The Geriatric Emergency Department

Training interprofessional teams in geriatric emergency medicine: A modified team-based learning approach

Background

Older adults deserve special healthcare provision in every branch of medicine. Turkey currently does not have geriatric emergency medicine (GEM) subspecialty training. Thus, interprofessional training for healthcare professionals involved in GEM services is required. Team-based learning (TBL) seems suitable to implement such training. We aimed to develop and implement a training program for healthcare professionals engaged with GEM services, and evaluate the program considering teacher and learner satisfaction and knowledge retention.

Methods

This was a design-based study in which a one-day GEM training program was developed based on the literature and expert opinions. The program was applied to 54 physicians, 98 nurses, 70 health officers, and 102 paramedics using a modified version of TBL. Teams included at least one representative from each profession. TBL was modified by adding a 1-h lecture and eliminating peer evaluation. Feedback forms, individual and group tests of TBL, and a retention test conducted six months later were used for program evaluation.

Results

The mean group test score was higher than that of individual tests in all professions. Physicians' individual test scores were higher than those of other professions, but this difference disappeared in the group test. The retention test mean score was higher than the individual test mean score but lower than that of the group test. Teacher and learner satisfaction was high.

Conclusion

We implemented a training program using a modified TBL approach to teach GEM to relevant healthcare professionals; it yielded promising results regarding knowledge gain and retention, as well as teacher and learner satisfaction. The instruction design and method used in this study can be applied to multidisciplinary team training.

PREDICTION OF MULTIDRUG-RESISTANT BACTERIA IN URINARY TRACT INFECTIONS IN THE EMERGENCY DEPARTMENT

BACKGROUND

Urinary tract infections (UTI) due to multidrug-resistant bacteria are a frequent reason for visiting the emergency department (ED).

OBJECTIVES

The aim of this study was to evaluate the applicability of a predictive model of infection by multidrug-resistant microorganisms in UTIs treated in an ED.

METHODS

This is a retrospective observational study. Adult patients admitted to an ED with a diagnosis of UTI and positive urine culture were included. The main objective was to evaluate the area under the curve of the receiver operating characteristic (AUC-ROC), the scale proposed by González-del-Castillo, considering infection by a resistant pathogen as the dependent variable and the scale score of the predictive model used as the independent variable.

RESULTS

The study included 414 patients with UTIs, 125 (30.2%) of which were caused by multidrug-resistant microorganisms. A total of 38.4% of patients were treated with antibiotics during the previous 3 months and a multidrug-resistant pathogen was isolated from 10.4% of the total during the previous 6 months. The AUC-ROC of the scale for predicting UTIs due to multidrug-resistant microorganisms was 0.79 (95% confidence interval 0.76-0.83), the optimal cut-off point being 9 points, with a sensitivity of 76.8% and a specificity of 71.6%.

CONCLUSIONS

The use of the predictive model evaluated is a useful tool in real clinical practice to improve the success of empirical treatment of patients presenting to the ED with a diagnosis of UTI and positive urine culture pending identification.

What are the needs of frail older patients in the emergency department? A qualitative study

BACKGROUND

There is an increase in the number of frail elderly patients presenting to the emergency department. Diagnosis and treatment for this patient group is challenging due to multimorbidity, a-typical presentation and polypharmacy and requires specialised knowledge and competencies from healthcare professionals. We aim to explore the needs and preferences regarding emergency care in frail older patients based on their experiences with received care during Emergency Department admission.

METHOD

A qualitative study design was used, and semi-structured interviews were conducted after discharge with twelve frail older patients admitted to emergency departments in the Netherlands. Data collection and analysis were performed iteratively, and data were thematically analysed.

RESULTS

The analysis enfolded the following themes; feeling disrupted, expecting to be cared for, suppressing their needs and wanting to be seen. These themes indicated a need for situational awareness by healthcare professionals when taking care of the participants and were influenced by the participants' life experiences.

