- Nantes Université, CHU Nantes, Movement – Interactions - Performance, MIP, UR 4334, Nantes, France
| | - Marie Gallet
- Nantes Université, CHU Nantes, Movement – Interactions - Performance, MIP, UR 4334, Nantes, France
| | - Christelle Volteau
- Nantes Université, CHU Nantes, Movement – Interactions - Performance, MIP, UR 4334, Nantes, France
| | - Philippe Le Conte
- Nantes Université, CHU Nantes, Movement – Interactions - Performance, MIP, UR 4334, Nantes, France
| | - Thomas Rulleau
- Nantes Université, CHU Nantes, Movement – Interactions - Performance, MIP, UR 4334, Nantes, France
| | - Guillaume Le Sant
- Nantes Université, CHU Nantes, Movement – Interactions - Performance, MIP, UR 4334, Nantes, France
- IFM3R, School of Physiotherapy, St-Sebastien-sur-Loire, France
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5
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Strauss DH, Davoodi NM, Resnik LJ, Keene S, Serina PT, Goldberg EM. Emergency Department-Based Physical Function Measures for Falls in Older Adults and Outcomes: A Secondary Analysis of GAPcare. J Geriatr Phys Ther 2024:00139143-990000000-00048. [PMID: 38656264 DOI: 10.1519/jpt.0000000000000403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND AND PURPOSE Falls are the leading reason for injury-related emergency department (ED) visits for older adults. The Geriatric Acute and Post-acute Fall Prevention Intervention (GAPcare), an in-ED intervention combining a medication therapy management session delivered by a pharmacist and a fall risk assessment and plan by a physical therapist, reduced ED revisits at 6 months among older adults presenting after a fall. Our objective was to evaluate the relationship between measures of function obtained in the ED and clinical outcomes. METHODS This was a secondary analysis of data from GAPcare, a randomized controlled trial conducted from January 2018 to October 2019 at 2 urban academic EDs. Standardized measures of function (Timed Up and Go [TUG] test, Barthel Activity of Daily Living [ADL], Activity Measure for Post Acute Care [AM-PAC] 6 clicks) were collected at the ED index visit. We performed a descriptive analysis and hypothesis testing (chi square test and analysis of variance) to assess the relationship of functional measures with outcomes (ED disposition, ED revisits for falls, and place of residence at 6 months). Emergency department disposition status refers to discharge location immediately after the ED evaluation is complete (eg, hospital admission, original residence, skilled nursing facility). RESULTS AND DISCUSSION Among 110 participants, 55 were randomized to the GAPcare intervention and 55 received usual care. Of those randomized to the intervention, 46 received physical therapy consultation. Median age was 81 years; participants were predominantly women (67%) and White (94%). Seventy-three (66%) were discharged to their original residence, 14 (13%) were discharged to a skilled nursing facility and 22 (20%) were admitted. There was no difference in ED disposition status by index visit Barthel ADLs (P = .371); however, TUG times were faster (P = .016), and AM-PAC 6 clicks score was higher among participants discharged to their original residence (P ≤ .001). Participants with slower TUG times at the index ED visit were more likely to reside in nursing homes by six months (P = .002), while Barthel ADL and AM-PAC 6 clicks did not differ between those residing at home and other settings. CONCLUSIONS Measures of function collected at the index ED visit, such as the AM-PAC 6 clicks and TUG time, may be helpful at predicting clinical outcomes for older adults presenting for a fall. Based on our study findings, we suggest a novel workflow to guide the use of these clinical measures for ED patients with falls.
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Affiliation(s)
- Daniel H Strauss
- Department of Emergency Medicine, The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Natalie M Davoodi
- Department of Emergency Medicine, The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Linda J Resnik
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
- Research Department, Providence VA Medical Center, Providence, Rhode Island
| | - Sarah Keene
- Department of Emergency Medicine, The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Peter T Serina
- Department of Emergency Medicine, The Warren Alpert Medical School, Brown University, Providence, Rhode Island
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Elizabeth M Goldberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
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Testa L, Richardson L, Cheek C, Hensel T, Austin E, Safi M, Ransolin N, Carrigan A, Long J, Hutchinson K, Goirand M, Bierbaum M, Bleckly F, Hibbert P, Churruca K, Clay-Williams R. Strategies to improve care for older adults who present to the emergency department: a systematic review. BMC Health Serv Res 2024; 24:178. [PMID: 38331778 PMCID: PMC10851482 DOI: 10.1186/s12913-024-10576-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/08/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND The aim of this systematic review was to examine the relationship between strategies to improve care delivery for older adults in ED and evaluation measures of patient outcomes, patient experience, staff experience, and system performance. METHODS A systematic review of English language studies published since inception to December 2022, available from CINAHL, Embase, Medline, and Scopus was conducted. Studies were reviewed by pairs of independent reviewers and included if they met the following criteria: participant mean age of ≥ 65 years; ED setting or directly influenced provision of care in the ED; reported on improvement interventions and strategies; reported patient outcomes, patient experience, staff experience, or system performance. The methodological quality of the studies was assessed by pairs of independent reviewers using The Joanna Briggs Institute critical appraisal tools. Data were synthesised using a hermeneutic approach. RESULTS Seventy-six studies were included in the review, incorporating strategies for comprehensive assessment and multi-faceted care (n = 32), targeted care such as management of falls risk, functional decline, or pain management (n = 27), medication safety (n = 5), and trauma care (n = 12). We found a misalignment between comprehensive care delivered in ED for older adults and ED performance measures oriented to rapid assessment and referral. Eight (10.4%) studies reported patient experience and five (6.5%) reported staff experience. CONCLUSION It is crucial that future strategies to improve care delivery in ED align the needs of older adults with the purpose of the ED system to ensure sustainable improvement effort and critical functioning of the ED as an interdependent component of the health system. Staff and patient input at the design stage may advance prioritisation of higher-impact interventions aligned with the pace of change and illuminate experience measures. More consistent reporting of interventions would inform important contextual factors and allow for replication.
