1
|
Chen RF, Cheng KC, Lin YY, Chang IC, Tsai CH. Predicting Unscheduled Emergency Department Return Visits Among Older Adults: Population-Based Retrospective Study. JMIR Med Inform 2021; 9:e22491. [PMID: 34319244 PMCID: PMC8367131 DOI: 10.2196/22491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 01/11/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022] Open
Abstract
Background Unscheduled emergency department return visits (EDRVs) are key indicators for monitoring the quality of emergency medical care. A high return rate implies that the medical services provided by the emergency department (ED) failed to achieve the expected results of accurate diagnosis and effective treatment. Older adults are more susceptible to diseases and comorbidities than younger adults, and they exhibit unique and complex clinical characteristics that increase the difficulty of clinical diagnosis and treatment. Older adults also use more emergency medical resources than people in other age groups. Many studies have reviewed the causes of EDRVs among general ED patients; however, few have focused on older adults, although this is the age group with the highest rate of EDRVs. Objective This aim of this study is to establish a model for predicting unscheduled EDRVs within a 72-hour period among patients aged 65 years and older. In addition, we aim to investigate the effects of the influencing factors on their unscheduled EDRVs. Methods We used stratified and randomized data from Taiwan’s National Health Insurance Research Database and applied data mining techniques to construct a prediction model consisting of patient, disease, hospital, and physician characteristics. Records of ED visits by patients aged 65 years and older from 1996 to 2010 in the National Health Insurance Research Database were selected, and the final sample size was 49,252 records. Results The decision tree of the prediction model achieved an acceptable overall accuracy of 76.80%. Economic status, chronic illness, and length of stay in the ED were the top three variables influencing unscheduled EDRVs. Those who stayed in the ED overnight or longer on their first visit were less likely to return. This study confirms the results of prior studies, which found that economically underprivileged older adults with chronic illness and comorbidities were more likely to return to the ED. Conclusions Medical institutions can use our prediction model as a reference to improve medical management and clinical services by understanding the reasons for 72-hour unscheduled EDRVs in older adult patients. A possible solution is to create mechanisms that incorporate our prediction model and develop a support system with customized medical education for older patients and their family members before discharge. Meanwhile, a reasonably longer length of stay in the ED may help evaluate treatments and guide prognosis for older adult patients, and it may further reduce the rate of their unscheduled EDRVs.
Collapse
Affiliation(s)
- Rai-Fu Chen
- Department of Information Management, Chia-Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Kuei-Chen Cheng
- Department of Information Management, National Chung Cheng University, Chiayi County, Taiwan
| | - Yu-Yin Lin
- Department of Information Management, National Chung Cheng University, Chiayi County, Taiwan
| | - I-Chiu Chang
- Department of Information Management, National Chung Cheng University, Chiayi County, Taiwan
| | - Cheng-Han Tsai
- Department of Information Management, National Chung Cheng University, Chiayi County, Taiwan.,Department of Emergency, Chiayi Branch, Taichung Veterans General Hospital, Chiayi City, Taiwan
| |
Collapse
|
2
|
van Loon-van Gaalen M, van Winsen B, van der Linden MC, Gussekloo J, van der Mast RC. The effect of a telephone follow-up call for older patients, discharged home from the emergency department on health-related outcomes: a systematic review of controlled studies. Int J Emerg Med 2021; 14:13. [PMID: 33602115 PMCID: PMC7893958 DOI: 10.1186/s12245-021-00336-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/02/2021] [Indexed: 01/08/2023] Open
Abstract
Background Older patients discharged from the emergency department (ED) are at increased risk for adverse outcomes. Transitional care programs offer close surveillance after discharge, but are costly. Telephone follow-up (TFU) may be a low-cost and feasible alternative for transitional care programs, but its effects on health-related outcomes are not clear. Aim We systematically reviewed the literature to evaluate the effects of TFU by health care professionals after ED discharge to an unassisted living environment on health-related outcomes in older patients compared to controls. Methods We conducted a multiple electronic database search up until December 2019 for controlled studies examining the effects of TFU by health care professionals for patients aged ≥65 years, discharged to an unassisted living environment from a hospital ED. Two reviewers independently assessed eligibility and risk of bias. Results Of the 748 citations, two randomized controlled trials (including a total of 2120 patients) met review selection criteria. In both studies, intervention group patients received a scripted telephone intervention from a trained nurse and control patients received a patient satisfaction survey telephone call or usual care. No demonstrable benefits of TFU were found on ED return visits, hospitalization, acquisition of prescribed medication, and compliance with follow-up appointments. However, many eligible patients were not included, because they were not reached or refused to participate. Conclusions No benefits of a scripted TFU call from a nurse were found on health services utilization and discharge plan adherence by older patients after ED discharge. As the number of high-quality studies was limited, more research is needed to determine the effect and feasibility of TFU in different older populations. PROSPERO registration number CRD42019141403. Supplementary Information The online version contains supplementary material available at 10.1186/s12245-021-00336-x.
