1
|
Chary AN, Bhananker AR, Brickhouse E, Torres B, Santangelo I, Godwin KM, Naik AD, Carpenter CR, Liu SW, Kennedy M. Implementation of delirium screening in the emergency department: A qualitative study with early adopters. J Am Geriatr Soc 2024. [PMID: 39264150 DOI: 10.1111/jgs.19188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/26/2024] [Accepted: 08/04/2024] [Indexed: 09/13/2024]
Abstract
INTRODUCTION Delirium affects 15% of older adults presenting to emergency departments (EDs) but is detected in only one-third of cases. Evidence-based guidelines for ED delirium screening exist, but are underutilized. Frontline staff perceptions about delirium and time and resource constraints are known barriers to ED delirium screening uptake. Early adopters of ED delirium screening can offer valuable lessons about successful implementation. METHODS We conducted semi-structured interviews with clinician-administrators leading ED delirium screening initiatives from 20 EDs in the United States and Canada. Interviews focused on experiences of planning and implementing ED delirium screening. Interviews lasted 15 to 50 minutes and were digitally recorded and transcribed. To identify factors that commonly impacted implementation of ED delirium screening, we used constructs from the Consolidated Framework for Implementation Research (CFIR), an Implementation Science framework widely used to evaluate healthcare improvement initiatives. RESULTS Overall, notable facilitators of successful implementation were having institutional and ED leadership support and designated clinical champions to longitudinally engage and educate frontline staff. We found specific examples of factors affecting implementation drawn from the following seven CFIR constructs: (1) intervention complexity, (2) intervention adaptability, (3) external policies and incentives, (4) peer pressure from other institutions, (5) the implementation climate of the ED, (6) staff knowledge and beliefs, and (7) engaging deliverers of intervention, that is, frontline ED staff. CONCLUSION Implementing ED delirium screening is complex and requires institutional resources as well as clinical champions to engage frontline staff in a sustained fashion.
Collapse
Affiliation(s)
- Anita N Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Annika R Bhananker
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Elise Brickhouse
- School of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Beatrice Torres
- University of Texas School of Public Health, UT Health Science Center, Houston, Texas, USA
| | - Ilianna Santangelo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kyler M Godwin
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Aanand D Naik
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- University of Texas School of Public Health, UT Health Science Center, Houston, Texas, USA
- Institute on Aging, University of Texas Health Science Center, Houston, Texas, USA
| | | | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Shen S, Zeng X, Hui X, Chen L, Zhang J, Chen X. Application, knowledge and training needs regarding comprehensive geriatric assessment among geriatric practitioners in healthcare institutions: a cross-sectional study. BMC Geriatr 2024; 24:349. [PMID: 38637724 PMCID: PMC11025239 DOI: 10.1186/s12877-024-04964-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 04/10/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND This study aimed to investigate the actual application, knowledge, and training needs of comprehensive geriatric assessment (CGA) among geriatric practitioners in China. METHODS A total of 225 geriatric practitioners attending the geriatric medicine or geriatric nursing training were recruited for this cross-sectional study. The questionnaire included demographics, healthcare institution characteristics, the actual application, knowledge, training needs, and barriers to CGA and geriatric syndromes (GS). RESULTS Physicians and nurses were 57.3% and 42.7%, respectively. 71.1% were female, with a median age was 35 years. Almost two-thirds (140/225) of geriatric practitioners reported exposure to CGA in their clinical practice. The top five CGA evaluation items currently used were malnutrition risk (49.8%), fall risk (49.8%), activity of daily living (48.0%), pain (44.4%), and cognitive function (42.7%). Median knowledge scores for the management procedures of GS ranged from 2 to 6. Physicians identified medical insurance payment issues (29.5%) and a lack of systematic specialist knowledge and technology (21.7%) as the two biggest barriers to practicing geriatrics. Nurses cited a lack of systematic specialist knowledge and technology (52.1%) as the primary barrier. In addition, physicians and nurses exhibited significant differences in their knowledge of CGA-specific evaluation items and management procedures for GS (all P < 0.05). However, there were no significant differences in their training needs, except for polypharmacy. CONCLUSIONS The rate of CGA application at the individual level, as well as the overall knowledge among geriatric practitioners, was not adequate. Geriatric education and continuous training should be tailored to address the specific roles of physicians and nurses, as well as the practical knowledge reserves, barriers, and training needs they face.
Collapse
Affiliation(s)
- Shanshan Shen
- Department of Geriatrics, Zhejiang Hospital, No. 12 Lingyin Road, Hangzhou, 310013, Zhejiang Province, P.R. China
| | - Xingkun Zeng
- Department of Geriatrics, Zhejiang Hospital, No. 12 Lingyin Road, Hangzhou, 310013, Zhejiang Province, P.R. China
| | - Xiaoliang Hui
- Department of Geriatrics, Zhejiang Hospital, No. 12 Lingyin Road, Hangzhou, 310013, Zhejiang Province, P.R. China
| | - Lingyan Chen
- Department of Nursing, Zhejiang Hospital, Hangzhou, China
| | - Jinmei Zhang
- Department of Geriatrics, Zhejiang Hospital, No. 12 Lingyin Road, Hangzhou, 310013, Zhejiang Province, P.R. China
| | - Xujiao Chen
- Department of Geriatrics, Zhejiang Hospital, No. 12 Lingyin Road, Hangzhou, 310013, Zhejiang Province, P.R. China.
| |
Collapse
|
3
|
Barton HJ, Maru A, Leaf MA, Hekman DJ, Wiegmann DA, Shah MN, Patterson BW. Academic Detailing as a Health Information Technology Implementation Method: Supporting the Design and Implementation of an Emergency Department-Based Clinical Decision Support Tool to Prevent Future Falls. JMIR Hum Factors 2024; 11:e52592. [PMID: 38635318 PMCID: PMC11066751 DOI: 10.2196/52592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 02/08/2024] [Accepted: 03/02/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Clinical decision support (CDS) tools that incorporate machine learning-derived content have the potential to transform clinical care by augmenting clinicians' expertise. To realize this potential, such tools must be designed to fit the dynamic work systems of the clinicians who use them. We propose the use of academic detailing-personal visits to clinicians by an expert in a specific health IT tool-as a method for both ensuring the correct understanding of that tool and its evidence base and identifying factors influencing the tool's implementation. OBJECTIVE This study aimed to assess academic detailing as a method for simultaneously ensuring the correct understanding of an emergency department-based CDS tool to prevent future falls and identifying factors impacting clinicians' use of the tool through an analysis of the resultant qualitative data. METHODS Previously, our team designed a CDS tool to identify patients aged 65 years and older who are at the highest risk of future falls and prompt an interruptive alert to clinicians, suggesting the patient be referred to a mobility and falls clinic for an evidence-based preventative intervention. We conducted 10-minute academic detailing interviews (n=16) with resident emergency medicine physicians and advanced practice providers who had encountered our CDS tool in practice. We conducted an inductive, team-based content analysis to identify factors that influenced clinicians' use of the CDS tool. RESULTS The following categories of factors that impacted clinicians' use of the CDS were identified: (1) aspects of the CDS tool's design (2) clinicians' understanding (or misunderstanding) of the CDS or referral process, (3) the busy nature of the emergency department environment, (4) clinicians' perceptions of the patient and their associated fall risk, and (5) the opacity of the referral process. Additionally, clinician education was done to address any misconceptions about the CDS tool or referral process, for example, demonstrating how simple it is to place a referral via the CDS and clarifying which clinic the referral goes to. CONCLUSIONS Our study demonstrates the use of academic detailing for supporting the implementation of health information technologies, allowing us to identify factors that impacted clinicians' use of the CDS while concurrently educating clinicians to ensure the correct understanding of the CDS tool and intervention. Thus, academic detailing can inform both real-time adjustments of a tool's implementation, for example, refinement of the language used to introduce the tool, and larger scale redesign of the CDS tool to better fit the dynamic work environment of clinicians.
Collapse
Affiliation(s)
- Hanna J Barton
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Apoorva Maru
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Margaret A Leaf
- Department of Information Services, UW Health, Madison, WI, United States
| | - Daniel J Hekman
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Douglas A Wiegmann
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Brian W Patterson
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, United States
| |
Collapse
|
4
|
Haimovich AD, Shah MN, Southerland LT, Hwang U, Patterson BW. Automating risk stratification for geriatric syndromes in the emergency department. J Am Geriatr Soc 2024; 72:258-267. [PMID: 37811698 PMCID: PMC10866303 DOI: 10.1111/jgs.18594] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/11/2023] [Accepted: 08/19/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Geriatric emergency department (GED) guidelines endorse screening older patients for geriatric syndromes in the ED, but there have been significant barriers to widespread implementation. The majority of screening programs require engagement of a clinician, nurse, or social worker, adding to already significant workloads at a time of record-breaking ED patient volumes, staff shortages, and hospital boarding crises. Automated, electronic health record (EHR)-embedded risk stratification approaches may be an alternate solution for extending the reach of the GED mission by directing human actions to a smaller subset of higher risk patients. METHODS We define the concept of automated risk stratification and screening using existing EHR data. We discuss progress made in three potential use cases in the ED: falls, cognitive impairment, and end-of-life and palliative care, emphasizing the importance of linking automated screening with systems of healthcare delivery. RESULTS Research progress and operational deployment vary by use case, ranging from deployed solutions in falls screening to algorithmic validation in cognitive impairment and end-of-life care. CONCLUSIONS Automated risk stratification offers a potential solution to one of the most pressing problems in geriatric emergency care: identifying high-risk populations of older adults most appropriate for specific GED care. Future work is needed to realize the promise of improved care with less provider burden by creating tools suitable for widespread deployment as well as best practices for their implementation and governance.
Collapse
Affiliation(s)
- Adrian D Haimovich
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ula Hwang
- Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New York, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Brian W Patterson
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Industrial and Systems Engineering, Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| |
Collapse
|
5
|
Hekman DJ, Cochran AL, Maru AP, Barton HJ, Shah MN, Wiegmann D, Smith MA, Liao F, Patterson BW. Effectiveness of an Emergency Department-Based Machine Learning Clinical Decision Support Tool to Prevent Outpatient Falls Among Older Adults: Protocol for a Quasi-Experimental Study. JMIR Res Protoc 2023; 12:e48128. [PMID: 37535416 PMCID: PMC10436111 DOI: 10.2196/48128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/04/2023] [Accepted: 05/23/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Emergency department (ED) providers are important collaborators in preventing falls for older adults because they are often the first health care providers to see a patient after a fall and because at-home falls are often preceded by previous ED visits. Previous work has shown that ED referrals to falls interventions can reduce the risk of an at-home fall by 38%. Screening patients at risk for a fall can be time-consuming and difficult to implement in the ED setting. Machine learning (ML) and clinical decision support (CDS) offer the potential of automating the screening process. However, it remains unclear whether automation of screening and referrals can reduce the risk of future falls among older patients. OBJECTIVE The goal of this paper is to describe a research protocol for evaluating the effectiveness of an automated screening and referral intervention. These findings will inform ongoing discussions about the use of ML and artificial intelligence to augment medical decision-making. METHODS To assess the effectiveness of our program for patients receiving the falls risk intervention, our primary analysis will be to obtain referral completion rates at 3 different EDs. We will use a quasi-experimental design known as a sharp regression discontinuity with regard to intent-to-treat, since the intervention is administered to patients whose risk score falls above a threshold. A conditional logistic regression model will be built to describe 6-month fall risk at each site as a function of the intervention, patient demographics, and risk score. The odds ratio of a return visit for a fall and the 95% CI will be estimated by comparing those identified as high risk by the ML-based CDS (ML-CDS) and those who were not but had a similar risk profile. RESULTS The ML-CDS tool under study has been implemented at 2 of the 3 EDs in our study. As of April 2023, a total of 1326 patient encounters have been flagged for providers, and 339 unique patients have been referred to the mobility and falls clinic. To date, 15% (45/339) of patients have scheduled an appointment with the clinic. CONCLUSIONS This study seeks to quantify the impact of an ML-CDS intervention on patient behavior and outcomes. Our end-to-end data set allows for a more meaningful analysis of patient outcomes than other studies focused on interim outcomes, and our multisite implementation plan will demonstrate applicability to a broad population and the possibility to adapt the intervention to other EDs and achieve similar results. Our statistical methodology, regression discontinuity design, allows for causal inference from observational data and a staggered implementation strategy allows for the identification of secular trends that could affect causal associations and allow mitigation as necessary. TRIAL REGISTRATION ClinicalTrials.gov NCT05810064; https://www.clinicaltrials.gov/study/NCT05810064. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/48128.