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Affiliation(s)
- Luke Testa
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Lieke Richardson
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Colleen Cheek
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia.
| | - Theresa Hensel
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
- Institute of Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), University of Cologne, Cologne, Germany
| | - Elizabeth Austin
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Mariam Safi
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
- Internal Medicine Research Unit, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Natália Ransolin
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
- Universidade Federal Do Rio Grande Do Sul, Porto Alegre, RS, Brasil
| | - Ann Carrigan
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Janet Long
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Karen Hutchinson
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Magali Goirand
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Mia Bierbaum
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
- Allied Health and Human Performance, IIMPACT in Health, University of South Australia, Adelaide, 5001, Australia
| | - Felicity Bleckly
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Peter Hibbert
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
- Allied Health and Human Performance, IIMPACT in Health, University of South Australia, Adelaide, 5001, Australia
| | - Kate Churruca
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Robyn Clay-Williams
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
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7
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Memedovich A, Asante B, Khan M, Eze N, Holroyd BR, Lang E, Kashuba S, Clement F. Strategies for improving ED-related outcomes of older adults who seek care in emergency departments: a systematic review. Int J Emerg Med 2024; 17:16. [PMID: 38302890 PMCID: PMC10835906 DOI: 10.1186/s12245-024-00584-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/12/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Despite constituting 14% of the general population, older adults make up almost a quarter of all emergency department (ED) visits. These visits often do not adequately address patient needs, with nearly 80% of older patients discharged from the ED carrying at least one unattended health concern. Many interventions have been implemented and tested in the ED to care for older adults, which have not been recently synthesized. METHODS A systematic review was conducted to identify interventions initiated in the ED to address the needs of older adults. Embase, MEDLINE, CINAHL, Cochrane CENTRAL, the Cochrane Database of Systematic Reviews, and grey literature were searched from January 2013 to January 18, 2023. Comparative studies assessing interventions for older adults in the ED were included. The quality of controlled trials was assessed with the Cochrane risk-of-bias tool for randomized trials, and the quality of observational studies was assessed with the risk of bias in non-randomized studies of interventions tool. Due to heterogeneity, meta-analysis was not possible. RESULTS Sixteen studies were included, assessing 12 different types of interventions. Overall study quality was low to moderate: 10 studies had a high risk of bias, 5 had a moderate risk of bias, and only 1 had a low risk of bias. Follow-up telephone calls, referrals, geriatric assessment, pharmacist-led interventions, physical therapy services, care plans, education, case management, home visits, care transition interventions, a geriatric ED, and care coordination were assessed, many of which were combined to create multi-faceted interventions. Care coordination with additional support and early assessment and intervention were the only two interventions that consistently reported improved outcomes. Most studies did not report significant improvements in ED revisits, hospitalization, time spent in the ED, costs, or outpatient utilization. Two studies reported on patient perspectives. CONCLUSION Few interventions demonstrate promise in reducing ED revisits for older adults, and this review identified significant gaps in understanding other outcomes, patient perspectives, and the effectiveness in addressing underlying health needs. This could suggest, therefore, that most revisits in this population are unavoidable manifestations of frailty and disease trajectory. Efforts to improve older patients' needs should focus on interventions initiated outside the ED.
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Affiliation(s)
- Ally Memedovich
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Benedicta Asante
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Maha Khan
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Nkiruka Eze
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Brian R Holroyd
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
- Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Eddy Lang
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
- Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada
| | - Sherri Kashuba
- Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Fiona Clement
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada.
