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Carpenter CR, Lee S, Kennedy M, Arendts G, Schnitker L, Eagles D, Mooijaart S, Fowler S, Doering M, LaMantia MA, Han JH, Liu SW. Delirium detection in the emergency department: A diagnostic accuracy meta-analysis of history, physical examination, laboratory tests, and screening instruments. Acad Emerg Med 2024; 31:1014-1036. [PMID: 38757369 DOI: 10.1111/acem.14935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/13/2024] [Accepted: 04/15/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Geriatric emergency department (ED) guidelines emphasize timely identification of delirium. This article updates previous diagnostic accuracy systematic reviews of history, physical examination, laboratory testing, and ED screening instruments for the diagnosis of delirium as well as test-treatment thresholds for ED delirium screening. METHODS We conducted a systematic review to quantify the diagnostic accuracy of approaches to identify delirium. Studies were included if they described adults aged 60 or older evaluated in the ED setting with an index test for delirium compared with an acceptable criterion standard for delirium. Data were extracted and studies were reviewed for risk of bias. When appropriate, we conducted a meta-analysis and estimated delirium screening thresholds. RESULTS Full-text review was performed on 55 studies and 27 were included in the current analysis. No studies were identified exploring the accuracy of findings on history or laboratory analysis. While two studies reported clinicians accurately rule in delirium, clinician gestalt is inadequate to rule out delirium. We report meta-analysis on three studies that quantified the accuracy of the 4 A's Test (4AT) to rule in (pooled positive likelihood ratio [LR+] 7.5, 95% confidence interval [CI] 2.7-20.7) and rule out (pooled negative likelihood ratio [LR-] 0.18, 95% CI 0.09-0.34) delirium. We also conducted meta-analysis of two studies that quantified the accuracy of the Abbreviated Mental Test-4 (AMT-4) and found that the pooled LR+ (4.3, 95% CI 2.4-7.8) was lower than that observed for the 4AT, but the pooled LR- (0.22, 95% CI 0.05-1) was similar. Based on one study the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is the superior instrument to rule in delirium. The calculated test threshold is 2% and the treatment threshold is 11%. CONCLUSIONS The quantitative accuracy of history and physical examination to identify ED delirium is virtually unexplored. The 4AT has the largest quantity of ED-based research. Other screening instruments may more accurately rule in or rule out delirium. If the goal is to rule in delirium then the CAM-ICU or brief CAM or modified CAM for the ED are superior instruments, although the accuracy of these screening tools are based on single-center studies. To rule out delirium, the Delirium Triage Screen is superior based on one single-center study.
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Affiliation(s)
| | - Sangil Lee
- University of Iowa, Iowa City, Iowa, USA
| | - Maura Kennedy
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Glenn Arendts
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Linda Schnitker
- Bolton Clarke Research Institute, Bolton Clarke School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | | | - Simon Mooijaart
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, The Netherlands
| | - Susan Fowler
- University of Connecticut Health Sciences, Farmington, Connecticut, USA
| | - Michelle Doering
- Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | | | - Jin H Han
- Geriatric Research Education and Clinical Center (GRECC), Tennessee Valley Healthcare Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Wang H, Takiue K, Liu X, Koujiya E, Takeya Y, Yamakawa M. Appropriateness of Nursing Home to Emergency Department Transitional Care for Older Adults With Dementia: A Scoping Review. J Gerontol Nurs 2024; 50:37-45. [PMID: 39194321 DOI: 10.3928/00989134-20240809-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
PURPOSE To systematically identify knowledge patterns and gaps in the appropriateness of nursing home (NH) to emergency department (ED) transitional care for older adults with dementia. METHOD A systematic search of multiple information sources was performed from July to August 2023 using predesigned search strategies. RESULTS From 13 articles, 54 identified pieces of specific care evidence were grouped into six major care domains: (1) Resource Support for Assessing Transfer Needs and Patient Status; (2) Resource Support, Shared Decision Making, and Early Advance Care Planning; (3) Standardized Multimodal Information Transfer; (4) Designated ED and NH Transition Coordinators; (5) Enhanced Interfacility Collaboration; and (6) Appropriate Transitional Care Education, Research, and Policy Beyond the Transfer Interface. CONCLUSION A comprehensive, consensus-based body of evidence is lacking. Despite person-centered, standardized, and professional resources supporting transitional care, reorienting NH cultural models remains unclear. Gaps include evidence tailored to diverse participants and contexts. Thus, a focus on policies, education, and research is required. [Journal of Gerontological Nursing, 50(9), 37-45.].
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Karjalainen KJ, Tuori H, Salminen M, Peltonen J, Rantanen S, Viikari P, Viitanen M, Nuotio MS, Viikari L. AEGIS-AcutE Geriatric Intervention Study: pilot study of frontline acute geriatric assessment to improve quality of care in emergency department. Age Ageing 2024; 53:afae171. [PMID: 39113469 PMCID: PMC11306315 DOI: 10.1093/ageing/afae171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 07/31/2024] [Indexed: 08/11/2024] Open
Abstract
INTRODUCTION Due to the increasing number of older patients in emergency departments (EDs) with frailty, cognitive impairment and multimorbidity, there is a need for geriatric expertise in EDs. METHODS This retrospective study is of older patients visiting Turku University Hospital ED between 2 January and 31 December 2022. Patients aged 75 years of older were screened for frailty using Triage Risk Screening Tool (TRST) and Clinical Frailty Scale (CFS). Nonacute, frail patients (CFS ≥4) suitable for Targeted Geriatric Assessment (TGA) (n = 1096) were scanned for the risk of delirium, cognitive impairment, change in functional status, falls, malnutrition and depression. A comprehensive patient record was made with recommendations for future care. RESULTS TRST was completed in 70% of the ED visits, and two-thirds of those were considered high-risk. Among the patients assessed by the geriatric team (TGA), nonspecific complaint (38%) and falls (35%) were the main reasons for ED admission. Cognitive impairment was present in over 60% and orthostatic hypotension in 40% of the patients. The 72-hour revisit rate for TGA-patients was 2.3%. For the real-life control group, the 72-hour revisit rate was 4.6% (P = .001). Thirty-day revisit rates were 10% and 16%, respectively (P < .001). The need for rehabilitation, cognitive evaluation and intensifying home care were the main recommendations for future care. CONCLUSIONS TGA approach provides structured and accurate information on older patients' background. This may lead to more precise diagnostics, a thorough consideration of hospital intake and a secure discharge from the ED. Ensuring continuity of care may help to reduce readmissions to EDs.
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Affiliation(s)
- Kaisa J Karjalainen
- Department of Geriatric Medicine, Faculty of Medicine/Clinical Medicine, University of Turku and Turku University Hospital, The wellbeing services county of Southwest Finland, Turku, Finland
| | - Hannele Tuori
- Department of Geriatric Medicine, Faculty of Medicine/Clinical Medicine, University of Turku and Turku University Hospital, The wellbeing services county of Southwest Finland, Turku, Finland
- Tyks Acute/Turku University Hospital, The wellbeing services county of Southwest Finland, Turku, Finland
| | - Marika Salminen
- Department of Geriatric Medicine, Faculty of Medicine/Clinical Medicine, University of Turku and Turku University Hospital, The wellbeing services county of Southwest Finland, Turku, Finland
- Department of General Practice, Faculty of Medicine/Clinical Medicine, University of Turku and The wellbeing services county of SouthwestFinland
| | - Juha Peltonen
- Tyks Acute/Turku University Hospital, The wellbeing services county of Southwest Finland, Turku, Finland
| | - Sirpa Rantanen
- Tyks Acute/Turku University Hospital, The wellbeing services county of Southwest Finland, Turku, Finland
| | - Paula Viikari
- Department of Geriatric Medicine, Faculty of Medicine/Clinical Medicine, University of Turku and Turku University Hospital, The wellbeing services county of Southwest Finland, Turku, Finland
| | - Matti Viitanen
- Department of Geriatric Medicine, Faculty of Medicine/Clinical Medicine, University of Turku and Turku University Hospital, The wellbeing services county of Southwest Finland, Turku, Finland
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Maria S Nuotio
- Department of Geriatric Medicine, Faculty of Medicine/Clinical Medicine, University of Turku and Turku University Hospital, The wellbeing services county of Southwest Finland, Turku, Finland
| | - Laura Viikari
- Department of Geriatric Medicine, Faculty of Medicine/Clinical Medicine, University of Turku and Turku University Hospital, The wellbeing services county of Southwest Finland, Turku, Finland
- Tyks Acute/Turku University Hospital, The wellbeing services county of Southwest Finland, Turku, Finland
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Pîslaru AI, Albișteanu SM, Ilie AC, Ștefaniu R, Mârza A, Moscaliuc Ș, Nicoară M, Turcu AM, Grigoraș G, Alexa ID. Lung Cancer: New Directions in Senior Patients Assessment. Geriatrics (Basel) 2024; 9:101. [PMID: 39195131 DOI: 10.3390/geriatrics9040101] [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: 06/04/2024] [Revised: 07/10/2024] [Accepted: 07/30/2024] [Indexed: 08/29/2024] Open
Abstract
Age is but one significant prognostic factor in lung cancer, influencing survival, treatment response, and outcomes. This narrative review synthesizes findings from searches of 11 leading databases of research studies, systematic reviews, book chapters, and clinical trial reports on lung cancer in senior patients, with a focus on geriatric assessment as well as biomarkers. Key prognostic factors for lung cancer in seniors include biological age, functional capability, physical and psychological comorbidities, frailty, nutrition, status, and biomarkers like DNA methylation age. We identified the most valuable assessments that balance efficacy with quality of life. Optimizing care and improving outcomes with senior lung cancer patients benefits from a tailored therapeutic approach incorporating a complex geriatric assessment. A multidisciplinary collaboration between geriatricians, oncologists, and pulmonologists is crucial.
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Affiliation(s)
- Anca Iuliana Pîslaru
- Department of Medical Specialties II, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Sabinne-Marie Albișteanu
- Department of Medical Specialties II, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Adina Carmen Ilie
- Department of Medical Specialties II, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Ramona Ștefaniu
- Department of Medical Specialties II, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Aurelia Mârza
- Department of Medical Specialties II, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Ștefan Moscaliuc
- Department of Oncology, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mălina Nicoară
- Department of Oncology, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Ana-Maria Turcu
- Department of Medical Specialties II, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Gabriela Grigoraș
- Department of Medical Specialties II, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Ioana Dana Alexa
- Department of Medical Specialties II, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
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Moloney E, O’Donovan MR, Carpenter CR, Salvi F, Dent E, Mooijaart S, Hoogendijk EO, Woo J, Morley J, Hubbard RE, Cesari M, Ahern E, Romero-Ortuno R, Mcnamara R, O’Keefe A, Healy A, Heeren P, Mcloughlin D, Deasy C, Martin L, Brousseau AA, Sezgin D, Bernard P, Mcloughlin K, Sri-On J, Melady D, Edge L, O’Shaughnessy I, Van Damme J, Cardona M, Kirby J, Southerland L, Costa A, Sinclair D, Maxwell C, Doyle M, Lewis E, Corcoran G, Eagles D, Dockery F, Conroy S, Timmons S, O’Caoimh R. Core requirements of frailty screening in the emergency department: an international Delphi consensus study. Age Ageing 2024; 53:afae013. [PMID: 38369629 PMCID: PMC10874925 DOI: 10.1093/ageing/afae013] [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: 01/17/2023] [Revised: 10/24/2023] [Indexed: 02/20/2024] Open
Abstract
INTRODUCTION Frailty is associated with adverse outcomes among patients attending emergency departments (EDs). While multiple frailty screens are available, little is known about which variables are important to incorporate and how best to facilitate accurate, yet prompt ED screening. To understand the core requirements of frailty screening in ED, we conducted an international, modified, electronic two-round Delphi consensus study. METHODS A two-round electronic Delphi involving 37 participants from 10 countries was undertaken. Statements were generated from a prior systematic review examining frailty screening instruments in ED (logistic, psychometric and clinimetric properties). Reflexive thematic analysis generated a list of 56 statements for Round 1 (August-September 2021). Four main themes identified were: (i) principles of frailty screening, (ii) practicalities and logistics, (iii) frailty domains and (iv) frailty risk factors. RESULTS In Round 1, 13/56 statements (23%) were accepted. Following feedback, 22 new statements were created and 35 were re-circulated in Round 2 (October 2021). Of these, 19 (54%) were finally accepted. It was agreed that ideal frailty screens should be short (<5 min), multidimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2-4 weeks before presentation. Screening should ideally be routine, prompt (<4 h after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use and social factors were identified as the most important variables to include. CONCLUSIONS Although a clear consensus was reached on important requirements of frailty screening in ED, and variables to include in an ideal screen, more research is required to operationalise screening in clinical practice.
