Der geriatrische Patient in der Notaufnahme

[Characteristics of older versus younger emergency patients : Analysis of over 356,000 visits from the AKTIN German emergency department data registry]

BACKGROUND

This nationwide study aims to analyze age-specific differences and characteristics of emergency patients with a special focus on older patients.

METHOD

In 2019, data were obtained from 11 emergency departments (EDs), all part of the German Emergency Department Data (AKTIN) registry. All patients 18 years and older visiting the EDs were included. In addition to demographic data, variables such as referral, type of transport, primary assessment, diagnoses, length of stay and type of transfer were recorded and compared by age group and specifically by younger (18-64 years) and older patients (65+ years).

RESULTS

Data from 356,354 patients (39.1% were aged 65+ years) were included. Compared to younger patients, older ED patients were more likely to be accompanied by emergency medical services (15.4 vs. 34.3%) and almost twice as often by an emergency physician (6.4 vs. 12.2%). The need for treatment increased with age; 47.1% of younger and 66.1% of older people were classified as yellow, orange or red. The proportion of patients with internal diseases was higher for patients 65+ years (22.5 vs. 38.8%). Older patients were more often hospitalized (27.5 vs. 60.3%) and were more frequently transferred to an intensive care unit (4.5 vs. 11.9%).

CONCLUSION

About 40% of adult emergency patients are 65+ years. They require more urgent treatment and are more often hospitalized than younger patients. In older patients, internal diseases were more common.

Quality indicators for a geriatric emergency care (GeriQ-ED) - an evidence-based delphi consensus approach to improve the care of geriatric patients in the emergency department

Introduction

In emergency care, geriatric requirements and risks are often not taken sufficiently into account. In addition, there are neither evidence-based recommendations nor scientifically developed quality indicators (QI) for geriatric emergency care in German emergency departments. As part of the GeriQ-ED© research project, quality indicators for geriatric emergency medicine in Germany have been developed using the QUALIFY-instruments.

Methods

Using a triangulation methodology, a) clinical experience-based quality aspects were identified and verified, b) research-based quality statements were formulated and assessed for relevance, and c) preliminary quality indicators were operationalized and evaluated in order to recommend a feasible set of final quality indicators.

Results

Initially, 41 quality statements were identified and assessed as relevant. Sixty-seven QI (33 process, 29 structure and 5 outcome indicators) were extrapolated and operationalised. In order to facilitate implementation into daily practice, the following five quality statements were defined as the GeriQ-ED© TOP 5: screening for delirium, taking a full medications history including an assessment of the indications, education of geriatric knowledge and skills to emergency staff, screening for patients with geriatric needs, and identification of patients with risk of falls/ recurrent falls.

Discussion

QIs are regarded as gold standard to measure, benchmark and improve emergency care. GeriQ-ED© QI focused on clinical experience- and research-based recommendations and describe for the first time a standard for geriatric emergency care in Germany. GeriQ-ED© TOP 5 should be implemented as a minimum standard in geriatric emergency care.

[Validation of the geriatrie-check for identification of geriatric patients in emergency departments]

Hintergrund

Der Geriatrie-Check wurde im Rahmen des Geriatriekonzept Baden-Württemberg zur Identifikation geriatrischer Patienten in der Notaufnahme entwickelt.

Ziel

Bestimmung der konvergenten und prädiktiven Validität des Geriatrie-Checks zu Identifikation und Verlaufsprädiktion geriatrischer Patienten in der Notaufnahme.

Material und Methoden

Prospektive Kohortenstudie zwischen November 2015 und April 2016 mit 146 Patienten, älter als 70 Jahre, der internistischen Notaufnahme der Uniklinik Ulm. Getrennte Erhebung durch Ärzte und Pflegende: Identification of Seniors at Risk (ISAR), Geriatrie-Check, weitere kognitive und funktionelle Assessments und als Endpunkte: Veränderung von Pflegestufe, Barthel-Index, Wohnform.