Collapse
Affiliation(s)
- Daniel J Hekman
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Amy L Cochran
- Department of Population Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Apoorva P Maru
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Hanna J Barton
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Douglas Wiegmann
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | - Maureen A Smith
- Health Innovation Program, University of Wisconsin-Madison, Madison, WI, United States
| | - Frank Liao
- Department of Applied Data Science, UWHealth Hospitals and Clinics, University of Wisconsin-Madison, Madison, WI, United States
| | - Brian W Patterson
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States
| |
Collapse
|
6
|
Mowbray FI, Heckman G, Hirdes JP, Costa AP, Beauchet O, Archambault P, Eagles D, Wang HT, Perry JJ, Sinha SK, Jantzi M, Hebert P. Agreement and prognostic accuracy of three ED vulnerability screeners: findings from a prospective multi-site cohort study. CAN J EMERG MED 2023; 25:209-217. [PMID: 36857018 PMCID: PMC10014815 DOI: 10.1007/s43678-023-00458-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 01/13/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVES To evaluate the agreement between three emergency department (ED) vulnerability screeners, including the InterRAI ED Screener, ER2, and PRISMA-7. Our secondary objective was to evaluate the discriminative accuracy of screeners in predicting discharge home and extended ED lengths-of-stay (> 24 h). METHODS We conducted a nested sub-group study using data from a prospective multi-site cohort study evaluating frailty in older ED patients presenting to four Quebec hospitals. Research nurses assessed patients consecutively with the three screeners. We employed Cohen's Kappa to determine agreement, with high-risk cut-offs of three and four for the PRISMA-7, six for the ER2, and five for the interRAI ED Screener. We used logistic regression to evaluate the discriminative accuracy of instruments, testing them in their dichotomous, full, and adjusted forms (adjusting for age, sex, and hospital academic status). RESULTS We evaluated 1855 older ED patients across the four hospital sites. The mean age of our sample was 84 years. Agreement between the interRAI ED Screener and the ER2 was fair (K = 0.37; 95% CI 0.33-0.40); agreement between the PRISMA-7 and ER2 was also fair (K = 0.39; 95% CI = 0.36-0.43). Agreement between interRAI ED Screener and PRISMA-7 was poor (K = 0.19; 95% CI 0.16-0.22). Using a cut-off of four for PRISMA-7 improved agreement with the ER2 (K = 0.55; 95% CI 0.51-0.59) and the ED Screener (K = 0.32; 95% CI 0.2-0.36). When predicting discharge home, the concordance statistics among models were similar in their dichotomous (c = 0.57-0.61), full (c = 0.61-0.64), and adjusted forms (c = 0.63-0.65), and poor for all models when predicting extended length-of-stay. CONCLUSION ED vulnerability scores from the three instruments had a fair agreement and were associated with important patient outcomes. The interRAI ED Screener best identifies older ED patients at greatest risk, while the PRISMA-7 and ER2 are more sensitive instruments.
Collapse
Affiliation(s)
- Fabrice I Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - George Heckman
- School of Public Health Science, University of Waterloo, Waterloo, ON, Canada
- Schlegel Research Institute for Aging, Waterloo, ON, Canada
| | - John P Hirdes
- School of Public Health Science, University of Waterloo, Waterloo, ON, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Olivier Beauchet
- Department of Medicine and Research Center of the Geriatric University Institute of Montreal, University of Montreal, Montreal, QC, Canada
- Division of Geriatric Medicine, Department of Medicine, Sir Mortimer B. Davis Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, Montreal, QC, Canada
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec, QC, Canada
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Sainte-Marie, QC, Canada
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada
| | - Debra Eagles
- Department of Emergency Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Han Ting Wang
- Division of Critical Care Medicine, Department of Medicine, Universite de Montreal, Montreal, QC, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Samir K Sinha
- Division of Geriatric Medicine, Department of Medicine, Sinai Health and University Health Network, Toronto, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Micaela Jantzi
- School of Public Health Science, University of Waterloo, Waterloo, ON, Canada
| | - Paul Hebert
- Division of Palliative Care, Department of Medicine, Bruyere Research Institute, University of Ottawa, Ottawa, ON, Canada.
| |
Collapse
|
7
|
Schonnop R, Dainty KN, McLeod SL, Melady D, Lee JS. Understanding why delirium is often missed in older emergency department patients: a qualitative descriptive study. CAN J EMERG MED 2022; 24:820-831. [PMID: 36138324 DOI: 10.1007/s43678-022-00371-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/29/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Unrecognized delirium is associated with significant adverse outcomes. Despite decades of effort and educational initiatives, validated screening tools have not improved delirium recognition in the emergency department (ED). There remains a fundamental knowledge gap of why it is consistently missed. The objective of this study was to explore the perceptions of ED physicians and nurses regarding factors contributing to missed delirium in older ED patients. METHODS We conducted a qualitative descriptive study at two academic tertiary care EDs in Toronto, Canada. Emergency physicians and nurses were interviewed by a trained qualitative researcher using a semi-structured interview guide. We coded transcripts with an iteratively developed codebook. Interviews were conducted until thematic saturation occurred. Thematic data analysis occurred in conjunction with data collection to continuously monitor emerging themes and areas for further exploration. RESULTS We interviewed 26 ED physicians and nurses. We identified key themes at four levels: clinical practice, provider attitudes, systematic processes, and education. The four themes include: (1) there are varied approaches to delirium recognition and infrequent use of screening tools; (2) delirium assessment is perceived as overly time consuming and of lower priority than other symptoms and syndromes; (3) it is unclear whose responsibility it is to recognize delirium; and (4) there is a need for a deeper or "functional" understanding of delirium that includes its consequences. CONCLUSIONS Our findings demonstrate a need for ED leadership to identify clear team roles for delirium recognition, standardize use of delirium screening tools, and prioritize delirium as a symptom of an acute medical emergency.
Collapse
Affiliation(s)
- Rebecca Schonnop
- Department of Emergency Medicine, Royal Alexandra Hospital, University of Alberta, Edmonton, AB, Canada.
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, ON, Toronto, Canada.
| | - Katie N Dainty
- North York General Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, ON, Toronto, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Don Melady
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, ON, Toronto, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Jacques S Lee
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, ON, Toronto, Canada
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
- Division of Emergency Services, Sunnybrook Research Institute, Toronto, ON, Canada
| |
Collapse
|
8
|
Adams JD, Anderson S, Cook KL, Tivis LJ. Enhancing Care for Older Adults Living in Rural Areas Using an Evidence-Based Screening Tool to Recognize Geriatric Syndromes. J Gerontol Nurs 2022; 48:47-51. [PMID: 36007211 DOI: 10.3928/00989134-20220808-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The objectives of the current process improvement project were to improve access to health care and enhance care for older adults living in rural areas and to decrease morbidity and mortality. This project implemented an evidence-based screening tool, the Rapid Geriatric Assessment (RGA), as a routine screening in a patient-centered medical home for older adults in rural areas. Z-testing was used to measure the change, defined as scoring positive for at least one of four geriatric syndromes, as a result of using the RGA tool. Approximately one third had at least one such change following implementation of the RGA. In addition to the change in geriatric conditions, a significant change (48%) was noted in the number of patients who implemented an advance directive. We recommend the RGA be integrated in routine screening as it can help providers establish a targeted treatment plan for older adults who may be at increased risk for burden of disease. [Journal of Gerontological Nursing, 48(9), 47-51.].
Collapse
|
9
|
Nowroozpoor A, Dussetschleger J, Perry W, Sano M, Aloysi A, Belleville M, Brackett A, Hirshon JM, Hung W, Moccia JM, Ohuabunwa U, Shah MN, Hwang U. Detecting Cognitive Impairment and Dementia in the Emergency Department: A Scoping Review. J Am Med Dir Assoc 2022; 23:1314.e31-1314.e88. [PMID: 35940682 PMCID: PMC10804640 DOI: 10.1016/j.jamda.2022.03.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 03/23/2022] [Accepted: 03/30/2022] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To identify research and practice gaps to establish future research priorities to advance the detection of cognitive impairment and dementia in the emergency department (ED). DESIGN Literature review and consensus-based rankings by a transdisciplinary, stakeholder task force of experts, persons living with dementia, and care partners. SETTING AND PARTICIPANTS Scoping reviews focused on adult ED patients. METHODS Two systematic scoping reviews of 7 medical research databases focusing on best tools and approaches for detecting cognitive impairment and dementia in the ED in terms of (1) most accurate and (2) most pragmatic to implement. The results were screened, reviewed, and abstracted for relevant information and presented at the stakeholder consensus conference for discussion and ranked prioritization. RESULTS We identified a total of 1464 publications and included 45 to review for accurate tools and approaches for detecting cognitive impairment and dementia. Twenty-seven different assessments and instruments have been studied in the ED setting to evaluate cognitive impairment and dementia, with many focusing on sensitivity and specificity of instruments to screen for cognitive impairment. For pragmatic tools, we identified a total of 2166 publications and included 66 in the review. Most extensively studied tools included the Ottawa 3DY and Six-Item Screener (SIS). The SIS was the shortest to administer (1 minute). Instruments with the highest negative predictive value were the SIS (vs MMSE) and the 4 A's Test (vs expert diagnosis). The GEAR 2.0 Advancing Dementia Care Consensus conference ranked research priorities that included the need for more approaches to recognize more effectively and efficiently persons who may be at risk for cognitive impairment and dementia, while balancing the importance of equitable screening, purpose, and consequences of differentiating various forms of cognitive impairment. CONCLUSIONS AND IMPLICATIONS The scoping review and consensus process identified gaps in clinical care that should be prioritized for research efforts to detect cognitive impairment and dementia in the ED setting. These gaps will be addressed as future GEAR 2.0 research funding priorities.
Collapse
Affiliation(s)
- Armin Nowroozpoor
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA; Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jeff Dussetschleger
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - William Perry
- Department of Psychiatry, University of California, San Diego, San Diego, CA, USA
| | - Mary Sano
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Research and Development, James J. Peters VAMC, Bronx, NY, USA
| | - Amy Aloysi
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Alexandria Brackett
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT, USA
| | - Jon Mark Hirshon
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - William Hung
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Geriatric Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA
| | | | - Ugochi Ohuabunwa
- Division of General Medicine and Geriatrics, Department of Medicine, Emory School of Medicine, Atlanta, GA, USA
| | - Manish N Shah
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA; Department of Medicine (Geriatrics and Gerontology), University of Wisconsin-Madison, Madison, WI, USA; Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA; Geriatric Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA.
| |
Collapse
|
10
|
Burns ER, Lee R, Hodge SE, Pineau VJ, Welch B, Zhu M. Validation and comparison of fall screening tools for predicting future falls among older adults. Arch Gerontol Geriatr 2022; 101:104713. [PMID: 35526339 PMCID: PMC10543920 DOI: 10.1016/j.archger.2022.104713] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 04/27/2022] [Accepted: 04/29/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Falls are the leading cause of injuries among older adults in the United States (US). Falls are preventable and clinicians are advised to screen for fall risk yearly. There are many falls screening tools and not all have been validated for their ability to predict future falls. METHODS We enrolled 1905 community-dwelling older adults into a 13-month study using a probability-based representative panel of the US population recruited from NORC at the University of Chicago's National Frame. Respondents completed a baseline survey, 11 monthly fall calendars, and a final survey. The baseline survey included six falls screening tools (the Stay Independent, Three Key Questions (3KQ), a modified American Geriatric/British Geriatric tool, the short Falls Efficacy-1[FES-I]) and two single screening questions ("I have fallen in the past year" and "How many times did you fall in the past 12 months?"). The baseline and final survey collected demographic and health information, including falls. Sensitivity, specificity, positive and negative likelihood ratios, and corresponding 95% confidence intervals were calculated in SAS using weighted proportions. RESULTS There were 1563 respondents who completed the final survey (completion rate 82%). Sensitivity estimates ranged from 22.5% for the short FES-I to 68.7% for the 3KQ. Specificity estimates ranged from 57.9% for the 3KQ to 89.4% for the short FES-I. CONCLUSIONS Falls screening tools have varying sensitivity and specificity for predicting the occurrence of a fall in the following 12 months.
Collapse
Affiliation(s)
- Elizabeth R Burns
- Division of Injury Prevention, National Center of Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA 30341, United States.
| | - Robin Lee
- Division of Injury Prevention, National Center of Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA 30341, United States
| | | | | | - Bess Welch
- NORC at the University of Chicago, United States
| | - Meimeizi Zhu
- NORC at the University of Chicago, United States
| |
Collapse
|
11
|
Yadgir SR, Engstrom C, Jacobsohn GC, Green RK, Jones CMC, Cushman JT, Caprio TV, Kind AJH, Lohmeier M, Shah MN, Patterson BW. Machine learning-assisted screening for cognitive impairment in the emergency department. J Am Geriatr Soc 2022; 70:831-837. [PMID: 34643944 PMCID: PMC8904269 DOI: 10.1111/jgs.17491] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 09/08/2021] [Accepted: 09/11/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND/OBJECTIVES Despite a high prevalence and association with poor outcomes, screening to identify cognitive impairment (CI) in the emergency department (ED) is uncommon. Identification of high-risk subsets of older adults is a critical challenge to expanding screening programs. We developed and evaluated an automated screening tool to identify a subset of patients at high risk for CI. METHODS In this secondary analysis of existing data collected for a randomized control trial, we developed machine-learning models to identify patients at higher risk of CI using only variables available in electronic health record (EHR). We used records from 1736 community-dwelling adults age > 59 being discharged from three EDs. Potential CI was determined based on the Blessed Orientation Memory Concentration (BOMC) test, administered in the ED. A nested cross-validation framework was used to evaluate machine-learning algorithms, comparing area under the receiver-operator curve (AUC) as the primary metric of performance. RESULTS Based on BOMC scores, 121 of 1736 (7%) participants screened positive for potential CI at the time of their ED visit. The best performing algorithm, an XGBoost model, predicted BOMC positivity with an AUC of 0.72. With a classification threshold of 0.4, this model had a sensitivity of 0.73, a specificity of 0.64, a negative predictive value of 0.97, and a positive predictive value of 0.13. In a hypothetical ED with 200 older adult visits per week, the use of this model would lead to a decrease in the in-person screening burden from 200 to 77 individuals in order to detect 10 of 14 patients who would fail a BOMC. CONCLUSION This study demonstrates that an algorithm based on EHR data can define a subset of patients at higher risk for CI. Incorporating such an algorithm into a screening workflow could allow screening efforts and resources to be focused where they have the most impact.