CONCLUSION

Frail older patients feel disrupted when admitted to the emergency department. Because of this, they expect to be cared for, lessen their own needs and want to be seen as human beings. The impact of the admission is influenced by the extent to which healthcare professionals show situational awareness.

Age as a Predictive Factor in Severity of Injuries in Riders of Electric Bikes and Powered Scooters: A Retrospective Cross-Sectional Study

The growth in worldwide popularity of electric bikes (E-bikes) and powered scooters (P-scooters) has been accompanied by an increase in injuries associated with their use. The aim of this study was to evaluate the contribution of rider age to injury severity, represented by need for hospitalization. A retrospective review of the database of a tertiary medical center yielded 1234 patients (75.7% male) who attended the emergency department (ED) in 2014−2020 for injuries sustained while riding an E-bike or P-scooter. Mean age was 31.52 ± 14.77 years: 23% were aged <20 years; 33%, 21−30 years; 23%, 31−40 years; 10%, 41−50 years; 11%, >51 years. Ninety patients (7.3%) were hospitalized. Older age was significantly associated with the need for hospitalization on univariate analysis (p <.001), but significance was not maintained on binary logistic regression (OR = 1.02, 95%CI 0.99−1.06; p = 0.11). Patients who underwent imaging evaluation in the ED were at lower risk of hospitalization, and patients who had surgery or a relatively long operative procedure were at higher risk of hospitalization. The study shows that older age (>51 years) is not associated with a significantly increased probability of severe injury in E-bike and P-scooter riders. This finding has important implications for insurers and healthcare administrators.

Quantification of chronic diseases presenting in the Emergency Department and their disposition outcomes: A hospital-based cross-sectional study in north India

A knowledge of the extent and distribution of chronic comorbidity plays an essential role in providing appropriate care, and allocating health resources to the patients admitted to the emergency department. We performed a cross-sectional study to quantify the chronic diseases presenting in the Emergency Department of PGIMER, Chandigarh (India). Out of 205 patients, 133 (64.9%) had pre-existing comorbidity. Common were chronic kidney disease (29, 14.1%), chronic liver disease (23, 11.2%), diabetes mellitus (21, 10.2%), malignancy (20, 9.8%), cardiac diseases (17, 8.3%), and chronic obstructive pulmonary disease (9, 4.4%). The median Charlson comorbidity index score was 2 (range, 0-9). In-hospital mortality was 43 (21%) and was predicted by older age (median, 60 v. 50 years; p-value, 0.017). Deaths with previous stroke (66.6%), chronic obstructive pulmonary disease (55.6%), and diabetes (28.6%) were higher than cardiac (2.3%) and renal (6.9%) comorbidity. Increasing comorbidity requires a shift in existing models of emergency care.

Care Experiences of Older People in the Emergency Department: A Concurrent Mixed-Methods Study

The growing population of older people has increased demand to meet their complex healthcare needs, including in emergency departments (EDs). This study explored the experiences of people aged 65+ in Irish EDs, involving secondary analysis of quantitative and qualitative data from the 2019 National Inpatient Experience Survey (NIES). Experiences in the ED and overall hospital experiences were dichotomized as poor to fair or good to very good. Logistic regression was used to model quantitative data. Free text comments relating to EDs were thematically analyzed. Of 12,343 survey participants, 4,442 (39.9%) were aged 65+ years and used the ED. Longer waiting times, completion of the questionnaire by another person either with or on behalf of the patient, and having both a medical card and private health insurance were predictors of poor to fair ED experiences. Patients aged 85+ years were more likely to report good to very good ED experiences. Poor experiences in the ED were associated with poorer overall hospital experiences (odds ratio [OR]: 2.19, 95% confidence interval [CI]: 1.76 to 2.73, p < .001). Thematic analysis revealed that long waiting times and unpleasant waiting conditions, including lack of communication, privacy, and personal care were important challenges encountered in the ED, with some older patients noting their preference for separate ED services. There is a need to reduce waiting times and integrate user perspectives in the planning, organization, and delivery of ED care to improve experiences and quality of care for a growing older population.