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Affiliation(s)
- Elizabeth Moloney
- HRB Clinical Research Facility, Mercy University Hospital, University College Cork, Cork City, T12 WE28, Ireland
| | - Mark R O’Donovan
- HRB Clinical Research Facility, Mercy University Hospital, University College Cork, Cork City, T12 WE28, Ireland
| | - Christopher R Carpenter
- Department of Emergency Medicine and Emergency Care Research Core, Washington University in St. Louis School of Medicine, St. Louis, MO 63110-1010, USA
| | - Fabio Salvi
- Department of Geriatrics and Emergency Care, INRCA-IRCCS, Ancona 5-60124, Italy
| | - Elsa Dent
- The Centre for Public Health, Equity and Human Flourishing (PHEHF), Torrens University Australia, Adelaide, South Australia 5000, Australia
| | - Simon Mooijaart
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Centre, Leiden 2300, Netherlands
| | - Emiel O Hoogendijk
- Department of Epidemiology and Data Science, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Centre, Amsterdam 1081, Netherlands
| | - Jean Woo
- Department of Medicine, Chinese University of Hong Kong, Hong Kong, Special Administrative Region, China
| | - John Morley
- Divisions of Geriatric Medicine and Endocrinology, Saint Louis University School of Medicine, St. Louis, MO 63104, USA
| | - Ruth E Hubbard
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland 4072, Australia
| | - Matteo Cesari
- IRCCS Istituti Clinici Scientifici Maugeri, University of Milan, Milan 20122, Italy
| | - Emer Ahern
- Department of Geriatric Medicine, Cork University Hospital, Cork, T12 DC4A, Ireland
| | - Roman Romero-Ortuno
- Discipline of Medical Gerontology, School of Medicine, Mercer’s Institute for Successful Ageing, St. James’s Hospital, Dublin, D08 NHY1, Ireland
- Mercers Institute for Successful Ageing, St James's Hospital, Dublin 8, D08 E9P6, Ireland
| | - Rosa Mcnamara
- Emergency Department, St Vincent's University Hospital, Dublin 4, D04 T6F4, Ireland
| | - Anne O’Keefe
- Emergency Department, Mercy University Hospital, Cork, T12WE28, Ireland
| | - Ann Healy
- Emergency Department, Mercy University Hospital, Cork, T12WE28, Ireland
| | - Pieter Heeren
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven 3000, Belgium
| | - Darren Mcloughlin
- Emergency Department, Mercy University Hospital, Cork, T12WE28, Ireland
| | - Conor Deasy
- Emergency Department, Cork University Hospital, Wilton, Cork, T12 DC4A, Ireland
| | - Louise Martin
- Emergency Department, Cork University Hospital, Wilton, Cork, T12 DC4A, Ireland
| | - Audrey Anne Brousseau
- Département de médecine familiale et de médecine d'urgence, Université de Sherbrooke, Sherbrooke, Quebec, J1K 2R1, Canada
| | - Duygu Sezgin
- School of Nursing and Midwifery, University of Galway, Galway City, H91 TK33, Ireland
| | - Paul Bernard
- Beaumont Hospital, Occupational Therapy, Dublin, D09V2N0, Ireland
| | - Kara Mcloughlin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, V94 T9PX, Ireland
| | - Jiraporn Sri-On
- Geriatric Emergency Medicine Unit, Department of Emergency Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok 10300, Thailand
| | - Don Melady
- Department of Family and Community Medicine, Schwarz/Reisman Emergency Medicine Institute, Mount Sinai Health System, University of Toronto, Toronto, Ontario, ON M5G 1E2, Canada
| | - Lucinda Edge
- Department of Physiotherapy, St James’s Hospital, Dublin 8, Dublin, Ireland
| | - Ide O’Shaughnessy
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, V94 T9PX, Ireland
| | - Jill Van Damme
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario N2L 3G1, Canada
| | - Magnolia Cardona
- Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane 4067, Australia
| | - Jennifer Kirby
- Urgent Care Team, University Hospital North Midlands NHS Trust, Stoke-on-Trent, ST4 6QG, UK
| | - Lauren Southerland
- Department of Emergency Medicine, The Ohio State University, Wexner Medical Centre, Columbus, Ohio 43210, USA
| | - Andrew Costa
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, L8S 4L8, Canada
| | - Douglas Sinclair
- Department of Medicine, Quality, and Safety, IWK Health Centre, Halifax, Nova Scotia, B3K 6R8, Canada
| | - Cathy Maxwell
- Vanderbilt University School of Nursing, Nashville, Tennessee 37240, USA
| | - Marie Doyle
- Emergency Department, University Hospital Waterford, Waterford, X91 ER8E, Ireland
| | - Ebony Lewis
- UNSW School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, NSW 2052, Australia
| | - Grace Corcoran
- Department of Physiotherapy, Beaumont Hospital, Dublin, D09V2N0, Ireland
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, K1H 8M5, Canada
| | - Frances Dockery
- Department of Geriatric Medicine, Beaumont Hospital, Dublin, D09V2N0, Ireland
| | - Simon Conroy
- MRC Unit for Lifelong Health and Ageing at UCL, University College London, London, WC1E 6BT, UK
| | - Suzanne Timmons
- HRB Clinical Research Facility, Mercy University Hospital, University College Cork, Cork City, T12 WE28, Ireland
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, T12 YN60, Ireland
| | - Rónán O’Caoimh
- HRB Clinical Research Facility, Mercy University Hospital, University College Cork, Cork City, T12 WE28, Ireland
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, T12 YN60, Ireland
- Department of Geriatric Medicine, Mercy University Hospital, Cork, Ireland
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Haimovich AD, Shah MN, Southerland LT, Hwang U, Patterson BW. Automating risk stratification for geriatric syndromes in the emergency department. J Am Geriatr Soc 2024; 72:258-267. [PMID: 37811698 PMCID: PMC10866303 DOI: 10.1111/jgs.18594] [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: 03/09/2023] [Revised: 08/11/2023] [Accepted: 08/19/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Geriatric emergency department (GED) guidelines endorse screening older patients for geriatric syndromes in the ED, but there have been significant barriers to widespread implementation. The majority of screening programs require engagement of a clinician, nurse, or social worker, adding to already significant workloads at a time of record-breaking ED patient volumes, staff shortages, and hospital boarding crises. Automated, electronic health record (EHR)-embedded risk stratification approaches may be an alternate solution for extending the reach of the GED mission by directing human actions to a smaller subset of higher risk patients. METHODS We define the concept of automated risk stratification and screening using existing EHR data. We discuss progress made in three potential use cases in the ED: falls, cognitive impairment, and end-of-life and palliative care, emphasizing the importance of linking automated screening with systems of healthcare delivery. RESULTS Research progress and operational deployment vary by use case, ranging from deployed solutions in falls screening to algorithmic validation in cognitive impairment and end-of-life care. CONCLUSIONS Automated risk stratification offers a potential solution to one of the most pressing problems in geriatric emergency care: identifying high-risk populations of older adults most appropriate for specific GED care. Future work is needed to realize the promise of improved care with less provider burden by creating tools suitable for widespread deployment as well as best practices for their implementation and governance.
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Affiliation(s)
- Adrian D Haimovich
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ula Hwang
- Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New York, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Brian W Patterson
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Industrial and Systems Engineering, Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Heeren P, Islam F, Desruelles D, Flamaing J, Sabbe M, Milisen K. A consensus statement on minimum operational standards for geriatric emergency care in Belgium: a modified Delphi study. BMC Geriatr 2023; 23:768. [PMID: 37993796 PMCID: PMC10666396 DOI: 10.1186/s12877-023-04474-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/09/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND As emergency department (ED) leaders started integrating geriatric emergency guidelines on a facultative basis, important variations have emerged between EDs in care for older patients. The aim of this study was to establish a consensus on minimum operational standards for Geriatric ED care in Belgium. METHODS A two-stage modified Delphi study was conducted. Twenty panellists were recruited from Dutch and French speaking regions in Belgium to join an interdisciplinary expert panel. In the first stage, an online survey was conducted to identify and define all possible elements of geriatric emergency care. In the second stage, an online survey and online expert panel meeting were organized consecutively to determine which elements should be recognized as minimum operational standards. RESULTS Between March 2020 and February 2021, the expert panel developed a broad consensus including ten statements focusing on the target population, specific goals, availability of geriatric practitioners and quality assurance. Additionally, the expert panel also determined which protocols, materials and accommodation criteria should be available in conventional EDs (39 standards) and in observational EDs (57 standards). CONCLUSIONS This study presents a consensus on minimum operational standards for geriatric emergency care in two ED types: the conventional ED and the observational ED. These findings may serve as a starting point towards broadly supported minimum standards of care stipulated by legislation in Belgium or other countries.
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Affiliation(s)
- Pieter Heeren
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, Leuven, 3000, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Research Foundation Flanders, Egmontstraat 5, 1000, Brussels, Belgium
| | - Farah Islam
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, Leuven, 3000, Belgium
- Department of Public Health, Institute of Nursing Science, University of Basel, Bernoullistrasse 38, 4056, Basel, Switzerland
| | - Didier Desruelles
- Department of Emergency Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, Emergency Medicine, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium
| | - Johan Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Marc Sabbe
- Department of Emergency Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, Emergency Medicine, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, Leuven, 3000, Belgium.
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Gagliano M, Bula CJ, Seematter-Bagnoud L, Michalski-Monnerat C, Nguyen S, Carron PN, Mabire C. Older patients referred for geriatric consultation in the emergency department: characteristics and healthcare utilization. BMC Geriatr 2023; 23:642. [PMID: 37817072 PMCID: PMC10565963 DOI: 10.1186/s12877-023-04321-2] [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: 01/10/2023] [Accepted: 09/15/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Comprehensive geriatric assessment (CGA) is difficult to perform in the emergency department (ED) environment and performance of screening tools in identifying vulnerable older ED patients who are best candidates for a geriatric consultation remain questionable. AIM To determine the characteristics of older patients referred for a geriatric consultation by ED staff and to investigate these patients' subsequent healthcare utilization. METHODS Secondary analysis of data previously collected for a prospective observational study of patients aged 75 + years visiting the ED of an academic hospital in Switzerland over four months (Michalski-Monnerat et al., J Am Geriatr Soc 68(12):2914-20, 2020). Socio-demographic, health, functional (basic activities of daily living; BADL), cognitive, and affective status data were collected at admission by a research nurse using a standardized brief geriatric assessment. Information on geriatric consultations, hospitalization, discharge destination, and 30-day readmission were retrieved from hospital database. Bivariable and multivariable analyses were performed using this data set collected previously. RESULTS Thirty-two (15.8%) of the 202 enrolled patients were referred for a geriatric consultation. Compared to the others, they were older (84.9 ± 5.4 vs 82.9 ± 5.4 years, p = .03), more impaired in BADL (4.8 ± 1.6 vs 5.5 ± 1.0, p = .01), with more comorbid conditions (5.3 ± 1.5 vs 4.5 ± 1.9, p = .03), more frequently admitted after a fall (43.7% vs 19.4%, p = .01), and hospitalized over the previous 6-month period (53.1% vs 30.6%, p = .02). Multivariable analyses that adjusted for variables significantly associated with outcomes in bivariable analysis found that being admitted after a fall (AdjOR 4.0, 95%CI 1.7-9.4, p < .01) and previously hospitalized (AdjOR 2.7, 95% CI 1.2-6.2, p = .02) remained associated with increased odds of consultation, whereas the inverse association with BADL performance remained (AdjOR 0.7, 95%CI 0.5-0.9, p = .01). Patients referred for geriatric consultation had higher odds of hospitalization (84.4% vs 49.4%; AdjOR 5.9, 95%CI 2.1-16.8, p < .01), but similar odds of home discharge when admitted, and of 30-day readmission. CONCLUSION About one in six older ED patients were referred for a geriatric consultation who appeared to be those most vulnerable, as suggested by their increased hospitalization rate. Alternative strategies are needed to enhance access to geriatric consultation in the ED.
