Structure and processes of emergency observation units with a geriatric focus: a scoping review

Service provision for Frailty in European Emergency Departments (FEED): a survey of operational characteristics

BACKGROUND

The observational Frailty in European Emergency Departments (FEED) study found 40% of older people attending for care to be living with frailty. Older people with frailty have poorer outcomes from emergency care. Current best practice calls for early identification of frailty and holistic multidisciplinary assessment. This survey of FEED sites explores variations in frailty-attuned service definitions and provision.

METHODS

This cross-sectional survey included study sites across Europe identified through snowball recruitment. Site co-ordinators (healthcare professionals in emergency and geriatric care) were surveyed online using Microsoft Forms. Items covered department and hospital capacity, frailty and delirium identification methods, staffing, and frailty-focused healthcare services in the ED. Descriptive statistics were reported.

RESULTS

A total of 68 sites from 17 countries participated. Emergency departments had median 30 (IQR 21-53) trolley spaces. Most defined "older people" by age 65+ (64%) or 75+ (25%). Frailty screening was used at 69% of sites and mandated at 38%. Night-time staffing was lower compared to day-time for nursing (10 [IQR 8-14] vs. 14 [IQR 10-18]) and physicians (5 [IQR 3-8] vs. 10 [IQR 7-15]). Most sites had provision for ED frailty specialist services by day, but these services were rarely available at night. Sites mostly had accessible facilities; however, hot meals were rarely available at night (18%).

CONCLUSION

This survey demonstrated variability in case definitions, screening practices, and frailty-attuned service provision. There is no unanimous definition for older age, and while the Clinical Frailty Scale was commonly used, this was rarely mandated or captured in electronic records. Frailty services were often unavailable overnight. Appreciation of the variation in frailty service models could inform operational configuration and workforce development.

Prevalence of Frailty in European Emergency Departments (FEED): an international flash mob study

INTRODUCTION

Current emergency care systems are not optimized to respond to multiple and complex problems associated with frailty. Services may require reconfiguration to effectively deliver comprehensive frailty care, yet its prevalence and variation are poorly understood. This study primarily determined the prevalence of frailty among older people attending emergency care.

METHODS

This cross-sectional study used a flash mob approach to collect observational European emergency care data over a 24-h period (04 July 2023). Sites were identified through the European Task Force for Geriatric Emergency Medicine collaboration and social media. Data were collected for all individuals aged 65 + who attended emergency care, and for all adults aged 18 + at a subset of sites. Variables included demographics, Clinical Frailty Scale (CFS), vital signs, and disposition. European and national frailty prevalence was determined with proportions with each CFS level and with dichotomized CFS 5 + (mild or more severe frailty).

RESULTS

Sixty-two sites in fourteen European countries recruited five thousand seven hundred eighty-five individuals. 40% of 3479 older people had at least mild frailty, with countries ranging from 26 to 51%. They had median age 77 (IQR, 13) years and 53% were female. Across 22 sites observing all adult attenders, older people living with frailty comprised 14%.

CONCLUSION

40% of older people using European emergency care had CFS 5 + . Frailty prevalence varied widely among European care systems. These differences likely reflected entrance selection and provide windows of opportunity for system configuration and workforce planning.

Risk identification and prediction of complaints and misconduct against health practitioners: a scoping review

Identifying the risk and predicting complaints and misconduct against health practitioners are essential for healthcare regulators to implement early interventions and develop long-term prevention strategies to improve professional practice and enhance patient safety. This scoping review aims to map out existing literature on the risk identification and prediction of complaints and misconduct against health practitioners. This scoping review followed Arksey and O'Malley's five-stage methodological framework. A comprehensive literature search was conducted on MEDLINE, EMBASE, and CINAHL databases and finished on the same day (6 September 2021). Articles meeting the eligibility criteria were charted and descriptively analysed through a narrative analysis method. The initial search generated 5473 articles. After the identification, screening, and inclusion process, 81 eligible studies were included for data charting. Three key themes were reported: methods used for identifying risk factors and predictors of the complaints and misconduct, synthesis of identified risk factors and predictors in eligible studies, and predictive tools developed for complaints and misconduct against health practitioners. The findings reveal that risk identification and prediction of complaints and misconduct are complex issues influenced by multiple factors, exhibiting non-linear patterns and being context specific. Further efforts are needed to understand the characteristics and interactions of risk factors, develop systematic risk prediction tools, and facilitate the application in the regulatory environment.