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Al-Hakeem H, Zhang Z, DeMarco EC, Bitter CC, Hinyard L. Emergency department visits in Parkinson's disease: The impact of comorbid conditions. Am J Emerg Med 2024; 75:7-13. [PMID: 37897921 DOI: 10.1016/j.ajem.2023.10.017] [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: 04/21/2023] [Revised: 10/04/2023] [Accepted: 10/08/2023] [Indexed: 10/30/2023] Open
Abstract
INTRODUCTION Older adults have complex, often overlapping, medical conditions requiring careful management that may lead to increased emergency department usage compared to younger adults. Parkinson's disease (PD), a progressive neurodegenerative disorder characterized by distinct motor and nonmotor features, frequently occurs with additional comorbid disease. Classifying comorbid conditions into clinical subgroups allows for further understanding of the heterogeneity in outcomes in patients with PD. The current study examines the reasons for emergency department (ED) visits in a cohort of patients with PD and identifies comorbidities that are potential risk factors for specific ED presenting conditions. METHODS Using data from Optum's de-identified Integrated Claims-Clinical dataset years 2010-2018, patients with PD were identified based on ICD-9/10 diagnosis codes. We identified all ED visits occurring after the first observed diagnosis code for PD. Comorbid conditions were classified using the AHRQ Clinical Classification Software (CCS). We classified patients using Latent Class Analysis (LCA) and conducted multiple logistic regression models with the outcome of reason-for-visit to examine the associations with comorbidity-profile class, patient demographics, and socio-economic characteristics. RESULTS The most common reasons for ED admission were injuries such as fractures and contusions, diseases of the circulatory system, and general signs and symptoms, including abdominal pain, malaise, and fatigue. Comorbid medical conditions often observed in this patient population include depression, diabetes mellitus, and chronic pulmonary disease. Patients in the "Poorest Health" classification of the LCA had greater odds for ED admission for diseases related to the gastrointestinal system, musculoskeletal system, and injury/poisoning categories and reduced odds for admission for diseases of the circulatory system. DISCUSSION Patients with PD who present to the emergency department with injuries are more likely to be in poor health overall with a high comorbidity burden. Clarifying the complex medical needs of patients with PD is the first step to further individualize care, which may reduce ED visits in this population, improve quality of life, and lessen the footprint on the healthcare system.
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Affiliation(s)
- Haider Al-Hakeem
- Saint Louis University School of Medicine, 1402 S Grand Blvd, St. Louis, MO 63104, USA.
| | - Zidong Zhang
- Department of Health & Clinical Outcomes Research, 3545 Lafayette Ave, St. Louis, MO 63104, USA; Advanced HEALTH Data (AHEAD) Institute, 3545 Lafayette Ave, St. Louis, MO 63104, USA.
| | - Elisabeth C DeMarco
- Department of Health & Clinical Outcomes Research, 3545 Lafayette Ave, St. Louis, MO 63104, USA; Advanced HEALTH Data (AHEAD) Institute, 3545 Lafayette Ave, St. Louis, MO 63104, USA.
| | - Cindy C Bitter
- Division of Emergency Medicine, Saint Louis University School of Medicine, St. Louis Missouri USA, 1402 S Grand Blvd, St. Louis, MO 63104, USA.
| | - Leslie Hinyard
- Department of Health & Clinical Outcomes Research, 3545 Lafayette Ave, St. Louis, MO 63104, USA; Advanced HEALTH Data (AHEAD) Institute, 3545 Lafayette Ave, St. Louis, MO 63104, USA.
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9
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McQuown CM, Tsivitse EK. Nonspecific Complaints in Older Emergency Department Patients. Clin Geriatr Med 2023; 39:491-501. [PMID: 37798061 DOI: 10.1016/j.cger.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Nonspecific complaints such as generalized weakness and fatigue are common in older adults presenting to an emergency department. These complaints may be caused by acute or chronic medical problems, or they may be exacerbated or caused by socioeconomic risks factors. Acute causes may be related to serious medical conditions requiring prompt treatment. A thorough history and physical examination in conjunction with an interdisciplinary approach allows emergency departments to identify acute conditions as well as geriatric syndromes and unmet home needs, such as food insecurity and caregiver burden. A whole-health system approach should be used for safe transitions of care.
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Affiliation(s)
- Colleen M McQuown
- Louis Stokes Veterans Affairs Medical Center, 10701 East Boulevard. Cleveland, OH 44106, USA.
| | - Emily K Tsivitse
- Louis Stokes Veterans Affairs Medical Center, 10701 East Boulevard. Cleveland, OH 44106, USA
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10
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Shankar KN, Li A. Older Adult Falls in Emergency Medicine, 2023 Update. Clin Geriatr Med 2023; 39:503-518. [PMID: 37798062 DOI: 10.1016/j.cger.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Of 4 older adults, 1 will fall each year in the United States. Based on 2020 data from the Centers of Disease Control, about 36 million older adults fall each year, resulting in 32,000 deaths. Emergency departments see about 3 million older adults for fall-related injuries with falls having the ability to cause serious injury such as catastrophic head injuries and hip fractures. One-third of older fall patients discharged from the ED experience one of these outcomes at 3 months.
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Affiliation(s)
- Kalpana N Shankar
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Neville House, Boston, MA 02115, USA.
| | - Angel Li
- Department of Emergency Medicine, The Ohio State University, 376 West 10th Avenue, Columbus, OH 43210, USA
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Southerland LT, Biese K, Hwang U. Geriatric assessment in the emergency department reduces healthcare costs-So when will CMS pay for it? J Am Geriatr Soc 2023; 71:2698-2700. [PMID: 37435831 DOI: 10.1111/jgs.18473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/20/2023] [Indexed: 07/13/2023]
Abstract
This editorial comments on the article by Haynesworth et al. in this issue.