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Affiliation(s)
- Mariangela Gagliano
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne, Chemin de Mont Paisible 16, Lausanne, CH-1011, Switzerland.
- Department of Geriatrics, Rehabilitation and Palliative Care, Neuchâtel Hospital Network, Rue du Chasseral 20, La Chaux-de-Fonds, CH-2300, Switzerland.
| | - Christophe J Bula
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne, Chemin de Mont Paisible 16, Lausanne, CH-1011, Switzerland
| | - Laurence Seematter-Bagnoud
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne, Chemin de Mont Paisible 16, Lausanne, CH-1011, Switzerland
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Route de la Corniche 10, Lausanne, CH-1010, Switzerland
| | - Carole Michalski-Monnerat
- Department of Internal Medicine, Neuchâtel Hospital Network, Rue de la Maladière 45, Neuchâtel, CH-2000, Switzerland
- Institute of Higher Education and Research in Healthcare-IUFRS, Lausanne University Hospital and University of Lausanne, Route de la Corniche 10, Lausanne, CH-1010, Switzerland
| | - Sylvain Nguyen
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne, Chemin de Mont Paisible 16, Lausanne, CH-1011, Switzerland
| | - Pierre-Nicolas Carron
- Emergency Department, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, Lausanne, CH-1011, Switzerland
| | - Cédric Mabire
- Institute of Higher Education and Research in Healthcare-IUFRS, Lausanne University Hospital and University of Lausanne, Route de la Corniche 10, Lausanne, CH-1010, Switzerland
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9
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Mowbray FI, Ellis B, Schumacher C, Heckman G, de Wit K, Strum RP, Jones A, Correia RH, Mercier E, Costa AP. The Association Between Frailty and a Nurse-Identified Need for Comprehensive Geriatric Assessment Referral from the Emergency Department. Can J Nurs Res 2023; 55:404-412. [PMID: 36632010 PMCID: PMC10416548 DOI: 10.1177/08445621221144667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Emergency nurses commonly conduct geriatric assessments in the emergency department (ED). However, little is known about what geriatric syndromes or clinical presentations prompt a nurse to document an identified need for comprehensive geriatric assessment (CGA). OBJECTIVES To examine the association between geriatric syndromes, like frailty, and a nurse-identified need for a CGA following emergency care. METHODS We conducted a secondary analysis of a multi-province Canadian cohort from the InterRAI Multinational Cohort Study. We collected data at ED registration from patients 75 years of age and older (n = 2,274) from eight ED sites across Canada between November 2009 and April 2012. Geriatric syndromes were assessed by trained emergency nurses using the interRAI ED Contact Assessment; and we retrospectively calculated the ED frailty index. We employed binary logistic regression to determine the adjusted associations between geriatric syndromes and a nurse-identified need for a CGA. RESULTS Approximately one-quarter (28%) of older adults were identified to need a CGA following emergency care. A 0.1 unit increase in the ED frailty index increased the likelihood of a nurse identify a need for CGA (RD: 6.6; 95% CI = 5.5-7.9). Most geriatric syndromes increased the probability of a nurse documenting the need for a CGA. CONCLUSION When assessed by emergency nurses, the identified need for CGA is strongly linked to the presence of geriatric syndromes, including frailty. We provide face validity for the continued use of emergency nurses for screening and assessing older ED patients.
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Affiliation(s)
- Fabrice I. Mowbray
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Brittany Ellis
- Department of Emergency Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Connie Schumacher
- School of Nursing, Faculty of Applied Health Sciences, Brock University, St. Catherine's, Ontario, Canada
| | - George Heckman
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Kerstin de Wit
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Ryan P. Strum
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Aaron Jones
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca H. Correia
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Eric Mercier
- Centre de recherche du CHU de Québec, Université Laval, Québec City, Québec, Canada
- Centre de recherche sur les soins et les services de première ligne, Université Laval, Québec City, Québec, Canada
| | - Andrew P. Costa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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10
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Miró Ò, Gil-Rodrigo A, García-Martínez A, Aguiló S, Alemany X, Nickel CH, Jacob J, Llorens P, Herrero P, Torres-Machado V, Cenjor R, Coll-Vinent B, Martínez-Nadal G, Del Nogal ML, Peacock F, Martín-Sánchez FJ. Sex differences in mortality of older adults with falls after emergency department consultation: FALL-ER registry. J Am Geriatr Soc 2023; 71:2715-2725. [PMID: 37224385 DOI: 10.1111/jgs.18401] [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: 08/24/2022] [Revised: 04/07/2023] [Accepted: 04/19/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND To investigate if sex is a risk factor for mortality in patients consulting at the emergency department (ED) for an unintentional fall. METHODS This was a secondary analysis of the FALL-ER registry, a cohort of patients ≥65 years with an unintentional fall presenting to one of 5 Spanish EDs during 52 predefined days (one per week during one year). We collected 18 independent patient baseline and fall-related variables. Patients were followed for 6 months and all-cause mortality recorded. The association between biological sex and mortality was expressed as unadjusted and adjusted hazard ratios (HR) with the 95% confidence interval (95% CI), and subgroup analyses were performed by assessing the interaction of sex with all baseline and fall-related mortality risk variables. RESULTS Of 1315 enrolled patients (median age 81 years), 411 were men (31%) and 904 women (69%). The 6-month mortality was higher in men (12.4% vs. 5.2%, HR = 2.48, 95% CI = 1.65-3.71), although age was similar between sexes. Men had more comorbidity, previous hospitalizations, loss of consciousness, and an intrinsic cause for falling. Women more frequently lived alone, with self-reported depression, and the fall results in a fracture and immobilization. Nonetheless, after adjustment for age and these eight divergent variables, older men aged 65 and over still showed a significantly higher mortality (HR = 2.19, 95% CI = 1.39-3.45), with the highest risk observed during the first month after ED presentation (HR = 4.18, 95% CI = 1.31-13.3). We found no interaction between sex and any patient-related or fall-related variables with respect to mortality (p > 0.05 in all comparisons). CONCLUSIONS Male sex is a risk factor for death following ED presentation for a fall in the older population adults aged 65 and over. The causes for this risk should be investigated in future studies.
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Affiliation(s)
- Òscar Miró
- Emergency Department, Hospital Clínic, Barcelona, Catalonia, Spain
- University of Barcelona, Catalonia, Spain
| | - Adriana Gil-Rodrigo
- Emergency Department, Short Stay Unit and Hospitalization at Home, Dr. Balmis General University Hospital, Alicante, Spain
- Institute for Health and Biomedical Research, Alicante, Spain
| | | | - Sira Aguiló
- Emergency Department, Hospital Clínic, Barcelona, Catalonia, Spain
| | - Xavier Alemany
- Emergency Department, Hospital Clínic, Barcelona, Catalonia, Spain
| | | | - Javier Jacob
- Emergency Department, Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Pere Llorens
- Emergency Department, Short Stay Unit and Hospitalization at Home, Dr. Balmis General University Hospital, Alicante, Spain
- Institute for Health and Biomedical Research, Alicante, Spain
- Miguel Hernández University, Elche, Alicante, Spain
| | - Pablo Herrero
- Emergency Department, Hospital Central de Asturias, Oviedo, Spain
| | - Victoria Torres-Machado
- Emergency Department, Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Raquel Cenjor
- Emergency Department, Hospital Central de Asturias, Oviedo, Spain
| | | | | | | | - Frank Peacock
- Henry JN Taub Emergency Department, Baylor College of Medicine, Houston, Texas, USA
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11
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Moloney E, O’Donovan MR, Sezgin D, Flanagan E, McGrath K, Timmons S, O’Caoimh R. Diagnostic Accuracy of Frailty Screening Instruments Validated for Use among Older Adults Attending Emergency Departments: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6280. [PMID: 37444127 PMCID: PMC10341387 DOI: 10.3390/ijerph20136280] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/25/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023]
Abstract
Early identification of frailty can prevent functional decline. Although multiple frailty screens exist for use in Emergency Departments (EDs), few are validated against diagnostic standards such as comprehensive geriatric assessment. To examine the diagnostic accuracy of ED screens for frailty, scientific databases were searched for prospective diagnostic accuracy test studies from January 2000 to September 2022. Studies were assessed for risk of bias using QUADAS-C. Psychometric properties were extracted and analysed using R. Six studies involving 1,663 participants describing seven frailty screening instruments (PRISMA-7, CFS, VIP, FRESH, BPQ, TRST, and ISAR), representing 13 unique data points, were included. The mean age of participants ranged from 76 to 86 years. The proportion that was female ranged from 45 to 60%. The pooled prevalence rate of frailty was high at 59%. The pooled estimate for sensitivity was 0.85 (95% CI: 0.76-0.91) versus 0.77 (95% CI: 0.62-0.88) for specificity. Pooled accuracy based on area under the ROC curve was 0.89 (95% CI: 0.86-0.90). Although few studies were found, limiting the ability to conduct a meta-analysis of individual instruments, available frailty screens can accurately diagnose frailty in older adults attending the ED. As specificity was comparatively low, additional assessment may be required to identify those requiring inpatient management or onward community referral. Further study is therefore required.
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Affiliation(s)
- Elizabeth Moloney
- HRB Clinical Research Facility, Mercy University Hospital, University College Cork, Grenville Place, T12 WE28 Cork, Ireland; (E.M.); (M.R.O.); (E.F.)
- Department of Geriatric Medicine, Mercy University Hospital, Grenville Place, T12 WE28 Cork, Ireland; (K.M.); (S.T.)
| | - Mark R. O’Donovan
- HRB Clinical Research Facility, Mercy University Hospital, University College Cork, Grenville Place, T12 WE28 Cork, Ireland; (E.M.); (M.R.O.); (E.F.)
| | - Duygu Sezgin
- School of Nursing and Midwifery, University of Galway, H91 TK33 Galway, Ireland;
| | - Evelyn Flanagan
- HRB Clinical Research Facility, Mercy University Hospital, University College Cork, Grenville Place, T12 WE28 Cork, Ireland; (E.M.); (M.R.O.); (E.F.)
| | - Keith McGrath
- Department of Geriatric Medicine, Mercy University Hospital, Grenville Place, T12 WE28 Cork, Ireland; (K.M.); (S.T.)
| | - Suzanne Timmons
- Department of Geriatric Medicine, Mercy University Hospital, Grenville Place, T12 WE28 Cork, Ireland; (K.M.); (S.T.)
- Centre for Gerontology and Rehabilitation, University College Cork, St Finbarr’s Hospital, Douglas Road, T12 XH60 Cork, Ireland
| | - Rónán O’Caoimh
- HRB Clinical Research Facility, Mercy University Hospital, University College Cork, Grenville Place, T12 WE28 Cork, Ireland; (E.M.); (M.R.O.); (E.F.)
- Department of Geriatric Medicine, Mercy University Hospital, Grenville Place, T12 WE28 Cork, Ireland; (K.M.); (S.T.)
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12
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Zaalberg T, Barten DG, van Heugten CM, Klijnsma P, Knarren L, Hiemstra Y, Kurvers RAJ, Lekx AW, Mooijaart SP, Janssen-Heijnen M. Prevalence and risk factors of burden among caregivers of older emergency department patients. Sci Rep 2023; 13:7250. [PMID: 37142628 PMCID: PMC10160020 DOI: 10.1038/s41598-023-31750-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 03/16/2023] [Indexed: 05/06/2023] Open
Abstract
The number of older individuals that live independently at home is rising. These older individuals often rely on caregivers who have a similar age and health status. Therefore, caregivers may experience a high burden. We determined the prevalence and associating factors of burden among caregivers of older patients in the emergency department (ED). A cross-sectional study of primary caregivers of patients aged ≥ 70 years visiting the ED of a Dutch teaching hospital was performed. Structured interviews were conducted with patients and their caregivers. Caregiver burden was measured using the caregiver strain index (CSI). Additionally, data from questionnaires and medical records were extracted to determine potential associating factors. Univariate and multivariate regression analyses were conducted to identify independent determinants for burden. Seventy-eight caregivers (39%) experienced a high burden. Multivariate analysis showed a significant association between high caregiver burden and patients with cognitive impairment or dependency for instrumental activities of daily living (IADL) and more self-reported hours of care per day. Almost 40% of older patients in the ED have a caregiver who experiences a high burden. Formal assessment in the ED may help provide adequate care to the patients and their caregivers.
