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Cheong TS, Zhu B, Chong E. The geriatric clinical pharmacist at the emergency department: a novel front-door transdisciplinary care model. Eur J Hosp Pharm 2022; 30:ejhpharm-2022-003458. [PMID: 35853691 PMCID: PMC10447951 DOI: 10.1136/ejhpharm-2022-003458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - Birong Zhu
- Nursing Service, Tan Tock Seng Hospital, Singapore
| | - Edward Chong
- Geriatrics Medicine, Tan Tock Seng Hospital, Singapore
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Chong E, Zhu B, Ng SHX, Tan H, Goh EF, Molina JDC, Pereira MJ, Kaur P, Baldevarona-Llego J, Chia JQ, Chong A, Cheong S, Foo CL, Chan M, Lim WS. Emergency department interventions for frailty (EDIFY): improving functional outcomes in older persons at the emergency department through a multicomponent frailty intervention. Age Ageing 2022; 51:6520521. [PMID: 35134848 DOI: 10.1093/ageing/afab251] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES emergency department interventions for frailty (EDIFY) delivers frailty-centric interventions at the emergency department (ED). We evaluated the effectiveness of a multicomponent frailty intervention (MFI) in improving functional outcomes among older persons. DESIGN a quasi-experimental study. SETTING a 30-bed ED observation unit within a 1,700-bed acute tertiary hospital. PARTICIPANTS patients aged ≥65 years, categorised as Clinical Frailty Scale 4-6, and planned for discharge from the unit. METHODS we compared patients receiving the MFI versus usual-care. Data on demographics, function, frailty, sarcopenia, comorbidities and medications were gathered. Our primary outcome was functional status-Modified Barthel Index (MBI) and Lawton's iADL. Secondary outcomes include hospitalisation, ED re-attendance, mortality, frailty, sarcopenia, polypharmacy and falls. Follow-up assessments were at 3, 6 and 12 months. RESULTS we recruited 140 participants (mean age 79.7 ± 7.6 years; 47% frail and 73.6% completed the study). Baseline characteristics between groups were comparable (each n = 70). For the intervention group, MBI scores were significantly higher at 6 months (mean: 94.5 ± 11.2 versus 88.5 ± 19.5, P = 0.04), whereas Lawton's iADL scores experienced less decline (change-in-score: 0.0 ± 1.7 versus -1.1 ± 1.8, P = 0.001). Model-based analyses revealed greater odds of maintaining/improving MBI in the intervention group at 6 months [odds ratio (OR) 2.51, 95% confidence interval (CI) 1.04-6.03, P = 0.04] and 12 months (OR 2.98, 95% CI 1.18-7.54, P = 0.02). This was similar for Lawton's iADL at 12 months (OR 4.01, 95% CI 1.70-9.48, P = 0.002). ED re-attendances (rate ratio 0.35, 95% CI 0.13-0.90, P = 0.03) and progression to sarcopenia (OR 0.19, 95% CI 0.04-0.94, P = 0.04) were also lower at 6 months. CONCLUSIONS the MFI delivered to older persons at the ED can possibly improve functional outcomes and reduce ED re-attendances while attenuating sarcopenia progression.
