Comprehensive geriatric assessment in the emergency department

Impact of dementia on 30-, 180-, and 365-day mortality during the first pandemic wave in older adults seen in spanish emergency departments diagnosed with or without COVID-19

OBJECTIVES

To assess whether dementia is an independent predictor of death after a hospital emergency department (ED) visit by older adults with or without a COVID-19 diagnosis during the first pandemic wave.

METHOD

We used data from the EDEN-Covid (Emergency Department and Elderly Needs during Covid) cohort formed by all patients ≥65 years seen in 52 Spanish EDs from March 30 to April 5, 2020. The association of prior history of dementia with mortality at 30, 180 and 365 d was evaluated in the overall sample and according to a COVID-19 or non COVID diagnosis.

RESULTS

We included 9,770 patients aged 78.7 ± 8.3 years, 51.1% men, 1513 (15.5%) subjects with prior history of dementia and 3055 (31.3%) with COVID-19 diagnosis. 1399 patients (14.3%) died at 30 d, 2008 (20.6%) at 180 days and 2456 (25.1%) at 365 d. The adjusted Hazard Ratio (aHR) for age, sex, comorbidity, disability and diagnosis for death associated with dementia were 1.16 (95% CI 1.01-1.34) at 30 d; 1.15 at 180 d (95% CI 1.03-1.30) and 1.19 at 365 d (95% CI 1.07-1.32), p < .001. In patients with COVID-19, the aHR were 1.26 (95% CI: 1.04-1.52) at 30 days; 1.29 at 180 d (95% CI: 1.09-1.53) and 1.35 at 365 d (95% CI: 1.15-1.58).

CONCLUSION

Dementia in older adults attending Spanish EDs during the first pandemic wave was independently associated with 30-, 180- and 365-day mortality. This impact was lower when adjusted for age, sex, comorbidity and disability, and was greater in patients diagnosed with COVID-19.

The application of health information technology for the elderly care in the emergency department: a conceptual model

INTRODUCTION

In the emergency departments (EDs), usually the longest waiting time for treatment and discharge belongs to the elderly patients. Moreover, the number of the ED admissions for the elderly increases every year. It seems that the use of health information technology in geriatric emergency departments can help to reduce the burden of the healthcare services for this group of patients. This research aimed to develop a conceptual model for using health information technology in the geriatric emergency department.

METHODS

This study was conducted in 2021. The initial conceptual model was designed based on the findings derived from the previous research phases (literature review and interview with the experts). Then, the model was examined by an expert panel (n = 7). Finally, using the Delphi technique (two rounds), the components of the conceptual model were reviewed and finalized. To collect data, a questionnaire was used, and data were analyzed using descriptive statistics.

RESULTS

The common information technologies appropriate for the elderly care in the emergency departments included emergency department information system, clinical decision support system, electronic health records, telemedicine, personal health records, electronic questionnaires for screening, and other technologies such as picture archiving and communication systems (PACS), electronic vital sign monitoring systems, etc. The participants approved all of the proposed systems and their applications in the geriatric emergency departments.

CONCLUSION

The proposed model can help to design and implement the most useful information systems in the geriatric emergency departments. As the application of technology accelerates care processes, investing in this field would help to support the care plans for the elderly and improve quality of care services. Further research is recommended to investigate the efficiency and effectiveness of using these technologies in the EDs.

Validation of the Korean Version of the Clinical Frailty Scale-Adjusted Korean Triage and Acuity Scale for Older Patients in the Emergency Department

Background and Objectives: The Clinical Frailty Scale (CFS), used to screen for prehospital frailty in patients aged >65 years, is simple, time-efficient, and has been validated in emergency departments (EDs). In this study, we analyzed whether the Korean Triage and Acuity Scale (KTAS) classification by level in older patients determined to have frailty based on the Korean version of the CFS increases the triage performance of the current KTAS. Materials and Methods: The primary outcome was 30-day in-hospital mortality, and secondary outcomes were hospital and intensive care unit (ICU) admissions. This study retrospectively analyzed prospectively collected data from three ED centers. Patients with a CFS score ranging from five (mildly frail) to nine (terminally ill) were categorized into the frailty group. We upgraded the KTAS classification of the frailty group by one level of urgency and defined this as the CFS-KTAS. Results: The cutoff values for predicting admission were three and two for the KTAS and CFS-KTAS, respectively. A significant difference was observed in the area under the receiver operating characteristic (AUROC) curve between the KTAS and CFS-KTAS. To predict ICU admission, the cutoff score was two for both scales. A significant difference was observed in the AUROC curve between the KTAS and CFS-KTAS. For predicting in-hospital mortality, the cutoff score was two for both scales. A significant difference was observed in the AUROC curve between the KTAS and CFS-KTAS. Conclusions: This study showed that the CFS-adjusted KTAS has a more useful prognostic value than the KTAS alone for predicting hospital outcomes in older patients.

Emergency nurses' and physicians' perceptions and self-assessed competence in providing care to older patients

AIM

This study examined emergency nurses' and physicians' perceptions and self-assessed competence in caring for older patients.

METHODS

Data were analyzed using a mixed methods approach and quantitative data were supplemented with qualitative responses. There were 451 nurses and physicians working at the two examined emergency departments, with 125 of them responding to the survey; the response rate was 27.7 %.

RESULTS

Physicians and nurses felt that acutely ill older patients are a responsibility of emergency services. Nurses were more critical than physicians (p = 0.000) of the failure to recognize older patients as a special group at the emergency department. Over half (51.8 %) of the physicians and 29.0 % of the nurses (p = 0.027) felt that older patients' special needs had been considered during facility planning. Nurses and physicians described the problems related to multimorbidity and aging relatively similarly. Both expressed a need for more knowledge in geriatrics and gerontology.

CONCLUSION

Future facility planning and care processes at the emergency department should better consider the specific needs of older patients. The results also emphasize a need to more effectively prioritize competence and educational needs of emergency staff and recognize caring for older patients as a specific competence area in the emergency department.

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.

Ethics rounds in the ambulance service: a qualitative evaluation

BACKGROUND

It is a common ethical challenge for ambulance clinicians to care for patients with impaired decision-making capacities while assessing and determining the degree of decision-making ability and considering ethical values. Ambulance clinicians' ethical competence seems to be increasingly important in coping with such varied ethical dilemmas. Ethics rounds is a model designed to promote the development of ethical competence among clinicians. While standard in other contexts, to the best of our knowledge, it has not been applied within the ambulance service context. Thus, the aim of this study was to describe ambulance clinicians' experiences of participating in ethics rounds.

METHODS

This was a qualitative descriptive study, evaluating an intervention. Data were collected through sixteen interviews with ambulance clinicians who had participated in an intervention involving ethics rounds. The analysis was performed by use of content analysis.

RESULTS

Two themes describe the participants' experiences: (1) Reflecting freely within a given framework, and (2) Being surprised by new insights. The following categories form the basis of the themes; 1a) Gentle guidance by the facilitator, 1b) A comprehensible structure, 2a) New awareness in the face of ethical problems, and 2b) Shared learning through dialogue.

CONCLUSION

Incorporating structured ethics rounds seems to create a continuous development in ethical competence that may improve the quality of care in the ambulance service. Structured guidance and facilitated group reflections offer ambulance clinicians opportunities for both personal and professional development. An important prerequisite for the development of ethical competence is a well-educated facilitator. Consequently, this type of ethics rounds may be considered a useful pedagogical model for the development of ethical competence in the ambulance service.

Frailty Knowledge, Use of Screening Tools, and Educational Challenges in Emergency Departments in Ireland: A Multisite Survey

BACKGROUND

Recognizing frailty and providing evidenced-based management in busy emergency departments is challenging. Understanding the knowledge and educational needs of ED staff is important to design training that might improve patient outcomes.

OBJECTIVE

This study aimed to explore frailty knowledge of ED staff, use of frailty screening instruments in Irish emergency departments, and educational challenges in the emergency department.

METHODS

A multisite survey of ED staff (different specialties) was conducted between April and September 2021. An anonymous online survey was distributed via email. Free-text sections were analyzed using content analysis.

RESULTS

In total, 168 staff (nursing, medical and allied health) participated, representing 9 of 26 Irish emergency departments (35%). Most respondents were nurses (n = 78, 46%). Less than half of respondents had received frailty identification training (n = 81, 48%). One-fifth of emergency doctors and nurses (20%) were unsure how to define frailty. Major barriers to ED frailty screening were resource deficits, insufficient diagnostic pathways from the emergency departments, and lack of education on suitable instruments.

CONCLUSIONS

Most of the ED staff surveyed relied on clinical judgment rather than formal training in frailty identification. A high proportion reported poor knowledge and low confidence in recognizing frailty. Dedicated staff with frailty management expertise, bespoke education initiatives, and clearly defined frailty screening pathways may help address the issues identified.