Ergebnisse

Der ISAR klassifizierte n =117 Patienten als geriatrisch, der Geriatrie-Check n =107. Die Übereinstimmung betrug 78,1 %. Mit dem ISAR als Goldstandard zeigte der Geriatrie-Check eine Sensitivität von 82,0 % und eine Spezifität von 62,1 %. Der positiv- bzw. negativ-prädiktive Wert lag bei 89,7 % bzw. 46,1 %. Mit dem ISAR als Goldstandard war die Einschätzung der Pflege präziser als die der Ärzte überlegen (Sensitivität 70,5 % vs. 58 %; Spezifität 88,9 % vs. 83,3 %). Die prädiktive Validität 5 Monate nach Aufnahme bezüglich oben genannter Endpunkte war am besten für die Einschätzung durch Pflege und Ärzte (insbesondere die Spezifität). Beide Tests waren sehr sensitiv, aber wenig spezifisch.

Diskussion

Der Geriatrie-Check ist dem ISAR vergleichbar. Die konvergente Validität unterscheidet sich nur wenig. Beide, ISAR und Geriatrie-Check, sind etwas sensitiver als Ärzte und Pflege. Bezüglich der prädiktiven Validität sind Ärzte und Pflege den Scores überlegen. Ein Algorithmus aus ISAR oder Geriatrie-Check mit nachfolgender Einschätzung durch Arzt oder Pflege könnte sich für eine bedarfsgerechte Ressourcenallokation am besten eignen.

["Emergency anesthesia" in geriatric patients]

BACKGROUND

The share of elderly patients undergoing emergency surgery is constantly increasing. Their postoperative outcome remains poor, even if surgery itself is survived in the short or medium term.

OBJECTIVES

Important aspects of anesthesiologic care for older emergency patients based upon recent literature and guideline recommendations are presented.

METHODS

Selective review of the literature, considering national and international guidelines, meta-analysis and Cochrane reviews.

CONCLUSION

Anesthesiologic care can significantly influence the perioperative outcome of elderly emergency surgery patients. In this context, emergency anesthesiology exceeds mere anesthesia itself and applies to the overall perioperative management.

[Triage, screening, and assessment of geriatric patients in the emergency department]

BACKGROUND

Geriatric patients are increasingly dominating the daily routine in German emergency departments (ED). With their typical characteristics multimorbidity, polypharmacy, vulnerability, frailty and cognitive impairment, especially delirium, they are a special challenge for the processes in the ED. Though some emergency physician might consider "the old patient" as not exciting, there is a broad consensus that pragmatic geriatric screening tools are required. This consensus exists not only among the medical societies but also within the German Society for Emergency Medicine itself. In this article the characteristics of the geriatric patient, the pitfalls of triage systems and the difficulties to screen geriatric patients in a sensible manner are described.

DISCUSSION

The common triage systems and the screening tools that have been developed for geriatric emergency patients have disadvantages. In Manchester Triage System (MTS) and Emergency Severity Index (ESI) geriatric patients are at risk of incorrect triage, though both systems, e.g., name acute cognitive impairment as a high-risk factor. The ESI has been validated for geriatric patients. The correct use of the triage algorithms is crucial, but for a triage nurse, acute cognitive impairment, e.g., might be difficult to identify. One reason for that is that many of the existing screening tools are not applicable in the ED or are without immediate benefit for the patient. More practical tools will have to be developed in the future.

[Empirical health services research in emergency and acute medicine : Preliminary results of concomitant monitoring of patient recruitment and sample quality]

BACKGROUND

Up until now, research data on the implementation of empirical health services research in emergency departments in Germany are scarce.

STUDY AIM

A monitoring instrument applied in a multicenter prospective cohort study in emergency departments (EDs) is described and discussed regarding requirements for the control and supervision of data collection.

MATERIALS AND METHODS

Patients with cardiac diseases, respiratory tract infections, and hip fractures were recruited in eight EDs located in a central district of Berlin. Enrolment figures and nonresponder reasons were analyzed through descriptive statistics. Potential sample bias was examined in terms of response rates as well as the distribution of age and sex in the group of participants and nonresponders. Qualitative content analysis was applied to data from routine supervisory and feedback meetings with study nurses.

RESULTS

Within the first 8 months of data collection, 61.1% of the aimed 1104 patients were recruited. Most frequently stated nonresponder reasons were the dense work and care processes in EDs (41.9%) and patients' disease burden (24.7%). Moreover, qualitative results revealed problems with identifying potentially eligible participants and difficulties because of missing research infrastructure in study centers. The response rate of 50.7% and approximately equal distribution of age and sex in participants and nonresponders do not indicate sample biases.

DISCUSSION

The monitoring instrument has proven to be suited for empirical research in EDs and revealed optimization potential. We recommend using qualitative and quantitative data systematically.