A consensus statement on minimum operational standards for geriatric emergency care in Belgium: a modified Delphi study

BACKGROUND

As emergency department (ED) leaders started integrating geriatric emergency guidelines on a facultative basis, important variations have emerged between EDs in care for older patients. The aim of this study was to establish a consensus on minimum operational standards for Geriatric ED care in Belgium.

METHODS

A two-stage modified Delphi study was conducted. Twenty panellists were recruited from Dutch and French speaking regions in Belgium to join an interdisciplinary expert panel. In the first stage, an online survey was conducted to identify and define all possible elements of geriatric emergency care. In the second stage, an online survey and online expert panel meeting were organized consecutively to determine which elements should be recognized as minimum operational standards.

RESULTS

Between March 2020 and February 2021, the expert panel developed a broad consensus including ten statements focusing on the target population, specific goals, availability of geriatric practitioners and quality assurance. Additionally, the expert panel also determined which protocols, materials and accommodation criteria should be available in conventional EDs (39 standards) and in observational EDs (57 standards).

CONCLUSIONS

This study presents a consensus on minimum operational standards for geriatric emergency care in two ED types: the conventional ED and the observational ED. These findings may serve as a starting point towards broadly supported minimum standards of care stipulated by legislation in Belgium or other countries.

Supporting clinical decision making in the emergency department for paediatric patients using machine learning: A scoping review protocol

INTRODUCTION

Machine learning as a clinical decision support system tool has the potential to assist clinicians who must make complex and accurate medical decisions in fast paced environments such as the emergency department. This paper presents a protocol for a scoping review, with the objective of summarising the existing research on machine learning clinical decision support system tools in the emergency department, focusing on models that can be used for paediatric patients, where a knowledge gap exists.

MATERIALS AND METHODS

The methodology used will follow the scoping study framework of Arksey and O'Malley, along with other guidelines. Machine learning clinical decision support system tools for any outcome and population (paediatric/adult/mixed) for use in the emergency department will be included. Articles such as grey literature, letters, pre-prints, editorials, scoping/literature/narrative reviews, non-English full text papers, protocols, surveys, abstract or full text not available and models based on synthesised data will be excluded. Articles from the last five years will be included. Four databases will be searched: Medline (EBSCO), CINAHL (EBSCO), EMBASE and Cochrane Central. Independent reviewers will perform the screening in two sequential stages (stage 1: clinician expertise and stage 2: computer science expertise), disagreements will be resolved by discussion. Data relevant to the research question will be collected. Quantitative analysis will be performed to generate the results.

DISCUSSION

The study results will summarise the existing research on machine learning clinical decision support tools in the emergency department, focusing on models that can be used for paediatric patients. This holds the promise to identify opportunities to both incorporate models in clinical practice and to develop future models by utilising reviewers from diverse backgrounds and relevant expertise.

Hospital Development of a Hybrid Emergency Department-Inpatient Care Observation Unit

INTRODUCTION

This project aimed to design and implement an emergency department-managed observation unit that improves inpatient bed and emergency department stretcher capacity, decreases observation patient length of stay, earns high patient satisfaction scores, and generates a positive fiscal impact on the organization.

METHODS

This quality improvement project followed a 1-group, pre- and postprogram implementation design.

RESULTS

In the first year of operations, 40% of the total observation patients treated in this hospital were managed in the new observation unit. Emergency department observation unit length of stay across all patient complaints was half of the average length of stay for observation patients located on hospital inpatient units. In most cases, the emergency department observation unit was in the top 25 percentile of hospital Press Ganey inpatient satisfaction categories. The hospital estimates a contribution margin of three-quarters of a million dollars in the first year.