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Affiliation(s)
- Edward Chong
- Department of Geriatric Medicine, Tan Tock Seng Hospital (TTSH), Singapore
- Institute of Geriatrics and Active Ageing (IGA), TTSH, Singapore
| | - Birong Zhu
- Department of Nursing Services, TTSH, Singapore
| | - Sheryl Hui Xian Ng
- Health Services and Outcomes Research (HSOR), National Healthcare Group, Singapore
| | - Hongyun Tan
- Department of Nursing Services, Woodlands Health, Singapore
| | - Eileen Fabia Goh
- Institute of Geriatrics and Active Ageing (IGA), TTSH, Singapore
| | | | | | - Palvinder Kaur
- Health Services and Outcomes Research (HSOR), National Healthcare Group, Singapore
| | | | - Jia Qian Chia
- Department of Geriatric Medicine, Tan Tock Seng Hospital (TTSH), Singapore
| | - Amanda Chong
- Department of Geriatric Medicine, Tan Tock Seng Hospital (TTSH), Singapore
| | | | | | - Mark Chan
- Department of Geriatric Medicine, Tan Tock Seng Hospital (TTSH), Singapore
- Institute of Geriatrics and Active Ageing (IGA), TTSH, Singapore
| | - Wee Shiong Lim
- Department of Geriatric Medicine, Tan Tock Seng Hospital (TTSH), Singapore
- Institute of Geriatrics and Active Ageing (IGA), TTSH, Singapore
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Zhu B, Cheong S, Chong E. The role of an advanced practice nurse (APN) in geriatric care at the emergency department. J Adv Nurs 2021; 78:e31-e32. [PMID: 34904268 DOI: 10.1111/jan.15029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Birong Zhu
- Department of Nursing Service, Tan Tock Seng Hospital, Singapore
| | - Selina Cheong
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore
| | - Edward Chong
- Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore.,Institute of Geriatrics and Active Ageing (IGA), Tan Tock Seng Hospital, Singapore
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Baldevarona-Llego J, Zhu B, Chong E. Emergency Department Staff Perceptions of Emergency Department Interventions for Frailty (EDIFY). J Am Med Dir Assoc 2021; 23:179-181.e3. [PMID: 34606764 DOI: 10.1016/j.jamda.2021.08.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 01/02/2023]
Affiliation(s)
| | - Birong Zhu
- Department of Nursing Services, TTSH, Singapore
| | - Edward Chong
- Department of Geriatric Medicine, Tan Tock Seng Hospital (TTSH), Singapore; Institute of Geriatrics and Active Ageing (IGA), TTSH, Singapore.
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A narrative review of frailty assessment in older patients at the emergency department. Eur J Emerg Med 2021; 28:266-276. [PMID: 33883392 DOI: 10.1097/mej.0000000000000811] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Optimizing emergency care for the aging population is an important future challenge, as the proportion of older patients at the emergency department (ED) rapidly increases. Older patients, particularly those who are frail, have a high risk of adverse outcomes after an ED visit, such as functional decline, institutionalization, and death. The ED can have a key position in identifying frail older patients who benefit most from comprehensive geriatric care [including delirium preventive measures, early evaluation of after-discharge care, and a comprehensive geriatric assessment (CGA)]. However, performing extensive frailty assessment is not suitable at the ED. Therefore, quick and easy-to-use instruments are needed to identify older patients at risk for adverse outcomes. This narrative review outlines the importance and complexity of frailty assessment at the ED. It aligns the available screening instruments, including clinical judgment as frailty assessment, and summarizes arguments for and against frailty assessment at the ED.
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Chong E, Zhu B, Tan H, Molina JDC, Goh EF, Baldevarona-Llego J, Chia JQ, Chong A, Cheong S, Kaur P, Pereira MJ, Ng SHX, Foo CL, Chan M, Lim WS. Emergency Department Interventions for Frailty (EDIFY): Front-Door Geriatric Care Can Reduce Acute Admissions. J Am Med Dir Assoc 2021; 22:923-928.e5. [PMID: 33675695 DOI: 10.1016/j.jamda.2021.01.083] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/19/2021] [Accepted: 01/28/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The EDIFY program was developed to deliver early geriatric specialist interventions at the emergency department (ED) to reduce the number of acute admissions by identifying patients for safe discharge or transfer to low-acuity care settings. We evaluated the effectiveness of EDIFY in reducing potentially avoidable acute admissions. DESIGN A quasi-experimental study. SETTING ED of a 1700-bed tertiary hospital. PARTICIPANTS ED patients aged ≥85 years. MEASUREMENTS We compared EDIFY interventions versus standard care. Patients with plans for acute admission were screened and recruited. Data on demographics, premorbid function, frailty status, comorbidities, and acute illness severity were gathered. We examined the primary outcome of "successful acute admission avoidance" among the intervention group, which was defined as no ED attendance within 72 hours of discharge from ED, no transfer to an acute ward from subacute-care units (SCU) within 72-hours, or no transfer to an acute ward from the short-stay unit (SSU). Secondary outcomes were rehospitalization, ED re-attendance, institutionalization, functional decline, mortality, and frailty transitions at 1, 3, and 6 months. RESULTS We recruited 100 participants (mean age 90.0 ± 4.1 years, 66.0% women). There were no differences in baseline characteristics between intervention (n = 43) and nonintervention (n = 57) groups. Thirty-five (81.4%) participants in the intervention group successfully avoided an acute admission (20.9% home, 23.3% SCU, and 44.2% SSU). All participants in the nonintervention group were hospitalized. There were no differences in rehospitalization, ED re-attendance, institutionalization and mortality over the study period. Additionally, we observed a higher rate of progression to a poorer frailty category at all time points among the nonintervention group (1, 3, and 6 months: all P < .05). CONCLUSIONS AND IMPLICATIONS Results from our single-center study suggest that early geriatric specialist interventions at the ED can reduce potentially avoidable acute admissions without escalating the risk of rehospitalization, ED re-attendance, or mortality, and with possible benefit in attenuating frailty progression.