Decreasing hospitalizations through geriatric hotlines: a prospective French multicenter study of people aged 75 and above

BACKGROUND

The Emergency unit of the hospital (Department) (ED) is the fastest and most common way for most French general practitioners (GPs) to respond to the complexity of managing older adults patients with multiple chronic diseases. In 2013, French regional health authorities proposed to set up telephone hotlines to promote interactions between GP clinics and hospitals. The main objective of our study was to analyze whether the hotlines and solutions proposed by the responding geriatrician reduced the number of hospital admissions, and more specifically the number of emergency room admissions.

METHODS

We conducted a multicenter observational study from April 2018 to April 2020 at seven French investigative sites. A questionnaire was completed by all hotline physicians after each call.

RESULTS

The study population consisted of 4,137 individuals who met the inclusion and exclusion criteria. Of the 4,137 phone calls received by the participants, 64.2% (n = 2 657) were requests for advice, and 35.8% (n = 1,480) were requests for emergency hospitalization. Of the 1,480 phone calls for emergency hospitalization, 285 calls resulted in hospital admission in the emergency room (19.3%), and 658 calls in the geriatric short stay (44.5%). Of the 2,657 calls for advice/consultation/delayed hospitalization, 9.7% were also duplicated by emergency hospital admission.

CONCLUSION

This study revealed the value of hotlines in guiding the care of older adults. The results showed the potential effectiveness of hotlines in preventing unnecessary hospital admissions or in identifying cases requiring hospital admission in the emergency room. Hotlines can help improve the care pathway for older adults and pave the way for future progress.

TRIAL REGISTRATION

Registered under Clinical Trial Number NCT03959475. This study was approved and peer-reviewed by the Ethics Committee for the Protection of Persons of Sud Est V of Grenoble University Hospital Center (registered under 18-CETA-01 No.ID RCB 2018-A00609-46).

A Physiotherapy-Led Transition to Home Intervention for Older Adults Following Emergency Department Discharge: A Pilot Feasibility Randomised Controlled Trial (ED PLUS)

Background

Older adults frequently attend the emergency department (ED) and experience high rates of subsequent adverse outcomes including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. Our aim was to evaluate the feasibility of a physiotherapy-led integrated care intervention for older adults discharged from the ED (ED PLUS).

Patients and Methods

Older adults presenting to the ED of a university teaching hospital with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED PLUS. ED PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient's home. Feasibility and acceptability were assessed quantitatively and qualitatively. All clinical and process outcomes were assessed by a research nurse blinded to group allocation. Data analyses were primarily descriptive.

Results

Twenty-nine participants were recruited indicating a 67% recruitment rate. At 6 months, there was 100% retention in the usual care group, 88% in the CGA group and 90% in the ED PLUS group. ED PLUS participants expressed positive feedback, and there was a trend towards improved function and quality of life and less ED revisits and unscheduled hospitalisations in the ED PLUS group.

Conclusion

ED PLUS bridges the transition of care between the index visit to the ED and the community and is feasible using systematic recruitment strategies. Despite recruitment challenges in the context of COVID-19, the intervention was successfully delivered and well received by participants. There was a lower incidence of functional decline and improved quality of life in the ED PLUS group.

Trial Registration

The trial was registered in Clinical Trials Protocols and Results System as of 21st July 2021, with registration number NCT04983602.

Older women's view on frailty and an Emergency Department evidence-based Frailty Intervention Team (FIT) program: An evaluation using the Reach, Effectiveness, Adoption, Implementation, Maintenance RE-AIM framework

BACKGROUND

Older women have higher levels of frailty resulting in disability and reduced quality of life. Presentation to an Emergency Department (ED) is an opportunity to address frailty and provide tailored interventions to promote function. An ED allied health team integrated frailty assessment and interventions into care through a 'Frailty Intervention Team' (FIT) program.

METHODS

A prospective study informed by the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to evaluate the FIT program tailored to female older adults. The purpose of this project was to evaluate the FIT program over a three-month period and use the findings to further develop the intervention.

RESULTS

Over three-months, 192 older females (>70 years) were identified with mild frailty and discharged directly home. Ninety percent were offered the FIT program with 83.3 % accepting all recommended frailty management strategies. Ninety percent of patients were satisfied with the FIT program, however staff and patient barriers to provision of frailty services were identified.

CONCLUSIONS

The FIT program was largely adopted by staff and accepted by older female patients with mild frailty in the ED. However, program effectiveness was limited by gaps in communication about frailty in the ED and implementation of frailty management strategies after discharge.

Screening instruments to predict adverse outcomes for undifferentiated older adults attending the Emergency Department: Results of SOAED prospective cohort study

BACKGROUND

frailty screening facilitates the stratification of older adults at most risk of adverse events for urgent assessment and subsequent intervention. We assessed the validity of the Identification of Seniors at Risk (ISAR), Clinical Frailty Scale (CFS), Programme on Research for Integrating Services for the Maintenance of Autonomy seven item questionnaire (PRISMA-7) and InterRAI-ED at predicting adverse outcomes at 30 days and 6 months amongst older adults presenting to the Emergency Department (ED).

METHODS

a prospective cohort study of adults ≥65 years who presented to the ED was conducted. The ISAR, CFS, PRISMA-7 and InterRAI-ED were assessed. Blinded follow-up telephone interviews were completed at 30 days and 6 months to assess the incidence of mortality, ED re-attendance, hospital readmission, functional decline and nursing home admission. The sensitivity, specificity, negative predictive value and positive predictive value of the screening tools were calculated using 2 × 2 tables.

RESULTS

a total of 419 patients were recruited; 47% female with a mean age of 76.9 (Standard deviation = 7.2). The prevalence of frailty varied across the tools (CFS 57% versus InterRAI-ED 70%). At 30 days, the mortality rate was 5.1%, ED re-attendance 18.1%, hospital readmission 14%, functional decline 47.6% and nursing home admission 7.1%. All tools had a high sensitivity and positive predictive value for predicting adverse outcomes.

CONCLUSION

older adults who screened positive for frailty were at significantly increased risk of experiencing an adverse outcome at 30 days with the ISAR being the most sensitive tool. We would recommend the implementation of the ISAR in the ED setting to support clinicians in identifying older adults most likely to benefit from specialised geriatric assessment and intervention.

A survey on the availability of geriatric-friendly protocols, equipment and physical environment across emergency departments in Flanders, Belgium

BACKGROUND

The acquisition of geriatric-friendly resources is an important part of adapting emergency department (ED) care to the needs of vulnerable older patients. The aim of this study was to explore the availability of geriatric-friendly protocols, equipment and physical environment criteria in EDs and to identify related improvement opportunities.

METHODS

The head nurse of 63 EDs in Flanders and Brussels Capital Region was invited to complete a survey in collaboration with the chief physician of the ED. The questionnaire was inspired by the American College of Emergency Physicians Geriatric ED Accreditation Program and explored the availability, relevance and feasibility of geriatric-friendly protocols, equipment and physical environment. Descriptive analyses were performed. A region-wide improvement opportunity was defined as a resource that was never to occasionally (0-50%) available on Flemish EDs and was scored (rather or very) relevant by at least 75% of respondents.

RESULTS

A total of 32 questionnaires were analysed. The response rate was 50.8%. All surveyed resources were available in at least one ED. Eighteen out of 52 resources (34.6%) were available in more than half of EDs. Ten region-wide improvement opportunities were identified. These comprised seven protocols and three physical environment characteristics: 1) a geriatric approach initiated from physical triage, 2) elder abuse, 3) discharge to residential facility, 4) frequent geriatric pathologies, 5) access to geriatric specific follow-up clinics, 6) medication reconciliation, 7) minimising 'nihil per os' designation, 8) a large-face, analogue clock in each patient room, 9) raised toilet seats and 10) non-slip floors.

CONCLUSIONS

Currently available resources supporting optimal ED care for older patients in Flanders are very heterogeneous. Researchers, clinicians and policy makers need to define which geriatric-friendly protocols, equipment and physical environment criteria should become region-wide minimum operational standards. Findings of this study are relevant to facilitate the development process of this endeavour.

Epidemiology of geriatric patients presenting to emergency departments in Europe: EGERS study

BACKGROUND AND IMPORTANCE

Patients aged 65 and above constitute a large and growing part of emergency department (ED) visits in western countries.

OBJECTIVE

The primary aim of this European prospective study was to determine the epidemiologic characteristics of elderly patients presenting to EDs across Europe. Our secondary objective was to determine the hospitalization rate, characteristics, and in-hospital mortality rates of geriatric patients presenting to EDs.