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Affiliation(s)
- Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Kevin Biese
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
- Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New York, USA
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Chary A, Brickhouse E, Torres B, Cameron‐Comasco L, Lee S, Punches B, Skains RM, Naik AD, Quatman‐Yates CC, Kennedy M, Southerland LT, Liu S. Physical therapy consultation in the emergency department for older adults with falls: A qualitative study. J Am Coll Emerg Physicians Open 2023; 4:e12941. [PMID: 37090953 PMCID: PMC10114865 DOI: 10.1002/emp2.12941] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/02/2023] [Accepted: 03/15/2023] [Indexed: 04/25/2023] Open
Abstract
Objectives Little is known about current practices in consulting physical therapy (PT) in the emergency department (ED) for older adults with falls, a practice that can reduce fall-related ED revisits. This qualitative study aimed to understand perspectives of ED staff about ED PT consultation for older adults with falls and fall-related complaints, specifically regarding perceived value and associated challenges and strategies. Methods We performed focus groups and key informant interviews with emergency physicians, advanced practice clinicians, nurses, physical therapists, occupational therapists, and technicians who perform ED geriatric screenings. We used rapid qualitative analysis to identify common themes related to decisions to consult PT from the ED, perceived value of PT, and common challenges and strategies in ED PT consultation. Results Twenty-five participants in 4 focus groups and 3 interviews represented 22 distinct institutions with ED PT consultation available for older adults with falls. About two thirds of EDs represented relied on clinician gestalt to request PT consultation (n = 15, 68%), whereas one third used formal consultation pathways (n = 7, 32%). Participants valued physical therapists' expertise, time, and facilitation of hospital throughput by developing safe discharge plans and contact with patients to improve outpatient follow-up. Common challenges included limited ED PT staffing and space for PT evaluations; strategies to promote ED PT consultation included advocating for leadership buy-in and using ED observation units to monitor patients and avoid admission until PT consultation was available. Conclusion ED PT consultation for older adults with falls may benefit patients, ED staff, and hospital throughput. Uncertainty remains over whether geriatric screening-triggered consultation versus emergency clinician gestalt successfully identifies patients likeliest to benefit from ED PT evaluation. Leadership buy-in, designated consultation space, and formalized consultation pathways are strategies to address current challenges in ED PT consultation.
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Affiliation(s)
- Anita Chary
- Department of Emergency MedicineBaylor College of MedicineHoustonTexasUSA
- Department of MedicineBaylor College of MedicineHoustonTexasUSA
- Center for Innovations in Quality, Effectiveness and SafetyMichael E. DeBakey VA Medical CenterHoustonTexasUSA
| | | | - Beatrice Torres
- UT Health Science CenterUniversity of Texas School of Public HealthHoustonTexasUSA
| | - Lauren Cameron‐Comasco
- Beaumont HospitalRoyal OakMichiganUSA
- School of MedicineOakland University William Beaumont School of MedicineRochesterMichiganUSA
| | - Sangil Lee
- College of MedicineUniversity of Iowa CarverIowa CityIowaUSA
| | - Brittany Punches
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
- College of NursingThe Ohio State UniversityColumbusOhioUSA
| | - Rachel M. Skains
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness and SafetyMichael E. DeBakey VA Medical CenterHoustonTexasUSA
- UT Health Science CenterUniversity of Texas School of Public HealthHoustonTexasUSA
- Consortium on AgingUniversity of Texas Health Science CenterHoustonTexasUSA
| | | | - Maura Kennedy
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | | | - Shan Liu
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
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Using Healthcare Resources Wisely: A Predictive Support System Regarding the Severity of Patient Falls. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:3100618. [PMID: 35958052 PMCID: PMC9359836 DOI: 10.1155/2022/3100618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 06/15/2022] [Accepted: 07/06/2022] [Indexed: 11/18/2022]
Abstract
Background An injurious fall is one of the main indicators of care quality in healthcare facilities. Despite several fall screen tools being widely used to evaluate a patient's fall risk, they are frequently unable to reveal the severity level of patient falls. The purpose of this study is to build a practical system useful to predict the severity level of in-hospital falls. This practice is done in order to better allocate limited healthcare resources and to improve overall patient safety. Methods Four hundred and forty-six patients who experienced fall events at a large Taiwanese hospital were referenced. Eight predictors were used to ascertain the severity of patient falls solely based on the above study population. Multinomial logistic regression, Naïve Bayes, random forest, support vector machine, eXtreme gradient boosting, deep learning, and ensemble learning were adopted to establish predictive models. Accuracy, F1 score, precision, and recall were utilized to assess the models' performance. Results Compared to other learners, random forest exhibited satisfying predictive performance in terms of all metrics (accuracy: 0.844, F1 score: 0.850, precision: 0.839, and recall: 0.875 for the test dataset), and it was adopted as the base learner for a severity-level predictive system which is web-based. Furthermore, age, ability of independent activity, patient sources, use of assistive devices, and fall history within the past 12 months were deemed the top five important risk factors for evaluating fall severity. Conclusions The application of machine learning techniques for predicting the severity level of patient falls may result in some benefits to monitor fall severity and to better allocate limited healthcare resources.