Collapse
Affiliation(s)
- Simon R Yadgir
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Collin Engstrom
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Computer Science, Winona State University, Rochester, MN, USA
| | - Gwen Costa Jacobsohn
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Rebecca K Green
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Courtney M C Jones
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Jeremy T Cushman
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, Maryland, USA
| | - Thomas V Caprio
- Division of Geriatrics, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Amy J H Kind
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
- William S. Middleton Veterans Affairs Geriatrics Research, Education, and Clinical Center, Madison, Wisconsin, USA
- UW Center for Health Disparities Research, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Michael Lohmeier
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Brian W Patterson
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
- Health Innovation Program, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Industrial and Systems Engineering, Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| |
Collapse
|
12
|
Jacobsohn GC, Leaf M, Liao F, Maru AP, Engstrom CJ, Salwei ME, Pankratz GT, Eastman A, Carayon P, Wiegmann DA, Galang JS, Smith MA, Shah MN, Patterson BW. Collaborative design and implementation of a clinical decision support system for automated fall-risk identification and referrals in emergency departments. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2022; 10:100598. [PMID: 34923354 PMCID: PMC8881336 DOI: 10.1016/j.hjdsi.2021.100598] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 11/15/2021] [Accepted: 11/22/2021] [Indexed: 11/04/2022]
Abstract
Of the 3 million older adults seeking fall-related emergency care each year, nearly one-third visited the Emergency Department (ED) in the previous 6 months. ED providers have a great opportunity to refer patients for fall prevention services at these initial visits, but lack feasible tools for identifying those at highest-risk. Existing fall screening tools have been poorly adopted due to ED staff/provider burden and lack of workflow integration. To address this, we developed an automated clinical decision support (CDS) system for identifying and referring older adult ED patients at risk of future falls. We engaged an interdisciplinary design team (ED providers, health services researchers, information technology/predictive analytics professionals, and outpatient Falls Clinic staff) to collaboratively develop a system that successfully met user requirements and integrated seamlessly into existing ED workflows. Our rapid-cycle development and evaluation process employed a novel combination of human-centered design, implementation science, and patient experience strategies, facilitating simultaneous design of the CDS tool and intervention implementation strategies. This included defining system requirements, systematically identifying and resolving usability problems, assessing barriers and facilitators to implementation (e.g., data accessibility, lack of time, high patient volumes, appointment availability) from multiple vantage points, and refining protocols for communicating with referred patients at discharge. ED physician, nurse, and patient stakeholders were also engaged through online surveys and user testing. Successful CDS design and implementation required integration of multiple new technologies and processes into existing workflows, necessitating interdisciplinary collaboration from the onset. By using this iterative approach, we were able to design and implement an intervention meeting all project goals. Processes used in this Clinical-IT-Research partnership can be applied to other use cases involving automated risk-stratification, CDS development, and EHR-facilitated care coordination.
Collapse
Affiliation(s)
- Gwen Costa Jacobsohn
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA.
| | - Margaret Leaf
- Applied Data Science, Enterprise Analytics, UW Health, Madison, WI, USA.
| | - Frank Liao
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA; Applied Data Science, Enterprise Analytics, UW Health, Madison, WI, USA.
| | - Apoorva P. Maru
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Collin J. Engstrom
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA,Department of Computer Science, Winona State University, Rochester, MN, USA
| | - Megan E. Salwei
- Department of Industrial and Systems Engineering, University of Wisconsin, Madison, Wisconsin, USA,Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, Wisconsin, USA,Center for Research and Innovation in Systems Safety, Departments of Anesthesiology and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gerald T Pankratz
- Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Alexis Eastman
- Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Pascale Carayon
- Department of Industrial and Systems Engineering, University of Wisconsin, Madison, WI, USA; Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI, USA.
| | - Douglas A. Wiegmann
- Department of Industrial and Systems Engineering, University of Wisconsin, Madison, Wisconsin, USA,Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Joel S. Galang
- Applied Data Science, Enterprise Analytics, UW Health, Madison, Wisconsin, USA
| | - Maureen A. Smith
- Health Innovation Program, University of Wisconsin-Madison, Madison, Wisconsin, USA,Department of Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Manish N. Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA,Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA,Department of Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Brian W. Patterson
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA,Health Innovation Program, University of Wisconsin-Madison, Madison, Wisconsin, USA
| |
Collapse
|
13
|
Southerland LT, Hunold KM, Van Fossen J, Caterino JM, Gulker P, Stephens JA, Bischof JJ, Farrell E, Carpenter CR, Mion LC. An implementation science approach to geriatric screening in an emergency department. J Am Geriatr Soc 2022; 70:178-187. [PMID: 34580860 PMCID: PMC8742753 DOI: 10.1111/jgs.17481] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND The Geriatric Emergency Department (ED) Guidelines recommend screening older adults during their ED visit for delirium, fall risk/safe mobility, and home safety needs. We used the Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementation Change (ERIC) tool for preimplementation planning. METHODS The cross-sectional survey was conducted among ED nurses at an academic medical center. The survey was adapted from the CFIR Interview Guide Tool and consisted of 21 Likert scale questions based on four CFIR domains. Potential barriers identified by the survey were mapped to identify recommended implementation strategies using ERIC. RESULTS Forty-six of 160 potential participants (29%) responded. Intervention Characteristics: Nurses felt geriatric screening should be standard practice for all EDs (76.1% agreed some/very much) and that there was good evidence (67.4% agreed some/very much). Outer setting: The national and regional practices such as the existence of guidelines or similar practices in other hospitals were unknown to many (20.0%). Nurses did agree some/very much (64.4%) that the intervention was good for the hospital/health system. Inner Setting: 67.4% felt more staff or infrastructure and 63.0% felt more equipment were needed for the intervention. When asked to pick from a list of potential barriers, the most commonly chosen were motivational (I often do not remember (n = 27, 58.7%) and It is not a priority (n = 14, 30.4%)). The identified barriers were mapped using the ERIC tool to rate potential implementation strategies. Strategies to target culture change were identifying champions, improve adaptability, facilitate the nurses performing the intervention, and increase demand for the intervention. CONCLUSION CFIR domains and ERIC tools are applicable to an ED intervention for older adults. This preimplementation process could be replicated in other EDs considering implementing geriatric screening.
Collapse
Affiliation(s)
| | | | - Jenifer Van Fossen
- Department of Emergency Medicine, The Ohio State University, Columbus OH
| | | | - Peg Gulker
- Department of Emergency Medicine, The Ohio State University, Columbus OH
| | - Julie A. Stephens
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State College of Medicine, Columbus, OH, USA
| | - Jason J. Bischof
- Department of Emergency Medicine, The Ohio State University, Columbus OH
| | - Erin Farrell
- Department of Emergency Medicine, The Ohio State University, Columbus OH
| | | | - Lorraine C. Mion
- College of Nursing, The Ohio State Wexner Medical Center, Columbus, OH, USA
| |
Collapse
|
14
|
Mowbray FI, Manlongat D, Correia RH, Strum RP, Fernando SM, McIsaac D, de Wit K, Worster A, Costa AP, Griffith LE, Douma M, Nolan JP, Muscedere J, Couban R, Foroutan F. Prognostic association of frailty with post-arrest outcomes following cardiac arrest: A systematic review and meta-analysis. Resuscitation 2021; 167:242-250. [PMID: 34166743 DOI: 10.1016/j.resuscitation.2021.06.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 05/28/2021] [Accepted: 06/15/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To synthesize the current evidence examining the association between frailty and a series of post-arrest outcomes following the provision of cardiopulmonary resuscitation (CPR). DATA SOURCES We searched MEDLINE, PubMed (exclusive of MEDLINE), EMBASE, CINAHL, and Web of Science from inception to August 2020 for observational studies that examined an association between frailty and post-arrest health outcomes, including in-hospital and post-discharge mortality. We conducted citation tracking for all eligible studies. STUDY SELECTION Our search yielded 20,480 citations after removing duplicate records. We screened titles, abstracts and full-texts independently and in duplicate. DATA EXTRACTION The prognosis research strategy group (PROGRESS) and the critical appraisal and data extraction for systematic review of prediction modelling studies (CHARMS) guidelines were followed. Study and outcome-specific risk of bias were assessed using the Quality in Prognosis Studies (QUIPS) instrument. We rated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) recommendations for prognostic factor research. DATA SYNTHESIS Four studies were included in this review and three were eligible for statistical pooling. Our sample comprised 1,134 persons who experienced in-hospital cardiac arrest (IHCA). The mean age of the sample was 71 years. The study results were pooled according to the specific frailty instrument. Three studies used the Clinical Frailty Scale (CFS) and adjusted age (our minimum confounder); the presence of frailty was associated with an approximate three-fold increase in the odds of dying in-hospital after IHCA (aOR = 2.93; 95% CI = 2.43-3.53, high certainty). Frailty was also associated with decreased incidence of ROSC (return of spontaneous circulation) and discharge home following IHCA. One study with high risk of bias used the Hospital Frailty Risk Score and reported a 43% decrease in the odds of discharge home for patients with frailty following IHCA. CONCLUSION High certainty evidence was found for an association between frailty and in-hospital mortality following IHCA. Frailty is a robust prognostic factor that contributes valuable information and can inform shared-decision making and policies surrounding advance care directives. Registration: PROSPERO Registration # CRD42020212922.
Collapse
Affiliation(s)
- Fabrice I Mowbray
- Department of Health Research Methods, Evidence and Impact, McMaster University, 175 Longwood Rd. S, Hamilton, Ontario L8P 0A1, Canada.
| | - Donna Manlongat
- College of Nursing, Wayne State University, 5557 Cass Ave, Detroit, MI 48202, USA.
| | - Rebecca H Correia
- Department of Health Research Methods, Evidence and Impact, McMaster University, 175 Longwood Rd. S, Hamilton, Ontario L8P 0A1, Canada.
| | - Ryan P Strum
- Department of Health Research Methods, Evidence and Impact, McMaster University, 175 Longwood Rd. S, Hamilton, Ontario L8P 0A1, Canada.
| | - Shannon M Fernando
- Department of Emergency Medicine, University of Ottawa, 451 Smyth Rd #2044, Ottawa, Ontario K1H 8M5, Canada; Division of Critical Care, Department of Medicine, University of Ottawa, 451 Smyth Rd #2044, Ottawa, Ontario K1H 8M5, Canada.
| | - Daniel McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, 451 Smyth Rd #2044, Ottawa, Ontario K1H 8M5, Canada; The Ottawa Hospital School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Cres, Rm 101, Ottawa, Ontario, K1G 5Z3, Canada.
| | - Kerstin de Wit
- Division of Emergency Medicine, Department of Medicine, McMaster University, 1280 Main St. W, Hamilton, Ontario L8S 4L8, Canada.
| | - Andrew Worster
- Division of Emergency Medicine, Department of Medicine, McMaster University, 1280 Main St. W, Hamilton, Ontario L8S 4L8, Canada.
| | - Andrew P Costa
- Department of Health Research Methods, Evidence and Impact, McMaster University, 175 Longwood Rd. S, Hamilton, Ontario L8P 0A1, Canada; St. Joseph's Health System, 50 Charlton Ave. E, Hamilton, Ontario L8N 4A6, Canada.
| | - Lauren E Griffith
- Department of Health Research Methods, Evidence and Impact, McMaster University, 175 Longwood Rd. S, Hamilton, Ontario L8P 0A1, Canada; McMaster Institute for Research on Aging, McMaster University, 1280 Main St. W, Hamilton, Ontario L8S 4L8, Canada.
| | - Matthew Douma
- Department of Critical Care Medicine, University of Alberta, 116 St & 85 Ave, Edmonton, Alberta T6G 2R3, Canada.
| | - Jerry P Nolan
- Resuscitation Medicine, Warwick Medical School, University of Warwick, Medical School Building, Coventry CV4 7HL, United Kingdom; Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, United Kingdom.
| | - John Muscedere
- Department of Critical Care Medicine, Queen's University, 99 University Ave, Kingston, Ontario K7L 3N6, Canada.
| | - Rachel Couban
- Department of Anesthesia, McMaster University, 1280 Main St. W, Hamilton, Ontario L8S 4L8, Canada.
| | - Farid Foroutan
- Ted Rogers Centre for Heart Research, University Health Network, 661 University Ave, Toronto, Ontario M5G 1X8, Canada.
| |
Collapse
|
15
|
Abstract
Geriatric emergency medicine has emerged as a subspecialty of emergency medicine over the past 25 years. This emergence has seen the development of increases in training opportunities, care delivery strategies, collaborative best practice guidelines, and formal geriatric emergency department accreditation. This multidisciplinary field remains ripe for continued development in the coming decades as the aging US population parallels a call from patients, health care providers, and health systems to improve the delivery of high-value care. This article educates emergency medicine practitioners and highlights high-value care practice trends to inform and prioritize decision-making for this unique patient population.