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Affiliation(s)
- Edward Chong
- Department of Geriatric Medicine, Tan Tock Seng Hospital (TTSH), Singapore; Institute of Geriatrics and Active Ageing (IGA), TTSH, Singapore.
| | - Birong Zhu
- Department of Nursing Services, TTSH, Singapore
| | - Hongyun Tan
- Department of Nursing Services, Woodlands Health Campus, Singapore
| | | | - Eileen Fabia Goh
- Institute of Geriatrics and Active Ageing (IGA), TTSH, Singapore
| | | | - Jia Qian Chia
- Department of Geriatric Medicine, Tan Tock Seng Hospital (TTSH), Singapore
| | - Amanda Chong
- Department of Geriatric Medicine, Tan Tock Seng Hospital (TTSH), Singapore
| | | | - Palvinder Kaur
- Health Services and Outcomes Research (HSOR), National Healthcare Group, Singapore
| | | | - Sheryl Hui Xian Ng
- Health Services and Outcomes Research (HSOR), National Healthcare Group, Singapore
| | | | - Mark Chan
- Department of Geriatric Medicine, Tan Tock Seng Hospital (TTSH), Singapore; Institute of Geriatrics and Active Ageing (IGA), TTSH, Singapore
| | - Wee Shiong Lim
- Department of Geriatric Medicine, Tan Tock Seng Hospital (TTSH), Singapore; Institute of Geriatrics and Active Ageing (IGA), TTSH, Singapore
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Tanderup A, Lassen AT, Rosholm JU, Ryg J. Disability and morbidity among older patients in the emergency department: a Danish population-based cohort study. BMJ Open 2018; 8:e023803. [PMID: 30552269 PMCID: PMC6303572 DOI: 10.1136/bmjopen-2018-023803] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 10/08/2018] [Accepted: 10/12/2018] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The objective was to describe the prevalence of geriatric conditions among older medical patients in the emergency department (ED) and the association with admission, mortality, reattendance and loss of independency. DESIGN Population-based prospective cohort study. SETTING ED of a large university hospital. PARTICIPANTS All medical patients ≥65 years of age from a single municipality with a first attendance to the ED during a 1-year period (November 2013 to November 2014). PRIMARY AND SECONDARY OUTCOME MEASURES Based on information from healthcare registers, we defined geriatric conditions as disability, recently increased disability, polypharmacy and comorbidity. Outcomes were admission, length of admission, 30 days postdischarge mortality, 30 days hospital reattendance and home care dependency 0-360 days following ED contact. RESULTS Totally, 3775 patients (55% women) were included, age 78 (71-85) years (median (IQR)). No patients were lost to follow-up. The prevalence of 0-4 geriatric conditions was 14.9%, 27.3%, 25.2%, 22.3% and 10.3%, respectively. The number of conditions was significantly associated with hospital admission, length of admission, 30 days postdischarge mortality and 30 days hospital reattendance. Among patients with no geriatric conditions, 70% lived independent all 360 days after discharge, whereas all patients with ≥3 conditions had some dependency or were dead within 360 days following discharge. CONCLUSION Among older medical patients in the ED, 50% had two or more geriatric conditions which were associated with poor health outcomes. This highlights the need for studies of the effect of geriatric awareness and competences in the ED.
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Affiliation(s)
- Anette Tanderup
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Annmarie Touborg Lassen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Jens-Ulrik Rosholm
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Houghton MP. Acute geriatrics at the front door. Clin Med (Lond) 2017; 17:590. [PMID: 29196372 PMCID: PMC6297681 DOI: 10.7861/clinmedicine.17-6-590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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