Functional assessment of older patients in the emergency department: comparison between standard instruments, medical records and physicians' perceptions

Optimizing older patient care in emergency departments: a comprehensive survey of current practices and challenges in Northern Italy

BACKGROUND

The progressive aging of the population and the increasing complexity of health issues contribute to a growing number of older individuals seeking emergency care. This study aims to assess the state of the art of care provided to older people in the Emergency Departments of Lombardy, the most populous region in Italy, counting over 2 million people aged 65 years and older.

METHODS

An online cross-sectional survey was developed and disseminated among emergency medicine physicians and physicians affiliated to the Lombardy section of the Italian Society of Geriatrics and Gerontology (SIGG), during June and July 2023. The questionnaire covered hospital profiles, geriatric consultation practices, risk assessment tools, discharge processes and perspectives on geriatric emergency care.

RESULTS

In this mixed method research, 219 structured interviews were collected. The majority of physicians were employed in hospitals, with 54.7% being geriatricians. Critical gaps in older patient's care were identified, including the absence of dedicated care pathways, insufficient awareness of screening tools, and a need for enhanced professional training.

CONCLUSIONS

Tailored protocols and geriatric educational programs are crucial for improving the quality of emergency care provided to older individuals. These measures might also help relieve the burden on the Emergency Departments, thereby potentially enhancing overall efficiency and ensuring better outcomes.

Occupational Therapy in the Emergency Department: Patient Frailty and Unscheduled Return Visits

Background. Occupational therapy facilitates care for complex frail emergency department (ED) patients who may have unscheduled return visits (URVs). Purpose. To determine the prevalence of frailty amongst ED patients referred to occupational therapy and if frailty affected the rates and reasons for URVs. Methods. A mixed-methods health records review was conducted of older adults referred to an ED-based occupational therapy program. Findings. Most patients were frail (60.6%). 31.0% of patients discharged home had a URV within 30 days, with no difference in URV rates between frail and non-frail populations. Providing occupational therapy education reduced the frequency of URVs. Frail patients had complex reasons for their URVs, including functional, social/environmental, safety concerns, and/or "failure to thrive". Occupational therapy ED patients were typically vulnerable to moderately frail, dependent in some activities of daily living, and complex. Implications. ED-based occupational therapists must be aware of their patient's frailty and risk of URVs.

Geriatrics-focused indicators predict mortality more than age in older adults hospitalized with COVID-19

BACKGROUND

Age has been implicated as the main risk factor for COVID-19-related mortality. Our objective was to utilize administrative data to build an explanatory model accounting for geriatrics-focused indicators to predict mortality in hospitalized older adults with COVID-19.

METHODS

Retrospective cohort study of adults age 65 and older (N = 4783) hospitalized with COVID-19 in the greater New York metropolitan area between 3/1/20-4/20/20. Data included patient demographics and clinical presentation. Stepwise logistic regression with Akaike Information Criterion minimization was used.

RESULTS

The average age was 77.4 (SD = 8.4), 55.9% were male, 20.3% were African American, and 15.0% were Hispanic. In multivariable analysis, male sex (adjusted odds ration (adjOR) = 1.06, 95% CI:1.03-1.09); Asian race (adjOR = 1.08, CI:1.03-1.13); history of chronic kidney disease (adjOR = 1.05, CI:1.01-1.09) and interstitial lung disease (adjOR = 1.35, CI:1.28-1.42); low or normal body mass index (adjOR:1.03, CI:1.00-1.07); higher comorbidity index (adjOR = 1.01, CI:1.01-1.02); admission from a facility (adjOR = 1.14, CI:1.09-1.20); and mechanical ventilation (adjOR = 1.52, CI:1.43-1.62) were associated with mortality. While age was not an independent predictor of mortality, increasing age (centered at 65) interacted with hypertension (adjOR = 1.02, CI:0.98-1.07, reducing by a factor of 0.96 every 10 years); early Do-Not-Resuscitate (DNR, life-sustaining treatment preferences) (adjOR = 1.38, CI:1.22-1.57, reducing by a factor of 0.92 every 10 years); and severe illness on admission (at 65, adjOR = 1.47, CI:1.40-1.54, reducing by a factor of 0.96 every 10 years).

CONCLUSION

Our findings highlight that residence prior to admission, early DNR, and acute illness severity are important predictors of mortality in hospitalized older adults with COVID-19. Readily available administrative geriatrics-focused indicators that go beyond age can be utilized when considering prognosis.

Predicting hospital admission for older emergency department patients: Insights from machine learning

BACKGROUND

Emergency departments (ED) are a portal of entry into the hospital and are uniquely positioned to influence the health care trajectories of older adults seeking medical attention. Older adults present to the ED with distinct needs and complex medical histories, which can make disposition planning more challenging. Machine learning (ML) approaches have been previously used to inform decision-making surrounding ED disposition in the general population. However, little is known about the performance and utility of ML methods in predicting hospital admission among older ED patients. We applied a series of ML algorithms to predict ED admission in older adults and discuss their clinical and policy implications.

MATERIALS AND METHODS

We analyzed the Canadian data from the interRAI multinational ED study, the largest prospective cohort study of older ED patients to date. The data included 2274 ED patients 75 years of age and older from eight ED sites across Canada between November 2009 and April 2012. Data were extracted from the interRAI ED Contact Assessment, with predictors including a series of geriatric syndromes, functional assessments, and baseline care needs. We applied a total of five ML algorithms. Models were trained, assessed, and analyzed using 10-fold cross-validation. The performance of predictive models was measured using the area under the receiver operating characteristic curve (AUC). We also report the accuracy, sensitivity, and specificity of each model to supplement performance interpretation.

RESULTS

Gradient boosted trees was the most accurate model to predict older ED patients who would require hospitalization (AUC = 0.80). The five most informative features include home intravenous therapy, time of ED presentation, a requirement for formal support services, independence in walking, and the presence of an unstable medical condition.

CONCLUSION

To the best of our knowledge, this is the first study to predict hospital admission in older ED patients using a series of geriatric syndromes and functional assessments. We were able to predict hospital admission in older ED patients with good accuracy using the items available in the interRAI ED Contact Assessment. This information can be used to inform decision-making about ED disposition and may expedite admission processes and proactive discharge planning.