Collapse
|
16
|
Mowbray FI, Aryal K, Mercier E, Heckman G, Costa AP. Older Emergency Department Patients: Does Baseline Care Status Matter? Can Geriatr J 2020; 23:289-296. [PMID: 33282049 PMCID: PMC7704072 DOI: 10.5770/cgj.23.421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Little is known about the prognostic differences between older emergency department (ED) patients who present with different formal support requirements in the community. We set out to describe and compare the patient profiles and patterns of health service use among three older ED cohorts: home care clients, nursing home residents and those receiving no formal support. Methods We conducted a secondary analysis of the Canadian cohort from the interRAI multinational ED study. Data were collected using interRAI ED contact assessment on patients 75 years of age and older (n = 2,274), in eight ED sites across Canada. A series of descriptive statistics were reported. Adjusted associations were determined using logistic regression. Results Older adults receiving no formal support services were most stable. However, they were most likely to be hospitalized. Older home care clients were most likely to report depressive symptoms and distressed caregivers. They also had the greatest odds of frequent ED visitation post-discharge (OR=1.9; 95% CI=1.39–2.59). Older adults transferred from a nursing home were the frailest but had the lowest odds of hospital admission (OR=0.14; 95% CI=0.09–0.23). Conclusion We demonstrated the importance of inquiring about community-based formal support services and provide data to support decision-making in the ED.
Collapse
Affiliation(s)
- Fabrice I Mowbray
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON
| | - Komal Aryal
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON
| | - Eric Mercier
- Département de Médecine Familiale et Médecine d'Urgence, Faculté de Médecine, Université Laval, Quebec City, QC.,Centre d'excellence sur le vieillissement, Centre de recherche sur les soins de première ligne de l'Université Laval, Quebec City, QC
| | - George Heckman
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON
| | - Andrew P Costa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON.,Michael G. DeGroote School of Medicine, Waterloo Regional Campus, Waterloo, ON, Canada
| |
Collapse
|
17
|
Mowbray F, Zargoush M, Jones A, de Wit K, Costa A. Predicting hospital admission for older emergency department patients: Insights from machine learning. Int J Med Inform 2020; 140:104163. [PMID: 32474393 DOI: 10.1016/j.ijmedinf.2020.104163] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/26/2020] [Accepted: 04/28/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Emergency departments (ED) are a portal of entry into the hospital and are uniquely positioned to influence the health care trajectories of older adults seeking medical attention. Older adults present to the ED with distinct needs and complex medical histories, which can make disposition planning more challenging. Machine learning (ML) approaches have been previously used to inform decision-making surrounding ED disposition in the general population. However, little is known about the performance and utility of ML methods in predicting hospital admission among older ED patients. We applied a series of ML algorithms to predict ED admission in older adults and discuss their clinical and policy implications. MATERIALS AND METHODS We analyzed the Canadian data from the interRAI multinational ED study, the largest prospective cohort study of older ED patients to date. The data included 2274 ED patients 75 years of age and older from eight ED sites across Canada between November 2009 and April 2012. Data were extracted from the interRAI ED Contact Assessment, with predictors including a series of geriatric syndromes, functional assessments, and baseline care needs. We applied a total of five ML algorithms. Models were trained, assessed, and analyzed using 10-fold cross-validation. The performance of predictive models was measured using the area under the receiver operating characteristic curve (AUC). We also report the accuracy, sensitivity, and specificity of each model to supplement performance interpretation. RESULTS Gradient boosted trees was the most accurate model to predict older ED patients who would require hospitalization (AUC = 0.80). The five most informative features include home intravenous therapy, time of ED presentation, a requirement for formal support services, independence in walking, and the presence of an unstable medical condition. CONCLUSION To the best of our knowledge, this is the first study to predict hospital admission in older ED patients using a series of geriatric syndromes and functional assessments. We were able to predict hospital admission in older ED patients with good accuracy using the items available in the interRAI ED Contact Assessment. This information can be used to inform decision-making about ED disposition and may expedite admission processes and proactive discharge planning.
Collapse
Affiliation(s)
- Fabrice Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Big Data and Geriatric Models of Care (BDG) Cluster, McMaster University, Hamilton, Ontario, Canada
| | - Manaf Zargoush
- Health Policy and Management, DeGroote School of Business, McMaster University, Hamilton, Ontario, Canada.
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Big Data and Geriatric Models of Care (BDG) Cluster, McMaster University, Hamilton, Ontario, Canada
| | - Kerstin de Wit
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Big Data and Geriatric Models of Care (BDG) Cluster, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
18
|
Eagles D, Otal D, Wilding L, Sinha S, Thiruganasambandamoorthy V, Wells GA, Stiell IG. Evaluation of the Ottawa 3DY as a screening tool for cognitive impairment in older emergency department patients. Am J Emerg Med 2020; 38:2545-2551. [PMID: 31937444 DOI: 10.1016/j.ajem.2019.12.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 11/07/2019] [Accepted: 12/17/2019] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE This study sought to evaluate the implementation of the Ottawa 3DY Tool, a simple screening instrument for cognitive impairment, by front-line ED clinicians. METHODS We conducted a prospective cohort study in an academic ED. Patients ≥75 years underwent cognitive screening with the Ottawa 3DY by front-line nurses and physicians. Descriptive statistics were used to describe level of implementation and acceptability of the tool. Sensitivity and specificity was calculated using an Mini-Mental State Exam <25 as the cut-off for cognitive impairment. A weighted kappa was calculated to establish inter-rater agreement. RESULTS Cognitive screening was completed in 260/332 eligible patients (78.3%), who were 60% female and had a mean age of 83.7 years. Facilitators to screening: perceived importance and ownership of screening and feasibility of Ottawa 3DY. Barriers to screening were: over confidence in clinical judgement and perceived lack of patient benefit. Ottawa 3DY had a sensitivity of 84.6% (64.3-95.0) and specificity of 54.2% (39.3-68.4) when completed by nurses. When completed by emergency physicians, sensitivity was 78.9% (53.9-93.0) and specificity was 70.0% (45.7-87.2). Inter-rater agreement kappa score was 0.67. DISCUSSION This study demonstrated that incorporating the Ottawa 3DY tool into the routine evaluation of older ED patients by front-line ED clinicians is both feasible and effective. With its demonstrated good inter-rater reliability and moderate level of sensitivity and specificity when compared with the much longer MMSE, the routine adoption of this tool may help lead to improved recognition of cognitive impairment and ultimately patient and system outcomes.
Collapse
Affiliation(s)
- Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Damanjot Otal
- Department of Family Medicine, University of Western Ontario, London, Ontario, Canada
| | - Laura Wilding
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Samir Sinha
- Departments of Medicine and Family and Community Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - George A Wells
- School of Epidemiology and Public Health, Department of Medicine and Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
19
|
Examining the relationship between triage acuity and frailty to inform the care of older emergency department patients: Findings from a large Canadian multisite cohort study. CAN J EMERG MED 2019; 22:74-81. [DOI: 10.1017/cem.2019.432] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
ABSTRACTBackgroundThe 2016 Canadian Triage and Acuity Scale (CTAS) updates introduced frailty screening within triage to more accurately code frail patients who may deteriorate waiting for care. The relationship between triage acuity and frailty is not well understood, but may help inform which supplemental geriatric assessments are beneficial to support care in the emergency department (ED). Our objectives were to investigate the relationship between triage acuity and frailty, and to compare their associations with a series of patient outcomes.MethodsWe conducted a secondary analysis of the Canadian cohort from a multinational prospective study. Data were collected on ED patients 75 years of age and older from eight ED sites across Canada between November 2009 and April 2012. Triage acuity was assigned using the CTAS, whereas frailty was measured using an ED frailty index. Spearman rank and binary logistic regression were used to examine associations.ResultsA total of 2,153 ED patients were analyzed. No association was found between the CTAS and ED frailty index scores assigned to patients (r = .001; p = 0.99). The ED frailty index was associated with hospital admission (odds ratio [OR] = 1.5; 95% confidence interval [CI] = 1.4–1.6), hospital length of stay (OR = 1.4; 95% CI = 1.2–1.6), future hospitalization (OR = 1.1; 95% CI = 1.05–1.2), and ED recidivism (OR = 1.1; 95% CI = 1.04–1.2). The CTAS was associated with hospital admission (e.g., CTAS 2 v. 5; OR = 6; 95% CI = 3.3–11.4).ConclusionOur findings demonstrate that frailty and triage acuity are independent but complementary measures. EDs may benefit from comprehensive frailty screening post-triage, as frailty and its associated geriatric syndromes drive outcomes separate from traditional measures of acuity.
Collapse
|
20
|
Goldberg EM, Resnik L, Marks SJ, Merchant RC. GAPcare: the Geriatric Acute and Post-acute Fall Prevention Intervention-a pilot investigation of an emergency department-based fall prevention program for community-dwelling older adults. Pilot Feasibility Stud 2019; 5:106. [PMID: 31463079 PMCID: PMC6710862 DOI: 10.1186/s40814-019-0491-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 08/14/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Falls are the leading cause of fatal and non-fatal injuries among older adults. Older emergency department (ED) patients who present for evaluations after falls have a 30% higher risk of falling again in the subsequent 6 months than age-matched controls. Although EDs frequently evaluate older adults after their falls, the typical evaluation consists of an injury assessment alone. As such, an opportunity is lost to assess and address the potential causes of falls in this vulnerable population. In this manuscript, we present a multidisciplinary fall prevention protocol for a pilot study of older adult ED patients who recently sustained a fall (GAPcare: the Geriatric Acute and Post-acute Fall Prevention Intervention). METHODS GAPcare is a randomized single-blinded pilot study. Participants in GAPcare are 120 older adults (≥ 65 years old) who present to 1 of 2 academic US EDs after a fall. We randomly assign participants 1:1 to an intervention or a usual care (control) arm. In the intervention arm, the patient's ED physician, a pharmacist, and a physical therapist (PT) collaborate to identify and address any risk factors that may have contributed to the fall. Intervention arm participants and their caregivers return home with a medication-related action plan to taper or stop potentially inappropriate medications and to address polypharmacy and a PT assessment and plan. Participants in the usual care arm receive standard assessments and care in the ED and a home safety brochure. Participants in both study arms complete fall calendars for 6 months to document the number of falls and healthcare visits during follow-up. The primary outcome is feasibility of the GAPcare fall prevention intervention (number and proportion of screened participants who are eligible, recruited, and retained; impact on ED length of stay), while the secondary outcome is to estimate its initial efficacy. DISCUSSION The GAPcare-ED fall prevention intervention has the potential to promote older adult-sensitive care for millions of Americans presenting to EDs after falls and establish a protocol for a future large-scale randomized controlled trial on this topic. TRIAL REGISTRATION ClinicalTrials.gov, NCT03360305. Trial registration date: December 4, 2017. Protocol version: 1.
Collapse
Affiliation(s)
- Elizabeth M. Goldberg
- Department of Emergency Medicine, Brown University, 55 Claverick Street, Providence, RI 02903 USA
- Department of Health Services, Practice and Policy, Brown University, 121 S. Main Street, Providence, RI 02912 USA
| | - Linda Resnik
- Department of Health Services, Practice and Policy, Brown University, 121 S. Main Street, Providence, RI 02912 USA
- Providence VA Medical Center, 830 Chalkstone Ave, Providence, RI 02908 USA
| | - Sarah J. Marks
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard University, 75 Francis Street, Boston, MA 02115 USA
| | - Roland C. Merchant
- Department of Emergency Medicine, Brown University, 55 Claverick Street, Providence, RI 02903 USA
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard University, 75 Francis Street, Boston, MA 02115 USA
| |
Collapse
|
21
|
Patterson BW, Engstrom CJ, Sah V, Smith MA, Mendonça EA, Pulia MS, Repplinger MD, Hamedani AG, Page D, Shah MN. Training and Interpreting Machine Learning Algorithms to Evaluate Fall Risk After Emergency Department Visits. Med Care 2019; 57:560-566. [PMID: 31157707 PMCID: PMC6590914 DOI: 10.1097/mlr.0000000000001140] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Machine learning is increasingly used for risk stratification in health care. Achieving accurate predictive models do not improve outcomes if they cannot be translated into efficacious intervention. Here we examine the potential utility of automated risk stratification and referral intervention to screen older adults for fall risk after emergency department (ED) visits. OBJECTIVE This study evaluated several machine learning methodologies for the creation of a risk stratification algorithm using electronic health record data and estimated the effects of a resultant intervention based on algorithm performance in test data. METHODS Data available at the time of ED discharge were retrospectively collected and separated into training and test datasets. Algorithms were developed to predict the outcome of a return visit for fall within 6 months of an ED index visit. Models included random forests, AdaBoost, and regression-based methods. We evaluated models both by the area under the receiver operating characteristic (ROC) curve, also referred to as area under the curve (AUC), and by projected clinical impact, estimating number needed to treat (NNT) and referrals per week for a fall risk intervention. RESULTS The random forest model achieved an AUC of 0.78, with slightly lower performance in regression-based models. Algorithms with similar performance, when evaluated by AUC, differed when placed into a clinical context with the defined task of estimated NNT in a real-world scenario. CONCLUSION The ability to translate the results of our analysis to the potential tradeoff between referral numbers and NNT offers decisionmakers the ability to envision the effects of a proposed intervention before implementation.