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Ellis B, Brousseau AA, Eagles D, Sinclair D, Melady D. Canadian Association of Emergency Physicians position statement on care of older people in Canadian Emergency Departments: executive summary. CAN J EMERG MED 2022; 24:376-381. [PMID: 35532853 DOI: 10.1007/s43678-022-00315-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/11/2022] [Indexed: 11/02/2022]
Affiliation(s)
- Brittany Ellis
- Department of Emergency Medicine, University of Saskatchewan, 103 Hospital Drive, Saskatoon, SK, S7N 0W8, Canada.
| | - Audrey-Anne Brousseau
- Département de médecine familiale et de médecine d'urgence, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Debra Eagles
- Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Douglas Sinclair
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Don Melady
- Faculty of Medicine, Schwartz/Reisman Emergency Medicine Institute, University of Toronto, Toronto, ON, Canada
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Qian XX, Chen Z, Fong DYT, Ho M, Chau PH. Post-hospital falls incidence and risk factors among older adults: a systematic review and meta-analysis. Age Ageing 2022; 51:6408804. [PMID: 34718373 DOI: 10.1093/ageing/afab209] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/25/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Post-hospital falls constitute a significant health concern for older adults who have been recently discharged from the hospital. OBJECTIVES To systematically summarise existing evidence on the incidence and risk factors for post-hospital falls among older adults. METHODS A systematic review and meta-analysis was conducted. Six electronic databases were searched to identify cohort studies investigating the incidence and risk factors for post-hospital falls in older adults. The incidence and risk factors for post-hospital falls were extracted. The meta-analysis was used to calculate pooled incidences and 95% confidence intervals (CI). The meta-regression and subgroup meta-analysis were conducted to explore sources of heterogeneity in incidence proportions across the eligible studies. A qualitative synthesis was performed for the post-hospital falls risk factors. RESULTS Eighteen studies from eight countries (n = 9,080,568) were included. The pooled incidence proportion of any and recurrent post-hospital falls was 14% (95% CI: 13%-15%) and 10% (95% CI: 5%-14%), respectively. Follow-up period, study quality, study country, setting, percentage of female subjects, percentage of subjects with previous falls and the primary data collection method for falls significantly contributed to the 64.8% of the heterogeneity in incidence proportions. Twenty-six risk factors for post-hospital falls were identified in the eligible studies, where biological factors were the most commonly identified factors. The highest risks were reported for previous falls, previous fractures, delirium and neurological diseases. CONCLUSION The findings of this study suggested future post-hospital falls prevention should prioritise the needs of older adults with the dominant risk factors. Further investigations into the period-specific incidence and socioeconomic and environmental risk factors for post-hospital falls are also required.
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Affiliation(s)
- Xing Xing Qian
- School of Nursing, The University of Hong Kong, Pok Lu Fam, Hong Kong
| | - Zi Chen
- School of Nursing, The University of Hong Kong, Pok Lu Fam, Hong Kong
| | - Daniel Y T Fong
- School of Nursing, The University of Hong Kong, Pok Lu Fam, Hong Kong
| | - Mandy Ho
- School of Nursing, The University of Hong Kong, Pok Lu Fam, Hong Kong
| | - Pui Hing Chau
- School of Nursing, The University of Hong Kong, Pok Lu Fam, Hong Kong
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Hammouda N, Carpenter C, Hung W, Lesser A, Nyamu S, Liu S, Gettel C, Malsch A, Castillo E, Forrester S, Souffront K, Vargas S, Goldberg EM. Moving the needle on fall prevention: A Geriatric Emergency Care Applied Research (GEAR) Network scoping review and consensus statement. Acad Emerg Med 2021; 28:1214-1227. [PMID: 33977589 PMCID: PMC8581064 DOI: 10.1111/acem.14279] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although falls are common, costly, and often preventable, emergency department (ED)-initiated fall screening and prevention efforts are rare. The Geriatric Emergency Medicine Applied Research Falls core (GEAR-Falls) was created to identify existing research gaps and to prioritize future fall research foci. METHODS GEAR's 49 transdisciplinary stakeholders included patients, geriatricians, ED physicians, epidemiologists, health services researchers, and nursing scientists. We derived relevant clinical fall ED questions and summarized the applicable research evidence, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. The highest-priority research foci were identified at the GEAR Consensus Conference. RESULTS We identified two clinical questions for our review (1) fall prevention interventions (32 studies) and (2) risk stratification and falls care plan (19 studies). For (1) 21 of 32 (66%) of interventions were a falls risk screening assessment and 15 of 21 (71%) of these were combined with an exercise program or physical therapy. For (2) 11 fall screening tools were identified, but none were feasible and sufficiently accurate for ED patients. For both questions, the most frequently reported study outcome was recurrent falls, but various process and patient/clinician-centered outcomes were used. Outcome ascertainment relied on self-reported falls in 18 of 32 (56%) studies for (1) and nine of 19 (47%) studies for (2). CONCLUSION Harmonizing definitions, research methods, and outcomes is needed for direct comparison of studies. The need to identify ED-appropriate fall risk assessment tools and role of emergency medical services (EMS) personnel persists. Multifactorial interventions, especially involving exercise, are more efficacious in reducing recurrent falls, but more studies are needed to compare appropriate bundle combinations. GEAR prioritizes five research priorities: (1) EMS role in improving fall-related outcomes, (2) identifying optimal ED fall assessment tools, (3) clarifying patient-prioritized fall interventions and outcomes, (4) standardizing uniform fall ascertainment and measured outcomes, and (5) exploring ideal intervention components.