DESIGN SETTING AND PARTICIPANTS

An observational prospective cohort study over seven consecutive days between 19 October and 30 November 2020, in 36 EDs from nine European countries. Patients aged 65 years and older presenting to EDs with any complaint during a period of seven consecutive days were included.

OUTCOME MEASURES

Data were collected on demographics, the major presenting complaint, the presenting vital signs, comorbidities, usual medication, and outcomes after the ED, including disposition, in-hospital outcome, and the final hospital diagnosis. The patients were stratified into three groups: old (65-74 years), older (75-84 years), and oldest age (>85 years).

MAIN RESULTS

A total of 5767 patients were included in the study. The median age of the patients was 77 (interquartile range: 71-84) years. The majority presented with a non-traumatic complaint (81%) and about 90% of the patients had at least one comorbid disease and were on chronic medication. An ED visit resulted in subsequent hospital admission in 51% of cases, with 9% of patients admitted to an intensive care unit. Overall in-hospital mortality was 8%, and ED mortality was 1%. Older age was associated with a higher female proportion, comorbidities, need for home care service, history of previous falls, admission rates, length of ED, and hospital stay.

CONCLUSION

The characteristics of ED elderly patients and their subsequent hospital stay are reported in this prospective study.

Atypical presentation of COVID-19 in older patients is associated with frailty but not with adverse outcomes

PURPOSE

Older patients with COVID-19 can present with atypical complaints, such as falls or delirium. In other diseases, such an atypical presentation is associated with worse clinical outcomes. However, it is not known whether this extends to COVID-19. We aimed to study the association between atypical presentation of COVID-19, frailty and adverse outcomes, as well as the incidence of atypical presentation.

METHODS

We conducted a retrospective observational multi-center cohort study in eight hospitals in the Netherlands. We included patients aged ≥ 70 years hospitalized with COVID-19 between February 2020 until May 2020. Atypical presentation of COVID-19 was defined as presentation without fever, cough and/or dyspnea. We collected data concerning symptoms on admission, demographics and frailty parameters [e.g., Charlson Comorbidity Index (CCI) and Clinical Frailty Scale (CFS)]. Outcome data included Intensive Care Unit (ICU) admission, discharge destination and 30-day mortality.

RESULTS

We included 780 patients, 9.5% (n = 74) of those patients had an atypical presentation. Patients with an atypical presentation were older (80 years, IQR 76-86 years; versus 79 years, IQR 74-84, p = 0.044) and were more often classified as severely frail (CFS 6-9) compared to patients with a typical presentation (47.6% vs 28.7%, p = 0.004). Overall, there was no significant difference in 30-day mortality between the two groups in univariate analysis (32.4% vs 41.5%; p = 0.173) or in multivariate analysis [OR 0.59 (95% CI 0.34-1.0); p = 0.058].

CONCLUSIONS

In this study, patients with an atypical presentation of COVID-19 were more frail compared to patients with a typical presentation. Contrary to our expectations, an atypical presentation was not associated with worse outcomes.

Machine learning to improve frequent emergency department use prediction: a retrospective cohort study

Frequent emergency department use is associated with many adverse events, such as increased risk for hospitalization and mortality. Frequent users have complex needs and associated factors are commonly evaluated using logistic regression. However, other machine learning models, especially those exploiting the potential of large databases, have been less explored. This study aims at comparing the performance of logistic regression to four machine learning models for predicting frequent emergency department use in an adult population with chronic diseases, in the province of Quebec (Canada). This is a retrospective population-based study using medical and administrative databases from the Régie de l'assurance maladie du Québec. Two definitions were used for frequent emergency department use (outcome to predict): having at least three and five visits during a year period. Independent variables included sociodemographic characteristics, healthcare service use, and chronic diseases. We compared the performance of logistic regression with gradient boosting machine, naïve Bayes, neural networks, and random forests (binary and continuous outcome) using Area under the ROC curve, sensibility, specificity, positive predictive value, and negative predictive value. Out of 451,775 ED users, 43,151 (9.5%) and 13,676 (3.0%) were frequent users with at least three and five visits per year, respectively. Random forests with a binary outcome had the lowest performances (ROC curve: 53.8 [95% confidence interval 53.5-54.0] and 51.4 [95% confidence interval 51.1-51.8] for frequent users 3 and 5, respectively) while the other models had superior and overall similar performance. The most important variable in prediction was the number of emergency department visits in the previous year. No model outperformed the others. Innovations in algorithms may slightly refine current predictions, but access to other variables may be more helpful in the case of frequent emergency department use prediction.

Effectiveness and cost-effectiveness of a telemedicine programme for preventing unplanned hospitalisations of older adults living in nursing homes: the GERONTACCESS cluster randomized clinical trial

OBJECTIVE

The GERONTACCESS trial evaluated the utility and cost-effectiveness of a gerontological telemedicine (TLM) programme for preventing unplanned hospitalisation of residents living in nursing homes (NHs) in regions lacking medical facilities and/or qualified medical providers ("medical deserts").

DESIGN

GERONTACCESS was a 12-month, multicentre, prospective cluster-randomised trial conducted in NHs. The intervention group underwent TLM assessments every 3 months. The control group received the usual care. In both groups, comprehensive on-site assessments were conducted at baseline and the final visit. Care requirements were documented throughout the study.

SETTING AND PARTICIPANTS

NH residents aged ≥ 60 years with multiple chronic diseases.

METHODS

The study outcomes were the proportion of patients who experienced avoidable and unplanned hospitalisation, and the incremental cost savings per quality-adjusted life years from baseline to the 12-month follow-up.

RESULTS

Of the 426 randomised participants (mean ± standard deviation age, 87.2 ± 7.6 years; 311 [73.0%] women), 23.4% in the intervention group and 32.5% in the control group experienced unplanned hospitalisation (odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.43 to 0.97; p = 0.034). Each avoided hospitalisation in the intervention group saved $US 3,846.

CONCLUSIONS AND IMPLICATIONS

The results of GERONTACCESS revealed that our gerontological, preventative TLM program significantly reduced unplanned hospitalisations. This innovative intervention limited disease progression and promoted a healthy lifestyle among NH residents.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02816177, registered June 28, 2016.

Comprehensive Geriatric Assessment in the Emergency Department for Identifying Elderly Individuals at Risk of Hip Fracture

BACKGROUND

Hip fracture (HF) is a major challenge for healthcare systems in terms of increased costs and lengths of stay, and it has been estimated that by 2050, half of the projected 6.26 million global HFs will occur in Asia. Owing to the high morbidity and mortality associated with HF in elderly individuals, it is crucial to recognize at-risk elderly patients in the ED so that special precautions and preventive measures can be taken. While comprehensive geriatric assessment (CGA) has been shown to improve outcomes and prevent secondary fractures in elderly individuals with HF in outpatient settings, there is a lack of data to identify elderly Asian patients who are at risk of HF via using CGA in the emergency department (ED). The aim of this study is to identify the characteristics of elderly Asian patients in the ED who have an increased risk of HF via CGA.

METHODS

A case-control study was conducted in the ED at Taipei Veterans General Hospital, a medical center located in Taipei, Taiwan, from October 2018 to December 2019. Patients > 75 years old with and without HF were compared using data obtained from CGAs conducted by trained nurses.

RESULTS

A total of 85 HF patients (cases) and 680 non-HF patients were enrolled, among whom 340 non-HF control individuals (controls) were selected by simple random sampling. HF occurred more frequently in women and in patients with depressive symptoms. An association between decreased handgrip strength and HF risk, especially in men, was also identified ( p = 0.011). The variables independently associated with the presence of HF in the multivariate analysis were female sex (odds ratio [OR]: 2.229; 95% confidence interval [CI]: 1.332-3.728) and decreased handgrip strength (OR: 2.462; 95% CI: 1.155-5.247).

CONCLUSIONS

By performing CGAs in the ED, we found that female sex and decreased handgrip strength were associated with HF risk. Therefore, we propose that targeted assessment of handgrip strength in female patients aged > 75 years in the ED may identify those at greatest risk of HF, resulting in improved emergency care for geriatric patients.

Comprehensive geriatric assessment for older orthopedic patients and analysis of risk factors for postoperative complications

Background

The comprehensive geriatric assessment (CGA) has been proposed as a supplementary tool to reduce perioperative complications of geriatric patients, however there is no universally accepted standardization of CGA for orthopedic surgery. In this study, a novel CGA strategy was applied to evaluate the conditions of older patients undergoing orthopedic surgery from a broad view and to identify potential risk factors for postoperative complications.