Collapse
Affiliation(s)
- Brian W Patterson
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health
- Health Innovation Program
| | | | - Varun Sah
- Department of Computer Sciences, University of Wisconsin-Madison
| | - Maureen A Smith
- Health Innovation Program
- Departments of Population Health Sciences
- Family Medicine
| | - Eneida A Mendonça
- Biostatistics and Medical Informatics
- Pediatrics, University of Wisconsin School of Medicine and Public Health
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health
| | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health
| | - Azita G Hamedani
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health
| | - David Page
- Department of Computer Sciences, University of Wisconsin-Madison
- Biostatistics and Medical Informatics
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health
- Departments of Population Health Sciences
- Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| |
Collapse
|
22
|
Factors for Self-Managing Care Following Older Adults’ Discharge from the Emergency Department: A Qualitative Study. Can J Aging 2018; 38:76-89. [DOI: 10.1017/s071498081800034x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
RÉSUMÉCette étude avait pour but d’identifier les facteurs qui influent sur la capacité des personnes âgées à prendre en charge leur santé après une consultation au service des urgences (SU). Les questionnaires de l’enquête (n = 380) ont été remplis en SU par des personnes âgées et leurs aidants et visaient à évaluer leur perception de la compréhension de l’information qui leur était fournie. Des entrevues (n = 51) ont été réalisées avec un sous-échantillon de participants au cours des quatre semaines suivant leur consultation au SU et ont examiné les facteurs ayant une incidence sur l’autogestion des problèmes de santé. La perception de la compréhension de l’information reçue en SU (« oui, certainement ») était meilleure lors de la consultation au SU (91 %) que lors du suivi (71 %), lorsque 20 % des participants ne comprenaient pas ou n’étaient pas certains qu’ils avaient compris ce qui leur avait été communiqué en SU. Les patients ont rapporté que l’autogestion de leurs problèmes de santé était influencée par: la communication avec le personnel du SU, la compréhension des attentes suivant le congé de l’hôpital, l’état de santé, la disponibilité des aidants et divers facteurs externes. De plus, les soignants ont aussi mentionné l’appui aux soignants et la résistance des patients aux recommandations. L’utilisation de stratégies adaptées aux aînés en SU (p. ex. recommandations écrites, confirmation de la compréhension des recommandations), particulièrement celles liées à l’identification des personnes à risque et de celles nécessitant davantage de soutiens transitoires ou un meilleur accès ou intégration aux ressources disponibles dans la communauté amélioreraient l’autogestion des problèmes de santé suivant les consultations en SU.
Collapse
|
23
|
Patterson BW, Repplinger MD, Pulia MS, Batt RJ, Svenson JE, Trinh A, Mendonça EA, Smith MA, Hamedani AG, Shah MN. Using the Hendrich II Inpatient Fall Risk Screen to Predict Outpatient Falls After Emergency Department Visits. J Am Geriatr Soc 2018; 66:760-765. [PMID: 29509312 PMCID: PMC5937931 DOI: 10.1111/jgs.15299] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the utility of routinely collected Hendrich II fall scores in predicting returns to the emergency department (ED) for falls within 6 months. DESIGN Retrospective electronic record review. SETTING Academic medical center ED. PARTICIPANTS Individuals aged 65 and older seen in the ED from January 1, 2013, through September 30, 2015. MEASUREMENTS We evaluated the utility of routinely collected Hendrich II fall risk scores in predicting ED visits for a fall within 6 months of an all-cause index ED visit. RESULTS For in-network patient visits resulting in discharge with a completed Hendrich II score (N = 4,366), the return rate for a fall within 6 months was 8.3%. When applying the score alone to predict revisit for falls among the study population the resultant receiver operating characteristic (ROC) plot had an area under the curve (AUC) of 0.64. In a univariate model, the odds of returning to the ED for a fall in 6 months were 1.23 times as high for every 1-point increase in Hendrich II score (odds ratio (OR)=1.23 (95% confidence interval (CI)=1.19-1.28). When included in a model with other potential confounders or predictors of falls, the Hendrich II score is a significant predictor of a return ED visit for fall (adjusted OR=1.15, 95% CI=1.10-1.20, AUC=0.75). CONCLUSION Routinely collected Hendrich II scores were correlated with outpatient falls, but it is likely that they would have little utility as a stand-alone fall risk screen. When combined with easily extractable covariates, the screen performs much better. These results highlight the potential for secondary use of electronic health record data for risk stratification of individuals in the ED. Using data already routinely collected, individuals at high risk of falls after discharge could be identified for referral without requiring additional screening resources.
Collapse
Affiliation(s)
- Brian W Patterson
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Health Innovation Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Robert J Batt
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Wisconsin School of Business, University of Wisconsin-Madison, Madison, Wisconsin
| | - James E Svenson
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Alex Trinh
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Eneida A Mendonça
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Maureen A Smith
- Health Innovation Program, University of Wisconsin-Madison, Madison, Wisconsin
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Department of Family Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Azita G Hamedani
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Division of Geriatrics, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| |
Collapse
|
24
|
Barbic D, Kim B, Salehmohamed Q, Kemplin K, Carpenter CR, Barbic SP. Diagnostic accuracy of the Ottawa 3DY and Short Blessed Test to detect cognitive dysfunction in geriatric patients presenting to the emergency department. BMJ Open 2018; 8:e019652. [PMID: 29549205 PMCID: PMC5857706 DOI: 10.1136/bmjopen-2017-019652] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES Cognitive dysfunction (CD) is a common finding in geriatric patients presenting to the emergency department (ED). Our primary objective was to determine the diagnostic accuracy of the Ottawa 3DY (O3DY) and Short Blessed Test (SBT) as screening tools for the detection of CD in the ED. Our secondary objective was to estimate the inter-rater reliability of these instruments. METHODS We conducted a prospective cross-sectional comparative study at an inner-city academic medical centre (annual ED visit census 86 000). Patients aged 75 years or greater were evaluated for inclusion, 163 were screened, 150 were deemed eligible and 117 were enrolled. The research team completed the O3DY, SBT and Mini-Mental State Exam (MMSE) for each participant. Descriptive statistics were calculated. Sensitivity and specificity of the O3DY and SBT were calculated in STATA V.11.2 using the MMSE as our criterion standard. RESULTS We enrolled 117 patients from June to November 2016. The median ED length of stay at the time of completion of all tests was 1:40 (IQR 1:34-1:46). The sensitivity of the O3DY was 71.4% (95% CI 47.8 to 95.1), and specificity was 56.3% (46.7-65.9). Sensitivity of the SBT was 85.7% (67.4-99.9) and specificity was 58.3% (48.7-67.8). The receiver operating characteristic area under the curve was calculated for the O3DY (0.51; 95% CI 0.42 to 0.61) and SBT (0.52; 95% CI 0.43 to 0.61) relative to the MMSE. Inter-rater reliability for the O3DY (k=0.64) and SBT (k=0.63) were good. CONCLUSION In a cohort of geriatric patients presenting to an inner-city academic ED, the O3DY and SBT tools demonstrate moderate sensitivity and specificity for the detection of CD. Inter-rater reliability for the O3DY and SBT were good. Future research on this topic should attempt to derive and validate ED-specific screening tools, which will hopefully result in more robust likelihood ratios for the screening of CD in ED geriatric patients.
Collapse
Affiliation(s)
- David Barbic
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian Kim
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Qadeem Salehmohamed
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kate Kemplin
- School of Nursing, University of Tennessee Chattanooga, Chattanooga, Tennessee, USA
| | | | - Skye Pamela Barbic
- Department of Occupational Therapy and Occupational Science, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation Outcome Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
25
|
Patterson BW, Smith MA, Repplinger MD, Pulia MS, Svenson JE, Kim MK, Shah MN. Using Chief Complaint in Addition to Diagnosis Codes to Identify Falls in the Emergency Department. J Am Geriatr Soc 2017; 65:E135-E140. [PMID: 28636072 PMCID: PMC5603381 DOI: 10.1111/jgs.14982] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To compare incidence of falls in an emergency department (ED) cohort using a traditional International Classification of Diseases, Ninth Revision (ICD-9) code-based scheme and an expanded definition that included chief complaint information and to examine the clinical characteristics of visits "missed" in the ICD-9-based scheme. DESIGN Retrospective electronic record review. SETTING Academic medical center ED. PARTICIPANTS Individuals aged 65 and older seen in the ED between January 1, 2013, and September 30, 2015. MEASUREMENTS Two fall definitions were applied (individually and together) to the cohort: an ICD-9-based definition and a chief complaint definition. Admission rates and 30-day mortality (per encounter) were measured for each definition. RESULTS Twenty-three thousand eight hundred eighty older adult visits occurred during the study period. Using the most-inclusive definition (ICD-9 code or chief complaint indicating a fall), 4,363 visits (18%) were fall related. Of these visits, 3,506 (80%) met the ICD-9 definition for a fall-related visit, and 2,664 (61%) met the chief complaint definition. Of visits meeting the chief complaint definition, 857 (19.6%) were missed when applying the ICD-9 definition alone. Encounters missed using the ICD-9 definition were less likely to lead to an admission (42.9%, 95% confidence interval (CI) = 39.7-46.3%) than those identified (54.4%, 95% CI = 52.7-56.0%). CONCLUSION Identifying individuals in the ED who have fallen based on diagnosis codes underestimates the true burden of falls. Individuals missed according to the code-based definition were less likely to have been admitted than those who were captured. These findings call attention to the value of using chief complaint information to identify individuals who have fallen in the ED-for research, clinical care, or policy reasons.
Collapse
Affiliation(s)
- Brian W Patterson
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
- Health Innovation Program, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Maureen A Smith
- Health Innovation Program, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
- Department of Family Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - James E Svenson
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Michael K Kim
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
- Division of Geriatrics, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| |
Collapse
|
26
|
Lo AX, Flood KL, Biese K, Platts-Mills TF, Donnelly JP, Carpenter CR. Factors Associated With Hospital Admission for Older Adults Receiving Care in U.S. Emergency Departments. J Gerontol A Biol Sci Med Sci 2017; 72:1105-1109. [PMID: 28329790 DOI: 10.1093/gerona/glw207] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 09/28/2016] [Indexed: 11/13/2022] Open
Abstract
Background Emergency departments (EDs) play a growing role in hospital admissions for older adults, yet nationally representative data on predictors of admission from the EDs are limited. Methods We examined sociodemographic, clinical, and hospital characteristics associated with non-ICU admissions, using National Hospital Ambulatory Medical Care Survey data and multivariate Poisson regression models. Results There were an estimated 175 million ED visits by adults older than 65 years from 2001 to 2010. Overall, 32.5% were admitted to non-ICU beds. In multivariate analysis, non-ICU admission was associated with increasing age (16% higher per 10-year increase in age), white versus black race (35% vs 31%), and EDs in the Northeast (40%) or Midwest (38%) versus South (31%) or West (30%). Conclusion Non-ICU admission rates for older adults receiving care in U.S. EDs vary by age, race, and region. Understanding the reasons for these disparities in hospitalization rates may guide interventions to reduce hospitalizations in older adults.