Geriatric Screening, Triage Urgency, and 30-Day Mortality in Older Emergency Department Patients

BACKGROUND

Urgency triage in the emergency department (ED) is important for early identification of potentially lethal conditions and extensive resource utilization. However, in older patients, urgency triage systems could be improved by taking geriatric vulnerability into account. We investigated the association of geriatric vulnerability screening in addition to triage urgency levels with 30‐day mortality in older ED patients.

DESIGN

Secondary analysis of the observational multicenter Acutely Presenting Older Patient (APOP) study.

SETTING

EDs within four Dutch hospitals.

PARTICIPANTS

Consecutive patients, aged 70 years or older, who were prospectively included.

MEASUREMENTS

Patients were triaged using the Manchester Triage System (MTS). In addition, the APOP screener was used as a geriatric screening tool. The primary outcome was 30‐day mortality. Comparison was made between mortality within the geriatric high‐ and low‐risk screened patients in every urgency triage category. We calculated the difference in explained variance of mortality by adding the geriatric screener (APOP) to triage urgency (MTS) by calculating Nagelkerke R².

RESULTS

We included 2,608 patients with a median age of 79 (interquartile range = 74‐84) years, of whom 521 (20.0%) patients were categorized as high risk according to geriatric screening. Patients were triaged on urgency as standard (27.2%), urgent (58.5%), and very urgent (14.3%). In total, 132 (5.1%) patients were deceased within a period of 30 days. Within every urgency triage category, 30‐day mortality was threefold higher in geriatric high‐risk compared to low‐risk patients (overall = 11.7% vs 3.4%; P < .001). The explained variance of 30‐day mortality with triage urgency was 1.0% and increased to 6.3% by adding the geriatric screener.

CONCLUSION

Combining triage urgency with geriatric screening has the potential to improve triage, which may help clinicians to deliver early appropriate care to older ED patients. J Am Geriatr Soc 68:1755‐1762, 2020.

A Call to Bridge Across Silos during Care Transitions

BACKGROUND

Older adults with complex medical conditions are vulnerable during care transitions. Poor care transitions can lead to poor patient outcomes and frequent readmissions to the hospital.

FACTORS CONTRIBUTING TO SUBOPTIMAL CARE TRANSITIONS

Key factors related to ineffective care transitions, which can lead to suboptimal patient outcomes, include poor cross-site communication and collaboration; lack of awareness of patient wishes, abilities, and goals of care; and incomplete medication reconciliation. Fundamental elements for effective care transitions put forth by The Joint Commission for effective care transitions include interdisciplinary coordination and collaboration of patient care in care transitions, shared accountability by all clinicians involved in care transitions, and provision of appropriate support and follow-up after discharge.

REVIEW OF FOUR EXISTING MODELS OF CARE TRANSITIONS

Consideration of four existing care transitions models representing different health care settings-Care Transitions Intervention® Guided Care, Interventions to Reduce Acute Care Transfers (INTERACT®), Home Health Model of Care Transitions-revealed that they are important but limited in their impact on transitions across health care settings.

PROPOSAL OF THE INTEGRATED CARE TRANSITIONS APPROACH

An innovative approach, Integrated Care Transitions Approach (ICTA), is proposed that incorporates the best practices of the four models discussed in this article and factors identified as essential for an effective care transition while addressing limitations of existing transitional care models. ICTA's four key characteristics and seven key elements are unique and stem from factors that help achieve effective care transitions.

Clinical, sonographic characteristics and long-term prognosis of valvular heart disease in elderly patients

Background

Valvular heart disease (VHD) is expected to become more prevail as the population ages and disproportionately affects older adults. However, direct comparison of clinical characteristics, sonographic diagnosis, and outcomes in VHD patients aged over 65 years is scarce. The objective of this study was to evaluate the differences in clinical characteristics and prognosis in two age-groups of geriatric patients with VHD.

Methods

We retrospectively enrolled consecutive individuals aged ≥ 65 years from Guangdong Provincial People's Hospital and screened for VHD using transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE). Finally, 260 (48.9%) patients were in the 65-74 years group, and 272 (51.1%) were in the ≥ 75-year group. Factors that affected long-term survival was explored. A multivariable Cox hazards regression was performed to identify the predictors of major adverse cardiac events (MACEs) in each group.

Results

In our population, the older group were more likely to have chronic obstructive pulmonary disease (COPD), degenerative VHD, but with less rheumatic VHD, aortic stenosis (AS) and mitral stenosis (MS). Compared with those aged 65-74 years, the older group had a higher incidence of all-cause death (10.0% vs. 16.5%, P = 0.027), ischemic stroke (13.5% vs. 20.2%, P = 0.038) and MACEs (37.3% vs. 48.2%, P = 0.011) at long-term follow-up. In multivariable Cox regression analysis, mitral regurgitation, a history of COPD, chronic kidney disease, diabetes, hypertension, atrial fibrillation and New York Heart Association (NYHA) functional class were identified as independent predictors of MACEs in the older group.

Conclusion

Advanced age profoundly affect prognosis and different predictors were associated with MACEs in geriatric patients with VHD.

The effect of systematic functional assessment and immediate rehabilitation on physical performance in acutely admitted older adults with reduced functional performance: a randomised clinical trial

Aims: We hypothesised that a systematic functional assessment in a short stay unit at an emergency department (ED) and/or immediate rehabilitation after discharge will result in sustained or improved physical performance in comparison to a regimen in which neither of these interventions is offered.Methods: A two-way factorial randomised clinical trial was completed in an ED and the primary sector. We enrolled 336 nonsurgical patients of 65 years or older, scoring eight or less in the 30-s chair stand test. The interventions were: 1) Usual assessment; 2) Usual rehabilitation; 3) A systematic functional assessment performed within 48 h of admission, in order to identify those with loss of functional mobility, or at risk thereof; and 4) Immediate rehabilitation initiated within five days after discharge. The primary outcome was the 30-s chair stand test three weeks after admission. Secondary outcome measures were Barthel, EQ-5D-3L, and length of stay (LOS).Results: An intention-to-treat analysis showed no significant difference in the 30-s chair stand test score nor when analysed by groups or by intervention. The changes were approximately 1% when compared to the reference. No significant differences were found in the secondary outcomes. A per-protocol analysis showed that 99% had received assessment as assigned; however, the extent of mobilisation during hospitalisation was not disclosed. Of the patients, 48% were received the post-discharge rehabilitation they were assigned to.Conclusions: Systematic functional assessment and immediate rehabilitation led to no significant differences in physical performance. The study was weakened by the incomplete implementation of mobilisation during hospitalisation and low adherence to protocol on immediate rehabilitation.Implications for rehabilitationA systematic functional assessment within the first 48 h of hospital admission is suitable for the identification of older adults in need of post-discharge rehabilitation when compared to usual assessment.To sustain physical performance in older adults during acute hospitalisation, further research focusing on mobilisation or physical activation is needed in older adults with a loss of functional mobility, or at risk thereof.Further research focusing on physical activation during transition is needed to ameliorate tiredness and inactivity in older adults after acute hospitalisation.

