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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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Nickel CH, Kellett J. Assessing Physiologic Reserve and Frailty in the Older Emergency Department Patient: Should the Paradigm Change? Clin Geriatr Med 2023; 39:475-489. [PMID: 37798060 DOI: 10.1016/j.cger.2023.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Older patients are more vulnerable to acute illness or injury because of reduced physiologic reserve associated with aging. Therefore, their assessment in the emergency department (ED) should include not only vital signs and their baseline values but also changes that reflect physiologic reserve, such as mobility, mental status, and frailty. Combining aggregated vitals sign scores and frailty might improve risk stratification in the ED. Implementing these changes in ED assessment may require the introduction of senior-friendly processes to ensure ED treatment is appropriate to the older patients' immediate discomfort, personal goals, and likely prognosis.
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Affiliation(s)
- Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, Basel CH-4031, Switzerland.
| | - John Kellett
- Department of Emergency Medicine, Odense University Hospital, University of Southern Denmark, Denmark
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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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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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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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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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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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10
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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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11
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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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12
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Carpenter CR, Mooijaart SP. Geriatric Screeners 2.0: Time for a Paradigm Shift in Emergency Department Vulnerability Research. J Am Geriatr Soc 2020; 68:1402-1405. [DOI: 10.1111/jgs.16502] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/11/2020] [Indexed: 01/05/2023]
Affiliation(s)
- Christopher R. Carpenter
- Department of Emergency MedicineWashington University in St. Louis School of Medicine, Emergency Care Research Core St. Louis Missouri USA
| | - Simon P. Mooijaart
- Department of Geriatrics and GerontologyLeiden University Medical Center Leiden The Netherlands
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