Methods

A prospective cohort study was conducted from March 2019 to December 2020.The study enrolled patients (age > 75 years) for elective or confined orthopedic surgery. All patients were treated by a multidisciplinary team. A structured CGA was conducted to identify high-risk older patients and to facilitate coordinated multidisciplinary team care by a geriatric team. The basic patient characteristics, CGA results, postoperative complication and mortality rates were collected. Multivariate logistic regression analysis was used to identify risk factors for postoperative complications.

Results

A total of 214 patients with an age of 81.07 ± 4.78 (range, 75–100) years were prospectively enrolled in this study. In total, 66 (30.8%) complications were registered, including one death from myocardial infarction (mortality rate, 0.5%). Poor Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) were accompanied by frailty, worse perioperative risk, pain, and nutritional status. Poor ADL was also associated with higher risks of falling, polypharmacy, and cardiac and respiration complications. Poor IADL was associated with a higher risk of cardiac and respiration complications. Higher stroke risk was accompanied by higher risks of cardiac complications, delirium, and hemorrhage. Worse American Society of Anesthesiologists (ASA) score was associated with worse ADL, IADL, frailty, and higher delirium risk. Multivariate logistic regression analysis showed that spinal fusion (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.65 to 0.83; p = 0.0214), blood loss(OR, 1.68; 95% CI, 1.31 to 2.01; p = 0.0168), ADL (severe dysfunction or worse) (OR, 1.45; 95% CI, 1.16 to 1.81; p = 0.0413), IADL (serious dependence) (OR, 1.08; 95% CI, 1.33 to 1.63; p = 0.0436), renal function (chronic kidney disease (CKD) ≥ stage 3a) (OR, 2.01; 95% CI, 1.54 to 2.55; p = 0.0133), and malnutrition(OR, 2.11; 95% CI, 1.74 to 2.56; p = 0.0101) were independent risk factors for postoperative complications.

Conclusion

The CGA process reduces patient mortality and increases safety in older orthopedic surgery patients. Spinal fusion, blood loss, ADL (severe dysfunction or worse), IADL (serious dependence), renal function (CKD ≥ stage 3a) and nutrition mini nutritional assessment (MNA) (malnourished) were independent risk factors of postoperative complications following orthopaedic surgery in older patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03328-5.

Emergency presentations of older patients living with frailty: Presenting symptoms compared with non-frail patients

BACKGROUND AND OBJECTIVE

Symptoms may differ between frail and non-frail patients presenting to Emergency Departments (ED). However, the association between frailty status and type of presenting symptoms has not been investigated. We aimed to systematically analyse presenting symptoms in frail and non-frail older emergency patients and hypothesized that frailty may be associated with nonspecific complaints (NSC), such as generalised weakness.

METHODS

Secondary analysis of a prospective, single centre, observational all-comer cohort study conducted in the ED of a Swiss tertiary care hospital. All presentations of patients aged 65 years and older were analysed. At triage, presenting symptoms and frailty were systematically assessed using a questionnaire. Patients with a Clinical Frailty Scale (CFS) > 4 were considered frail. Presenting symptoms, stratified by frailty status, were analysed. The association between frailty and generalised weakness was tested by logistic regression.

RESULTS

Overall, 2'416 presentations of patients 65 years and older were analysed. Mean age was 78.9 (SD 8.4) years, 1'228 (50.8%) patients were female, and 885 (36.6%) patients were frail (CFS > 4). Generalised weakness, dyspnea, localised weakness, speech disorder, loss of consciousness and gait disturbance were recorded more often in frail patients, whereas chest pain was reported more often by non-frail patients. Generalised weakness was reported as presenting symptom in 166 (18.8%) frail patients and in 153 (10.0%) non-frail patients. Frailty was associated with generalised weakness after adjusting for age, gender and elevated National Early Warning Score 2 (NEWS) ≥ 3 (OR 1.19, CI 1.10-1.29, p < 0.001).

CONCLUSION

Presenting symptoms differ in frail and non-frail patients. Frailty is associated with generalised weakness at ED presentation.

The effectiveness of interventions to reduce adverse outcomes among older adults following Emergency Department discharge: umbrella review

Background

Population ageing is increasing rapidly worldwide. Older adults are frequent users of health care services including the Emergency Department (ED) and experience a number of adverse outcomes following an ED visit. Adverse outcomes include functional decline, unplanned hospital admission and an ED revisit. Given these adverse outcomes a number of interventions have been examined to improve the outcomes of older adults following presentation to the ED. The aim of this umbrella review was to evaluate the effectiveness of ED interventions in reducing adverse outcomes in older adults discharged from the ED.

Methods

Systematic reviews of randomised controlled trials investigating ED interventions for older adults presenting to the ED exploring clinical, patient experience and healthcare utilisation outcomes were included. A comprehensive search strategy was employed in eleven databases and the PROSPERO register up until June 2020. Grey literature was also searched. Quality was assessed using the A MeaSurement Tool to Assess Systematic Reviews 2 tool. Overlap between systematic reviews was assessed using a matrix of evidence table. An algorithm to assign the Grading of Recommendations Assessment, Development and Evaluation to assess the strength of evidence was applied for all outcomes.

Results

Nine systematic reviews including 29 randomised controlled trials were included. Interventions comprised of solely ED-based or transitional interventions. The specific interventions delivered were highly variable. There was high overlap and low methodological quality of the trials informing the systematic reviews. There is low quality evidence to support ED interventions in reducing functional decline, improving patient experience and improving quality of life. The quality of evidence of the effectiveness of ED interventions to reduce mortality and ED revisits varied from very low to moderate. Results were presented narratively and summary of evidence tables created.

Conclusion

Older adults are the most important emerging group in healthcare for several economic, social and political reasons. The existing evidence for the effectiveness of ED interventions for older adults is limited. This umbrella review highlights the challenge of synthesising evidence due to significant heterogeneity in methods, intervention content and reporting of outcomes. Higher quality intervention studies in line with current geriatric medicine research guidelines are recommended, rather than the publication of further systematic reviews.

Trial registration

UMBRELLA REVIEW REGISTRATION: PROSPERO (CRD42020145315).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03007-5.

Preoperative and Postoperative Cognitive Assessment in Geriatric Patients Following Acute Traumatic Injuries: Towards Improving Geriatric Trauma Outcomes

INTRODUCTION

A growing percentage of the US population is over the age of 65, and geriatrics account for a large portion of trauma admissions, expected to reach nearly 40% by 2050. Cognitive status is important for operative management, especially in elderly populations. This study aims to investigate preoperative and postoperative cognitive function assessment tools in geriatric patients following acute trauma and associated outcomes, including functional status, postdischarge disposition, mortality, and hospital length of stay (H-LOS).

METHODS

A literature search was conducted using Medline/PubMed, Google Scholar, Embase, JAMA Networks, and Cochrane databases for studies investigating the use of cognitive assessment tools for geriatric patients with acute trauma. The last literature search was conducted on November 13, 2021.

RESULTS

Ten studies were included in this review, of which five focused on preoperative cognitive assessment and five focused on postoperative. The evidence suggests patients with preoperative cognitive impairment had worse functional status, mortality, and postdischarge disposition along with increased LOS. Acute trauma patients with postoperative cognitive impairment also had worse functional status, mortality, and adverse postdischarge disposition.

CONCLUSIONS

Preoperative and postoperative cognitive impairment is common in geriatric patients with acute trauma and is associated with worse outcomes, including decreased functional status, increased LOS, and adverse discharge disposition. Cognitive assessment tools such as MMSE, MoCA, and CAM are fast and effective at detecting cognitive impairment in the acute trauma setting and allow clinicians to address preoperative or postoperative cognitive impairments to improve patient outcomes.

The characteristics of geriatric patients managed within the resuscitation unit of a district-level emergency centre in Cape Town

Introduction

The world's population is aging and this trend is also seen in South Africa. This increase will invariably affect acute care services. The geriatric population attending emergency centres have not been described in the South African setting. The objective was to describe the characteristics of geriatric patients presenting to the resuscitation unit of a district-level hospital in Cape Town.

Methods

All patients (≥65 years) managed within the resuscitation unit of Khayelitsha Hospital over an 8-month period (01 January–30 August 2018) were retrospective analysed. Data were collected from the Khayelitsha Hospital Emergency Centre database and by means of a retrospective chart review. Summary statistics are presented of all variables.