DISCUSSION

This effective and efficient hybrid observation unit possessed specific aspects of inpatient and emergency department patient care models. Placing providers and nurses at the workstation for faster communication expedited care. Prioritizing all observation patient testing, transportation, phlebotomy, and intravenous (IV) services shortened disposition times. Emergency nurses transitioning to the observation unit were challenged to acquire inpatient care knowledge. Observation unit management struggled to maintain staffing while under an inpatient productivity model managed by the inpatient house supervisor. Reducing patient disposition time required clear communication between observation unit and inpatient staffing managers, between physician consultants and advanced practice nursing providers, and among nurses, patients, and providers. Observation units are 1 solution to decrease observation patient length of stay and improve emergency department capacity.

Appropriateness of frequent use of emergency departments: A retrospective analysis in Rome, Italy

Background

Frequent users (FUs) are patients who repeatedly and inappropriately visit the emergency department (ED) for low-grade symptoms that could be treated outside the hospital setting. This study aimed to investigate the phenomenon of the FU in Rome by profiling such users and analyzing ED attendance by FUs.

Methods

The analysis was carried out for attendance in 2021 at 15 EDs in the Local Health Authority Roma 1 geographical area. A digital app collected data, including information on the following variables: number of attendance, demographic characteristics, emergency medical service (EMS) usage, triage code, and appropriateness of attendance. COVID-19 diagnosis was also studied to analyze any possible influence on ED attendance. Differences between FUs and non-FUs were investigated statistically by t-test and chi-square test. Univariate analysis and multivariable logistic regression were performed to analyze the associated factors.

Results

A total of 122,762 ED attendance and 89,036 users were registered. The FU category represented 2.9% of all users, comprising 11.9% of total ED attendance. There was a three times higher frequency of non-urgent codes in attendance of FU patients (FU: 9.7%; non-FU: 3.2%). FUs were slightly more likely to have used the EMS (13.6% vs. 11.4%) and had a lower frequency of appropriate ED attendance (23.8% vs. 27.0%). Multivariate logistic analysis confirmed a significant effect of triage code, gender, age, EMS usage, and COVID-19 diagnosis for the appropriateness of attendance. The results were statistically significant (p < 0.001).

Conclusion

The FU profile describes mostly non-urgent and inappropriate attendance at the ED, including during the COVID-19 pandemic. This study represents an important tool for strengthening preventive policies outside the hospital setting. The Italian National Recovery and Resilience Plan represents an excellent opportunity for the development of new strategies to mitigate the phenomenon of FUs.

Implementing a multidisciplinary rapid geriatric observation unit for non-critical older patients referred to hospital: observational study on real-world data

BACKGROUND

Geriatric rapid observation units may represent an alternative to hospitalization in older patients with non-critical acute illness.

AIMS

To describe the characteristics and outcomes of patients admitted to a geriatric observation unit called URGe (Unità Geriatrica Rapida), implemented in an Italian hospital and characterized by multidisciplinary medical staff with geriatric expertise, fast-track access to diagnostic resources, regular use of point-of-care ultrasound and predicted length of stay (LOS) < 72 h.

METHODS

The medical records of patients admitted to URGe during a 3-month period (452 subjects, 247 F and 205 M, median age 82 years, IQR 77-87) were retrospectively examined. The primary study endpoint was transferral from URGe to regular wards. Baseline covariates included demographics, comprehensive geriatric assessment, acute illnesses, comorbidities, vital signs and routine laboratory tests.

RESULTS

Despite elevated burden of multimorbidity (median number of chronic diseases 4, IQR 2-5) and frailty (median Rockwood Clinical Frailty Scale score 4, IQR 3-6), only 137 patients (30.3%) required transferral from URGe to regular wards. The main factors positively associated with this outcome were Rockwood score, fever, cancer and red cell distribution width (P < 0.05 on multivariate logistic regression model). The rate of complications (mortality, delirium, and falls) during URGe stay was low (0.5%, 7% and 2%, respectively). Overall duration of hospital stay was lower than that of a group of historical controls matched by age, sex, main diagnosis, multimorbidity and frailty.