Collapse
Affiliation(s)
| | - Kellie L Flood
- Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham
| | - Kevin Biese
- Department of Emergency Medicine, University of North Carolina at Chapel Hill
| | | | - John P Donnelly
- Department of Epidemiology, University of Alabama at Birmingham
| | | |
Collapse
|
27
|
Devriendt E, De Brauwer I, Vandersaenen L, Heeren P, Conroy S, Boland B, Flamaing J, Sabbe M, Milisen K. Geriatric support in the emergency department: a national survey in Belgium. BMC Geriatr 2017; 17:68. [PMID: 28302066 PMCID: PMC5356306 DOI: 10.1186/s12877-017-0458-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 03/04/2017] [Indexed: 11/22/2022] Open
Abstract
Background Older people in the emergency department (ED) represent a growing population and increasing proportion of the workload in the ED. This study investigated the support for frail older people in the ED, by exploring the collaboration between the geriatric services (GS) and the EDs in Belgian hospitals. Methods An electronic cross-sectional survey in all Belgian hospitals with an ED (n = 100) about care aspects, collaboration, education and infrastructure for older patients in the ED was collected. Descriptive analyses were performed at national level. Results Forty-nine of 100 surveys were completed by the GS. The heads of the ED returned only 12 incomplete questionnaires and these results are therefore not reported. Twenty-six of the 49 heads of GSs (53%) indicated that there was an agreement, mainly informal, between the geriatric and the emergency department concerning the management of older people on the ED. A geriatrician was available for specific problems, by phone or in person, in 96% of the EDs during daytime on weekdays. Almost all responding hospitals (96%) had an inpatient geriatric consultation team, of which 85% was available for specific problems at the ED, by phone or bedside during the daytime on weekdays. Twenty-nine heads of the GSs (59%) reported that older patients were screened at ED admission during the day to identify ‘at risk’ patients. The results of the screening were used in the context of further treatment (76%), to decide on hospital admission (27%), or to justify admission on a geriatric ward (55%). In the year preceding the survey, 25% of the responding hospitals had organised geriatric training for ED healthcare workers. Thirty-four heads of the GS (69%) felt that the infrastructure of the ED was insufficient to give high-quality care for older persons. Conclusion Collaborations between EDs and GS are emerging in Belgium, but are currently rather limited and not yet sufficiently embedded in the ED care. Exploratory studies are necessary to identify how these collaborations can be improved. Electronic supplementary material The online version of this article (doi:10.1186/s12877-017-0458-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Els Devriendt
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium.,Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Isabelle De Brauwer
- Division of Geriatric Medicine, Cliniques Universitaires St-Luc, av Hippocrate 10, 1200, Brussels, Belgium.,Institute of Health and Society, Université catholique de Louvain, clos Chapelle-aux-champs 30, 1200, Brussels, Belgium
| | - Lies Vandersaenen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium
| | - Pieter Heeren
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium.,Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Simon Conroy
- Geriatric Medicine, University Hospitals of Leicester, Leicester, LE1 5WW, UK
| | - Benoit Boland
- Division of Geriatric Medicine, Cliniques Universitaires St-Luc, av Hippocrate 10, 1200, Brussels, Belgium.,Institute of Health and Society, Université catholique de Louvain, clos Chapelle-aux-champs 30, 1200, Brussels, Belgium
| | - Johan Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Clinical and Experimental Medicine, Gerontology and Geriatrics, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Marc Sabbe
- Department of Emergency Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Public Health and Primary Care, Emergency Medicine, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium. .,Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| |
Collapse
|
28
|
Brahmandam S, Holland WC, Mangipudi SA, Braz VA, Medlin RP, Hunold KM, Jones CW, Platts-Mills TF. Willingness and Ability of Older Adults in the Emergency Department to Provide Clinical Information Using a Tablet Computer. J Am Geriatr Soc 2016; 64:2362-2367. [PMID: 27804126 DOI: 10.1111/jgs.14366] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To estimate the proportion of older adults in the emergency department (ED) who are willing and able to use a tablet computer to answer questions. DESIGN Prospective, ED-based cross-sectional study. SETTING Two U.S. academic EDs. PARTICIPANTS Individuals aged 65 and older. MEASUREMENTS As part of screening for another study, potential study participants were asked whether they would be willing to use a tablet computer to answer eight questions instead of answering questions orally. A custom user interface optimized for older adults was used. Trained research assistants observed study participants as they used the tablets. Ability to use the tablet was assessed based on need for assistance and number of questions answered correctly. RESULTS Of 365 individuals approached, 248 (68%) were willing to answer screening questions, 121 of these (49%) were willing to use a tablet computer; of these, 91 (75%) were able to answer at least six questions correctly, and 35 (29%) did not require assistance. Only 14 (12%) were able to answer all eight questions correctly without assistance. Individuals aged 65 to 74 and those reporting use of a touchscreen device at least weekly were more likely to be willing and able to use the tablet computer. Of individuals with no or mild cognitive impairment, the percentage willing to use the tablet was 45%, and the percentage answering all questions correctly was 32%. CONCLUSION Approximately half of this sample of older adults in the ED was willing to provide information using a tablet computer, but only a small minority of these were able to enter all information correctly without assistance. Tablet computers may provide an efficient means of collecting clinical information from some older adults in the ED, but at present, it will be ineffective for a significant portion of this population.
Collapse
Affiliation(s)
| | - Wesley C Holland
- Department of Emergency Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Sowmya A Mangipudi
- Department of Emergency Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Valerie A Braz
- Department of Emergency Medicine, Cooper Medical School, Rowan University, Camden, New Jersey
| | - Richard P Medlin
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Christopher W Jones
- Department of Emergency Medicine, Cooper Medical School, Rowan University, Camden, New Jersey
| | - Timothy F Platts-Mills
- Department of Emergency Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina.,Division of Geriatrics, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| |
Collapse
|
29
|
Tucker PW, Evans DD, Clevenger CK, Ardisson M, Hwang U. Feasibility of nurses measuring gait speed in older community-dwelling Emergency Department patients. Geriatr Nurs 2016; 37:453-457. [PMID: 27477084 DOI: 10.1016/j.gerinurse.2016.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 06/13/2016] [Accepted: 06/19/2016] [Indexed: 11/27/2022]
Abstract
Gait speed assessment is a rapid, simple and objective measure for predicting risk of unfavorable outcomes which may provide better prognostic and reliable information than existing geriatric ED (Emergency Department) screening tools. This descriptive pilot project was designed to determine feasibility of implementing gait speed screening into routine nursing practice by objectively identifying patients with sub-optimal gait speeds. Participants included community-dwelling adults 65 years and older with plans for discharge following ED treatment. Patients with a gait speed <1.0 m/s were identified as "high-risk" for an adverse event, and referred to the ED social worker for individualized resources prior to discharge. Thirty-five patients were screened and nurse initiated gait speed screens were completed 60% of the time. This project demonstrates ED gait speed screening may be feasible. Implications for practice should consider incorporating gait speed screening into routine nursing assessment to improve provider ED decision-making and disposition planning.
Collapse
Affiliation(s)
- Paula W Tucker
- Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA 30033, USA; Emory University Hospital, Emergency Department, 1364 Clifton Road, NE, Atlanta, GA 30322, USA; Nell Hodgson Woodruff School of Nursing, 1520 Clifton Road, Atlanta, GA 30322, USA.
| | - Dian Dowling Evans
- Emory University Hospital, Emergency Department, 1364 Clifton Road, NE, Atlanta, GA 30322, USA; Nell Hodgson Woodruff School of Nursing, 1520 Clifton Road, Atlanta, GA 30322, USA
| | - Carolyn K Clevenger
- Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA 30033, USA; Nell Hodgson Woodruff School of Nursing, 1520 Clifton Road, Atlanta, GA 30322, USA
| | - Michelle Ardisson
- Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240, USA
| | - Ula Hwang
- Department of Emergency Medicine, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, P.O. Box 1620, New York, NY 10029, USA; GRECC (Geriatric Research, Education and Clinical Center), James J. Peters VA Medical Center, 130 Kingsbridge Road, Bronx, NY 10468, USA
| |
Collapse
|
30
|
Huded JM, Dresden SM, Gravenor SJ, Rowe T, Lindquist LA. Screening for Fall Risks in the Emergency Department: A Novel Nursing-Driven Program. West J Emerg Med 2015; 16:1043-6. [PMID: 26759651 PMCID: PMC4703188 DOI: 10.5811/westjem.2015.10.26097] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 09/24/2015] [Accepted: 10/13/2015] [Indexed: 11/11/2022] Open
Abstract
Introduction Seniors represent the fasting growing population in the U.S., accounting for 20.3 million visits to emergency departments (EDs) annually. The ED visit can provide an opportunity for identifying seniors at high risk of falls. We sought to incorporate the Timed Up & Go Test (TUGT), a commonly used falls screening tool, into the ED encounter to identify seniors at high fall risk and prompt interventions through a geriatric nurse liaison (GNL) model. Methods Patients aged 65 and older presenting to an urban ED were evaluated by a team of ED nurses trained in care coordination and geriatric assessment skills. They performed fall risk screening with the TUGT. Patients with abnormal TUGT results could then be referred to physical therapy (PT), social work or home health as determined by the GNL. Results Gait assessment with the TUGT was performed on 443 elderly patients between 4/1/13 and 5/31/14. A prior fall was reported in 37% of patients in the previous six months. Of those screened with the TUGT, 368 patients experienced a positive result. Interventions for positive results included ED-based PT (n=63, 17.1%), outpatient PT referrals (n=56, 12.2%) and social work consultation (n=162, 44%). Conclusion The ED visit may provide an opportunity for older adults to be screened for fall risk. Our results show ED nurses can conduct the TUGT, a validated and time efficient screen, and place appropriate referrals based on assessment results. Identifying and intervening on high fall risk patients who visit the ED has the potential to improve the trajectory of functional decline in our elderly population.
Collapse
Affiliation(s)
- Jill M Huded
- Case Western Reserve University School of Medicine, Department of Medicine, Cleveland, Ohio; Louis Stokes VA Medical Center, Department of Medicine, Cleveland, Ohio
| | - Scott M Dresden
- Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Stephanie J Gravenor
- Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Theresa Rowe
- Northwestern University Feinberg School of Medicine, Department of Medicine, Division of General Internal Medicine and Geriatrics, Chicago, Illinois
| | - Lee A Lindquist
- Northwestern University Feinberg School of Medicine, Department of Medicine, Division of General Internal Medicine and Geriatrics, Chicago, Illinois
| |
Collapse
|
31
|
Wilding L, Eagles D, Molnar F, O'Brien JA, Dalziel WB, Moors J, Stiell I. Prospective Validation of the Ottawa 3DY Scale by Geriatric Emergency Management Nurses to Identify Impaired Cognition in Older Emergency Department Patients. Ann Emerg Med 2015; 67:157-63. [PMID: 26607333 DOI: 10.1016/j.annemergmed.2015.09.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 08/19/2015] [Accepted: 09/02/2015] [Indexed: 01/12/2023]
Abstract
STUDY OBJECTIVE Assessment of older emergency department (ED) patients with cognitive impairment is challenging because few tools exist that can be quickly administered by front-line practitioners. Our objective is to validate the Ottawa 3DY Scale, a 4-question screening tool for cognitive impairment, in older ED patients and compare its performance with that of the Animal Fluency Test. METHODS We conducted a prospective cohort study in 2 EDs and enrolled a convenience sample of patients aged 75 years or older with no history of cognitive impairment. Eligible patients were assessed by geriatric emergency management nurses who administered the Mini-Mental State Examination, ordered with the Ottawa 3DY Scale questions first, followed by the Animal Fluency Test. Mini-Mental State Examination score less than 25 was our criterion standard for cognitive impairment. RESULTS Study patients (N=238) had a mean age of 81.9 years and were 60.1% women, and 26.5% were admitted to the hospital. The Ottawa 3DY Scale and Mini-Mental State Examination were in agreement for 75.6% of cases, with a sensitivity of 93.8% (95% confidence interval [CI] 77.8% to 98.9%) and specificity of 72.8% (95% CI 66.1% to 78.7%). The Animal Fluency Test score less than 15 and Mini-Mental State Examination score were in agreement for 46.2% of cases, with sensitivity 90.6% (95% CI 73.8% to 97.5%) and specificity 39.3% (95% CI 32.7% to 46.4%). CONCLUSION Both the Ottawa 3DY Scale and the Animal Fluency Test demonstrated excellent sensitivity versus the Mini-Mental State Examination; however, the Animal Fluency Test exhibited poor specificity. The Ottawa 3DY Scale is an effective tool to screen for cognitive impairment in older ED patients, and its use may facilitate improved care in this vulnerable population.
Collapse
Affiliation(s)
- Laura Wilding
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Frank Molnar
- Regional Geriatric Program of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada; Division of Geriatric Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jo-Anne O'Brien
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - William B Dalziel
- Division of Geriatric Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Joy Moors
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
32
|
Sirois MJ, Griffith L, Perry J, Daoust R, Veillette N, Lee J, Pelletier M, Wilding L, Émond M. Measuring Frailty Can Help Emergency Departments Identify Independent Seniors at Risk of Functional Decline After Minor Injuries. J Gerontol A Biol Sci Med Sci 2015; 72:68-74. [PMID: 26400735 DOI: 10.1093/gerona/glv152] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 08/04/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND This study aims to (i) describe frailty in the subgroup of independent community-dwelling seniors consulting emergency departments (EDs) for minor injuries, (ii) examine the association between frailty and functional decline 3 months postinjury, (iii) ascertain the predictive accuracy of frailty measures and emergency physicians' for functional decline. METHOD Prospective cohort in 2011-2013 among 1,072 seniors aged 65 years or older, independent in basic daily activities, evaluated in Canadian EDs for minor injuries.Frailty was assessed at EDs using the Canadian Study of Health and Aging-Clinical Frailty scale (CSHA-CFS) and the Study of Osteoporotic Fracture frailty index (SOF). Functional decline was defined as a loss ≥2/28 on the Older American Resources Services scale 3 months postinjury. Generalized mixed models were used to explore differences in functional decline across frailty levels. Areas under the receiver operating characteristic curve were used to ascertain the predictive accuracy of frailty measures and emergency physicians' clinical judgment. RESULTS The SOF and CSHA-CFS were available in 342 and 1,058 participants, respectively. The SOF identified 55.6%, 32.7%, 11.7% patients as robust, prefrail, and frail. These CSHA-CFS (n = 1,058) proportions were 51.9%, 38.3%, and 9.9%. The 3-month incidence of functional decline was 12.1% (10.0%-14.6%). The Areas under the receiver operating characteristic curves of the CSHA-CFS and the emergency physicians' were similar (0.548-0.777), while the SOF was somewhat higher (0.704-0.859). CONCLUSION Measuring frailty in community-dwelling seniors with minor injuries in EDs may enhance current risk screening for functional decline. However, before implementation in usual care, feasibility issues such as inter-rater reliability and acceptability of frailty tools in the EDs have to be addressed.