Results

A total of 225 patients were analysed. The median age was 71.1 years, 148 (65.8%) were female and all were residing in their family home. The majority (n = 162, 72%) presented outside office hours, 124 (55.1%) arrived by ambulance, and 94 (41.8%) had presented to the emergency centre within the previous year. Only half the patients (n = 114, 50.7%) were triaged as very urgent or higher. Most patients (n = 169, 75.1%) were admitted by in-hospital services and the in-hospital mortality was 21.8% (n = 49). Diseases related to the circulatory system (n = 54, 24.0%) were the most frequent primary diagnosis and acute kidney injury were the most frequent secondary diagnosis (n = 101, 44.9%). The most common comorbidities were hypertension (n = 176, 78.2%) and diabetes (n = 110, 48.9%), and 99 (44%) had three or more comorbidities. Polypharmacy (≥5 medications) occurred in 100 (44.4%) patients with 114 (50.7%) using medications from three or more different classes. The prevalence of hypernatremia was 2.6% and for hyponatremia 54.4%.

Conclusion

Geriatric patients managed within the resuscitation unit of a district-level hospital had a high return rate, multiple comorbidities and a high prevalence of polypharmacy and hyponatraemia.

•

The average life expectancy in Africa is increasing

•

Geriatric patients often present with multiple co-morbidities and polypharmacy

•

Geriatric-friendly processes should be considered to ensure that geriatric patients are appropriately triaged and managed in the acute care setting

Factors Associated With Mortality in Elderly Hospitalized Patients at Admission

Background

Several factors have been associated with mortality prediction among older inpatients. The objective of this study was to assess the factors associated with mortality in hospitalized elderly patients.

Methods

A total of 353 consecutively admitted elderly patients (47.9% women), with a median age of 83 years (interquartile range 75.00-88.00), were enrolled in the study and patient characteristics were recorded. Comorbidities were assessed using Charlson Comorbidity Index (CCI), activities of daily living by Barthel Index (BI), frailty was assessed using the Clinical Frailty Scale (CFS), cognition by Global Deterioration Scale (GDS) and symptom severity at admission by quick Sequential Organ Function Assessment (qSOFA) score. CFS, GDS and BI were estimated for the premorbid patients’ status. Parametric and non-parametric tests and binary logistic regression analysis were applied to identify the factors associated with mortality. A receiver operating characteristic (ROC) curve was used to analyse the prognostic value of CFS and qSOFA.

Results

In total, 55 patients (15.6%) died during hospitalization. In regression analysis, the factors associated with mortality were the qSOFA score at admission (p=0.001, odds ratio [OR]=1.895, 95% confidence interval [CI] 1.282-2.802) and the premorbid CFS score (p=0.001, OR=1.549, 95% CI 1.1204-1.994). The classifiers both have almost similar area under the curve (AUC) scores, with CFS performing slightly better. More specifically, both CFS (AUC 0.79, 95% CI 0.73-0.85, p=0.001) and qSOFA (AUC 0.75, 95% CI 0.67-0.83, p<0.001) showed almost the same accuracy for predicting inpatients’ mortality.

Conclusion

This study strengthens the perception of premorbid frailty and disease severity at admission as factors closely related to mortality in hospitalized elderly patients. Simple measures such as CFS and qSOFA score may help identify, in the emergency department, elderly patients at risk, in order to provide timely interventions.

Challenges in Geriatric Oncology—A Surgeon’s Perspective

As our global population ages, we will see more cancer diagnoses in older adults. Surgery is an important treatment modality for solid tumours, forming the majority of all cancers. However, the management of older adults with cancer can be more complex compared to their younger counterparts. This narrative review will outline the current challenges facing older adults with cancer and potential solutions. The challenges facing older adults with cancer are complex and include lack of high-level clinical trials targeting older adults and selection of the right patient for surgery. This may be standard surgical treatment, minimally invasive surgery or alternative therapies (no surgery) which can be local or systemic. The next challenge is to identify the individual patient’s vulnerabilities to allow them to be maximally optimised for treatment. Prehabilitation has been shown to be of benefit in some cancer settings but uniform guidance across all surgical specialties is required. Greater awareness of geriatric conditions amongst surgical oncologists and integration of geriatric assessment into a surgical clinic are potential solutions. Enhanced recovery programmes tailored to older adults could reduce postoperative functional decline. Ultimately, the greatest challenge an older adult with cancer may face is the mindset of their treating clinicians—a shared care approach between surgical oncologists and geriatricians is required.

A physiotherapy-led transition to home intervention for older adults following emergency department discharge: protocol for a pilot feasibility randomised controlled trial

Background

Older adults frequently attend the emergency department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. This paper reports a protocol designed to evaluate the feasibility of conducting a three arm randomised controlled trial (RCT) within the ED setting and in the patient’s home. The interventions are comprehensive geriatric assessment (CGA), ED PLUS and usual care.

Methods

The ED PLUS pilot trial is designed as a feasibility RCT conducted in the ED and Acute Medical Assessment Unit of a university teaching hospital in the mid-west region of Ireland. We aim to recruit 30 patients, aged 65 years and over presenting to the ED with undifferentiated medical complaints and discharged within 72 h of index visit.

Patients will be randomised by a computer in a ratio of 1:1:1 to deliver usual care, CGA or ED PLUS during a 6-month study period. A randomised algorithm is used to perform randomization. CGA will include a medical assessment, medication review, nursing assessment, falls assessment, assessment of mobility and stairs, transfers, personal care, activities of daily living (ADLs), social supports and baseline cognition. ED PLUS, a physiotherapist led, multidisciplinary intervention, aims to bridge the transition of care between the index visit to the ED and the community by initiating a CGA intervention in the ED and implementing a 6-week follow-up self-management programme in the patient’s own home following discharge from the ED. The outcomes will be parameters of the feasibility of the intervention and trial methods and will be assessed quantitatively and qualitatively.

Discussion

Rising ED visits and an ageing population with chronic health issues render ED interventions to reduce adverse outcomes in older adults a research priority. This feasibility RCT will generate data and experience to inform the conduct and delivery of a definite RCT.

Trial registration

The trial was registered in Clinical Trials Protocols and Results System as of 21^st July 2021, with registration number NCT049836020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00954-5.

Opportunities for Using Health Information Technology for Elderly Care in the Emergency Departments: A Qualitative Study

INTRODUCTION

Recently, several technologies have been developed for being used in the field of geriatric emergency medicine. As a large number of elderly patients visit emergency departments, the use of health information technology in this department can help to improve patient care and control the outcome of diseases. The present study aimed to identify opportunities for using various health information technologies for elderly care in the emergency department.

METHODS

This qualitative study was conducted in 2020. The participants included geriatricians, geriatric nurses, emergency medicine specialists, and nurses who worked in the emergency department. In total, 33 semi-structured interviews were conducted, and data were analyzed by using framework analysis method and MAXQDA software.

RESULTS

The findings of the qualitative study included four main themes, nine subthemes, and 20 categories. The main themes were the common process of elderly care in the emergency departments, data required for elderly care in the emergency departments, the elderly treatment team, and current information technologies used in the emergency departments for elderly care. Overall, the results showed that there was no specific workflow for elderly care in the emergency departments; the great workload of this department prevents the clinicians to conduct cognitive and functional assessments; geriatricians were not involved in the care process; and none of the current information systems were designed specifically for elderly patients. It seems that using specific heath information technology for elderly care in the emergency department can help to overcome current challenges.

CONCLUSION

Identifying opportunities for using health information technologies for geriatric patients in the emergency department can lead to better use of financial, physical, and human resources, and improve staff performance. These systems can be designed and used for different purposes such as reducing work load, readmissions, and hospitalization. Improving access to data and better collaboration between different specialties are other benefits of using these systems. However, more research is required to evaluate the effectiveness of technology in this area.

The pain in the Emergency Department: Choosing and treating wisely before and during the COVID-19 era

Pain is a frequent reason for referral to the Emergency Department (ED). Adequate management of pain is a moral and ethical imperative. If not correctly treated, acute pain can cause physical and psychological complications, and become chronic with severe consequences such as anxiety, depression, and social isolation. As consequence, emergency clinicians should treat pain as soon as possible, avoiding delays even in case of acute abdominal pain. Pain management is particularly complex in the elderly and emergency clinicians should always consider AGS Beers criteria ® to avoid inappropriate medications, severe side-effects, and drug-drug interactions. Pain is also a common cause of delirium in older patients. The SARS CoV-2 infection not only can cause acute pain, but also exacerbate chronic pain, particularly in the elderly, who are at high risk to be infected. Looking at all this evidence, emergency clinicians should treat pain with different strategies according to their experience and cultural background, making the right choice for each patient. This work is a critical review of the pain management in the ED, with a particular attention on the effects of COVID-19 in the EDs. We conducted a systematic search of the following databases: PubMed, Google Scholar, Science Direct, Medline from 2000 to 2020, using the keywords of “pain”, “emergency”, “COVID19”, “elderly”, “palliative care”, “ketamine”, “dexmedetomidine”, and “post-traumatic stress disorder”. The aim of this review is to help emergency clinicians to correctly manage pain in the ED with a new point of view regarding the pain management in COVID-19 patients.