Dutch emergency physicians insufficiently educated in geriatric emergency medicine: results of a nationwide survey

Background

Emergency physicians (EPs) provide care to older adults with complex health problems. Treating these patients is challenging for many EPs, which might originate from modest geriatric education.

Objective

Our aim was to assess EPs’ self-perceived needs regarding geriatric emergency medicine (GEM) education, factors determining these needs and the utilization of this education. Our secondary aim was to assess emergency department (ED) managers’ view and support for GEM education.

Methods

All EPs and ED managers in the Netherlands received a survey by e-mail. The questionnaires focused on EPs’ needs in GEM education, EPs’ utilization of GEM education and managerial support for GEM education. We used descriptive statistics to analyse needs, utilization of- and support for GEM education. Regression analyses were used to identify factors associated with EPs’ need for GEM education.

Results

EPs reported to need better training in diagnosing, treating and communicating with older adults. Seventy percent of EPs reported no GEM education program in their hospital, and 83% reported no utilization of GEM education outside their hospital. EPs working in EDs with a possibility for geriatric consultation, and EPs aware of actual GEM education programs, had lower educational needs. Of responding managers, 86.2% reported the care for older adults as an important topic; lack of finances and time were obstacles to provide GEM education for EPs.

Conclusion

EPs in the Netherlands feel insufficiently educated to treat older adults. ED managers largely recognize this educational challenge. This nationwide survey underlines the need to prioritize GEM education for EPs.

Nurses' conceptualizations of managing emergencies in nursing homes

Emergencies can negatively affect the morbidity and mortality of nursing home residents. As nurses employed at nursing homes play a key role in such situations, their conceptualizations of emergency management should be considered to improve care. Accordingly, this study aimed to identify nurses' conceptualizations of managing emergencies in nursing homes. A qualitative research design was conducted using interviews with 20 nurses working in five different nursing homes in the Republic of Korea between September 2019 and August 2020. The data were analyzed using phenomenography. This study identified two main perspectives used by nurses in nursing homes to manage emergencies, depending on the resident's condition: emergency care and daily preventive care. Nurses' conceptualizations of care provided in emergencies were organized under the frames of assessment and intervention, whereas routine care carried out during daily life activities fell under the frame of prevention. This study's findings, which elucidate nurses' complex practical and experiential knowledge, provide insights for the development of emergency management training.

Front-line emergency department nurses' and physicians' assessments of processes of elder-friendly care for quality improvement

INTRODUCTION

Geriatric emergency department (ED) care has gained increasing importance and interest due to increasing visits in seniors.

AIM

Among ED front-line nurses and physicians, to assess and compare ratings of elder-friendly care process indicators, variability in ratings, and concurrent validity of ratings.

METHODS

Four Quebec EDs' full-time registered nurses and physicians rated their geriatric care using 9 subscales. Nurse and physician subscale scores were compared. Inter-rater variability within disciplines and variability between nurses and physicians were measured. Associations between the subscale scores and perceived overall quality of care were tested.

RESULTS

38 nurses and 36 physicians completed the survey (83% of 89 eligible). Scores differed by discipline for 3 of 9 subscales computed; nurses had higher mean scores on Protocols, Family-Centered Discharge, and Staff Education. Very high variation for Staff Education was found within disciplines. Variations for Family-Centered Discharge differed significantly between nurses and physicians. Almost all subscale scores were significantly positively associated with perceived overall quality of care.

CONCLUSIONS

ED nurses and physicians rate geriatric care components similarly except for protocols, discharge processes, and continuing education. The subscales have concurrent validity. Results suggest a need for improvement in continuing educational strategies with a particular attention to discharge processes.

Lessons learned from an evaluation of referrals to the emergency department

BACKGROUND

Emergency department (ED) crowding is an international phenomenon dependent on input, throughput, and output factors. This study aims to determine whether patterns of potentially unnecessary referrals from either primary care physicians (PCPs) or urgent care centers (UCCs) can be identified, thereby to reduce ED visits by patients who could be treated elsewhere. Literature from the United States reports up to 35% unnecessary referrals from UCCs.