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Affiliation(s)
- Tessel Zaalberg
- Department of Emergency Medicine, VieCuri Medical Center, P.O. Box 1926, 5900 BX, Venlo, The Netherlands.
| | - Dennis G Barten
- Department of Emergency Medicine, VieCuri Medical Center, P.O. Box 1926, 5900 BX, Venlo, The Netherlands
| | - Caroline M van Heugten
- Department of Neuropsychology and Psychopharmacology, Maastricht University, Maastricht, The Netherlands
- Limburg Brain Injury Center, Maastricht, the Netherlands
- School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Petra Klijnsma
- Department of Geriatric Medicine, VieCuri Medical Center, Venlo, The Netherlands
| | - Lieve Knarren
- Department of Internal Medicine, VieCuri Medical Center, Venlo, The Netherlands
| | - Ytje Hiemstra
- Caregiver Representative, MantelzorgNL, Zeist, The Netherlands
| | - Roel A J Kurvers
- Department of Pediatrics, Maastricht University Medical Center, Maastricht, The Netherlands
- Sleep Medicine Center Kempenhaeghe, Heeze, The Netherlands
| | - Anita W Lekx
- Department of Emergency Medicine, VieCuri Medical Center, P.O. Box 1926, 5900 BX, Venlo, The Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Maryska Janssen-Heijnen
- Department of Clinical Epidemiology, VieCuri Medical Center, Venlo, The Netherlands
- Department of Epidemiology, Faculty of Health, Medicine and Life Sciences, GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
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13
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Ekermo D, Ronnås M, Muntlin Å. Fundamental nursing actions for frail older people in the emergency department: A national cross-sectional survey and a qualitative analysis of practice guidelines. J Adv Nurs 2023. [PMID: 36861791 DOI: 10.1111/jan.15627] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 02/09/2023] [Accepted: 02/19/2023] [Indexed: 03/03/2023]
Abstract
AIMS To map how frailty among older people is assessed at Swedish emergency departments and to describe fundamental nursing care actions for these patients. DESIGN Descriptive national survey and a qualitative analysis of text. METHODS A majority (82%, n = 54) of the Swedish hospital-based emergency departments for adults were included, representing all six healthcare regions. An online survey was used to collect data, together with submitted local practice guidelines for older people at the emergency departments. Data were collected during February-October 2021. Descriptive and comparative statistics were performed together with a deductive content analysis framed by the Fundamentals of Care framework. RESULTS Sixty-five per cent (35 of 54) of the emergency departments identified frailty, with less than half of them using an established assessment instrument. Twenty-eight (52%) of the emergency departments have practice guidelines containing fundamental nursing actions for the care of frail older people. The majority of nursing actions in the practice guidelines were related to patients' physical care needs (91%), followed by psychosocial care needs (9%). No actions could be identified as relational actions (0%) according to the Fundamentals of Care framework. CONCLUSION Many Swedish emergency departments identify frail older people, but they use a range of different assessment instruments. While practice guidelines directing fundamental nursing actions for frail older people are often in place, a holistic, person-centred view addressing the patient's physical, psychosocial and relational care needs is missing. IMPACT The population is growing older, and more people are needing more complex hospital care. Frail older people have an increased risk of negative outcomes. The use of a variety of assessment instruments for frailty may pose a challenge to equal care. To ensure a holistic, person-centred view of frail older people, the Fundamentals of Care framework can be used in developing and reviewing practice guidelines. PATIENT OR PUBLIC CONTRIBUTION Clinicians and non-health professionals were invited to review the survey to ensure face and content validity.
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Affiliation(s)
- David Ekermo
- Department of Emergency Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Matilda Ronnås
- Department of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Åsa Muntlin
- Department of Medical Sciences/Clinical Epidemiology, Uppsala University, Uppsala, Sweden.,Department of Emergency Care and Internal Medicine, Uppsala University Hospital, Uppsala, Sweden.,College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
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14
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Mowbray FI, Heckman G, Hirdes JP, Costa AP, Beauchet O, Archambault P, Eagles D, Wang HT, Perry JJ, Sinha SK, Jantzi M, Hebert P. Agreement and prognostic accuracy of three ED vulnerability screeners: findings from a prospective multi-site cohort study. CAN J EMERG MED 2023; 25:209-217. [PMID: 36857018 PMCID: PMC10014815 DOI: 10.1007/s43678-023-00458-6] [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: 06/15/2022] [Accepted: 01/13/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVES To evaluate the agreement between three emergency department (ED) vulnerability screeners, including the InterRAI ED Screener, ER2, and PRISMA-7. Our secondary objective was to evaluate the discriminative accuracy of screeners in predicting discharge home and extended ED lengths-of-stay (> 24 h). METHODS We conducted a nested sub-group study using data from a prospective multi-site cohort study evaluating frailty in older ED patients presenting to four Quebec hospitals. Research nurses assessed patients consecutively with the three screeners. We employed Cohen's Kappa to determine agreement, with high-risk cut-offs of three and four for the PRISMA-7, six for the ER2, and five for the interRAI ED Screener. We used logistic regression to evaluate the discriminative accuracy of instruments, testing them in their dichotomous, full, and adjusted forms (adjusting for age, sex, and hospital academic status). RESULTS We evaluated 1855 older ED patients across the four hospital sites. The mean age of our sample was 84 years. Agreement between the interRAI ED Screener and the ER2 was fair (K = 0.37; 95% CI 0.33-0.40); agreement between the PRISMA-7 and ER2 was also fair (K = 0.39; 95% CI = 0.36-0.43). Agreement between interRAI ED Screener and PRISMA-7 was poor (K = 0.19; 95% CI 0.16-0.22). Using a cut-off of four for PRISMA-7 improved agreement with the ER2 (K = 0.55; 95% CI 0.51-0.59) and the ED Screener (K = 0.32; 95% CI 0.2-0.36). When predicting discharge home, the concordance statistics among models were similar in their dichotomous (c = 0.57-0.61), full (c = 0.61-0.64), and adjusted forms (c = 0.63-0.65), and poor for all models when predicting extended length-of-stay. CONCLUSION ED vulnerability scores from the three instruments had a fair agreement and were associated with important patient outcomes. The interRAI ED Screener best identifies older ED patients at greatest risk, while the PRISMA-7 and ER2 are more sensitive instruments.
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Affiliation(s)
- Fabrice I Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - George Heckman
- School of Public Health Science, University of Waterloo, Waterloo, ON, Canada
- Schlegel Research Institute for Aging, Waterloo, ON, Canada
| | - John P Hirdes
- School of Public Health Science, University of Waterloo, Waterloo, ON, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Olivier Beauchet
- Department of Medicine and Research Center of the Geriatric University Institute of Montreal, University of Montreal, Montreal, QC, Canada
- Division of Geriatric Medicine, Department of Medicine, Sir Mortimer B. Davis Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, Montreal, QC, Canada
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec, QC, Canada
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Sainte-Marie, QC, Canada
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada
| | - Debra Eagles
- Department of Emergency Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Han Ting Wang
- Division of Critical Care Medicine, Department of Medicine, Universite de Montreal, Montreal, QC, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Samir K Sinha
- Division of Geriatric Medicine, Department of Medicine, Sinai Health and University Health Network, Toronto, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Micaela Jantzi
- School of Public Health Science, University of Waterloo, Waterloo, ON, Canada
| | - Paul Hebert
- Division of Palliative Care, Department of Medicine, Bruyere Research Institute, University of Ottawa, Ottawa, ON, Canada.
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15
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Mowbray FI, Heckman G, Hirdes JP, Costa AP, Beauchet O, Eagles D, Perry JJ, Sinha S, Archambault P, Wang H, Jantzi M, Hebert P. Examining the utility and accuracy of the interRAI Emergency Department Screener in identifying high-risk older emergency department patients: A Canadian multiprovince prospective cohort study. J Am Coll Emerg Physicians Open 2023; 4:e12876. [PMID: 36660313 PMCID: PMC9838565 DOI: 10.1002/emp2.12876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 11/08/2022] [Accepted: 11/30/2022] [Indexed: 01/15/2023] Open
Abstract
Objectives We set out to determine the accuracy of the interRAI Emergency Department (ED) Screener in predicting the need for detailed geriatric assessment in the ED. Our secondary objective was to determine the discriminative ability of the interRAI ED Screener for predicting the odds of discharge home and extended ED length of stay (>24 hours). Methods We conducted a multiprovince prospective cohort study in Canada. The need for detailed geriatric assessment was determined using the interRAI ED Screener and the interRAI ED Contact Assessment as the reference standard. A score of ≥5 was used to classify high-risk patients. Assessments were conducted by emergency and research nurses. We calculated the sensitivity, positive predictive value, and false discovery rate of the interRAI ED Screener. We employed logistic regression to predict ED outcomes while adjusting for age, sex, academic status, and the province of care. Results A total of 5629 older ED patients across 11 ED sites were evaluated using the interRAI ED Screener and 1061 were evaluated with the interRAI ED Contact Assessment. Approximately one-third of patients were discharged home or experienced an extended ED length of stay. The interRAI ED Screener had a sensitivity of 93%, a positive predictive value of 82%, and a false discovery rate of 18%. The interRAI ED Screener predicted discharge home and extended ED length of stay with fair accuracy. Conclusion The interRAI ED Screener is able to accurately and rapidly identify individuals with medical complexity. The interRAI ED Screener predicts patient-important health outcomes in older ED patients, highlighting its value for vulnerability screening.