What do we know about frailty in the acute care setting? A scoping review

Background

The ability of acute care providers to cope with the influx of frail older patients is increasingly stressed, and changes need to be made to improve care provided to older adults. Our purpose was to conduct a scoping review to map and synthesize the literature addressing frailty in the acute care setting in order to understand how to tackle this challenge. We also aimed to highlight the current gaps in frailty research.

Methods

This scoping review included original research articles with acutely-ill Emergency Medical Services (EMS) or hospitalized older patients who were identified as frail by the authors. We searched Medline, CINAHL, Embase, PsycINFO, Eric, and Cochrane from January 2000 to September 2015.

Results

Our database search initially resulted in 8658 articles and 617 were eligible. In 67% of the articles the authors identified their participants as frail but did not report on how they measured frailty. Among the 204 articles that did measure frailty, the most common disciplines were geriatrics (14%), emergency department (14%), and general medicine (11%). In total, 89 measures were used. This included 13 established tools, used in 51% of the articles, and 35 non-frailty tools, used in 24% of the articles. The most commonly used tools were the Clinical Frailty Scale, the Frailty Index, and the Frailty Phenotype (12% each). Most often (44%) researchers used frailty tools to predict adverse health outcomes. In 74% of the cases frailty predicted the outcome examined, typically mortality and length of stay.

Conclusions

Most studies (83%) were conducted in non-geriatric disciplines and two thirds of the articles identified participants as frail without measuring frailty. There was great variability in tools used and more recently published studies were more likely to use established frailty tools. Overall, frailty appears to be a good predictor of adverse health outcomes. For frailty to be implemented in clinical practice frailty tools should help formulate the care plan and improve shared decision making. How this will happen has yet to be determined.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0823-2) contains supplementary material, which is available to authorized users.

The use of functional and cognitive assessment in the emergency department to inform decision making: A scoping review

BACKGROUND

The use of functional and/or cognitive assessment in the emergency department (ED) to inform decision making in the complex older adult is considered important, yet not routinely administered.

METHOD

Electronic databases were searched to identify eligible published research studies: older adults >65 years; the administration of a functional and/or cognition assessment instrument whilst the older adult is in any part of the ED; interventions resulting from the administration of the instrument; and a measured outcome post ED visit. A revised scoping review methodology was applied to chart study data and to identify key differences.

RESULTS

Ten research studies were identified that met the criteria for review. There are a variety of assessments, aimed at different age groups, for several purposes and used at different times in the ED journey. Assessments are not being used in conjunction with routine medical assessment early in the ED patient journey.

CONCLUSION

This scoping review identified no consistent suite of tools being administered in the ED to influence the disposition decision with measurable outcomes. Further research is required to identify a suite of assessment instruments suitable for use in the ED setting aimed at improving disposition decision making in the complex elderly person.

Can routine clinical data identify older patients at risk of poor healthcare outcomes on admission to hospital?

Objective

Older patients who are at risk of poor healthcare outcomes should be recognised early during hospital admission to allow appropriate interventions. It is unclear whether routinely collected data can identify high-risk patients. The aim of this study was to define current practice with regard to the identification of older patients at high risk of poor healthcare outcomes on admission to hospital.

Results

Interviews/focus groups were conducted to establish the views of 22 healthcare staff across five acute medicine for older people wards in one hospital including seven nurses, four dieticians, seven doctors, and four therapists. In addition, a random sample of 60 patients’ clinical records were reviewed to characterise the older patients, identify risk assessments performed routinely on admission, and describe usual care. We found that staff relied on their clinical judgment to identify high risk patients which was influenced by a number of factors such as reasons for admission, staff familiarity with patients, patients’ general condition, visible frailty, and patients’ ability to manage at home. “Therapy assessment” and patients’ engagement with therapy were also reported to be important in recognising high-risk patients. However, staff recognised that making clinical judgments was often difficult and that it might occur several days after admission potentially delaying specific interventions. Routine risk assessments carried out on admission to identify single healthcare needs included risk of malnutrition (completed for 85% patients), falls risk (95%), moving and handling assessments (85%), and pressure ulcer risk assessments (88%). These were not used collectively to highlight patients at risk of poor healthcare outcomes. Thus, patients at risk of poor healthcare outcomes were not explicitly identified on admission using routinely collected data. There is a need for an early identification of these patients using a valid measure alongside staff clinical judgment to allow timely interventions to improve healthcare outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2705-7) contains supplementary material, which is available to authorized users.

[Profile and evolution of chronic complex patients in a subacute unit]

Objetivo

Para mejorar el manejo de pacientes pluripatológicos, en Cataluña se ha promovido la identificación como paciente crónico complejo (PCC) o con enfermedad crónica avanzada (MACA). Ante descompensaciones se promueve el ingreso de estos pacientes en unidades de subagudos (SG) ubicadas en hospitales de atención intermedia y especializadas en geriatría, como alternativa al hospital de agudos. Queremos evaluar los resultados del ingreso de PCC/MACA en SG.

Diseño

Estudio cuantitativo descriptivo-comparativo, transversal.

Emplazamiento

Unidad de subagudos de un hospital de atención intermedia.

Participantes

Pacientes ingresados consecutivamente en SG durante 6 meses.

Mediciones principales

Comparamos características basales (datos demográficos, clínicos y de valoración geriátrica integral), resultados al alta y a 30 días post-alta entre pacientes identificados como PCC/MACA vs otros pacientes.