METHODS

A retrospective cohort study was conducted of patients referred to an ED in Jerusalem by either their PCP or a group of UCCs with a full range of laboratory tests and basic imaging capabilities between January 2017 and December 2017. The data were analyzed to identify referrals involving diagnoses, specialist consultations, and examinations unavailable in the PCP's office or UCC (e.g., ultrasound, CT, echocardiogram, or stress test); these referrals were considered necessary for completion of the patient work-up. If patients were evaluated by an ED physician and sent home after an examination or laboratory test available at least in the UCC, the referrals were considered potentially unnecessary.

RESULTS

Significantly more referrals were made by PCPs than UCCs (1712 vs. 280, p < 0.001). Significant differences were observed for orthopedics, general surgery, and obstetrics/gynecology referrals (p = 0.039, p < 0.001, p = 0.003). A higher percentage of patients referred by PCPs had potentially unnecessary visits compared to patients referred by UCCs (13.9% vs. 7.9%, p = 0.005).

CONCLUSION

A robust UCC system may help further reduce potentially unnecessary visits (including complex patients) to the ED.

Interventions to improve older adults' Emergency Department patient experience: A systematic review

STUDY OBJECTIVE

To summarize interventions that impact the experience of older adults in the emergency department (ED) as measured by patient experience instruments.

METHODS

This is a systematic review to evaluate interventions aimed to improve geriatric patient experience in the ED. We searched Ovid CENTRAL, Ovid EMBASE, Ovid MEDLINE and PsycINFO from inception to January 2019. The main outcome was patient experience measured through instruments to assess patient experience or satisfaction. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the confidence in the evidence available.

RESULTS

The search strategy identified 992 studies through comprehensive literature search and hand-search of reference lists. A total of 21 studies and 3163 older adults receiving an intervention strategy aimed at improve patient experience in the ED were included. Department-wide interventions, including geriatric ED and comprehensive geriatric assessment unit, focused care coordination with discharge planning and referral for community services, were associated with improved patient experience. Providing an assistive listening device to those with hearing loss and having a pharmacist reviewing the medication list showed an improved patient perception of quality of care provided. The confidence in the evidence available for the outcome of patient experience was deemed to be very low.

CONCLUSION

While all studies reported an outcome of patient experience, there was significant heterogeneity in the tools used to measure it. The very low certainty in the evidence available highlights the need for more reliable tools to measure patient experience and studies designed to measure the effect of the interventions.

Toppling Oranges: Death, Disability, Decline, and Readmission of Community-Dwelling Elderly Patients After an Emergency Department Visit

BACKGROUND

Every emergency department (ED) faces both a rising tide and a revolving door of elderly patients. Unplanned short-term returns after a recent ED evaluation or hospital admission are sentinel events. Consequences include substantial functional decline, reduced health-related quality of life, and increased risk of dependency or death. Returning families, unaware of the significant likelihood of deterioration after an ED or hospital discharge, often harbor suspicions that something was missed. Literature describing the significant likelihood of functional decline in elderly patients after ED or hospital discharge is presented. Suggestions for incorporating the potential for subsequent deterioration into the evaluation of elderly ED patients and the discussions surrounding disposition decisions are included.

DISCUSSION

In addition to impacting patients and families, posthospitalization decline and short-term readmissions create serious burdens for hospitals and their EDs. Education, vigilance, specialized geriatric EDs, dedicated inpatient units, and ED access to outpatient services for the elderly can aid in the recognition and mitigation of postvisit functional decline and associated returns. Financial incentives for reducing short-term readmissions can translate into novel approaches and referral arrangements.

CONCLUSIONS

Currently, and for the foreseeable future, EDs are integral to predicting, identifying, and preventing functional decline in the elderly. For now, we are all Geriatric EDs.