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Affiliation(s)
- Fabrice I. Mowbray
- Department of Health Research Methods, Evidence, and ImpactMcMaster UniversityHamiltonOntarioCanada
| | - George Heckman
- School of Public Health ScienceUniversity of WaterlooWaterlooOntarioCanada
- Schlegel Research Institute for AgingWaterlooOntarioCanada
| | - John P. Hirdes
- School of Public Health ScienceUniversity of WaterlooWaterlooOntarioCanada
| | - Andrew P. Costa
- Department of Health Research Methods, Evidence, and ImpactMcMaster UniversityHamiltonOntarioCanada
| | - Olivier Beauchet
- Departments of Medicine and Research Center of the Geriatric University Institute of MontrealUniversity of MontrealMontrealQuebecCanada
- Department of MedicineDivision of Geriatric MedicineSir Mortimer B. Davis Jewish General Hospital and Lady Davis Institute for Medical ResearchMcGill UniversityMontrealQuebecCanada
- Lee Kong Chian School of MedicineNanyang Technological UniversitySingaporeSingapore
| | - Debra Eagles
- Department of Emergency MedicineSchool of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada
- Ottawa Hospital Research InstituteOttawaOntarioCanada
| | - Jeffrey J. Perry
- Department of Emergency MedicineSchool of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada
- Ottawa Hospital Research InstituteOttawaOntarioCanada
| | - Samir Sinha
- Department of MedicineDivision of Geriatric MedicineSinai Health and University Health NetworkTorontoOntarioCanada
- Department of MedicineDivision of Geriatric MedicineUniversity of TorontoTorontoOntarioCanada
| | - Patrick Archambault
- Department of Family Medicine and Emergency MedicineUniversité LavalQuébec CityOntarioCanada
- Centre intégré de santé et de services sociaux de Chaudière‐AppalachesSainte‐MarieOntarioCanada
- Department of Anesthesiology and Critical Care MedicineDivision of Critical Care MedicineUniversité LavalQuébec CityOntarioCanada
| | - Hanting Wang
- Department of MedicineDivision of Critical Care MedicineUniversite de MontrealMontrealQuebecCanada
| | - Michaela Jantzi
- School of Public Health ScienceUniversity of WaterlooWaterlooOntarioCanada
| | - Paul Hebert
- Department of MedicineDivision of Palliative CareBruyere Research InstituteUniversity of OttawaOttawaOntarioCanada
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16
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Kabell Nissen S, Rueegg M, Carpenter CR, Kaeppeli T, Busch J, Fournaise A, Dreher‐Hummel T, Bingisser R, Brabrand M, Nickel CH. Prognosis for older people at presentation to emergency department based on frailty and aggregated vital signs. J Am Geriatr Soc 2022; 71:1250-1258. [PMID: 36511431 DOI: 10.1111/jgs.18170] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 11/07/2022] [Accepted: 11/19/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Risk stratification for older people based on aggregated vital signs lack the accuracy to predict mortality at presentation to the Emergency Department (ED). We aimed to develop and internally validate the Frailty adjusted Prognosis in ED tool (FaP-ED) for 30-day mortality combining frailty and aggregated vital signs. METHODS Single-center prospective cohort of undifferentiated ED patients aged 65 or older, consecutively sampled upon ED presentation from a tertiary Emergency Center. Vital signs were aggregated using the National Early Warning Score (NEWS) as a measure of illness or injury severity and frailty was assessed with the Clinical Frailty Scale (CFS). The FaP-ED was constructed by combining NEWS and CFS in multivariable logistic regression. The primary outcome was 30-day mortality. Measures of discrimination and calibration were assessed to evaluate predictive performance and internally validated using bootstrapping. RESULTS 2250 patients were included, 67 (1.8%) were omitted from analyses due to missing CFS, loss to follow-up, or terminal illness. Thirty-day mortality rate was 5.4% (N = 122, 95% CI = 4.5%-6.4%). Median NEWS was 1 (Inter-Quartile Range (IQR): 0-3) and median CFS was 4 (IQR: 3-5). The Area Under Receiver Operating Characteristic (AUROC) for FaP-ED was 0.86 (95% CI = 0.83-0.90). This was significantly higher than NEWS (0.81, 95% CI = 0.77-0.85, DeLong: Z = 3.5, p < 0.001) or CFS alone (0.82, 95% CI = 0.78-0.86, DeLong: Z = 4.4, p < 0.001). Bootstrapped estimates of FaP-ED AUROC, calibration slope, and intercept were 0.86, 0.95, and -0.09, respectively, suggesting internal validity. A decision-threshold of CFS 5 and NEWS 3 was proposed based on qualitative comparison of positive Likelihood Ratio at all relevant FaP-ED cutoffs. CONCLUSION Combining aggregated vital signs and frailty accurately predicted 30-day mortality at ED presentation and illustrated an important clinical interaction between frailty and illness severity. Pending external validation, the Fap-ED operationalizes the concept of such "geriatric urgency" for the ED setting.
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Affiliation(s)
- Søren Kabell Nissen
- Institute of Regional Health Research University of Southern Denmark Esbjerg Denmark
- Department of Emergency Medicine Hospital South West Jutland, University hospital of Southern Denmark Esbjerg Denmark
| | - Marco Rueegg
- Department of Emergency Medicine University Hospital Basel, University of Basel Basel Switzerland
| | - Christopher R. Carpenter
- Department of Emergency Medicine Washington University in St. Louis School of Medicine, Emergency Care Research Core St. Louis Michigan USA
| | - Tobias Kaeppeli
- Department of Emergency Medicine University Hospital Basel, University of Basel Basel Switzerland
| | - Jeanette‐Marie Busch
- Department of Emergency Medicine University Hospital Basel, University of Basel Basel Switzerland
| | - Anders Fournaise
- Department of Cross‐sectoral Collaboration Region of Southern Denmark Vejle Denmark
- Epidemiology, Biostatistics and Biodemography, Department of Public Health University of Southern Denmark Odense Denmark
- Geriatric Research Unit, Department of Geriatric Medicine Odense University Hospital Odense Denmark
| | - Thomas Dreher‐Hummel
- Department of Emergency Medicine University Hospital Basel, University of Basel Basel Switzerland
| | - Roland Bingisser
- Department of Emergency Medicine University Hospital Basel, University of Basel Basel Switzerland
| | - Mikkel Brabrand
- Institute of Regional Health Research University of Southern Denmark Esbjerg Denmark
- Department of Emergency Medicine Odense University Hospital Odense Denmark
| | - Christian H. Nickel
- Department of Emergency Medicine University Hospital Basel, University of Basel Basel Switzerland
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17
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The feasibility and acceptability of frailty screening tools in the Emergency Department and the additional value of clinical judgment for frailty detection. Eur J Emerg Med 2022; 29:301-303. [PMID: 35773203 DOI: 10.1097/mej.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Gettel CJ, Falvey JR, Gifford A, Hoang L, Christensen LA, Hwang U, Shah MN. Emergency Department Care Transitions for Patients With Cognitive Impairment: A Scoping Review. J Am Med Dir Assoc 2022; 23:1313.e1-1313.e13. [PMID: 35247358 PMCID: PMC9378565 DOI: 10.1016/j.jamda.2022.01.076] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES We aimed to describe emergency department (ED) care transition interventions delivered to older adults with cognitive impairment, identify relevant patient-centered outcomes, and determine priority research areas for future investigation. DESIGN Systematic scoping review. SETTING AND PARTICIPANTS ED patients with cognitive impairment and/or their care partners. METHODS Informed by the clinical questions, we conducted systematic electronic searches of medical research databases for relevant publications following published guidelines. The results were presented to a stakeholder group representing ED-based and non-ED-based clinicians, individuals living with cognitive impairment, care partners, and advocacy organizations. After discussion, they voted on potential research areas to prioritize for future investigations. RESULTS From 3848 publications identified, 78 eligible studies underwent full text review, and 10 articles were abstracted. Common ED-to-community care transition interventions for older adults with cognitive impairment included interdisciplinary geriatric assessments, home visits from medical personnel, and telephone follow-ups. Intervention effects were mixed, with improvements observed in 30-day ED revisit rates but most largely ineffective at promoting connections to outpatient care or improving secondary outcomes such as physical function. Outcomes identified as important to adults with cognitive impairment and their care partners included care coordination between providers and inclusion of care partners in care management within the ED setting. The highest priority research area for future investigation identified by stakeholders was identifying strategies to tailor ED-to-community care transitions for adults living with cognitive impairment complicated by other vulnerabilities such as social isolation or economic disadvantage. CONCLUSIONS AND IMPLICATIONS This scoping review identified key gaps in ED-to-community care transition interventions delivered to older adults with cognitive impairment. Combined with a stakeholder assessment and prioritization, it identified relevant patient-centered outcomes and clarifies priority areas for future investigation to improve ED care for individuals with impaired cognition, an area of critical need given the current population trends.
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Affiliation(s)
- Cameron J Gettel
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA.
| | - Jason R Falvey
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Angela Gifford
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Ly Hoang
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA; Department of Medicine (Geriatrics and Gerontology), University of Wisconsin-Madison, Madison, WI, USA; Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA; Center for Health Disparities Research, University of Wisconsin-Madison, Madison, WI, USA; Wisconsin Alzheimer's Disease Research Center, University of Wisconsin-Madison, Madison, WI, USA
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19
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Silva VBO, Aliberti MJR, Morinaga CV, Avelino-Silva TJ, Curiati PK. Unplanned intensive care unit admission in hospitalized older patients: Association with a geriatric vulnerability score. J Am Geriatr Soc 2022; 70:3321-3324. [PMID: 35781877 DOI: 10.1111/jgs.17944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/12/2022] [Accepted: 06/15/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Vinicius B O Silva
- Geriatric Emergency Department Research Group (ProAGE), Hospital Sirio-Libanes, São Paulo, Brazil
| | - Márlon J R Aliberti
- Geriatric Emergency Department Research Group (ProAGE), Hospital Sirio-Libanes, São Paulo, Brazil.,Geriatrics Center for Advanced Medicine, Hospital Sirio-Libanês, São Paulo, Brazil.,Laboratory of Medical Research in Aging (LIM-66), Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Christian V Morinaga
- Geriatric Emergency Department Research Group (ProAGE), Hospital Sirio-Libanes, São Paulo, Brazil
| | - Thiago J Avelino-Silva
- Geriatric Emergency Department Research Group (ProAGE), Hospital Sirio-Libanes, São Paulo, Brazil.,Geriatrics Center for Advanced Medicine, Hospital Sirio-Libanês, São Paulo, Brazil.,Laboratory of Medical Research in Aging (LIM-66), Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Pedro Kallas Curiati
- Geriatric Emergency Department Research Group (ProAGE), Hospital Sirio-Libanes, São Paulo, Brazil.,Geriatrics Center for Advanced Medicine, Hospital Sirio-Libanês, São Paulo, Brazil
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20
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van Dam CS, Trappenburg MC, Ter Wee MM, Hoogendijk EO, de Vet R, Smulders YM, Nanayakkara PB, Muller M, Peters ML. The Prognostic Accuracy of Clinical Judgment Versus a Validated Frailty Screening Instrument in Older Patients at the Emergency Department: Findings of the AmsterGEM Study. Ann Emerg Med 2022; 80:422-431. [PMID: 35717270 DOI: 10.1016/j.annemergmed.2022.04.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/23/2022] [Accepted: 04/28/2022] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE To compare the prognostic accuracy of clinical judgment for frailty in older patients at the emergency department with a validated screening instrument and patient-perceived frailty. METHODS A prospective cohort study in patients 70 years of age and older in 2 Dutch EDs with a follow-up of 3 months. A dichotomous question was asked to the physician and patient: "Do you consider the patient / yourself to be frail?" The Identification of Seniors At Risk-Hospitalized Patients (ISAR-HP) was used as a validated screening instrument. The primary composite outcome consisted of either functional decline, institutionalization, or mortality. RESULTS A total of 736 patients were included. The physician identified 59% as frail, compared with 49% by ISAR-HP and 43% by patients themselves. The level of agreement was fair (Fleiss Kappa, 0.31). After 3 months, 31% of the patients experienced at least 1 adverse health outcome. The sensitivity was 79% for the physician, 72% for ISAR-HP, 61% for the patient, and 48% for all 3 combined. The specificity was 50% for the physician, 63% for ISAR-HP, 66% for the patient, and 85% for all 3 positive. The highest positive likelihood ratio was 3.03 (physician, ISAR-HP, patient combined), and the lowest negative likelihood ratio was 0.42 (physician). The areas under the receiver operating curves were all poor: 0.68 at best for ISAR-HP. CONCLUSION Clinical judgment for frailty showed fair agreement with a validated screening instrument and patient-perceived frailty. All 3 instruments have poor prognostic accuracy, which does not improve when combined. These findings illustrate the limited prognostic value of clinical judgment as a frailty screener in older patients at the ED.