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Affiliation(s)
- Nada Hammouda
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York City, NY
| | | | - William Hung
- Department of Geriatrics and Palliative Care, Mount Sinai School of Medicine, New York City, NY
| | | | - Sylviah Nyamu
- Department of Emergency Medicine, Mount Sinai Hospital, New York City, NY
| | - Shan Liu
- Department of Emergency Medicine, Harvard School of Medicine, Boston, MA
| | - Cameron Gettel
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | | | - Edward Castillo
- Department of Emergency Medicine, University of California San Diego, San Diego, CA
| | - Savannah Forrester
- Department of Emergency Medicine, Queen’s University, Kingston, Ontario, CA
| | - Kimberly Souffront
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York City, NY
| | - Samuel Vargas
- Department of Emergency Medicine, Mount Sinai Hospital, New York City, NY
| | - Elizabeth M. Goldberg
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI
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Physical therapists in the emergency department, Do they affect disposition decisions of older adults? Am J Emerg Med 2021; 56:372-374. [PMID: 34810075 DOI: 10.1016/j.ajem.2021.10.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/25/2021] [Accepted: 10/27/2021] [Indexed: 11/22/2022] Open
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Clare D, Zink KL. Geriatric Trauma. Emerg Med Clin North Am 2021; 39:257-271. [PMID: 33863458 DOI: 10.1016/j.emc.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Geriatric trauma patients will continue to increase in prevalence as the population ages, and many specific considerations need to be made to provide appropriate care to these patients. This article outlines common presentations of trauma in geriatric patients, with consideration to baseline physiologic function and patterns of injury that may be more prevalent in geriatric populations. Additionally, the article explores specific evidence-based management practices, the significance of trauma team and geriatrician involvement, and disposition decisions.
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Affiliation(s)
- Drew Clare
- Department of Emergency Medicine, University of Florida, 655 W 8th st, Jacksonville, FL 32209, USA.
| | - Korie L Zink
- Johns Hopkins University, 1830 E. Monument St, St 6-100, Baltimore, MD 21224, USA. https://twitter.com/koriezinkmd
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Harper KJ, Arendts G, Barton AD, Celenza A. Providing fall prevention services in the emergency department: Is it effective? A systematic review and meta-analysis. Australas J Ageing 2021; 40:116-128. [PMID: 33605050 DOI: 10.1111/ajag.12914] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/21/2020] [Accepted: 12/15/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess the effects of fall prevention services initiated in the emergency department (ED) to support patients after discharge. METHODS A systematic review and meta-analysis were conducted. Analysis of pooled data used random-effects modelling with results presented as a risk ratio (RR). RESULTS Eleven studies were identified (n = 4,018). The proportion of older adults who fell did not differ between the intervention and control groups (RR 0.93; 95% CI, 0.82-1.06, I2 68%, P = 0.28). There was a significant (P = 0.01) reduction in the monthly rate of falling (RR 0.69; 95% CI, 0.52-0.91, I2 93%), fall-related injuries (RR 0.72; 95% CI, 0.59-0.88, I2 0%, P = 0.001), and hospital admissions (RR 0.76; 95% CI, 0.64-0.90, I2 0%, P = 0.002). CONCLUSIONS ED fall prevention services did not significantly reduce the proportion of older adults who had future falls. However, multifactorial intervention significantly reduced fall-related injuries and hospital admissions with low heterogeneity.
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Affiliation(s)
- Kristie J Harper
- Occupational Therapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Glenn Arendts
- Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Annette D Barton
- Occupational Therapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Antonio Celenza
- Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
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Goldberg EM, Marks SJ, Resnik LJ, Long S, Mellott H, Merchant RC. Can an Emergency Department-Initiated Intervention Prevent Subsequent Falls and Health Care Use in Older Adults? A Randomized Controlled Trial. Ann Emerg Med 2020; 76:739-750. [PMID: 32854965 PMCID: PMC7686139 DOI: 10.1016/j.annemergmed.2020.07.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 12/28/2022]
Abstract
STUDY OBJECTIVE We determine whether an emergency department (ED)-initiated fall-prevention intervention can reduce subsequent fall-related and all-cause ED visits and hospitalizations in older adults. METHODS The Geriatric Acute and Post-acute Fall Prevention intervention was a randomized controlled trial conducted from January 2018 to October 2019. Participants at 2 urban academic EDs were randomly assigned (1:1) to an intervention or usual care arm. Intervention participants received a brief, tailored, structured, pharmacy and physical therapy consultation in the ED, with automated communication of the recommendations to their primary care physicians. RESULTS Of 284 study-eligible participants, 110 noninstitutionalized older adults (≥65 years) with a recent fall consented to participate; median age was 81 years, 67% were women, 94% were white, and 16.3% had cognitive impairment. Compared with usual care participants (n=55), intervention participants (n=55) were half as likely to experience a subsequent ED visit (adjusted incidence rate ratio 0.47 [95% CI 0.29 to 0.74]) and one third as likely to have fall-related ED visits (adjusted incidence rate ratio 0.34 [95% CI 0.15 to 0.76]) within 6 months. Intervention participants experienced half the rate of all hospitalizations (adjusted incidence rate ratio 0.57 [95% CI 0.31 to 1.04]), but confidence intervals were wide. There was no difference in fall-related hospitalizations between groups (adjusted incidence rate ratio 0.99 [95% CI 0.31 to 3.27]). Self-reported adherence to pharmacy and physical therapy recommendations was moderate; 73% of pharmacy recommendations were adhered to and 68% of physical therapy recommendations were followed. CONCLUSION Geriatric Acute and Post-acute Fall Prevention, a postfall, in-ED, multidisciplinary intervention with pharmacists and physical therapists, reduced 6-month ED encounters in 2 urban EDs. The intervention could provide a model of care to other health care systems aiming to reduce costly and burdensome fall-related events in older adults.