Collapse
Affiliation(s)
- Marie-Josée Sirois
- Centre d'excellence sur le vieillissement de Québec, Québec, Canada. .,Département de réadaptation, Université Laval, Québec, Canada
| | - Lauren Griffith
- Department of Clinical Epidemilogy & Biostatistics, McMaster University, Hamilton, Canada
| | - Jeffrey Perry
- Emergency Department, Ottawa Hospital Research Institute, Canada
| | - Raoul Daoust
- Départment d'urgence, Hôpital du Sacré-Coeur de Montréal, Canada
| | | | - Jacques Lee
- Emergency Department, Sunnybrooke Health Sciences Center, Toronto, Canada
| | | | - Laura Wilding
- Emergency Department, Ottawa Hospital Research Institute, Canada
| | - Marcel Émond
- Centre d'excellence sur le vieillissement de Québec, Québec, Canada.,Département de médecine familiale et de médecine d'urgence, Université Laval, Québec, Canada
| |
Collapse
|
33
|
Martin S, Kelly S, Khan A, Cullum S, Dening T, Rait G, Fox C, Katona C, Cosco T, Brayne C, Lafortune L. Attitudes and preferences towards screening for dementia: a systematic review of the literature. BMC Geriatr 2015; 15:66. [PMID: 26076729 PMCID: PMC4469007 DOI: 10.1186/s12877-015-0064-6] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 05/26/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Population screening might provide a mechanism to enable early detection of dementia. Yet the potential benefits, harms or acceptability of such a large-scale intervention are not well understood. This research aims to examine the attitudes and preferences of the general public, health care professionals, people with dementia and their carers towards population screening for dementia. METHODS A systematic review of the international literature was undertaken. A search of fifteen bibliographic databases was conducted (up to 12 July 2012; no language restriction) using terms related to dementia, screening, specific screening tools, case finding, and attitudes and preferences; genetic screening and biomarkers were excluded. All study designs were included except opinion-based papers. Included papers were doubly quality assessed and thematically analysed using NVivo. RESULTS 29,910 papers were identified of which 29 met the inclusion criteria. We identified seventeen themes relating to the 3 phases of the screening process (pre-, in- and post-screen) - none emerged as more of a facilitator than a barrier to the acceptance of dementia screening. Seven themes emerged in relation to the patient, carer and general population: existing health state; lifestyle and life view; awareness of dementia; role of clinician; communication; benefit; and role of the family. Ten themes emerged in relation to the clinician and healthcare professional: patient's existing health and comorbidities; awareness of dementia; confidence; duration of patient contact; suitability of screening tool; cost; disclosure; time; treatment and prognosis; and stigma. CONCLUSIONS As for all screening programmes, screening for dementia raises complex issues around preference and choice for clinicians and the public, and it is unclear what specific factors promote or reduce screening acceptance the most. Overall, the level of evidence is low, few large scale studies have been undertaken and none were conducted in representative samples, all affecting the generalizability of identified themes across healthcare contexts. Nevertheless, our findings suggest that population screening for dementia may not be acceptable to either the general public or health care professionals, and highlight where focused efforts are needed to gain insights into dementia specific issues.
Collapse
Affiliation(s)
- Steven Martin
- Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK.
| | - Sarah Kelly
- Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK.
| | - Ayesha Khan
- Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK.
| | - Sarah Cullum
- Academic Unit of Psychiatry, University of Bristol, Bristol, UK.
| | - Tom Dening
- Institute of Mental Health, University of Nottingham, Nottingham, UK.
| | - Greta Rait
- Research Department of Primary Care and Population Health, UCL Medical School, UCL, London, UK.
| | - Chris Fox
- Faculty of Medicine and Health Sciences, Norwich, UK Medical School, University of East Anglia, Norwich, UK.
| | | | - Theodore Cosco
- Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK.
| | - Carol Brayne
- Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK.
| | - Louise Lafortune
- Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK.
| |
Collapse
|
34
|
Hwang U, Shah MN, Han JH, Carpenter CR, Siu AL, Adams JG. Transforming emergency care for older adults. Health Aff (Millwood) 2015; 32:2116-21. [PMID: 24301394 DOI: 10.1377/hlthaff.2013.0670] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Already crowded and stressful, US emergency departments (EDs) are facing the challenge of serving an aging population that requires complex and lengthy evaluations. Creative solutions are necessary to improve the value and ensure the quality of emergency care delivered to older adults while more fully addressing their complex underlying physical, social, cognitive, and situational needs. Developing models of geriatric emergency care, including some that are already in use at dedicated geriatric EDs, incorporate a variety of physical, procedural, and staffing changes. Among the options for "geriatricizing" emergency care are approaches that may eliminate the need for an ED visit, such as telemedicine; for initial hospitalization, such as patient observation units; and for rehospitalization, such as comprehensive discharge planning. By transforming their current safety-net role to becoming a partner in care coordination, EDs have the opportunity to become better integrated into the broader health care system, improve patient health outcomes, contribute to optimizing the health care system, and reduce overall costs of care-keys to improving emergency care for patients of all ages.
Collapse
|
35
|
Carpenter CR, Shelton E, Fowler S, Suffoletto B, Platts-Mills TF, Rothman RE, Hogan TM. Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: a systematic review and meta-analysis. Acad Emerg Med 2015; 22:1-21. [PMID: 25565487 DOI: 10.1111/acem.12569] [Citation(s) in RCA: 215] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 07/21/2014] [Accepted: 08/24/2014] [Indexed: 12/20/2022]
Abstract
OBJECTIVES A significant proportion of geriatric patients experience suboptimal outcomes following episodes of emergency department (ED) care. Risk stratification screening instruments exist to distinguish vulnerable subsets, but their prognostic accuracy varies. This systematic review quantifies the prognostic accuracy of individual risk factors and ED-validated screening instruments to distinguish patients more or less likely to experience short-term adverse outcomes like unanticipated ED returns, hospital readmissions, functional decline, or death. METHODS A medical librarian and two emergency physicians conducted a medical literature search of PubMed, EMBASE, SCOPUS, CENTRAL, and ClinicalTrials.gov using numerous combinations of search terms, including emergency medical services, risk stratification, geriatric, and multiple related MeSH terms in hundreds of combinations. Two authors hand-searched relevant specialty society research abstracts. Two physicians independently reviewed all abstracts and used the revised Quality Assessment of Diagnostic Accuracy Studies instrument to assess individual study quality. When two or more qualitatively similar studies were identified, meta-analysis was conducted using Meta-DiSc software. Primary outcomes were sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for predictors of adverse outcomes at 1 to 12 months after the ED encounters. A hypothetical test-treatment threshold analysis was constructed based on the meta-analytic summary estimate of prognostic accuracy for one outcome. RESULTS A total of 7,940 unique citations were identified yielding 34 studies for inclusion in this systematic review. Studies were significantly heterogeneous in terms of country, outcomes assessed, and the timing of post-ED outcome assessments. All studies occurred in ED settings and none used published clinical decision rule derivation methodology. Individual risk factors assessed included dementia, delirium, age, dependency, malnutrition, pressure sore risk, and self-rated health. None of these risk factors significantly increased the risk of adverse outcome (LR+ range = 0.78 to 2.84). The absence of dependency reduces the risk of 1-year mortality (LR- = 0.27) and nursing home placement (LR- = 0.27). Five constructs of frailty were evaluated, but none increased or decreased the risk of adverse outcome. Three instruments were evaluated in the meta-analysis: Identification of Seniors at Risk, Triage Risk Screening Tool, and Variables Indicative of Placement Risk. None of these instruments significantly increased (LR+ range for various outcomes = 0.98 to 1.40) or decreased (LR- range = 0.53 to 1.11) the risk of adverse outcomes. The test threshold for 3-month functional decline based on the most accurate instrument was 42%, and the treatment threshold was 61%. CONCLUSIONS Risk stratification of geriatric adults following ED care is limited by the lack of pragmatic, accurate, and reliable instruments. Although absence of dependency reduces the risk of 1-year mortality, no individual risk factor, frailty construct, or risk assessment instrument accurately predicts risk of adverse outcomes in older ED patients. Existing instruments designed to risk stratify older ED patients do not accurately distinguish high- or low-risk subsets. Clinicians, educators, and policy-makers should not use these instruments as valid predictors of post-ED adverse outcomes. Future research to derive and validate feasible ED instruments to distinguish vulnerable elders should employ published decision instrument methods and examine the contributions of alternative variables, such as health literacy and dementia, which often remain clinically occult.
Collapse
Affiliation(s)
- Christopher R. Carpenter
- The Department of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Erica Shelton
- The Department of Emergency Medicine; Johns Hopkins University; Baltimore MD
| | - Susan Fowler
- The Department of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Brian Suffoletto
- The Department of Emergency Medicine; University of Pittsburgh Medical Center; Pittsburgh PA
| | - Timothy F. Platts-Mills
- The Department of Emergency Medicine; University of North Carolina-Chapel Hill; Chapel Hill NC
| | - Richard E. Rothman
- The Department of Emergency Medicine; Johns Hopkins University; Baltimore MD
| | - Teresita M. Hogan
- The Department of Emergency Medicine; University of Chicago; Chicago IL
| |
Collapse
|
36
|
Carpenter CR, Avidan MS, Wildes T, Stark S, Fowler SA, Lo AX. Predicting geriatric falls following an episode of emergency department care: a systematic review. Acad Emerg Med 2014; 21:1069-82. [PMID: 25293956 DOI: 10.1111/acem.12488] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 06/19/2014] [Accepted: 06/21/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Falls are the leading cause of traumatic mortality in geriatric adults. Despite recent multispecialty guideline recommendations that advocate for proactive fall prevention protocols in the emergency department (ED), the ability of risk factors or risk stratification instruments to identify subsets of geriatric patients at increased risk for short-term falls is largely unexplored. OBJECTIVES This was a systematic review and meta-analysis of ED-based history, physical examination, and fall risk stratification instruments with the primary objective of providing a quantitative estimate for each risk factor's accuracy to predict future falls. A secondary objective was to quantify ED fall risk assessment test and treatment thresholds using derived estimates of sensitivity and specificity. METHODS A medical librarian and two emergency physicians (EPs) conducted a medical literature search of PUBMED, EMBASE, CINAHL, CENTRAL, DARE, the Cochrane Registry, and Clinical Trials. Unpublished research was located by a hand search of emergency medicine (EM) research abstracts from national meetings. Inclusion criteria for original studies included ED-based assessment of pre-ED or post-ED fall risk in patients 65 years and older with sufficient detail to reproduce contingency tables for meta-analysis. Original study authors were contacted for additional details when necessary. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to assess individual study quality for those studies that met inclusion criteria. When more than one qualitatively similar study assessed the same risk factor for falls at the same interval following an ED evaluation, then meta-analysis was performed using Meta-DiSc software. The primary outcomes were sensitivity, specificity, and likelihood ratios for fall risk factors or risk stratification instruments. Secondary outcomes included estimates of test and treatment thresholds using the Pauker method based on accuracy, screening risk, and the projected benefits or harms of fall prevention interventions in the ED. RESULTS A total of 608 unique and potentially relevant studies were identified, but only three met our inclusion criteria. Two studies that included 660 patients assessed 29 risk factors and two risk stratification instruments for falls in geriatric patients in the 6 months following an ED evaluation, while one study of 107 patients assessed the risk of falls in the preceding 12 months. A self-report of depression was associated with the highest positive likelihood ratio (LR) of 6.55 (95% confidence interval [CI] = 1.41 to 30.48). Six fall predictors were identified in more than one study (past falls, living alone, use of walking aid, depression, cognitive deficit, and more than six medications) and meta-analysis was performed for these risk factors. One screening instrument was sufficiently accurate to identify a subset of geriatric ED patients at low risk for falls with a negative LR of 0.11 (95% CI = 0.06 to 0.20). The test threshold was 6.6% and the treatment threshold was 27.5%. CONCLUSIONS This study demonstrates the paucity of evidence in the literature regarding ED-based screening for risk of future falls among older adults. The screening tools and individual characteristics identified in this study provide an evidentiary basis on which to develop screening protocols for geriatrics adults in the ED to reduce fall risk.