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Affiliation(s)
- Carmen S van Dam
- Department of Internal Medicine and Geriatrics, Amsterdam Cardiovascular Sciences research institute, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands.
| | - Marijke C Trappenburg
- Department of Internal Medicine and Geriatrics, Amsterdam Cardiovascular Sciences research institute, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Marieke M Ter Wee
- Department of Epidemiology and Data Science, Amsterdam Public Health research institute, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Emiel O Hoogendijk
- Department of Epidemiology and Data Science, Amsterdam Public Health research institute, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Riekie de Vet
- Department of Epidemiology and Data Science, Amsterdam Public Health research institute, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Yvo M Smulders
- Department of Internal Medicine and Vascular Medicine, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Prabath B Nanayakkara
- Section General Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Majon Muller
- Department of Internal Medicine and Geriatrics, Amsterdam Cardiovascular Sciences research institute, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Mike L Peters
- Department of Internal Medicine and Geriatrics, Amsterdam Cardiovascular Sciences research institute, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands; Department of Internal Medicine and Vascular Medicine, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands; Department of Internal Medicine and Geriatrics, University Medical Center Utrecht, the Netherlands
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21
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Rueegg M, Nissen SK, Brabrand M, Kaeppeli T, Dreher T, Carpenter CR, Bingisser R, Nickel CH. The clinical frailty scale predicts 1-year mortality in emergency department patients aged 65 years and older. Acad Emerg Med 2022; 29:572-580. [PMID: 35138670 PMCID: PMC9320818 DOI: 10.1111/acem.14460] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/13/2021] [Accepted: 12/28/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To validate the Clinical Frailty Scale (CFS) for prediction of 1-year all-cause mortality in the emergency department (ED) and compare its performance to the Emergency Severity Index (ESI). METHODS Prospective cohort study at the ED of a tertiary care center in Northwestern Switzerland. All patients aged ≥65 years were included from March 18 to May 20, 2019, after informed consent. Frailty status was assessed using CFS, excluding level 9 (palliative). Acuity level was assessed using ESI. Both CFS and ESI were adjusted for age, sex and presenting condition in multivariable logistic regression. Prognostic performance was assessed for discrimination and calibration separately. Estimates were internally validated by Bootstrapping. Restricted mean survival time (RMST) was determined for all levels of CFS. RESULTS In the final study population of 2191 patients, 1-year all-cause mortality was 17% (n = 372). RMST values ranged from 219 days for CFS 8 to 365 days for CFS 1. The adjusted CFS model had an area under receiver operating characteristic of 0.767 (95% confidence interval [CI]: 0.741-0.793), compared to 0.703 (95% CI: 0.673-0.732) for the adjusted ESI model. CONCLUSION The CFS predicts 1-year all-cause mortality for older ED patients and predicts survival time in a graded manner. The CFS is superior to the ESI when adjusted for age, sex, and presenting condition.
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Affiliation(s)
- Marco Rueegg
- Emergency DepartmentUniversity Hospital Basel, University of BaselBaselSwitzerland
| | - Søren Kabell Nissen
- Institute of Regional Health Research, Centre South‐West JutlandUniversity of Southern DenmarkOdenseDenmark
| | - Mikkel Brabrand
- Institute of Regional Health Research, Centre South‐West JutlandUniversity of Southern DenmarkOdenseDenmark
- Department of Emergency MedicineOdense University Hospital, University of Southern DenmarkOdenseDenmark
| | - Tobias Kaeppeli
- Emergency DepartmentUniversity Hospital Basel, University of BaselBaselSwitzerland
| | - Thomas Dreher
- Emergency DepartmentUniversity Hospital Basel, University of BaselBaselSwitzerland
| | - Christopher R. Carpenter
- Department of Emergency MedicineWashington University in St. Louis School of Medicine, Emergency Care Research CoreSt. LouisMichiganUSA
| | - Roland Bingisser
- Emergency DepartmentUniversity Hospital Basel, University of BaselBaselSwitzerland
| | - Christian H. Nickel
- Emergency DepartmentUniversity Hospital Basel, University of BaselBaselSwitzerland
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22
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Yadgir SR, Engstrom C, Jacobsohn GC, Green RK, Jones CMC, Cushman JT, Caprio TV, Kind AJH, Lohmeier M, Shah MN, Patterson BW. Machine learning-assisted screening for cognitive impairment in the emergency department. J Am Geriatr Soc 2022; 70:831-837. [PMID: 34643944 PMCID: PMC8904269 DOI: 10.1111/jgs.17491] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 09/08/2021] [Accepted: 09/11/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND/OBJECTIVES Despite a high prevalence and association with poor outcomes, screening to identify cognitive impairment (CI) in the emergency department (ED) is uncommon. Identification of high-risk subsets of older adults is a critical challenge to expanding screening programs. We developed and evaluated an automated screening tool to identify a subset of patients at high risk for CI. METHODS In this secondary analysis of existing data collected for a randomized control trial, we developed machine-learning models to identify patients at higher risk of CI using only variables available in electronic health record (EHR). We used records from 1736 community-dwelling adults age > 59 being discharged from three EDs. Potential CI was determined based on the Blessed Orientation Memory Concentration (BOMC) test, administered in the ED. A nested cross-validation framework was used to evaluate machine-learning algorithms, comparing area under the receiver-operator curve (AUC) as the primary metric of performance. RESULTS Based on BOMC scores, 121 of 1736 (7%) participants screened positive for potential CI at the time of their ED visit. The best performing algorithm, an XGBoost model, predicted BOMC positivity with an AUC of 0.72. With a classification threshold of 0.4, this model had a sensitivity of 0.73, a specificity of 0.64, a negative predictive value of 0.97, and a positive predictive value of 0.13. In a hypothetical ED with 200 older adult visits per week, the use of this model would lead to a decrease in the in-person screening burden from 200 to 77 individuals in order to detect 10 of 14 patients who would fail a BOMC. CONCLUSION This study demonstrates that an algorithm based on EHR data can define a subset of patients at higher risk for CI. Incorporating such an algorithm into a screening workflow could allow screening efforts and resources to be focused where they have the most impact.
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Affiliation(s)
- Simon R Yadgir
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Collin Engstrom
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Computer Science, Winona State University, Rochester, MN, USA
| | - Gwen Costa Jacobsohn
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Rebecca K Green
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Courtney M C Jones
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Jeremy T Cushman
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, Maryland, USA
| | - Thomas V Caprio
- Division of Geriatrics, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Amy J H Kind
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
- William S. Middleton Veterans Affairs Geriatrics Research, Education, and Clinical Center, Madison, Wisconsin, USA
- UW Center for Health Disparities Research, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Michael Lohmeier
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Brian W Patterson
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
- Health Innovation Program, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Industrial and Systems Engineering, Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin, USA
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23
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Mooijaart SP, Carpenter CR, Conroy SP. Geriatric emergency medicine-a model for frailty friendly healthcare. Age Ageing 2022; 51:6550832. [PMID: 35307733 DOI: 10.1093/ageing/afab280] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Indexed: 11/12/2022] Open
Abstract
As the world's population continues to age over the decades ahead, medical educators and researchers in every adult medical and surgical specialty will need to 'geriatricise' their clinical science. Many have already engaged with geriatrics. Here we describe the progress that has been made and the opportunities ahead in the field of Geriatric Emergency Medicine (GEM), a field that has taken large steps in integrating holistic care. Future opportunities exist in the three domains of evidence-based medicine: including patient preferences and needs, generating scientific evidence, and improving physician knowledge and expertise. Implementation requires new innovations also in the organisation of care. Similar strategies may be useful in other fields of medicine, in making holistic care the standard for older people.
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Affiliation(s)
- Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Christopher R Carpenter
- Emergency Care Research Core, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Simon P Conroy
- UCL MRC Unit for Lifelong Health and Ageing at UCL 5th Floor, 1-19 Torrington Place, London, WC1E7HB, UK
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24
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Hirshon JM. Automating cognitive impairment screening in emergency departments: A small step forward. J Am Geriatr Soc 2022; 70:695-697. [PMID: 35043418 DOI: 10.1111/jgs.17654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 12/21/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Jon Mark Hirshon
- Department of Emergency Medicine, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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25
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Flaherty JH, Rodin MB, Morley JE. Changing Hospital Care For Older Adults: The Case for Geriatric Hospitals in the United States. Gerontol Geriatr Med 2022; 8:23337214221109005. [PMID: 35813982 PMCID: PMC9260589 DOI: 10.1177/23337214221109005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hospital care of frail older adults is far from optimal. Although some geriatric models of care have been shown to improve outcomes, the effect size is small and models are difficult to fully implement, sustain and replicate. The two root causes for these shortcomings are competing interests (high revenue generating diseases, procedures and surgeries) and current hospital cultures (for example a culture of safety that emphasizes bed alarms and immobility rather than frequent ambulation). Geriatric hospitals would be hospitals completely dedicated to the care of frail older patients, a group which is most vulnerable to the negative consequences of a hospitalization. They would differ from a typical adult hospital because they could implement evidence based principles of successful geriatric models of care on a hospital wide basis, which would make them sustainable and allow for scaling up of proven outcomes. Innovative structural designs, unachievable in a typical adult hospital, would enhance mobility while maintaining safety. Financial viability and stability would be a challenge but should be feasible, likely through affiliation with larger health care systems with other hospitals because of cost savings associated with geriatric models of care (decreased length of stay, increased likelihood of discharge home, without increasing costs).
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Affiliation(s)
- Joseph H. Flaherty
- Regional Medical Director of Geriatrics,
Envision Physician Services, Dallas, Texas, Division of Geriatrics, University of Texas Southwestern, Dallas, Texas, USA
| | - Miriam B. Rodin
- Division of Geriatrics, Department of
Internal Medicine, Saint Louis University, St Louis, Missouri
| | - John E. Morley
- Division of Geriatrics, Department of
Internal Medicine, Saint Louis University, St Louis, Missouri
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26
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A narrative review of frailty assessment in older patients at the emergency department. Eur J Emerg Med 2021; 28:266-276. [PMID: 33883392 DOI: 10.1097/mej.0000000000000811] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Optimizing emergency care for the aging population is an important future challenge, as the proportion of older patients at the emergency department (ED) rapidly increases. Older patients, particularly those who are frail, have a high risk of adverse outcomes after an ED visit, such as functional decline, institutionalization, and death. The ED can have a key position in identifying frail older patients who benefit most from comprehensive geriatric care [including delirium preventive measures, early evaluation of after-discharge care, and a comprehensive geriatric assessment (CGA)]. However, performing extensive frailty assessment is not suitable at the ED. Therefore, quick and easy-to-use instruments are needed to identify older patients at risk for adverse outcomes. This narrative review outlines the importance and complexity of frailty assessment at the ED. It aligns the available screening instruments, including clinical judgment as frailty assessment, and summarizes arguments for and against frailty assessment at the ED.
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27
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The Accuracy of Four Frequently Used Frailty Instruments for the Prediction of Adverse Health Outcomes Among Older Adults at Two Dutch Emergency Departments: Findings of the AmsterGEM Study. Ann Emerg Med 2021; 78:538-548. [PMID: 34304915 DOI: 10.1016/j.annemergmed.2021.04.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Older adults presenting to the emergency department (ED) are at high risk of adverse health outcomes. This study aimed to evaluate the accuracy of 4 frequently used screening instruments for the prediction of adverse health outcomes among older adults in the ED. METHODS This was a prospective cohort study in patients ≥70 years of age presenting to the ED in 2 hospitals in the Netherlands. Screening instruments included the acutely presenting older patient screening program (APOP) (providing 2 risk scores-functional decline [APOP1] and mortality [APOP2]), the International Resident Assessment Instrument Emergendy Department screener (InterRAI ED), the Identification of Seniors At Risk-Hospitalized Patients (ISAR-HP), and the safety management system (VMS). The primary outcome measure was a composite outcome encompassing functional decline, institutionalization, and mortality at 3 months after ED presentation. Other follow-up time points were 1 and 6 months. Analyses were performed to assess prognostic accuracy. RESULTS In total, 889 patients were included. After 3 months, 267 (31%) patients experienced at least 1 adverse outcome. The positive likelihood ratio ranged from 1.67 (VMS) to 3.33 (APOP1), and the negative likelihood ratio ranged from 0.41 (ISAR-HP) to 0.88 (APOP2). Sensitivity ranged from 17% (APOP2) to 74% (ISAR-HP), and specificity ranged from 63% (ISAR-HP) to 94% (APOP2). The area under the curve ranged from 0.62 (APOP2) to 0.72 (APOP1 and ISAR-HP). Calibration was reasonable for APOP1 and VMS. The prognostic accuracy was comparable across all outcomes and at all follow-up time points. CONCLUSION The frailty screening instruments assessed in this study showed poor to moderate prognostic accuracy, which brings into question their usability in the prediction of adverse health outcomes among older adults who present to the ED.