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Affiliation(s)
- Elizabeth M Goldberg
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI; Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI.
| | - Sarah J Marks
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, MA
| | - Linda J Resnik
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI; Providence VA Medical Center, Providence, RI
| | - Sokunvichet Long
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Hannah Mellott
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Roland C Merchant
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, MA
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Gurley KL, Blodgett MS, Burke R, Shapiro NI, Edlow JA, Grossman SA. The utility of emergency department physical therapy and case management consultation in reducing hospital admissions. J Am Coll Emerg Physicians Open 2020; 1:880-886. [PMID: 33145536 PMCID: PMC7593441 DOI: 10.1002/emp2.12075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 04/02/2020] [Accepted: 04/03/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND A significant number of patients who present to the emergency department (ED) following a fall or with other injuries require evaluation by a physical therapist. Traditionally, once emergent conditions are excluded in the ED, these patients are admitted to the hospital for evaluation by a physical therapist to determine whether they should be transferred to a sub-acute rehabilitation facility, discharged, require services at home, or require further inpatient care. Case management is typically used in conjunction with a physical therapist to determine eligibility for recommended services and to aid in placement. OBJECTIVE To evaluate the benefit of using ED-based physical therapist and case management services in lieu of routine hospital admission. METHODS Retrospective, observational study of consecutive patients presenting to an urban, tertiary care academic medical center ED between December 1, 2017, and November 30, 2018, who had a physical therapist consult placed in the ED. We additionally evaluated which of these patients were placed into ED observation for physical therapist consultation, how many required case management, and ED disposition: discharged home from the ED or ED observation with or without services, placed in a rehabilitation facility, or admitted to the hospital. RESULTS During the 12-month study period, 1296 patients (2.4% of the total seen in the ED) were assessed by a physical therapist. The mean age was 75.5 ± 15.2 and 832 (64.2%) were female. Case management was involved in 91.8% of these cases. The final patient disposition was as follows: admission 24.3% (95% CI = 22.1-26.7%), home discharge with or without services 47.8% (95% CI = 45.1-50.5%), rehabilitation (rehab) setting 27.9% (95% CI = 25.6%-30.4). The median (interquartile range) time in observation was 13.1 (6.0-20.3), 9.9 (1.8-15.8), and 18.4 (14.1-24.8) hours for patients admitted, discharged home, or sent to rehabilitation (P < 0.001). Among the 979 patients discharged home or sent to rehabilitation, 17 (1.7%) returned to the ED within 72 hours and were ultimately admitted. CONCLUSION Given that the standard of care would otherwise be an admission to the hospital for 1 day or more for all patients requiring physical therapist consultation, an ED-based physical therapy and case management system serves as a viable method to substantially decrease hospital admissions and potentially reduce resource use, length of hospital stay, and cost both to patients and the health care system.
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Affiliation(s)
- Kiersten L. Gurley
- Emergency Medicine, Harvard Medical School, Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusetts
- Mount Auburn HospitalCambridgeMassachusetts
| | - Maxwell S. Blodgett
- Emergency Medicine, Harvard Affiliated Emergency Medicine Residency, Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusetts
| | - Ryan Burke
- Beth Israel Deaconess Medical CenterBostonMassachusetts
| | - Nathan I. Shapiro
- Emergency Medicine, Harvard Medical School, Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusetts
| | - Jonathan A. Edlow
- Emergency Medicine, Harvard Medical School, Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusetts
| | - Shamai A Grossman
- Emergency Medicine, Harvard Medical School, Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusetts
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Collaborative Care Across the Acute and Subacute Continuum Facilitated by Physical Therapy in the Emergency Department. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2020. [DOI: 10.1097/jat.0000000000000121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Goldberg EM, Marks SJ, Ilegbusi A, Resnik L, Strauss DH, Merchant RC. GAPcare: The Geriatric Acute and Post-Acute Fall Prevention Intervention in the Emergency Department: Preliminary Data. J Am Geriatr Soc 2020; 68:198-206. [PMID: 31621901 PMCID: PMC7001768 DOI: 10.1111/jgs.16210] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/25/2019] [Accepted: 09/07/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVES We aimed to describe a new multidisciplinary team fall prevention intervention for older adults who seek care in the emergency department (ED) after having a fall, assess its feasibility and acceptability, and review lessons learned during its initiation. DESIGN Single-blind randomized controlled pilot study. SETTING Two urban academic EDs PARTICIPANTS: Adults 65 years old or older (n = 110) who presented to the ED within 7 days of a fall. INTERVENTION Participants were randomized to a usual care (UC) and an intervention (INT) arm. Participants in the INT arm received a brief medication therapy management session delivered by a pharmacist and a fall risk assessment and plan by a physical therapist (PT). INT participants received referrals to outpatient services (eg, home safety evaluation, outpatient PT). MEASUREMENTS We used participant, caregiver, and clinician surveys, as well as electronic health record review, to assess the feasibility and acceptability of the intervention. RESULTS Of the 110 participants, the median participant age was 81 years old, 67% were female, 94% were white, and 16.3% had cognitive impairment. Of the 55 in the INT arm, all but one participant received the pharmacy consult (98.2%); the PT consult was delivered to 83.6%. Median consult time was 20 minutes for pharmacy and 20 minutes for PT. ED length of stay was not increased in the INT arm: UC 5.25 hours vs INT 5.0 hours (P < .94). After receiving the Geriatric Acute and Post-acute Fall Prevention Intervention (GAPcare), 100% of participants and 97.6% of clinicians recommended the pharmacy consult, and 95% of participants and 95.8% of clinicians recommended the PT consult. CONCLUSION These findings support the feasibility and acceptability of the GAPcare model in the ED. A future larger randomized controlled trial is planned to determine whether GAPcare can reduce recurrent falls and healthcare visits in older adults. J Am Geriatr Soc 68:198-206, 2019.