Collapse
Affiliation(s)
| | | | - Tanya Wildes
- The Department of Medicine Division of Medical Oncology; St. Louis MO
| | - Susan Stark
- The Department of Occupational Therapy; St. Louis MO
- The Department of Neurology; St. Louis MO
| | - Susan A. Fowler
- Washington University in St. Louis School of Medicine; St. Louis MO
| | | |
Collapse
|
37
|
Geriatric Emergency Department Guidelines. Ann Emerg Med 2014; 63:e7-25. [DOI: 10.1016/j.annemergmed.2014.02.008] [Citation(s) in RCA: 172] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 02/06/2014] [Accepted: 02/06/2014] [Indexed: 12/16/2022]
|
38
|
Costa AP, Hirdes JP, Heckman GA, Dey AB, Jonsson PV, Lakhan P, Ljunggren G, Singler K, Sjostrand F, Swoboda W, Wellens NI, Gray LC. Geriatric syndromes predict postdischarge outcomes among older emergency department patients: findings from the interRAI Multinational Emergency Department Study. Acad Emerg Med 2014; 21:422-33. [PMID: 24730405 DOI: 10.1111/acem.12353] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 09/22/2013] [Accepted: 10/26/2013] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Identifying older emergency department (ED) patients with clinical features associated with adverse postdischarge outcomes may lead to improved clinical reasoning and better targeting for preventative interventions. Previous studies have used single-country samples to identify limited sets of determinants for a limited number of proxy outcomes. The objective of this study was to identify and compare geriatric syndromes that influence the probability of postdischarge outcomes among older ED patients from a multinational context. METHODS A multinational prospective cohort study of ED patients aged 75 years or older was conducted. A total of 13 ED sites from Australia, Belgium, Canada, Germany, Iceland, India, and Sweden participated. Patients who were expected to die within 24 hours or did not speak the native language were excluded. Of the 2,475 patients approached for inclusion, 2,282 (92.2%) were enrolled. Patients were assessed at ED admission with the interRAI ED Contact Assessment, a geriatric ED assessment. Outcomes were examined for patients admitted to a hospital ward (62.9%, n=1,436) or discharged to a community setting (34.0%, n=775) after an ED visit. Overall, 3% of patients were lost to follow-up. Hospital length of stay (LOS) and discharge to higher level of care was recorded for patients admitted to a hospital ward. Any ED or hospital use within 28 days of discharge was recorded for patients discharged to a community setting. Unadjusted and adjusted odds ratios (ORs) were used to describe determinants using standard and multilevel logistic regression. RESULTS A multi-country model including living alone (OR=1.78, p≤0.01), informal caregiver distress (OR=1.69, p=0.02), deficits in ambulation (OR=1.94, p≤0.01), poor self-report (OR = 1.84, p≤0.01), and traumatic injury (OR=2.18, p≤0.01) best described older patients at risk of longer hospital lengths of stay. A model including recent ED visits (OR=2.10, p≤0.01), baseline functional impairment (OR=1.68, p≤0.01), and anhedonia (OR=1.73, p≤0.01) best described older patients at risk of proximate repeat hospital use. A sufficiently accurate and generalizable model to describe the risk of discharge to higher levels of care among admitted patients was not achieved. CONCLUSIONS Despite markedly different health care systems, the probability of long hospital lengths of stay and repeat hospital use among older ED patients is detectable at the multinational level with moderate accuracy. This study demonstrates the potential utility of incorporating common geriatric clinical features in routine clinical examination and disposition planning for older patients in EDs.
Collapse
Affiliation(s)
- Andrew P. Costa
- The Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- The Department of Medicine; McMaster University; Hamilton Ontario Canada
- The School of Public Health and Health Systems; University of Waterloo; Waterloo Ontario Canada
| | - John P. Hirdes
- The School of Public Health and Health Systems; University of Waterloo; Waterloo Ontario Canada
| | - George A. Heckman
- The Department of Medicine; McMaster University; Hamilton Ontario Canada
- The School of Public Health and Health Systems; University of Waterloo; Waterloo Ontario Canada
| | - Aparajit B. Dey
- The Department of Geriatric Medicine; All India Institute of Medical Sciences; New Delhi India
| | - Palmi V. Jonsson
- The Department of Geriatrics; Landspitali University Hospital; Faculty of Medicine; University of Iceland; Reykjavik Iceland
| | - Prabha Lakhan
- The Centre for Research in Geriatric Medicine; The University of Queensland; Brisbane Queensland Australia
| | - Gunnar Ljunggren
- The Medical Management Centre; Department of Learning, Informatics; Management and Ethics; Karolinska Institutet; Stockholm Sweden
| | - Katrin Singler
- The Institute for Biomedicine of Aging; University of Erlangen-Nuremberg; Klinikum Nuremberg Germany
| | - Fredrik Sjostrand
- Karolinska Institutet; Department of Clinical Science and Education; Södersjukhuset, and the Section of Emergency Medicine; Södersjukhuset AB Stockholm Sweden
| | - Walter Swoboda
- The Institute for Biomedicine of Aging; University of Erlangen-Nuremberg; Klinikum Nuremberg Germany
| | - Nathalie I.H. Wellens
- The Department of Public Health; Centre for Health Services and Nursing Research; KU Leuven Belgium
- The Geriatrics Center and Institute of Gerontology; University of Michigan; Ann Arbor MI
| | - Leonard C. Gray
- The Centre for Research in Geriatric Medicine; The University of Queensland; Brisbane Queensland Australia
| |
Collapse
|
39
|
Hogan TM, Olade TO, Carpenter CR. A profile of acute care in an aging America: snowball sample identification and characterization of United States geriatric emergency departments in 2013. Acad Emerg Med 2014; 21:337-46. [PMID: 24628759 DOI: 10.1111/acem.12332] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 09/06/2013] [Accepted: 09/07/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aging of America poses a challenge to emergency departments (EDs). Studies show that elderly patients have poor outcomes despite increased testing, prolonged periods of observation, and higher admission rates. In response, emergency medicine (EM) leaders have implemented strategies for improved ED elder care, enhancing expertise, equipment, policies, and protocols. One example is the development of geriatric EDs gaining in popularity nationwide. To the authors' knowledge, this is the first research to systematically identify and qualitatively characterize the existence, locations, and features of geriatric EDs across the United States. OBJECTIVES The primary objective was to determine the number, distribution, and characteristics of geriatric EDs in the United States in 2013. METHODS This was a survey with potential respondents identified via a snowball sampling of known geriatric EDs, EM professional organizations' geriatric interest groups, and a structured search of the Internet using multiple search engines. Sites were contacted by telephone, and those confirming geriatric EDs presence received the survey via e-mail. Category questions included date of opening, location, volumes, staffing, physical plant changes, screening tools, policies, and protocols. Categories were reported based on general interest to those seeking to understand components of a geriatric ED. RESULTS Thirty-six hospitals confirmed geriatric ED existence and received surveys. Thirty (83%) responded to the survey and confirmed presence or plans for geriatric EDs: 24 (80%) had existing geriatric EDs, and six (20%) were planning to open geriatric EDs by 2014. The majority of geriatric EDs are located in the Midwest (46%) and Northeast (30%) regions of the United States. Eighty percent serve from 5,000 to 20,000 elder patients annually. Seventy percent of geriatric EDs are attached to the main ED, and 66% have from one to 10 geriatric beds. Physical plant changes include modifications to beds (96%), lighting (90%), flooring (83%), visual aids (73%), and sound level (70%). Seventy-seven percent have staff overlapping with the nongeriatric portion of their ED, and 80% require geriatric staff didactics. Sixty-seven percent of geriatric EDs report discharge planning for geriatric ED patients, and 90% of geriatric EDs had direct follow-up through patient callbacks. CONCLUSIONS The snowball sample identification of U.S. geriatric EDs resulted in 30 confirmed respondents. There is significant variation in the components constituting a geriatric ED. The United States should consider external validation of self-identified geriatric EDs to standardize the quality and type of care patients can expect from an institution with an identified geriatric ED.
Collapse
Affiliation(s)
- Teresita M. Hogan
- The Section of Emergency Medicine; Department of Medicine; University of Chicago School of Medicine; Chicago IL
| | | | - Christopher R. Carpenter
- The Division of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| |
Collapse
|
40
|
Cohn B, Keim SM, Sanders AB. Can Anticoagulated Patients be Discharged Home Safely from the Emergency Department after Minor Head Injury? J Emerg Med 2014; 46:410-7. [DOI: 10.1016/j.jemermed.2013.08.107] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Accepted: 08/18/2013] [Indexed: 11/25/2022]
|
41
|
Sirois MJ, Émond M, Ouellet MC, Perry J, Daoust R, Morin J, Dionne C, Camden S, Moore L, Allain-Boulé N. Cumulative Incidence of Functional Decline After Minor Injuries in Previously Independent Older Canadian Individuals in the Emergency Department. J Am Geriatr Soc 2013; 61:1661-8. [DOI: 10.1111/jgs.12482] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Marie-Josée Sirois
- Department of Rehabilitation; Université Laval; Québec Canada
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
| | - Marcel Émond
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
- Hôpital Enfant-Jésus; Centre Hospitalier Universitaire de Québec; Québec Canada
| | - Marie-Christine Ouellet
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
- Centre Interdisciplinaire de Recherche en Réadaptation et Intégration Sociale; Institut de Réadaptation en Déficience Physique de Québec; Québec Canada
| | | | - Raoul Daoust
- Hôpital du Sacré-Cœur de Montréal; Montreal Canada
| | - Jacques Morin
- Hôpital Enfant-Jésus; Centre Hospitalier Universitaire de Québec; Québec Canada
| | - Clermont Dionne
- Department of Rehabilitation; Université Laval; Québec Canada
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
| | - Stéphanie Camden
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
| | - Lynne Moore
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
| | - Nadine Allain-Boulé
- Centre de Recherche and Centre Hospitalier Universitaire de Québec; Québec Canada
| |
Collapse
|
42
|
Palliative medicine and geriatric emergency care: challenges, opportunities, and basic principles. Clin Geriatr Med 2013. [PMID: 23177598 DOI: 10.1016/j.cger.2012.09.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patients with serious or life-threatening illness are likely to find themselves in an emergency department at some point along their trajectory of illness, and they should expect to receive high-quality palliative care in that setting. Recently, emergency medicine has increasingly taken a central role in the early implementation of palliative care. This article presents an overview of palliative care in the emergency department and describes commonly encountered palliative emergencies, strategies for acute symptom management, communication strategies, and issues related to optimal use of hospice service in the emergency department.
Collapse
|
43
|
Carpenter CR, Platts-Mills TF. Evolving prehospital, emergency department, and "inpatient" management models for geriatric emergencies. Clin Geriatr Med 2013; 29:31-47. [PMID: 23177599 PMCID: PMC3875836 DOI: 10.1016/j.cger.2012.09.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Alternative management methods are essential to ensure high-quality and efficient emergency care for the growing number of geriatric adults worldwide. Protocols to support early condition-specific treatment of older adults with acute severe illness and injury are needed. Improved emergency department care for older adults will require providers to address the influence of other factors on the patient's health. This article describes recent and ongoing efforts to enhance the quality of emergency care for older adults using alternative management approaches spanning the spectrum from prehospital care, through the emergency department, and into evolving inpatient or outpatient processes of care.
Collapse
|
44
|
Carpenter CR, Shah MN, Hustey FM, Heard K, Gerson LW, Miller DK. High yield research opportunities in geriatric emergency medicine: prehospital care, delirium, adverse drug events, and falls. J Gerontol A Biol Sci Med Sci 2011; 66:775-83. [PMID: 21498881 PMCID: PMC3143344 DOI: 10.1093/gerona/glr040] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 02/10/2011] [Indexed: 11/13/2022] Open
Abstract
Emergency services constitute crucial and frequently used safety nets for older persons, an emergency visit by a senior very often indicates high vulnerability for functional decline and death, and interventions via the emergency system have significant opportunities to change the clinical course of older patients who require its services. However, the evidence base for widespread employment of emergency system-based interventions is lacking. In this article, we review the evidence and offer crucial research questions to capitalize on the opportunity to optimize health trajectories of older persons seeking emergency care in four areas: prehospital care, delirium, adverse drug events, and falls.
Collapse
Affiliation(s)
| | - Manish N. Shah
- Department of Emergency Medicine, University of Rochester, New York
| | | | - Kennon Heard
- Rocky Mountain Poison and Drug Center, Denver, Colorado
- Department of Emergency Medicine, University of Colorado, Aurora
| | - Lowell W. Gerson
- Department of Emergency Medicine, Summa Health System, Akron Ohio
- Department of Behavioral and Community Health Sciences, Northeastern Ohio Universities Colleges of Medicine and Pharmacy, Rootstown
| | - Douglas K. Miller
- Center for Aging Research, Indiana University, Indianapolis
- Regenstrief Institute, Inc., Indianapolis, Indiana
| |
Collapse
|