QUALITY OF LIFE AND BURDEN OF CAREGIVERS OF ELDERLY PEOPLE

ABSTRACT Objective: to assess caregivers’ quality of life and correlate it with elderly people’s quality of life, as well as assess the burden of caregivers of elderly people hospitalized in an Emergency Service and correlate it with their quality of life. Method: this is a cross-sectional and analytical study conducted with 250 caregivers of elderly patients admitted to the Emergency Service of Hospital São Paulo, Brazil, from December 2015 to January 2017. To assess caregivers’ quality of life, the generic Short-Form-36 questionnaire, item short-form health survey was used; burden was assessed using the Zarit Burden Interview. Results: the mean age was 48.36 years, with a predominance of females, most of whon were elderly people’s children. Caregivers showed mild to moderate burden, and in quality of life assessment, the most compromised domains were general health status, vitality, and social aspects. The Short-Form-36 dimensions that had a significant correlation with Zarit Burden Interview scores were physical aspect, general health status, vitality, social aspects, and emotional aspect. Conclusion: caregivers’ quality of live is associated with elderly people’s quality of life. Burden is related to the worsening quality of life of caregivers. It is necessary to identify the work demands and specific needs of caregivers of elderly people in order to develop care strategies involving this population.

Feasibility of predictive model by clinical and laboratory parameters for risk stratification of geriatric abdominal pain

Background:

Assessment of geriatric patients presented with abdominal pain had been challenge for emergency physicians with the ageing population. A rapid, reproducible risk stratification model for the assessment of the need for admission for geriatric abdominal pain would be required to identify low-risk patients to be managed as out-patient basis.

Objective:

Assess the feasibility of risk stratification model to predict the need of hospital admission based on readily available bedside parameters in emergency departments.

Methods:

This is a multicenter retrospective cohort study in four emergency departments. Patients aged at least 65 who presented with chief complaint of abdominal pain within the previous 7 days of attendance as the chief complaint were included. Chart review was performed for the included patients. The primary outcome was defined as a composite of mortality, abdominal surgery or endoscopic treatment, and other inpatient treatments for abdominal diseases within 14 days, surrogating the need of hospital admission. Logistic regression was modeled to identify independent predictors. The diagnostic accuracy of the risk model was evaluated with the receiver operating characteristic curve and compared with the clinical gestalt of decision for hospital admission by the attending physician.

Results:

In total, 553 patients were included. Symptoms of upper gastrointestinal bleeding, non-ambulatory presenting status, pain duration, focal abdominal tenderness, hyperglycemia, leukocytosis, and elevated creatinine were independent predictors of the outcome. The area under the receiver operating characteristic curve of the predicted probabilities of the logistic model was 0.741. In keeping for a low-risk criterion to achieve more than 90% sensitivity, the predictive model would only achieve 18.2% specificity which was inferior to clinical gestalt for hospital admission (sensitivity 99.3%, specificity 44.3%).

Conclusion:

Risk stratification model by clinical assessment and laboratory markers alone were inadequate and inferior to clinical gestalt for identification of the group of patients requiring inpatient treatment.

Elderly care in the emergency department: an integrative review

Abstract Objective: To identify the care practices of nurses for the elderly in emergency departments. Method: An integrative review was carried out in the CAPES database, selecting publications in English, Portuguese and Spanish published between January 2011 and October 2016. The descriptors used were: "Emergency nursing"; "Geriatric nursing"; "Health services for the elderly"; "Elderly person"; "Nursing care". Results: Sixteen articles were analyzed in English, the majority of which had a qualitative approach (56.2%). Australia had the largest number of publications (31.2%). After reading the studies in full, the common themes were organized and classified into three categories: Challenges/difficulties in the care of the elderly in the emergency department, Positive experiences of elderly care in the emergency department and The emergency department as a space of death and dying. Conclusion: The care practices of nurses are focused on identifying the main problems regarding elderly care, adaptation and the planning of their work routine. Another strategy is the implementation of instruments of evaluation specific to elderly patients and the involvement of the family in all stages of care.