Resultados

De 244 pacientes (promedio edad ± DE = 85,6 ± 7,5; 65,6% mujeres), 91 (37,3%) eran PCC/MACA (PCC = 79,1%, MACA = 20,9%). Estos, comparado con los no identificados, presentaban mayor comorbilidad (Charlson = 3,2 ± 1,8 vs 2,0; p = 0,001) y polifarmacia (9,5 ± 3,7 fármacos vs 8,1 ± 3,8, p = 0,009). Al alta, el retorno al domicilio habitual y la mortalidad fueron comparables. PCC/MACA tuvieron mayor mortalidad sumando los 30 días post-alta (15,4% vs 8%; p = 0,010); en un análisis multivariable, la identificación PCC/MACA (p = 0,006) y demencia (p = 0,004) se asociaba a mayor mortalidad. A pesar de que PCC/MACA reingresaban más a 30 días (18,7% vs 10,5%; p = 0,014), en el análisis multivariable las únicas variables asociadas independientemente a reingresos fueron sexo masculino, polifarmacia e insuficiencia cardiaca.

Conclusiones

A pesar de mayor comorbilidad y polifarmacia, los resultados de PCC/MACA al alta de SG fueron comparables con los otros pacientes, aunque experimentaron más reingresos a 30 días, posiblemente por su comorbilidad y polimedicación.

Comparison of self-reported and performance-based measures of functional ability in elderly patients in an emergency department: implications for selection of clinical outcome measures

Background

Assessment of functional ability in elderly patients is often based on self-reported rather than performance-based measures. This study aims to compare self-reported and performance-based measures of functional ability in a population of elderly patients at an emergency department (ED).

Methods

Participants were 61 patients aged 65 years and above admitted to an ED. The self-reported measure used was the Barthel-20; the performance-based measures were Timed Up and Go (TUG); 30s-Chair Stand Test (30s-CST) and Assessment of Motor and Process Skills (AMPS) with the two scales; motor and process. Correlation analyses were conducted to examine the relationships between the self-reported and performance-based measures of functional ability.

Results

The correlation between the Barthel-20 and the TUG was moderate (r = −0.64). The correlation between the Barthel-20 and the AMPS motor was also moderate (r = 0.53). The correlation between the Barthel-20 and the 30s-CST was fair (r = 0.45). The correlation between Barthel-20 and the AMPS process was non-significant. The results were affected by high ceiling effect (Barthel-20).

Conclusion

Self-reported and performance-based measures seem to assess different aspects of functional ability. Thus, the two methods provide different information, and this highlight the importance of supplementing self-reported measures with performance-based measures when assessing functional ability in elderly patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0376-1) contains supplementary material, which is available to authorized users.

Heart valve disease in elderly Chinese population: effect of advanced age and comorbidities on treatment decision-making and outcomes

Background

A considerable proportion of elderly patients with symptomatic severe heart valve disease are treated conservatively despite clear indications for surgical intervention. However, little is known about how advanced age and comorbidities affect treatment decision-making and therapeutic outcomes.

Methods

Patients (n = 234, mean age: 78.5 ± 3.7 years) with symptomatic severe heart valve disease hospitalized in our center were included. One hundred and fifty-one patients (65%) were treated surgically (surgical group) and 83 (35%) were treated conservatively (conservative group). Factors that affected therapeutic decision-making and treatment outcomes were investigated and long-term survival was explored.

Results

Isolated aortic valve disease, female sex, chronic renal insufficiency, aged ≥ 80 years, pneumonia, and emergent status were independent factors associated with therapeutic decision-making. In-hospital mortality for the surgical group was 5.3% (8/151). Three patients (3.6%) in the conservative group died during initial hospitalization. Low cardiac output syndrome and chronic renal insufficiency were identified as predictors of in-hospital mortality in the surgical group. Conservative treatment was identified as the single risk factor for late death in the entire study population. The surgical group had better 5-year (77.2% vs. 45.4%, P < 0.0001) and 10-year (34.5% vs. 8.9%, P < 0.0001) survival rates than the conservative group, even when adjusted by propensity score-matched analysis.

Conclusions

Advanced age and geriatric comorbidities profoundly affect treatment decision-making for severe heart valve disease. Valve surgery in the elderly was not only safe but was also associated with good long-term survival while conservative treatment was unfavorable for patients with symptomatic severe valve disease.

Therapeutic Decision-Making for Elderly Patients With Symptomatic Severe Valvular Heart Diseases

The aim of this study was to determine how older age and co-morbidities affect the treatment decision-making and long-term survival in elderly patients with symptomatic severe valvular heart diseases.A total of 181 elderly patients (mean age, 78.4 ± 3.4 years) hospitalized between January 2003 and June 2012 with symptomatic severe valvular heart diseases were enrolled. Cardiac and geriatric factors associated with treatment decision-making were analyzed. Survival outcomes were investigated.Surgical treatment was performed in 116 (64%) patients (surgical group) and 65 patients (36%) were treated conservatively (conservative group). The most common [62% (40/65)] reason for refusing surgical treatment was high operative risk as assessed by the physicians who initially cared for the patients. Multivariate logistic regression analysis identified female gender, chronic renal insufficiency, older age, pneumonia, and emergent status as independent predictors of the conservative treatment. Patients with isolated aortic valve disease tended to undergo an operation. Overall 5-year survival in the surgical group was 76.8% versus 42.9% in the conservative group (P < 0.0001). After matching using the propensity score, the surgical group still had a better long-term survival than the conservative group (P = 0.001). Cox regression analysis revealed conservative treatment as the single risk factor associated with poor long-term survival in all series.Approximately 40% of the elderly patients with symptomatic severe heart valve disease were treated conservatively despite a definite indication for surgical intervention. Cardiac and geriatric co-morbidities profoundly affect the treatment decision-making. Interdisciplinary discussion should be encouraged to optimize therapeutic options for elderly patients with valvular heart disease.