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Beauchet O, Lubov J, Galery K, Afilalo M, Launay CP. Emergency room evaluation and recommendations for older emergency department users: results of the ER 2 experimental study. Eur Geriatr Med 2021; 12:921-929. [PMID: 34089148 DOI: 10.1007/s41999-021-00517-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 05/15/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE The study aims to examine whether the use of "emergency room evaluation and recommendations" (ER2) tool in daily ED practice reduces the length of stay in ED and hospital, and hospital admission in older patients visiting ED on stretcher. METHODS A total of 3931 older patients visiting ED of the Jewish General Hospital (Montreal, Quebec, Canada) on stretcher were recruited in this non-randomized, pre-post intervention, single arm, prospective and longitudinal open-label trial. ED staff and patients were blinded of the ER2 score and patients received usual ED care over the observational phase, whereas ED staff were informed about the ER2 score and patients had usual care plus interventions based on tailor-made geriatric recommendations during the interventional phase. The length of stay in ED and in hospital, and hospital admission were the outcomes. RESULTS The ER2 recommendations were associated with increased length of stay in ED (β = 2.94 with P ≤ 0.001) and decreased length of stay in hospital (β = - 2.07 with P = 0.011). No effect was found for hospital admission (Odd Ratio (OR) = 0.92 with P = 0.182). CONCLUSION Emergency room evaluation and recommendations (ER2) tool had mixed effects. Shorter hospital stay has been reported for older ED users hospitalized, but increased ED stay and no effects on hospital admission were found.
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Affiliation(s)
- Olivier Beauchet
- Department of Medicine, University of Montreal, Montreal, QC, Canada. .,Research Centre of the Geriatric University Institute of Montreal, Montreal, QC, Canada. .,Department of Medicine, Division of Geriatric Medicine, Sir Mortimer B. Davis Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, Montreal, QC, Canada. .,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
| | - Joshua Lubov
- Department of Medicine, Division of Geriatric Medicine, Sir Mortimer B. Davis Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, Montreal, QC, Canada
| | - Kevin Galery
- Research Centre of the Geriatric University Institute of Montreal, Montreal, QC, Canada
| | - Marc Afilalo
- Emergency Department, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Cyrille P Launay
- Department of Medicine, Division of Geriatric Medicine, Sir Mortimer B. Davis Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, Montreal, QC, Canada
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Mooijaart SP, Nickel CH, Conroy SP, Lucke JA, van Tol LS, Olthof M, Blomaard LC, Buurman BM, Dundar ZD, de Groot B, Gasperini B, Heeren P, Karamercan MA, McNamara R, Mitchell A, van Oppen JD, Martin Sanchez FJ, Schoon Y, Singler K, Spode R, Skúldóttir S, Thorrsteindottir T, van der Velde M, Wallace J. A European Research Agenda for Geriatric Emergency Medicine: a modified Delphi study. Eur Geriatr Med 2021; 12:413-422. [PMID: 33219983 PMCID: PMC7990812 DOI: 10.1007/s41999-020-00426-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/29/2020] [Indexed: 11/01/2022]
Abstract
PURPOSE Geriatric Emergency Medicine (GEM) focuses on delivering optimal care to (sub)acutely ill older people. This involves a multidisciplinary approach throughout the whole healthcare chain. However, the underpinning evidence base is weak and it is unclear which research questions have the highest priority. The aim of this study was to provide an inventory and prioritisation of research questions among GEM professionals throughout Europe. METHODS A two-stage modified Delphi approach was used. In stage 1, an online survey was administered to various professionals working in GEM both in the Emergency Department (ED) and other healthcare settings throughout Europe to make an inventory of potential research questions. In the processing phase, research questions were screened, categorised, and validated by an expert panel. Subsequently, in stage 2, remaining research questions were ranked based on relevance using a second online survey administered to the same target population, to identify the top 10 prioritised research questions. RESULTS In response to the first survey, 145 respondents submitted 233 potential research questions. A total of 61 research questions were included in the second stage, which was completed by 176 respondents. The question with the highest priority was: Is implementation of elements of CGA (comprehensive geriatric assessment), such as screening for frailty and geriatric interventions, effective in improving outcomes for older patients in the ED? CONCLUSION This study presents a top 10 of high-priority research questions for a European Research Agenda for Geriatric Emergency Medicine. The list of research questions may serve as guidance for researchers, policymakers and funding bodies in prioritising future research projects.
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Affiliation(s)
- Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands.
- Institute for Evidence-Based Medicine for Older People (IEMO), Leiden, The Netherlands.
| | - Christian H Nickel
- Department of Emergency Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Simon P Conroy
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Jacinta A Lucke
- Department of Gerontology and Geriatrics, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Department of Emergency Medicine, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Lisa S van Tol
- Department of Gerontology and Geriatrics, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Mareline Olthof
- Department of Gerontology and Geriatrics, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Laura C Blomaard
- Department of Gerontology and Geriatrics, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Bianca M Buurman
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Zerrin D Dundar
- Department of Emergency Medicine, Necmettin Erbakan University Meram Faculty of Medicine, Konya, Turkey
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Beatrice Gasperini
- Department of Geriatrics and Rehabilitation, Santa Croce Hospital, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Fano, Italy
| | - Pieter Heeren
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Research Foundation-Flanders (FWO), Brussels, Belgium
| | - Mehmet A Karamercan
- Department of Emergency Medicine, Gazi University School of Medicine, Ankara, Turkey
| | - Rosa McNamara
- Department of Emergency Medicine, St. Vincent University Hospital, Dublin, Ireland
| | - Aine Mitchell
- Department of Emergency Medicine, Sligo University Hospital, Sligo, Ireland
| | - James D van Oppen
- Department of Health Sciences, University of Leicester, Leicester, UK
- Emergency Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - F Javier Martin Sanchez
- Emergency Department, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), Universidad Complutense de Madrid, Madrid, Spain
| | - Yvonne Schoon
- Department of Emergency Medicine and Department of Geriatrics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Katrin Singler
- Department of Geriatrics, Klinikum Nürnberg, Paracelsus Private, Medical University, Nuremberg, Germany
| | - Renan Spode
- Department of Emergency Medicine, Charité University Hospital, Berlin, Germany
| | - Sigrun Skúldóttir
- Research Institute in Emergency Care, Landspitali National University Hospital of Iceland, Reykjavík, Iceland
- The Icelandic Gerontological Research Institute, Reykjavík, Iceland
| | - Thordis Thorrsteindottir
- Research Institute in Emergency Care, Landspitali National University Hospital of Iceland, Reykjavík, Iceland
| | | | - James Wallace
- Emergency Department, Warrington and Halton Hospitals NHS Teaching Trust, Warrington, England, UK
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Abstract
Geriatric emergency medicine has emerged as a subspecialty of emergency medicine over the past 25 years. This emergence has seen the development of increases in training opportunities, care delivery strategies, collaborative best practice guidelines, and formal geriatric emergency department accreditation. This multidisciplinary field remains ripe for continued development in the coming decades as the aging US population parallels a call from patients, health care providers, and health systems to improve the delivery of high-value care. This article educates emergency medicine practitioners and highlights high-value care practice trends to inform and prioritize decision-making for this unique patient population.
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Blomaard LC, Olthof M, Meuleman Y, de Groot B, Gussekloo J, Mooijaart SP. Experiences with and attitudes towards geriatric screening among older emergency department patients: a qualitative study. BMC Geriatr 2021; 21:198. [PMID: 33743607 PMCID: PMC7981953 DOI: 10.1186/s12877-021-02144-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/08/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The patient perspective on the use of screening for high risks of adverse health outcomes in Emergency Department (ED) care is underexposed, although it is an important perspective influencing implementation in routine care. This study explores the experiences with, and attitudes towards geriatric screening in routine ED care among older people who visited the ED. METHODS This was a qualitative study using individual face-to-face semi-structured interviews. Interviews were conducted in older patients (≥70 years) who completed the 'Acutely Presenting Older Patient' screener while visiting the ED of a Dutch academic hospital. Purposive convenience sampling was used to select a heterogeneous sample of participants regarding age, disease severity and the result from screening. Transcripts were analyzed inductively using thematic analysis. RESULTS After 13 interviews (7 women, median age 82 years), data saturation was reached. The participants had noticed little of the screening administration during triage and screening was considered as a normal part of ED care. Most participants believed that geriatric screening contributes to assessing older patients holistically, recognizing geriatric problems early and comforting patients with communication and attention. None of the participants had a negative attitude towards screening or thought that screening is discrimination on age. Care providers should communicate respectfully with frail older patients and involve them in decision-making. CONCLUSIONS Older patients experienced geriatric screening as a normal part of ED care and had predominantly positive attitudes towards its use in the ED. This qualitative study advocates for continuing the implementation of geriatric screening in routine ED practice.
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Affiliation(s)
- Laura C Blomaard
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, PO Box 9600, 2300, RC, Leiden, The Netherlands.
| | - Mareline Olthof
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, PO Box 9600, 2300, RC, Leiden, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Yvette Meuleman
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacobijn Gussekloo
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, PO Box 9600, 2300, RC, Leiden, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Simon P Mooijaart
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, PO Box 9600, 2300, RC, Leiden, The Netherlands
- Institute of Evidence-Based Medicine in Old Age | IEMO, Leiden, The Netherlands
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Improving the care for older emergency department patients: the Acutely Presenting Older Patient study. Z Gerontol Geriatr 2021; 54:97-98. [PMID: 33693970 PMCID: PMC7945600 DOI: 10.1007/s00391-021-01856-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/20/2021] [Indexed: 10/26/2022]
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Blomaard LC, Mooijaart SP, van Meer LJ, Leander J, Lucke JA, de Gelder J, Anten S, Gussekloo J, de Groot B. Geriatric screening, fall characteristics and 3- and 12 months adverse outcomes in older patients visiting the emergency department with a fall. Scand J Trauma Resusc Emerg Med 2021; 29:43. [PMID: 33663559 PMCID: PMC7934471 DOI: 10.1186/s13049-021-00859-5] [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: 11/18/2020] [Accepted: 02/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Falls in older Emergency Department (ED) patients may indicate underlying frailty. Geriatric follow-up might help improve outcomes in addition to managing the direct cause and consequence of the fall. We aimed to study whether fall characteristics and the result of geriatric screening in the ED are independently related to adverse outcomes in older patients with fall-related ED visits. METHODS This was a secondary analysis of the observational multicenter Acutely Presenting Older Patient (APOP) study, of which a subset of patients aged ≥70 years with fall-related ED visits were prospectively included in EDs of two Dutch hospitals. Fall characteristics (cause and location) were retrospectively collected. The APOP-screener was used as a geriatric screening tool. The outcome was 3- and 12-months functional decline and mortality. We assessed to what extent fall characteristics and the geriatric screening result were independent predictors of the outcome, using multivariable logistic regression analysis. RESULTS We included 393 patients (median age 80 (IQR 76-86) years) of whom 23.0% were high risk according to screening. The cause of the fall was extrinsic (49.6%), intrinsic (29.3%), unexplained (6.4%) or missing (14.8%). A high risk geriatric screening result was related to increased risk of adverse outcomes (3-months adjusted odds ratio (AOR) 2.27 (1.29-3.98), 12-months AOR 2.20 (1.25-3.89)). Independent of geriatric screening result, an intrinsic cause of the fall increased the risk of 3-months adverse outcomes (AOR 1.92 (1.13-3.26)) and a fall indoors increased the risk of 3-months (AOR 2.14 (1.22-3.74)) and 12-months adverse outcomes (AOR 1.78 (1.03-3.10)). CONCLUSIONS A high risk geriatric screening result and fall characteristics were both independently associated with adverse outcomes in older ED patients, suggesting that information on both should be evaluated to guide follow-up geriatric assessment and interventions in clinical care.