CONCLUSIONS

The URGe model of acute geriatric care is feasible, safe and has the potential of reducing unnecessary hospitalizations of older patients.

Providing care for older adults in the Emergency Department: expert clinical recommendations from the European Task Force on Geriatric Emergency Medicine

Aim

The aim was to develop expert clinical recommendations on Geriatric Emergency Medicine to be disseminated across Europe.

Findings

Eight posters with expert clinical guidelines on the most important topics in Geriatric Emergency Medicine are now available through https://posters.geriemeurope.eu/.

Message

Expert clinical recommendations for Geriatric Emergency Medicine in Europe were created and are ready for dissemination across Europe.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00578-1.

Purpose

Despite the rapidly expanding knowledge in the field of Geriatric Emergency Medicine in Europe, widespread implementation of change is still lacking. Many opportunities in everyday clinical care are missed to improve care for this susceptible and growing patient group. The aim was to develop expert clinical recommendations on Geriatric Emergency Medicine to be disseminated across Europe.

Methods

A group of multi-disciplinary experts in the field of Geriatric Emergency Medicine in Europe was assembled. Using a modified Delphi procedure, a prioritized list of topics related to Geriatric Emergency Medicine was created. Next, a multi-disciplinary group of nurses, geriatricians and emergency physicians performed a review of recent guidelines and literature to create recommendations. These recommendations were voted upon by a group of experts and placed on visually attractive posters. The expert group identified the following eight subject areas to develop expert recommendations on: Comprehensive Geriatric Assessment in the Emergency Department (ED), age/frailty adjusted risk stratification, delirium and cognitive impairment, medication reviews in the ED for older adults, family involvement, ED environment, silver trauma, end of life care in the acute setting.

Results

Eight posters with expert clinical recommendations on the most important topics in Geriatric Emergency Medicine are now available through https://posters.geriemeurope.eu/.

Conclusion

Expert clinical recommendations for Geriatric Emergency Medicine may help to improve care for older patients in the Emergency Department and are ready for dissemination across Europe.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00578-1.

Predictors of Emergency Room Access and Not Urgent Emergency Room Access by the Frail Older Adults

Background: Emergency rooms (ERs) overcrowded by older adults have been the focus of public health policies during the recent COVID-19 outbreak too. This phenomenon needed a change in the nursing care of older frail people. Health policies have tried to mitigate the frequent use of ER by implementing community care to meet the care demands of older adults. The present study aimed to investigate the predictors of emergency room access (ERA) and not-urgent emergency room access (NUERA) of community-dwelling frail older adults in order to provide an indication for out-of-hospital care services.

Method: Secondary analysis of an observational longitudinal cohort study was carried out. The cohort consisted of 1,246 community-dwelling frail older adults (over 65 years) in the Latium region in Italy. The ER admission rate was assessed over 3 years from the administration of the functional geriatric evaluation (FGE) questionnaire. The ordinal regression model was used to identify the predictors of ERA and NUERA. Moreover, the ERA and NUERA rate per 100 observations/year was analyzed.

Results: The mean age was 73.6 (SD ± 7.1) years, and 53.4% were women. NUERAs were the 39.2% of the ERAs; robust and pre-frail individuals (79.3% of the sample) generated more than two-third of ERAs (68.17%), even if frails and very frails showed the higher ER rates per observation/year. The ordinal logistic regression model highlighted a predictive role on ERAs of comorbidity (OR = 1.13, p < 0.001) and frailty level (OR = 1.29; p < 0.001). Concerning NUERAs, social network (OR 0.54, P = 0.015) and a medium score of pulmo-cardio-vascular function (OR 1.50, P = 0.006) were the predictors.

Conclusion: Comorbidity, lack of social support, and functional limitations increase both ERA and NUERA rates generated by the older adult population. Overall, bio-psycho-social frailty represents an indicator of the frequency of ERAs. However, to reduce the number of ERAs, intervention should focus mainly on the robust and pre-frail needs for prevention and care.

Emergency room evaluation and recommendations for older emergency department users: results of the ER2 experimental study

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.