Effectiveness of acute geriatric unit care on functional decline and process outcomes among older adults admitted to hospital with acute medical complaints: a protocol for a systematic review

INTRODUCTION

Older adults are clinically heterogeneous and are at increased risk of adverse outcomes during hospitalisation due to the presence of multiple comorbid conditions and reduced homoeostatic reserves. Acute geriatric units (AGUs) are units designed with their own physical location and structure, which provide care to older adults during the acute phase of illness and are underpinned by an interdisciplinary comprehensive geriatric assessment model of care. This review aims to update and synthesise the totality of evidence related to the effectiveness of AGU care on clinical and process outcomes among older adults admitted to hospital with acute medical complaints.

DESIGN

Updated systematic review and meta-analysis METHODS AND ANALYSIS: MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Controlled Trials in the Cochrane Library and Embase electronic databases will be systematically searched from 2008 to February 2021. Trials with a randomised design that deliver an AGU intervention to older adults admitted to hospital for acute medical complaints will be included. The primary outcome measure will be functional decline at discharge from hospital and at follow-up. Secondary outcomes will include length of stay, cost of index admission, incidence of unscheduled hospital readmission, living at home (the inverse of death or institutionalisation combined; used to describe someone who is in their own home at follow-up), mortality, cognitive function and patient satisfaction with index admission. Title and abstract screening of studies for full-text extraction will be conducted independently by two authors. The Cochrane risk of bias 2 tool will be used to assess the methodological quality of the included trials. The quality of evidence for outcomes reported will be assessed using the Grading of Recommendations Assessment, Development and Evaluations framework. A pooled meta-analysis will be conducted using Review Manager, depending on the uniformity of the data.

ETHICS AND DISSEMINATION

Formal ethical approval is not required as all data collected will be secondary data and will be analysed anonymously. The authors will present the findings of the review to a patient and public involvement stakeholder panel of older adults that has been established at the Ageing Research Centre in the University of Limerick. This will enable the views and opinions of older adults to be integrated into the discussion section of the paper.

PROSPERO REGISTRATION NUMBER

CRD42021237633.

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.

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.

Construct Validity and Clinical Utility of World Health Organization Disability Assessment Schedule 2.0 in Older Patients Discharged From Emergency Departments

Introduction: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is designed to measure functioning and disability in six domains. It is included in the International Classification of Diseases 11th revision (ICD-11). The objective of the study was to examine the construct validity of WHODAS 2.0 and describe its clinical utility for the assessment of functioning and disability among older patients discharged from emergency departments (EDs). Material and Methods: This cross-sectional study is based on data from 129 older patients. Patients completed the 36-item version of WHODAS 2.0 together with the Barthel-20, the Assessment of Motor and Process Skills (AMPS), Timed Up and Go (TUG), and the 30-Second Chair Stand Test (30 s-CST). Construct validity was examined through hypothesis testing by correlating the WHODAS with the other instruments and specifically the mobility domain in WHODAS 2.0 with the TUG and 30 s-CST tests. The clinical utility of WHODAS 2.0 was explored through floor/ceiling effect and missing item responses. Results: WHODAS 2.0 correlated fair with Barthel-20 (r = -0.49), AMPS process skills (r = -0.26) and TUG (r=0.30) and correlated moderate with AMPS motor skills (r = -0.58) and 30s-CST (r = -0.52). The WHODAS 2.0 mobility domain correlated fair with TUG (r = 0.33) and moderate with 30s-CST (r = -0.60). Four domains demonstrated floor effect: D1 "Cognition," D3 "Self-care," D4 "Getting along," and D5 "Household." Ceiling effect was not identified. The highest proportion of missing item responses were present for Item 3.4 (Staying by yourself for a few days), Item 4.4 (Making new friends), and Item 4.5 (Sexual activities). Conclusion: WHODAS 2.0 had fair-to-moderate correlations with Barthel-20, AMPS, TUG, and 30s-CST and provides additional aspects of disability compared with commonly used instruments. However, the clinical utility of WHODAS 2.0 applied to older patients discharged from EDs poses some challenges due to floor effect and missing item responses. Accordingly, patient and health professional perspectives need further investigation.

Where Skilled Nursing Facility Residents Get Acute Care: Is the Emergency Department the Medical Home?

OBJECTIVES

This study aimed to characterize the distribution of acute care visits among Medicare beneficiaries receiving skilled nursing facility (SNF) services.

METHODS

We conducted a cross-sectional analysis of a 20% sample of continuously enrolled Medicare beneficiaries in the 2012 Chronic Condition Warehouse data set. Beneficiaries were grouped by the number of days of SNF services, and acute care visits were categorized as "before SNF," "during SNF," or "after SNF."

RESULTS

Among the 10,717,786 Medicare beneficiaries analyzed, 384,312 (3.6%) had at least one SNF stay.

DISCUSSION

Beneficiaries who received SNF services had a higher proportion of acute care visits made to emergency departments (EDs) than beneficiaries who did not receive SNF services. Also, a higher proportion of acute care visits were made to EDs by beneficiaries after a SNF stay in comparison to residents actively residing in a SNF. The acute care capabilities of SNFs and post-SNF transitions of care to the community setting are discussed.

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

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.

Comprehensive Geriatric Assessment and Clinical Outcomes in the Older People at the Emergency Department

Visits by older people to the Emergency Department (ED) have increased in recent decades with higher revisiting and admission rates after discharge, particularly for those with frailties. This study used a before-after design aimed at evaluating Comprehensive Geriatric Assessment (CGA) screening in older ED patients (aged ≥ 75 years) during the 12-month preintervention period. Additionally, a CGA-based structured follow-up program after ED discharge was executed during the next 12-month intervention period. Amongst the 358 participants (median age 82 years), involving 122 in the preintervention period and 236 in the intervention period, 77 participants (21.5%) were identified as pre-frailty, while 274 (76.5%) were identified as frail using the Fried frailty phenotype. One-hundred ten (110) (30.7%) patients revisited the ED with 73 (20.4%) being admitted and 20 (5.6%) dying within three months after ED discharge. Compared with preintervention and intervention period, it was shown that the rates of admission at the index ED visit (50.8% vs. 23.1%), and mortality (10.7% vs. 3.0%), were both were significantly reduced. Using multivariate regression analysis, it was shown frailty was significantly associated with three-month mortality after adjusting for potential confounders. On the contrary, the program significantly decreased admission and death rate. It is suggested that frailty was prevalent amongst the older ED patients, and should be screened for in order to decrease revisits/admissions after ED discharge.

Effectiveness of interventions to reduce adverse outcomes among older adults following emergency department discharge: Protocol for an overview of systematic reviews

Background: Older adults are frequent users of Emergency departments (ED) and this trend will continue due to population ageing and the associated increase in healthcare needs. Older adults are vulnerable to adverse outcomes following ED discharge. A number of heterogeneous interventions have been developed and implemented to improve clinical outcomes among this cohort. A growing number of systematic reviews have synthesised evidence regarding ED interventions using varying methodologies. This overview aims to synthesise the totality of evidence in order to evaluate the effectiveness of interventions to reduce adverse outcomes in older adults discharged from the ED. Methods: To identify relevant reviews, the following databases will be searched: Cochrane Database of Systematic reviews, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Databases of Abstracts of Reviews of Effects, PubMed, MEDLINE, Epistemonikos, Ageline, Embase, PEDro, Scopus, CINAHL and the PROSPERO register. The search for grey literature will include Open Grey and Grey Literature Reports. Systematic reviews of randomised controlled trials will be analysed to assess the effect of ED interventions on clinical and process outcomes in older adults. Methodological quality of the reviews will be assessed using the Assessment of Multiple Systematic Reviews 2 tool. The review will be reported in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Summary of findings will include a hierarchical rank of interventions based on estimates of effects and the quality of evidence. Discussion: This overview is required given the number of systematic reviews published regarding the effectiveness of various ED interventions for older adults at risk of adverse outcomes following discharge from the ED. There is a need to examine the totality of evidence using rigorous analytic techniques to inform best care and potentially develop a hierarchy of treatment options. PROSPERO registration: CRD42020145315 (28/04/2020).