Management of Patients Aged ≥85 Years With ST-Elevation Myocardial Infarction

Guidelines mandate urgent revascularization in patients presenting with ST-elevation myocardial infarction (STEMI) irrespective of age. Whether this strategy is optimal in patients aged ≥85 years remains uncertain. We aimed to assess the clinical characteristics and outcomes of patients aged ≥85 years with STEMI stratified by their management strategy. We analyzed baseline clinical characteristics of 101 consecutive patients aged ≥85 years who presented with STEMI to a tertiary Australian hospital. Patients were stratified based on whether they underwent invasive management with urgent coronary angiography ± percutaneous coronary intervention or conservative management. Our primary outcome was long-term mortality. Independent predictors of conservative management and long-term mortality were assessed by multivariate logistic regression and Cox proportional hazard modeling respectively. Of the 101 patients included, 45 underwent invasive management. Independent predictors of having conservative management were older age, anterior STEMI, and cognitive impairment (all p <0.01). Patients managed invasively had lower in-hospital (13.3% vs 32.1%, p = 0.03), 30-day (13.3% vs 37.5%, p <0.01), 12-month (22.2% vs 57.1%, p <0.01), and long-term (40.0% vs 75.0%, p <0.01) mortality. Invasive management was an independent predictor of lower long-term mortality (hazard ratio 0.29, 95% CI 0.11 to 0.76, p <0.01). In conclusion, patients aged ≥85 years with STEMI who were older, had cognitive impairment or presented with anterior ST-elevation were more likely to be managed conservatively. Those who underwent invasive management had reasonable short- and long-term outcomes.

National Survey of Geriatricians to Define Functional Decline in Elderly People with Minor Trauma

Background

This study was designed to determine a clinically significant point drop in function to define functional decline and the required sensitivity for a clinical decision tool to identify elderly patients at high risk of functional decline following a minor injury.

Methods

After a rigorous development process, a survey questionnaire was administered to a random sample of 178 geriatricians selected from those registered in a national medical directory. The surveys were distributed using a modified Dillman technique.

Results

We obtained a satisfactory response rate of 70.5%. Ninety percent of the geriatricians required a sensitivity of 90% or less for a clinical decision tool to identify injured seniors at high risk of functional decline 6 months post injury. Our results indicate that 90% of the respondents considered a drop in function of at least 2 points in activities of daily living (ADL) as clinically significant when considering all 14 ADL items. Considering only the 7 basic ADL items, 90% of physicians considered a 1 point drop as clinically significant.

Conclusions

A tool with a sensitivity of 90% to detect patients at risk of functional decline at 6 months post minor injury would meet or exceed the sensitivity required by 90% of geriatric specialists. These findings clearly define what is a clinically significant decline following a “minor injury.”

Self-Reported Versus Performance-Based Assessments of a Simple Mobility Task Among Older Adults in the Emergency Department

STUDY OBJECTIVE

Accurate information about the mobility of independently living older adults is essential in determining whether they may be safely discharged home from the emergency department (ED). We assess the accuracy of self-reported ability to complete a simple mobility task among older ED patients.

METHODS

This was a cross-sectional study of cognitively intact patients aged 65 years and older who were neither nursing home residents nor critically ill, conducted in 2 academic EDs. Consenting participants were asked whether they could get out of bed, walk 10 feet, turn around, and get back in bed without assistance, and if not, whether they could perform this task with a cane, walker, or assistance. Each participant was then asked to perform the task and was provided with a mobility device or assistance as needed.

RESULTS

Of 272 patients who met eligibility criteria and answered the physical task question, 161 (59%) said they could do the task unassisted, 45 (17%) said they could do it with a cane or walker, 21 (8%) said they could do it with assistance, and 45 (17%) said they would be unable to do it even with assistance. Among those who said they could do the task either with or without assistance and who were subsequently willing to attempt the task (N=172), discrepancies between self-reported ability and actual performance were common. Of those who said they could perform the task without assistance, 12% required some assistance or were unable to complete the task. Of those who said they could perform the task with a cane or walker, 48% required either assistance or were unable to perform the task. Of those who said they could perform the task with assistance, 24% were unable to perform the task even with assistance.

CONCLUSION

In this sample of older adults receiving care in the ED, the accuracy of their self-reported ability to perform a simple mobility task was poor, particularly for those who reported some need for assistance. For older adults being considered for discharge who report a need for assistance with mobility, direct observation of the patient's mobility by a member of the emergency care team should be considered.

Use of a risk nomogram to predict emergency department reattendance in older people after discharge: a validation study

In older people, revisit to the emergency department (ED) in the short period after discharge is not entirely avoidable, but in a proportion of cases is preventable, and should ideally be minimised. We have previously derived a risk probability nomogram to predict the likelihood of revisit. In this study, we sought to validate the nomogram for use as a general risk stratification tool for use in older people being discharged from ED. We conducted a prospective cohort study, applying the nomogram to consecutive community dwelling discharged patients aged 65 and over. Patients were followed up at 28 days post-discharge to determine whether there had been any unplanned ED revisit in that period. We cross tabulated predicted risk versus revisit rates. In 1143 study subjects, we find the odds of revisit increases progressively with increasing strata of predicted risk, culminating in an OR of 9.7 (95% CI 4.7-19.9) in the highest risk group. The 28-day revisit rates across strata range from 16% through 65%, with the difference between strata being statistically highly significant (p < 0.001). The area under the ROC curve is 0.65. We conclude that the risk nomogram can classify older people discharged from ED into risk strata, and has modest overall predictive value.

Characteristics of older adults admitted to the emergency department (ED) and their risk factors for ED readmission based on comprehensive geriatric assessment: a prospective cohort study

Background

Patients aged 75 years and older represent 12% of the overall emergency department (ED) population, and this proportion will increase over the next decades. Many of the discharged patients suffer an unplanned readmission in the immediate and midterm post-discharge period, suggesting under recognition of psychosocial, cognitive and medical problems. The aim of this study was to compare the characteristics of older patients admitted and discharged from the ED and to determine independent predictors for ED readmission 1 month and 3 months after ED discharge based on comprehensive geriatric assessment (CGA).

Methods

Cohort study in a Belgian university hospital. A CGA, including demographic and medical data (e.g. reason for admission, comorbidity, number of medications), functional (e.g. activities of daily living, falls), mental (i.e. cognition, dementia, delirium), and nutritional status, and pain, was performed in 442 ED patients aged 75 years or older.