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Affiliation(s)
- Elizabeth M Goldberg
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Health Services, Practice and Policy, Brown University School of Public Health, Providence, Rhode Island
| | - Sarah J Marks
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - Aderonke Ilegbusi
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Linda Resnik
- Department of Health Services, Practice and Policy, Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
| | - Daniel H Strauss
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Roland C Merchant
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
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Abstract
"Standing-level falls represent the most frequent cause of trauma-related death in older adults and a common emergency department (ED) presentation. However, these patients rarely receive guideline-directed screening and interventions during or following an episode of care. Reducing injurious falls in an aging society begins with prehospital evaluations and continues through definitive risk assessments and interventions that usually occur after ED care. Although ongoing obstacles to ED-initiated, evidence-based older adult fall-reduction strategies include the absence of a compelling emergency medicine evidence basis, innovations under way include validation of pragmatic screening instruments and incorporation of contemporary technology to improve fall detection rates."
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Goldberg EM, Gettel CJ, Hayes K, Shield RR, Guthrie KM. GAPcare: The Geriatric Acute and Post-Acute Fall Prevention Intervention for Emergency Department Patients - A Qualitative Evaluation. ACTA ACUST UNITED AC 2019; 3. [PMID: 32352082 PMCID: PMC7189708 DOI: 10.21926/obm.geriatr.1904078] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: Three million US emergency department (ED) visits occur for falls each year. The mortality of falls is increasing and only one fourth of older adults report their fall to their primary care provider, suggesting that valuable preventative opportunities are missed. A fall prevention intervention initiated in the ED immediately after a fall has the potential to reduce subsequent falls, but ED providers lack the time and resources to complete fall risk assessments on their patients. GAPcare, the Geriatric Acute and Post-Acute Fall Prevention Intervention, was developed to address this need. Methods: GAPcare combines a pharmacist-led medication therapy management intervention with a physical therapist (PT)-administered fall risk assessment and disposition planning. A key objective of this pilot randomized controlled trial (RCT) was to create a patient and caregiver-centric intervention. This manuscript reports on the results of the qualitative companion study in which we conducted in-depth interviews with patients and caregivers to determine their lived experience with the intervention, barriers and perceived impact of the intervention, and to obtain their recommendations for the improvement of GAPcare. We recruited patients and their caregivers from the RCT into 30 minutes interviews in the participants’ home singularly or in dyads (patient and caregiver together). Interviews were audio-recorded, transcribed, and double-coded. We used applied thematic analysis to guide the data analysis. Results: We conducted 20 interviews; patients (n=12), caregivers (n=11). Patients were on average 83 years old, 7/12 were female, and 2/14 had cognitive impairment. 6/11 caregiver interviews were in reference to a patient with dementia. Patients and caregivers reported they embraced the experience of motivational interviewing elements, citing its collaborative and inclusive nature. Caregivers in particular said they felt that PT helped their loved one recognize and overcome functional limitations. Barriers included lack of time, the burden of coordinating multiple service providers once home, and concerns that PT would be ineffective or increase pain. Areas for improvement included better screening for those who would benefit from the individual components (pharmacy vs. PT consultation), improving identification of GAPcare pharmacists and PTs vs. other hospital staff in the ED, and expanding the role of GAPcare personnel to provide culturally competent, comprehensive care to improve adherence and medication education. Conclusions: We found that GAPcare, a new team-based intervention for fall prevention in the ED, was welcomed by patients and their caregivers. Several suggestions to improve the intervention were made that will inform the screening, content, and communication with patients in GAPcare.
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Affiliation(s)
- Elizabeth M Goldberg
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Health Services, Policy and Practice, Brown University School of Public Health, 121 South Main Street, Providence, RI, USA
| | - Cameron J Gettel
- Department of Emergency Medicine, National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT, USA
| | - Kelsey Hayes
- College of Our Lady of the Elms, Chicopee, MA, USA
| | - Renee R Shield
- Department of Health Services, Policy and Practice, Brown University School of Public Health, 121 South Main Street, Providence, RI, USA
| | - Kate M Guthrie
- Centers for Behavioral and Preventive Medicine, Miriam Hospital, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, RI, USA
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