Effectiveness of interventions to reduce adverse outcomes among older adults following emergency department discharge: Protocol for an overview of systematic reviews

Background: Older adults are frequent users of Emergency departments (ED) and this trend will continue due to population ageing and the associated increase in healthcare needs. Older adults are vulnerable to adverse outcomes following ED discharge. A number of heterogeneous interventions have been developed and implemented to improve clinical outcomes among this cohort. A growing number of systematic reviews have synthesised evidence regarding ED interventions using varying methodologies. This overview aims to synthesise the totality of evidence in order to evaluate the effectiveness of interventions to reduce adverse outcomes in older adults discharged from the ED. Methods: To identify relevant reviews, the following databases will be searched: Cochrane Database of Systematic reviews, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Databases of Abstracts of Reviews of Effects, PubMed, MEDLINE, Epistemonikos, Ageline, Embase, PEDro, Scopus, CINAHL and the PROSPERO register. The search for grey literature will include Open Grey and Grey Literature Reports. Systematic reviews of randomised controlled trials will be analysed to assess the effect of ED interventions on clinical and process outcomes in older adults. Methodological quality of the reviews will be assessed using the Assessment of Multiple Systematic Reviews 2 tool. The review will be reported in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Summary of findings will include a hierarchical rank of interventions based on estimates of effects and the quality of evidence. Discussion: This overview is required given the number of systematic reviews published regarding the effectiveness of various ED interventions for older adults at risk of adverse outcomes following discharge from the ED. There is a need to examine the totality of evidence using rigorous analytic techniques to inform best care and potentially develop a hierarchy of treatment options. PROSPERO registration: CRD42020145315 (28/04/2020).

Prediction of functional loss in emergency surgery is possible with a simple frailty screening tool

Background

Senior adults fear postoperative loss of independence the most, and this might represent an additional burden for families and society. The number of geriatric patients admitted to the emergency room requiring an urgent surgical treatment is rising, and the presence of frailty is the main risk factor for postoperative morbidity and functional decline. Frailty assessment in the busy emergency setting is challenging. The aim of this study is to verify the effectiveness of a very simple five-item frailty screening tool, the Flemish version of the Triage Risk Screening Tool (fTRST), in predicting functional loss after emergency surgery among senior adults who were found to be independent before surgery.

Methods

All consecutive individuals aged 70 years and older who were independent (activity of daily living (ADL) score ≥5) and were admitted to the emergency surgery unit with an urgent need for abdominal surgery between December 2015 and May 2016 were prospectively included in the study. On admission, individuals were screened using the fTRST and additional metrics such as the age-adjusted Charlson Comorbidity Index (CACI) and the ASA score. Thirty- and 90-day complications and postoperative decline in the ADL score where recorded. Regression analysis was performed to identify preoperative predictors of functional loss.

Results

Seventy-eight patients entered the study. Thirty-day mortality rate was 12.8% (10/78), and the 90-day overall mortality was 15.4% (12/78). One in every four patients (17/68) experienced a significant functional loss at 30-day follow-up. At 90-day follow-up, only 3/17 patients recovered, 2 patients died, and 12 remained permanently dependent. On the regression analysis, a statistically significant correlation with functional loss was found for fTRST, CACI, and age≥85 years old both at 30 and 90 days after surgery. fTRST≥2 showed the highest effectiveness in predicting functional loss at 90 days with AUC 72 and OR 6.93 (95% CI 1.71–28.05). The institutionalization rate with the need to discharge patients to a healthcare facility was 7.6% (5/66); all of them had a fTRST≥2.

Conclusion

fTRST is an easy and effective tool to predict the risk of a postoperative functional decline and nursing home admission in the emergency setting.

Impact of emergency department length of stay on anxiety and comfort in older people

INTRODUCTION

Older people are frequent emergency department (ED) users, a vulnerable population and often have long stays in the ED. The aim of this study was to determine whether ED length of stay (LOS) had an impact on older people's (aged ≥65 years) anxiety, comfort and adverse events.

METHODS

This prospective observational study was conducted in Melbourne, Australia. Patients (n = 301) from three EDs were classified by ED LOS: ≤4-hours (n = 89), 4-8 h (n = 136) and >8-hours (n = 76). Current state and trait anxiety and comfort were measured in ED. Adverse event data were collected from medical records. LOS groups were compared using Chi-Square and Kruskal-Wallis test.

RESULTS

There was no significant difference in Trait Anxiety Scores. Patients with ED LOS ≤ 4-hours had lower median State Anxiety Scores (p = 0.003), were less likely to require ward admission (p < 0.001), and more likely to require short stay unit admission (p < 0.001). There were no significant differences between groups in comfort or adverse events during ED care or hospitalisation (for admitted patients).

CONCLUSION

The impact of ED LOS on the anxiety of older ED users appears limited. There was no association identified between ED LOS and comfort during ED care or adverse events during ED care or hospitalisation.

Implementation of the acutely presenting older patient (APOP) screening program in routine emergency department care : A before-after study

OBJECTIVE

The aim of this study was to evaluate the effects of implementation of the acutely presenting older patient (APOP) screening program for older patients in routine emergency department (ED) care shortly after implementation.

METHODS

We conducted an implementation study with before-after design, using the plan-do-study-act (PDSA) model for quality improvement, in the ED of a Dutch academic hospital. All consecutive patients ≥ 70 years during 2 months before and after implementation were included. The APOP program comprises screening for risk of functional decline, mortality and cognitive impairment, targeted interventions for high-risk patients and education of professionals. Outcome measures were compliance with interventions and impact on ED process, length of stay (LOS) and hospital admission rate.

RESULTS

Two comparable groups of patients (median age 77 years) were included before (n = 920) and after (n = 953) implementation. After implementation 560 (59%) patients were screened of which 190 (34%) were high-risk patients. Some of the program interventions for high-risk patients in the ED were adhered to, some were not. More hospitalized patients received comprehensive geriatric assessment (CGA) after implementation (21% before vs. 31% after; p = 0.002). In 89% of high-risk patients who were discharged to home, telephone follow-up was initiated. Implementation did not influence median ED LOS (202 min before vs. 196 min after; p = 0.152) or hospital admission rate (40% before vs. 39% after; p = 0.410).

CONCLUSION

Implementation of the APOP screening program in routine ED care did not negatively impact the ED process and resulted in an increase of CGA and telephone follow-up in older patients. Future studies should investigate whether sustainable changes in management and patient outcomes occur after more PDSA cycles.

Prognosis tools for short-term adverse events in older emergency department users: result of a Québec observational prospective cohort

Background

The “Program of Research on the Integration of Services for the Maintenance of Autonomy” (PRISMA-7) and “Emergency room evaluation and recommendations” (ER²) are both clinical tools used in Québec Emergency Departments (EDs) for screening of older ED users at higher risk of poor outcomes, such as prolonged length of stay (LOS) in EDs and in hospital. The study aimed to: 1) examine whether the PRISMA-7 and ER² risk levels were associated with length of stays in ED and hospital, as well as hospital admission; and 2) compare the criteria performance (i.e., sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios and area under receiver operating characteristic curve) of the PRISMA-7 and ER2 high-risk levels for these three ED adverse events in Québec older patients visiting ED on a stretcher.

Methods

A total of 1905 older patients who visited the ED of the Jewish General Hospital (Montreal, Québec, Canada) on stretchers were recruited in this prospective observational cohort. Upon their ED arrival, PRISMA-7 and ER² were performed. The outcomes were LOS in ED and in hospital, and hospital admission.

Results

The PRISMA-7 and ER² risk levels were associated with length of stay in ED and hospital as well as with hospital admission. Prolonged stays and higher hospitalization rates were associated with high-risk levels, whereas those in low-risk level groups had significantly shorter LOS and a lower rate of hospital admission (P < 0.006). While performance measures were poor for both assessment tools, ER² had a greater prognostic testing accuracy compared with PRISMA-7.

Conclusion

PRISMA-7 and ER² were both associated with incidental short-term ED adverse events but their overall prognostic testing accuracy was low, suggesting that they cannot be used as prognostic tools for this purpose.

Risk Factors for Disability After Emergency Department Discharge in Older Adults

OBJECTIVES

We have previously shown that older adults discharged from the emergency department (ED) experience an increased disability burden within a 6-month time period after ED discharge. The objective of this study was to identify risk factors associated with increased disability burden among older adults discharged from the ED.

METHODS

This study is part of an ongoing longitudinal study of 754 community-living persons aged ≥70 years. The analytic sample included 813 ED visits without hospitalization from 430 participants who had at least one visit to an ED during a 14-year follow-up period (1998-2012). Information on ED visits and disability burden in 13 functional activities was collected during monthly interviews. Twenty-nine candidate risk factors were evaluated for their independent associations with increased disability burden using a longitudinal multivariable model.

RESULTS

In the multivariable analyses, age ≥85 (adjusted risk ratio [aRR] = 1.14, 95% confidence interval [CI] = 1.05 to 1.24), being unmarried (aRR = 1.15, 95% CI = 1.05 to 1.27), lower-extremity weakness (aRR = 1.20, 95% CI = 1.07 to 1.34), and physical frailty (aRR = 1.25, 95% CI = 1.13 to 1.37) were associated with increased disability burden. As the number of risk factors increased, the predicted mean disability burden (on a scale of 0 to 13) also increased, ranging from a value of 1.80 (95% CI = 1.43 to 2.27) for 0 risk factors to a value of 8.59 (95% CI = 7.93 to 9.29) for four risk factors.