Results

Patients discharged from the ED (n = 117, 26.5%) were significantly less dependent for ADL, mobility, shopping and finances compared with hospitalised patients. Hospitalised patients (n = 325, 73.5%) were significantly more at risk for having nutritional problems, had a higher comorbidity index, and a lower cognitive status compared with those discharged. Ninety-seven patients (82.9%) were discharged home from the ED. Of the latter, 18 (18.6%) and 28 patients (28.9%) suffered an ED readmission within 1 and 3 months, respectively. At one month post-discharge, nursing care at home, meals on wheels, and risk for depression; and at 3 months post-discharge previous hospitalisation in the last 3 months, physiotherapy and meals on wheels were found to be independent predictors for ED readmission, respectively.

Conclusions

This study observed a geriatric risk profile in older adults at the ED and a high readmission rate of those discharged, and suggests the potential value of CGA in identifying older patients at high risk for ED readmission.

A qualitative evaluation of the crucial attributes of contextual information necessary in EHR design to support patient-centered medical home care

Background

Effective implementation of a Primary Care Medical Home model of care (PCMH) requires integration of patients’ contextual information (physical, mental, social and financial status) into an easily retrievable information source for the healthcare team and clinical decision-making.

This project explored clinicians’ perceptions about important attributes of contextual information for clinical decision-making, how contextual information is expressed in CPRS clinical documentation as well as how clinicians in a highly computerized environment manage information flow related to these areas.

Methods

A qualitative design using Cognitive Task Analyses and a modified Critical Incident Technique were used. The study was conducted in a large VA with a fully implemented EHR located in the western United States. Seventeen providers working in a PCMH model of care in Primary Care, Home Based Care and Geriatrics reported on a recent difficult transition requiring contextual information for decision-making. The transcribed interviews were qualitatively analyzed for thematic development related to contextual information using an iterative process and multiple reviewers with ATLAS@ti software.

Results

Six overarching themes emerged as attributes of contextual information: Informativeness, goal language, temporality, source attribution, retrieval effort, and information quality.

Conclusions

These results indicate that specific attributes are needed to in order for contextual information to fully support clinical decision-making in a Medical Home care delivery environment. Improved EHR designs are needed for ease of contextual information access, displaying linkages across time and settings, and explicit linkages to both clinician and patient goals. Implications relevant to providers’ information needs, team functioning and EHR design are discussed.

Geriatric syndromes predict postdischarge outcomes among older emergency department patients: findings from the interRAI Multinational Emergency Department Study

OBJECTIVES

Identifying older emergency department (ED) patients with clinical features associated with adverse postdischarge outcomes may lead to improved clinical reasoning and better targeting for preventative interventions. Previous studies have used single-country samples to identify limited sets of determinants for a limited number of proxy outcomes. The objective of this study was to identify and compare geriatric syndromes that influence the probability of postdischarge outcomes among older ED patients from a multinational context.

METHODS

A multinational prospective cohort study of ED patients aged 75 years or older was conducted. A total of 13 ED sites from Australia, Belgium, Canada, Germany, Iceland, India, and Sweden participated. Patients who were expected to die within 24 hours or did not speak the native language were excluded. Of the 2,475 patients approached for inclusion, 2,282 (92.2%) were enrolled. Patients were assessed at ED admission with the interRAI ED Contact Assessment, a geriatric ED assessment. Outcomes were examined for patients admitted to a hospital ward (62.9%, n=1,436) or discharged to a community setting (34.0%, n=775) after an ED visit. Overall, 3% of patients were lost to follow-up. Hospital length of stay (LOS) and discharge to higher level of care was recorded for patients admitted to a hospital ward. Any ED or hospital use within 28 days of discharge was recorded for patients discharged to a community setting. Unadjusted and adjusted odds ratios (ORs) were used to describe determinants using standard and multilevel logistic regression.

RESULTS

A multi-country model including living alone (OR=1.78, p≤0.01), informal caregiver distress (OR=1.69, p=0.02), deficits in ambulation (OR=1.94, p≤0.01), poor self-report (OR = 1.84, p≤0.01), and traumatic injury (OR=2.18, p≤0.01) best described older patients at risk of longer hospital lengths of stay. A model including recent ED visits (OR=2.10, p≤0.01), baseline functional impairment (OR=1.68, p≤0.01), and anhedonia (OR=1.73, p≤0.01) best described older patients at risk of proximate repeat hospital use. A sufficiently accurate and generalizable model to describe the risk of discharge to higher levels of care among admitted patients was not achieved.

CONCLUSIONS

Despite markedly different health care systems, the probability of long hospital lengths of stay and repeat hospital use among older ED patients is detectable at the multinational level with moderate accuracy. This study demonstrates the potential utility of incorporating common geriatric clinical features in routine clinical examination and disposition planning for older patients in EDs.

Comparing narrative versus numerical display of functional information: impact on sense-making

Contextual information consists of functional, social, and financial information about patients. Physicians routinely have difficulty incorporating contextual information into clinical decision-making despite the emphasis on patient-centered care and functional status. One reason for this difficulty is that such information is not well-represented in the patient medical record. This study assesses the impact of a "story-form" model versus a "medical" model on a practitioner's ability to recall and incorporate contextual information. We assessed this question through the analysis of responses of 30 clinicians to 2 vignettes presenting contextual information in both formats. Overall, there was a statistically significant difference between the narrative and numerical form with those receiving the narrative form for contextual information being more likely to consider it a top issue. Reference to goals in the report of key clinical factors was also significantly higher for the group receiving goal information. Implications for sharing contextual information in EMRs are discussed.

Geriatric assessment in frail older patients in the emergency department

Emergency care of elderly patients is frequent and complex in the emergency department. Frail older patients have a high risk of poor short-term results following emergency care. There is no practical universal or standardized tool defining frailty. It must be systematically identified in older patients at risk using a screening test, and in those who are positive, a diagnostic scale of frailty or preferably a geriatric scale adapted to emergency care is carried out. An adapted geriatric assessment including brief scales related to clinical, mental, functional and social aspects has been proposed. There are currently no geriatric intervention models with sufficient evidence in frail older patients.

Joint segmentation and named entity recognition using dual decomposition in Chinese discharge summaries

OBJECTIVE

In this paper, we focus on three aspects: (1) to annotate a set of standard corpus in Chinese discharge summaries; (2) to perform word segmentation and named entity recognition in the above corpus; (3) to build a joint model that performs word segmentation and named entity recognition.