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Affiliation(s)
- Laura C Blomaard
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.
| | - Simon P Mooijaart
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Institute of Evidence-Based Medicine in Old Age | IEMO, Leiden, The Netherlands
| | - Leonie J van Meer
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Julia Leander
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Jacinta A Lucke
- Department of Emergency Medicine, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Jelle de Gelder
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Sander Anten
- Department of Internal Medicine, section Acute Care, Alrijne Hospital, Leiderdorp, The Netherlands
| | - Jacobijn Gussekloo
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Liu J, Palmgren T, Ponzer S, Masiello I, Farrokhnia N. Can dedicated emergency team and area for older people reduce the hospital admission rate? - An observational pre- and post-intervention study. BMC Geriatr 2021; 21:115. [PMID: 33568087 PMCID: PMC7877031 DOI: 10.1186/s12877-021-02044-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 01/20/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Emergency department (ED) care of older patients is often complex. Geriatric ED guidelines can help to meet this challenge. However, training requirements, the use of time-consuming tools for comprehensive geriatric assessment (CGA), a lack of golden standard to identify the frail patients, and the weak evidence of positive outcomes of using CGA in EDs pose barriers to introduce the guidelines. Dedicating an interprofessional team of regular ED medical and nursing staff and an older-friendly ED area can be another approach. Previous studies of geriatrician-led CGA in EDs have reported a reduced hospital admission rate. The aim of this study was to investigate whether a dedicated interprofessional emergency team also can reduce the hospital admission rate without the resources required by the formal use of CGA. METHODS An observational pre-post study at a large adult ED, where all patients 80 years or older arriving on weekdays in the intervention period from 2016.09.26 to 2016.11.28 and the corresponding weekdays in the previous year from 2015.09.28 to 2015.11.30 were included. In the intervention period, older patients either received care in the geriatric module by the dedicated team or in the regular team modules for patients of mixed ages. In 2015, all patients received care in regular team modules. The primary outcome measure was the total hospital admission rate and the ED length of stay was the secondary outcome measure. RESULTS We included 2377 arrivals in the intervention period, when 26.7% (N = 634) received care in the geriatric module, and 2207 arrivals in the 2015 period. The total hospital admission rate was 61.7% (N = 1466/2377) in the intervention period compared to 64.8% (N = 1431/2207) in 2015 (p = 0.03). The difference was larger for patients treated in the geriatric module, 51.1% compared to 62.1% (95% CI: 56.3 to 68.0%) for patients who would have been eligible in 2015. The ED length of stay was longer in the intervention period. CONCLUSIONS An interprofessional team and area dedicated to older patients was associated to a lower hospital admission rate. Further studies are needed to confirm the results.
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Affiliation(s)
- Jenny Liu
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden.
| | - Therese Palmgren
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden
| | - Sari Ponzer
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden
| | - Italo Masiello
- Department of Computer Science and Media Technology, Linnaeus University, Växjö, Sweden
| | - Nasim Farrokhnia
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset AB, KI SÖS, Sjukhusbacken 10, 118 83, Stockholm, Sweden
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Heeren P, Hendrikx A, Ceyssens J, Devriendt E, Deschodt M, Desruelles D, Flamaing J, Sabbe M, Milisen K. Structure and processes of emergency observation units with a geriatric focus: a scoping review. BMC Geriatr 2021; 21:95. [PMID: 33526029 PMCID: PMC7852183 DOI: 10.1186/s12877-021-02029-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 01/13/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Combining observation principles and geriatric care concepts is considered a promising strategy for risk-stratification of older patients with emergency care needs. We aimed to map the structure and processes of emergency observation units (EOUs) with a geriatric focus and explore to what extent the comprehensive geriatric assessment (CGA) approach was implemented in EOUs. METHODS The revised scoping methodology framework of Arksey and O'Malley was applied. Manuscripts reporting on dedicated areas within hospitals for observation of older patients with emergency care needs were eligible for inclusion. Electronic database searches were performed in MEDLINE, EMBASE and CINAHL in combination with backward snowballing. Two researchers conducted data charting independently. Data-charting forms were developed and iteratively refined. Data inconsistencies were judged by a third researcher or discussed in the research team. Quality assessment was conducted with the Methodological Index for Non-Randomized Studies. RESULTS Sixteen quantitative studies were included reporting on fifteen EOUs in seven countries across three continents. These units were located in the ED, immediately next to the ED or remote from the ED (i.e. hospital-based). All studies reported that staffing consisted of at least three healthcare professions. Observation duration varied between 4 and 72 h. Most studies focused on medical and functional assessment. Four studies reported to assess a patients' medical, functional, cognitive and social capabilities. If deemed necessary, post-discharge follow-up (e.g. community/primary care services and/or outpatient clinics) was provided in eleven studies. CONCLUSION This scoping review documented that the structure and processes of EOUs with a geriatric focus are very heterogeneous and rarely cover all elements of CGA. Further research is necessary to determine how complex care principles of 'observation medicine' and 'CGA' can ideally be merged and successfully implemented in clinical care.
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Affiliation(s)
- Pieter Heeren
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Research Foundation Flanders, Egmontstraat 5, 1000, Brussels, Belgium
| | - Annabelle Hendrikx
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium
| | - Janne Ceyssens
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium
| | - Els Devriendt
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Mieke Deschodt
- Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Public Health, Nursing Science, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
- Faculty of Medicine and Life Sciences, Healthcare and Ethics, UHasselt, Martelarenlaan 42, 3500, Hasselt, Belgium
| | - Didier Desruelles
- Department of Emergency Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Johan Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Marc Sabbe
- Department of Emergency Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, Emergency Medicine, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium.
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Aliberti MJR, Covinsky KE, Garcez FB, Smith AK, Curiati PK, Lee SJ, Dias MB, Melo VJD, Rego-Júnior OFD, Richinho VDP, Jacob-Filho W, Avelino-Silva TJ. A fuller picture of COVID-19 prognosis: the added value of vulnerability measures to predict mortality in hospitalised older adults. Age Ageing 2021; 50:32-39. [PMID: 33068099 PMCID: PMC7665299 DOI: 10.1093/ageing/afaa240] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 09/28/2020] [Accepted: 10/04/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Although coronavirus disease 2019 (COVID-19) disproportionally affects older adults, the use of conventional triage tools in acute care settings ignores the key aspects of vulnerability. OBJECTIVE This study aimed to determine the usefulness of adding a rapid vulnerability screening to an illness acuity tool to predict mortality in hospitalised COVID-19 patients. DESIGN Cohort study. SETTING Large university hospital dedicated to providing COVID-19 care. PARTICIPANTS Participants included are 1,428 consecutive inpatients aged ≥50 years. METHODS Vulnerability was assessed using the modified version of PRO-AGE score (0-7; higher = worse), a validated and easy-to-administer tool that rates physical impairment, recent hospitalisation, acute mental change, weight loss and fatigue. The baseline covariates included age, sex, Charlson comorbidity score and the National Early Warning Score (NEWS), a well-known illness acuity tool. Our outcome was time-to-death within 60 days of admission. RESULTS The patients had a median age of 66 years, and 58% were male. The incidence of 60-day mortality ranged from 22% to 69% across the quartiles of modified PRO-AGE. In adjusted analysis, compared with modified PRO-AGE scores 0-1 ('lowest quartile'), the hazard ratios (95% confidence interval) for 60-day mortality for modified PRO-AGE scores 2-3, 4 and 5-7 were 1.4 (1.1-1.9), 2.0 (1.5-2.7) and 2.8 (2.1-3.8), respectively. The modified PRO-AGE predicted different mortality risk levels within each stratum of NEWS and improved the discrimination of mortality prediction models. CONCLUSIONS Adding vulnerability to illness acuity improved accuracy of predicting mortality in hospitalised COVID-19 patients. Combining tools such as PRO-AGE and NEWS may help stratify the risk of mortality from COVID-19.
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Affiliation(s)
- Márlon Juliano Romero Aliberti
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
- Research Institute, Hospital Sirio-Libanes, Sao Paulo, Brazil
| | - Kenneth E Covinsky
- Division of Geriatrics, University of California, San Francisco, California, USA
- Veterans Affairs Medical Center, San Francisco, California, USA
| | - Flavia Barreto Garcez
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Alexander K Smith
- Division of Geriatrics, University of California, San Francisco, California, USA
- Veterans Affairs Medical Center, San Francisco, California, USA
| | - Pedro Kallas Curiati
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
- Research Institute, Hospital Sirio-Libanes, Sao Paulo, Brazil
| | - Sei J Lee
- Division of Geriatrics, University of California, San Francisco, California, USA
- Veterans Affairs Medical Center, San Francisco, California, USA
| | - Murilo Bacchini Dias
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Victor José Dornelas Melo
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Otávio Fortes do Rego-Júnior
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Valéria de Paula Richinho
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Wilson Jacob-Filho
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Thiago J Avelino-Silva
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
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Michalski-Monnerat C, Carron PN, Nguyen S, Büla C, Mabire C. Assessing Older Patients' Vulnerability in the Emergency Department: A Study of InterRAI ED Screener Accuracy. J Am Geriatr Soc 2020; 68:2914-2920. [PMID: 32964415 DOI: 10.1111/jgs.16829] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/30/2020] [Accepted: 08/20/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Identifying vulnerable older patients admitted to an emergency department (ED) who are at increased risk for adverse events and require a comprehensive geriatric assessment remains a major challenge. The interRAI Emergency Department Screener (EDS) was developed for this specific purpose, but data regarding its validity are scarce. OBJECTIVES To determine (1) convergent validity of the EDS with results of a geriatrician's assessment in defining the need for prompt versus delayed/no further geriatric assessment and (2) predictive validity of the EDS for hospital admission, prolonged hospital length of stay (LOS), and 30-day readmission. DESIGN Prospective observational study. SETTING ED of an academic hospital in Switzerland. PARTICIPANTS Older patients, aged 75 years or older (N = 202), who visited the ED over a 4-month period. Patients with life-threatening conditions were excluded. MEASUREMENTS Data for EDS were collected by two clinical nurses. A brief geriatric assessment was performed separately and interpreted by a geriatrician blinded to the EDS results. Orientation after ED discharge, hospital LOS, and 30-day readmission were retrieved from the administrative database. RESULTS Participants were aged 83.2 ± 5.4 years, 56.9% were female, and 43.6% lived alone. Frequent findings at geriatric assessment were impairment in gait/balance (69.3%), polypharmacy (64.9%), cognitive impairment/delirium (48.2%), risk of malnutrition (46.0%), and mood impairment (38.1%). The proportions of participants who required prompt, delayed, and no further geriatric assessment, according to the EDS, were 27.2%, 29.2%, and 43.6%, respectively. The EDS had low sensitivity in predicting hospital admission (28.8%), prolonged LOS (26.3%), and 30-day readmission (26.1%), with the Area Under the Receiver Operating Characteristics (AUROC) being 51.8%, 48.1%, and 49.4%, respectively. CONCLUSION The EDS performed poorly in both convergent and predictive validity analyses, precluding its use as a screening tool in this ED environment. Further efforts should be undertaken to better target interventions to reduce adverse health trajectories in the older ED population.
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Affiliation(s)
- Carole Michalski-Monnerat
- Institute of Higher Education and Research in Healthcare-IUFRS, University of Lausanne, Lausanne University Hospital, Lausanne, Switzerland
- Neuchâtel Hospital Network, Neuchâtel, Switzerland
| | - Pierre-Nicolas Carron
- Emergency Department, Lausanne University Hospital (CHUV), and University of Lausanne, Lausanne, Switzerland
| | - Sylvain Nguyen
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital (CHUV), and University of Lausanne, Lausanne, Switzerland
| | - Christophe Büla
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital (CHUV), and University of Lausanne, Lausanne, Switzerland
| | - Cédric Mabire
- Institute of Higher Education and Research in Healthcare-IUFRS, University of Lausanne, Lausanne University Hospital, Lausanne, Switzerland
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Heeren P, Devriendt E, Wellens NIH, Deschodt M, Flamaing J, Sabbe M, Milisen K. Comment on: Geriatric Screeners 2.0: Time for a Paradigm Shift in Emergency Department Vulnerability Research. J Am Geriatr Soc 2020; 68:2414-2415. [PMID: 32621613 DOI: 10.1111/jgs.16691] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/06/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Pieter Heeren
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium.,Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.,Research Foundation Flanders, Brussels, Belgium
| | - Els Devriendt
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium.,Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Nathalie I H Wellens
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium.,Department of Public Health and Social Affairs DSAS, Direction Générale de la Santé Canton Vaud, Etat de Vaud, Lausanne, Switzerland
| | - Mieke Deschodt
- Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, Leuven, Belgium.,Department of Public Health, Nursing Science, University of Basel, Basel, Switzerland
| | - Johan Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, Leuven, Belgium
| | - Marc Sabbe
- Department of Emergency Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Public Health and Primary Care, Emergency Medicine, KU Leuven, Leuven, Belgium
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium.,Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
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