CONCLUSIONS

Among older adults discharged from the ED, several risk factors were associated with increased disability burden over the following 6 months, including age ≥85, being unmarried, lower-extremity weakness, and physical frailty. Further research is needed to evaluate whether risk stratification based on nonmodifiable factors or interventions targeting modifiable risk factors improve functional outcomes for older adults discharged from the ED.

Profiles of Frequent Geriatric Users of Emergency Departments: A Latent Class Analysis

BACKGROUND/OBJECTIVES

Frequent geriatric users of emergency departments (EDs) represent a complex and heterogeneous population. Identifying their specific subgroups would allow the development of interventions better customized to their needs and characteristics. Thus, this study aimed to develop profiles of frequent geriatric ED users using the individual characteristics of patients.

DESIGN

This was a retrospective cohort study.

SETTING

Databases from the Régie de l'assurance maladie du Québec (RAMQ) were utilized. PARTICIPANTSThis study included individuals aged 65 years or older living in the community in the Province of Quebec (Canada), who consulted in an ED at least four times in the year after an ED index date (an ED visit, chosen randomly, during an index period of January 1, 2012 to December 31, 2013) and who had received a diagnosis of ambulatory care-sensitive conditions (ACSCs) in the 2 years preceding the index date.

MEASUREMENTS

A latent class analysis was used to identify subgroups of frequent geriatric ED users according to their individual characteristics, including ACSC type, dementia, mental health disorders, cancer diagnosis, and comorbidity index.

RESULTS

The study cohort consisted of 21,393 frequent geriatric ED users. Four groups of frequent geriatric ED users were identified: people with low comorbidity (39.0%), comprising the individuals with the lowest number of physical and mental health conditions; people with cancer (32.7%); people with pulmonaryand cardiac diseases (18.1%); and people with dementia or mental health disorders (10.2%), composed of individuals with the highest proportion of common and severe mental health disease, as well as dementia. This group accounts for the highest use of overall healthcare services.

CONCLUSION

These profiles will be useful in developing customized interventions addressing the needs of each subgroup of frequent geriatric ED users. More research is needed to bridge the remaining gaps, especially regarding the healthiest frequent geriatric users of EDs.

Prognostic value of screening instrument based on the Dutch national VMS guidelines for older patients in the emergency department

PURPOSE

It is important to identify which older patients attending the emergency department are at risk of adverse outcomes to introduce preventive interventions. This study aimed to assess the prognostic value of a shortened screening instrument based on the Dutch national Safety Management System [Veiligheidsmanagementsysteem (VMS)] guidelines for adverse outcomes in older emergency department patients.

METHODS

A cohort study was performed including patients aged 70 years or older who visited the emergency department. Adverse outcomes included hospital admission, return emergency department visits within 30 days, and 90-day mortality. The prognostic value of the VMS-score was assessed for these adverse events and, in addition, a prediction model was developed for 90-day mortality.

RESULTS

A high VMS-score was independently associated with an increased risk of hospital admission [OR 2.26 (95% CI 1.32-3.86)] and 90-day mortality [HR 2.48 (95% CI 1.31-4.71)]. The individual VMS-questions regarding history of delirium and help in activities of daily living were associated with these outcomes as well. A prediction model for 90-day mortality was developed and showed satisfactory calibration and good discrimination [AUC 0.80 (95% CI 0.72-0.87)]. A cut-off point that selected 30% of patients at the highest risk yielded a sensitivity of 67.4%, a specificity of 75.3%, a positive predictive value of 28.5%, and a negative predictive value of 94.1%.

CONCLUSION

The shortened VMS-based screening instrument showed to be of good prognostic value for hospitalization and 90-day mortality. The prediction model for mortality showed promising results and will be further validated and optimized.

Prevalence of Geriatric Syndromes and the Need for Hospice Care in Older Patients of the Emergency Department: A Study in an Asian Medical Center

Background

The prevalence of geriatric syndromes and the need for hospice care in the emergency department (ED) in Asian populations remain unclear. This study was conducted to fill the data gap.

Methods

Using a newly developed emergency geriatric assessment (EGA), we investigated the prevalence of geriatric syndromes and the need for hospice care in older ED patients of a tertiary medical center between September 1, 2016, and January 31, 2017.

Results

We recruited a total of 693 patients with a mean age of 78.0 years (standard deviation 8.2 years), comprising 46.6% of females. According to age subgroups, 37.4% of patients were aged 65-74 years, 37.4% were aged 75-84 years, and 25.2% were aged ≥85 years. The prevalence rates of geriatric syndromes were as follows: delirium (11.4%), depression (23.4%), dementia (43.1%), deterioration of activities of daily living (ADL) for <1 year (29.4%), vision impairment (22.2%), hearing impairment (23.8%), sleep disturbance (13.1%), any fall in <1 year (21.8%), polypharmacy (28.7%), pain (35.1%), pressure ulcer (5.6%), incontinence or retention (29.6%), indwelling device or physical restrain (21.6%), nutrition problem (35.7%), frequent use of medical resources (50.1%), lack of advance care planning (84.0%), caregiver problem (4.6%), socioeconomic problem (5.5%), and need for family meeting (6.2%). The need for hospice care was 11.9%. Most geriatric syndromes increased with advancing age except depression, sleep disturbance, polypharmacy, pain, nutrition problem, lack of advance care planning, caregiver problem, and socioeconomic problem.

Conclusion

Geriatric syndromes and the need for hospice care were common in the older ED patients. Further studies about subsequent intervention for improving geriatric care are needed.

Effects of a geriatric education program for emergency physicians: a mixed-methods study

Emergency physicians (EPs) often regard care for older adults as complex, while they lack sufficient geriatric skills. This study evaluates the effect of a geriatric education program on EPs' geriatric knowledge, attitude and medical practice when treating older adults. A mixed-methods study was performed on EPs from two Dutch hospitals. Effects were measured by pre-post tests of EPs' (n = 21) knowledge of geriatric syndromes and attitudes toward older adults, and by a retrospective pre-post analysis of 100 records of patients aged 70 years or more. Six EPs were purposively sampled and interviewed after completion of the education program. The program significantly improved EPs' geriatric knowledge. EPs indicated that the program improved their ability and attentiveness to recognize frailty and geriatric syndromes. The program also significantly improved EPs' attention for the older patient's social history and circumstances (P = 0.04) but did not have a significant effect on medical decision making. EPs valued especially the case-based teaching and indicated that the interactive setting helped them to better understand and retain knowledge. Combined quantitative and qualitative data suggest that EPs benefit from geriatric emergency teaching. Future enhancement and evaluation of the geriatric education program is needed to confirm benefits to clinical practice and patient outcomes.

Evaluation of an emergency department falls pathway for older people: A patient chart review

The number of older adults presenting to EDs following a fall continues to rise, yet falls management often ignores opportunities for secondary falls risk reduction. Advanced Nurse Practitioners (ANPs) in EDs have an important clinical leadership role in improving outcomes for this group of patients.

AIM

This study describes the development of an ANP led falls pathway in an ED to improve safe discharge. It evaluates compliance with the pathway and referrals to community falls prevention services. It also draws comparison with baseline practice as recorded in 2014.

METHODS

The Falls Pathway involves four steps: 1) screening at triage (3 questions), 2) risk stratification (low, medium, high), 3) risk assessment (lying and standing blood pressure (B/P), timed-up and go (TUG), 4-AT for delirium screening, polypharmacy), and 4) referral to community falls services. We undertook a 12-month chart review of all patients aged 65 years or older presenting following a fall to the ANP service in 2018. We compared data to a baseline audit in 2014; descriptive and Chi squared statistics were used to examine the data.

RESULTS

The 2018 audit involved 77 patients representing 27% of ANP caseload. A repeat fall occurred in 42% (32/77) of cases and 35% (22/77) reported a fear of falling. The Falls Pathway was initiated in nearly 80% (62/77) of patients and compliance with falls risk assessment ranged from 42% for lying and standing B/P to 75% for TUG. In 2014, a review of 59 patient charts showed 27% (16/59) experienced a repeat fall, but other risk factors such as fear of falling were not recorded. In 2018, the majority of patients (88%) discharged home were referred to community falls prevention services compared to 22% in 2014.

CONCLUSION

The Falls Pathway improved falls risk assessment in the ED, identified opportunities for risk reduction and optimised referral to community falls services. The pathway continues to be a valuable tool but requires resources for ongoing implementation among the wider ED team.