DESIGN

Two independent systems of word segmentation and named entity recognition were built based on conditional random field models. In the field of natural language processing, while most approaches use a single model to predict outputs, many works have proved that performance of many tasks can be improved by exploiting combined techniques. Therefore, in this paper, we proposed a joint model using dual decomposition to perform both the two tasks in order to exploit correlations between the two tasks. Three sets of features were designed to demonstrate the advantage of the joint model we proposed, compared with independent models, incremental models and a joint model trained on combined labels.

MEASUREMENTS

Micro-averaged precision (P), recall (R), and F-measure (F) were used to evaluate results.

RESULTS

The gold standard corpus is created using 336 Chinese discharge summaries of 71 355 words. The framework using dual decomposition achieved 0.2% improvement for segmentation and 1% improvement for recognition, compared with each of the two tasks alone.

CONCLUSIONS

The joint model is efficient and effective in both segmentation and recognition compared with the two individual tasks. The model achieved encouraging results, demonstrating the feasibility of the two tasks.

Functional assessments utilised in emergency departments: a systematic review

BACKGROUND

functional assessment is an important component of the management of older adults in the emergency department (ED) as the function level has been identified as a predictor of adverse events including ED re-presentation. A systematic review (SR) of all functional assessments utilised in EDs has not been undertaken making assessment selection, on the basis of evidence, difficult for staff.

OBJECTIVE

this SR: (i) identified functional assessments that have been utilised in ED settings, (ii) examined what psychometric properties analysis has been completed and (iii) established recommendations for practice.

METHODS

electronic database searching was completed utilising key search terms. Articles were reviewed using pre-determined inclusion criteria. Each study was appraised using quality criteria for aspects of validity and reliability in addition to clinical utility, interpretability and responsiveness. Recommendations for practice were determined on the basis of the extent of psychometric data generated in ED settings and whether or not the assessment was specifically developed for ED use.

RESULTS

a total of 332 articles were identified of which 43 articles utilising 14 functional assessments were retained. Psychometric testing was scarce. Functional assessment has been reported internationally and only with older adults. Following appraisal four assessments [the Identification of Seniors at Risk (ISAR), Triage Risk Stratification Tool (TRST), Older Adult Resources and Services (OARS) and Functional Status Assessment of Seniors in Emergency Departments (FSAS-ED)] were recommended for practice with moderate reservations.

CONCLUSION

the ISAR or TRST are suitable for fast screening, whereas the OARS or FSAS-ED are more suitable for a comprehensive understanding of functional performance. Further research is warranted and recommendations for ED assessment may change as more becomes known about psychometric properties and clinical applications of other assessments.

The role of the electronic medical record in the assessment of health related quality of life

We applied a hybrid Natural Language Processing (NLP) and machine learning (ML) approach (NLP-ML) to assessment of health related quality of life (HRQOL). The approach uses text patterns extracted from HRQOL inventories and electronic medical records (EMR) as predictive features for training ML classifiers. On a cohort of 200 patients, our approach agreed with patient self-report (EQ5D) and manual audit of the EMR 65-74% of the time. In an independent cohort of 285 patients, we found no association of HRQOL (by EQ5D or NLP-ML) with quality measures of metabolic control (HbA1c, Blood Pressure, Lipids). In addition; while there was no association between patient self-report of HRQOL and cost of care, abnormalities in Usual Activities and Anxiety/Depression assessed by NLP-ML were 40-70% more likely to be associated with greater health care costs. Our method represents an efficient and scalable surrogate measure of HRQOL to predict healthcare spending in ambulatory diabetes patients.

Efficiency and applicability of comprehensive geriatric assessment in the emergency department: a systematic review

BACKGROUND AND AIMS

Comprehensive geriatric assessment (CGA) may benefit frail or chronically ill patients in the emergency department (ED), but take too much time to be performed routinely in ED. An alternative approach is to use first a screening tool to detect high-risk patients and then perform CGA in these patients only. This systematic review focuses on the use and value of CGA in ED for evaluation of older patients and its influence on adverse outcomes. This approach is compared with an alternative one using existing screening tools, validated in ED, to detect high-risk patients needing subsequent CGA. This review ends by suggesting a short assessment of CGA to be used in ED and ways to improve home discharge management from ED.

METHODS

A systematic English Medline literature search was conducted in December 2009, with no date limit with the following Medical Subject Heading (MeSH) terms: "Frail Elderly", "Health Services for Aged", "Community Health Nursing", "Emergency Service, Hospital", "Geriatric Assessment", "Patient Discharge", "Risk Assessment" and "Triage".

RESULTS

We selected 8 studies on CGA efficiency and 14 on screening tools. CGA in ED is efficient for decreasing functional decline, ED readmission and possibly nursing home admission in high-risk patients. As CGA takes too much time to be performed routinely in ED, validated screening tools can be applied to detect high-risk patients who will benefit most from CGA.

CONCLUSIONS

The selected studies demonstrated that screening of high-risk patients is more efficient than age-based screening, and that CGA performed in ED, followed by appropriate interventions, improves outcomes.

Research priorities for high-quality geriatric emergency care: medication management, screening, and prevention and functional assessment

BACKGROUND

Geriatric adults represent an increasing proportion of emergency department (ED) users and can be particularly vulnerable to acute illnesses. Health care providers have recently begun to focus on the development of quality indicators (QIs) to define a minimal standard of care.

OBJECTIVES

The original objective of this project was to develop additional ED-specific QIs for older patients within the domains of medication management, screening and prevention, and functional assessment, but the quantity and quality of evidence were insufficient to justify unequivocal minimal standards of care for these three domains. Accordingly, the authors modified the project objectives to identify key research opportunities within these three domains that can be used to develop QIs in the future.

METHODS

Each domain was assigned one or two content experts who created potential QIs based on a systematic review of the literature, supplemented by expert opinion. Candidate QIs were then reviewed by four groups: the Society for Academic Emergency Medicine (SAEM) Geriatric Task Force, the SAEM Geriatric Interest Group, and audiences at the 2008 SAEM Annual Meeting and the 2009 American Geriatrics Society Annual Meeting, using anonymous audience response system technology as well as verbal and written feedback.

RESULTS

High-quality evidence based on patient-oriented outcomes was insufficient or nonexistent for all three domains. The participatory audiences did not reach a consensus on any of the proposed QIs. Key research questions for medication management (three), screening and prevention (two), and functional assessment (three) are presented based on proposed QIs that the majority of participants accepted.

CONCLUSIONS

In assessing a minimal standard of care by which to systematically derive geriatric QIs for medication management, screening and prevention, and functional assessment, compelling clinical research evidence is lacking. Patient-oriented research questions that are essential to justify and characterize future QIs within these domains are described.

Grau de dependência de idosos hospitalizados para realização das atividades básicas da vida diária

Este estudo objetivou identificar o grau de dependência de idosos hospitalizados para a realização das Atividades Básicas da Vida Diária. Trata-se de estudo quantitativo, transversal e descritivo, desenvolvido na Enfermaria de Adultos do Pronto-Socorro do Hospital das Clínicas de Botucatu. A coleta de dados ocorreu mediante entrevistas, observação e consulta nos prontuários individuais. Os dados foram analisados com pacote estatístico SAS for Windows, versão 9.2, utilizando regressão logística. A amostra foi constituída por 71 sujeitos, com idade média de 74,30 anos. Verificou-se que 30,99% dos idosos se apresentaram independentes na realização das atividades propostas, 22,53%, parcialmente dependentes e 46,48% totalmente dependentes. O cuidado em gerontologia deve estar voltado para a manutenção do estado funcional, promovendo-se a independência e preservando a dignidade dos sujeitos.

[Cognitive assessment of elderly patients in the emergency department: a comparison between standard tools, medical records and physicians' perception]

INTRODUCTION

We evaluated the accuracy of physician recognition of cognitive impairment in elderly patients in emergency departments (ED). In particular, we evaluated the accuracy of the subjective impression of the physician on patients' cognition (a comparison of the information obtained from the responsible physician with the S-IQCODE, a cognitive impairment screening test), and the accuracy of the medical records (a comparison of the information in the medical record with the S-IQCODE).

MATERIAL AND METHODS

Cross-sectional study on 101 elderly patients selected at random from those attending ED, their ED physicians, and family member-carer. The study was conducted in the ED of four tertiary university teaching hospitals in a city, from July through November 2003. Cognitive data shown in the patient's medical records were compared against the S-IQCODE obtained from the family member-carer, using the kappa (kappa) concordance index. The physicians' impressions on the patients' cognitive status were also compared against the S-IQCODE results, using the kappa (kappa) concordance index. Each patient and their family member-carer were paired with a single physician. A logistic regression model was constructed to identify factors associated with the physicians' impressions of the patients' cognitive capacity.

RESULTS

The concordance between information on cognitive decline from medical records and the results of the S-IQCODE, was 0.47 (IC95%: 0.05-0.88). Concordance between the physicians' impression on the presence of cognitive impairment, and the S-IQCODE obtained from family member-carer was 0.26 (IC95% 0.06-0.45). The multivariate analysis demonstrated that the functional status of patients, as perceived by the physicians, were the variable that better explained the physicians' impressions of patient cognitive function.

CONCLUSIONS

The cognitive status of elderly patients is not properly assessed by emergency department physicians.

Prevalence of functional disability in activities of daily living (ADL), instrumental activities of daily living (IADL) and associated factors, as predictors of morbidity and mortality

The aim of this study is to establish the existing relationship among variables referred to the person, specifically age and gender, and the functional dependence in basic ADL and in IADL, as well as the possible relationship it has with the increase of morbidity and mortality in a random sample of 598 individuals older than 65 years. Of these individuals, 34.6% were categorized as dependent for at least one ADL, and 53.5% if we refer to IADL. Regarding the ADL, the risk of dependence increases (odds ratio=OR=1.089) per year of age, (OR=2.48) in women's case; while there is an IADL correlation between age and the score (r=-0.527; p<0.001). A relationship exists between dependence and the days of hospitalization (for ADL: r=-0.12, p=0.018 and IADL: r=-0.97, p=0.003), the number of visits to the doctor (ADL: r=-0.27, p<0.001; IADL: r=-0.25, p<0.001) or the presence of concomitant pathologies such as dementia (ADL: p<0.001; IADL: p<0.001). There is a significant association between age, gender and dependence, as well as between dependence and morbidity and mortality, so that dependence could be used as a predictor of both.

Do ED staffs have a role to play in the prevention of repeat falls in elderly patients?

BACKGROUND

Fall-related morbidity is a serious public health issue in older adults referred to emergency departments (EDs). Emergency physicians mostly focus on immediate injuries, whereas the specific assessment of functional consequences and opportunities for prevention remain scarce. The aim of this study was to determine the factors influencing 6-month independence.

METHODS

We used a prospective observational study at the ED of a tertiary teaching hospital over a 6-month period. Uni- and multivariate assessments of factors related to loss of independence were examined.

RESULTS

A total of 367 patients survived to 6 months, mean age was 86 years, and 79% were women. The population was initially healthy and independent. Because this independence reassured the medical staff, more than 42% percent were directly discharged home without any improvement of home facilities; only 63% had recovered their independence at the end of the follow-up. There were 111 patients were hospitalized for 30 days or more. Older patients, initial Katz score, and absence of immediate trauma consequences were associated with an increased risk for loss of independence.

CONCLUSIONS

Because prevention is an emerging role of ED, a multidisciplinary team should evaluate fallers and propose medical and environmental changes as required for those discharged after their ED visit.

The elderly in the emergency department: a critical review of problems and solutions

The elderly are an ever increasing population in overcrowded emergency departments (EDs) in many countries. They have multiple health problems and consume more time and resources than younger patients. They are more frequently admitted and experience adverse outcomes after they are discharged from the ED. These frail patients could require specific skills, instruments and organisational models of emergency care in order to look after their complex needs. As such, several approaches have been tried and tested to improve emergency care for them. This article analyses the epidemiological load and problems faced when confronted with elder ED patients. We critically review organisational models, clinical approaches and methodologies in order to reduce ED physicians' difficulties and to improve quality of care and outcomes for elder patients. Triage, clinical assessment and discharge are identified as critical moments during an emergency care process, and interesting and useful instruments are proposed as possible solutions.