Collapse
Affiliation(s)
- Merel van Loon-van Gaalen
- Emergency Department, Haaglanden Medical Center, P.O. Box 432, 2501, CK, The Hague, The Netherlands.
| | - Britt van Winsen
- Emergency Department, Haaglanden Medical Center, P.O. Box 432, 2501, CK, The Hague, The Netherlands
| | | | - Jacobijn Gussekloo
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands.,Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Roos C van der Mast
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands.,Department of Psychiatry, CAPRI-University, Antwerp, Belgium
| |
Collapse
|
3
|
Sheikh S, Booth-Norse A, Smotherman C, Kalynych C, Lukens-Bull K, Guerrido E, Henson M, Gautam S, Hendry P. Predicting Pain-Related 30-Day Emergency Department Return Visits in Middle-Aged and Older Adults. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:2748-2756. [PMID: 32875332 PMCID: PMC8557807 DOI: 10.1093/pm/pnaa213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE The objective of this study was to determine predictive factors for pain-related emergency department returns in middle-aged and older adults. Design, Setting, and Subjects. This was a subanalysis of patients > 55 years of age enrolled in a prospective observational study of adult patients presenting within 30 days of an index visit to a large, urban, academic center. METHODS Demographic and clinical data were collected and compared to determine significant differences between patients who returned for pain and those who did not. Multiple logistic regressions were used to determine significant predictive variables for return visits. RESULTS The majority of the 130 enrolled patients > 55 years of age returned for pain (57%), were African American (78%), were younger (55-64 years old, 67%), had a high emergency department acuity level (level 1 or 2) at their index visit (56%), had low health literacy (Rapid Estimate of Adult Literacy in Medicine [REALM] score, 62%), lived in an area of extreme deprivation (69%), and were admitted (61%) during their index visit. Age (odds ratio [OR] = 0.9, 95% CI = 0.8-0.9, P = 0.047), health literacy (REALM scores; OR = 3.1, 95% CI = 1.3-7.5, P = 0.011), and index visit pain scores (OR = 1.1, 95% CI = 1.0-1.2, P = 0.004) were predictive of emergency department returns for pain in middle-aged and older adults. CONCLUSIONS The likelihood of emergency department return visits for pain in middle-aged and older adults decreased with older age, increased with higher health literacy (REALM scores), and increased with increase in pain scores.
Collapse
Affiliation(s)
- Sophia Sheikh
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Ashley Booth-Norse
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Carmen Smotherman
- Center for Health Equity and Quality Research, University of Florida College of Medicine, Jacksonville, Florida
| | - Colleen Kalynych
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Katryne Lukens-Bull
- Center for Health Equity and Quality Research, University of Florida College of Medicine, Jacksonville, Florida
| | - Erika Guerrido
- Center for Health Equity and Quality Research, University of Florida College of Medicine, Jacksonville, Florida
| | - Morgan Henson
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Shiva Gautam
- Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Phyllis Hendry
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| |
Collapse
|
4
|
Sheikh S. Risk Factors Associated with Emergency Department Recidivism in the Older Adult. West J Emerg Med 2019; 20:931-938. [PMID: 31738721 PMCID: PMC6860386 DOI: 10.5811/westjem.2019.7.43073] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/29/2019] [Accepted: 07/28/2019] [Indexed: 01/09/2023] Open
Abstract
Our objective was to review risk factors predictive of older adult recidivism in the emergency department. Certain risk factors and themes commonly occurred in the literature. These recurring factors included increasing age, male gender, certain diagnoses (abdominal pain, traumatic injuries, and respiratory complaints), psychosocial factors (depression, anxiety, poor social support, and limited health literacy), and poor general health (cognitive health and physical functioning). Many of the identified risk factors are not easily modifiable posing a significant challenge in the quest to develop and implement effective intervention strategies.
Collapse
Affiliation(s)
- Sophia Sheikh
- University of Florida-Jacksonville, Department of Emergency Medicine, Jacksonville, Florida
| |
Collapse
|
5
|
Fuchs C, Çelik B, Brouns SHA, Kaymak U, Haak HR. No age thresholds in the emergency department: A retrospective cohort study on age differences. PLoS One 2019; 14:e0210743. [PMID: 30699209 PMCID: PMC6353140 DOI: 10.1371/journal.pone.0210743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 12/31/2018] [Indexed: 11/26/2022] Open
Abstract
Emergency care in elderly patients has gained attention by researchers due to high utilization rate and the importance of emergency services in elderly care. We examine if there is a clear age threshold between young and old patients at which there is a need for extra care and facilities in the emergency department. This retrospective cohort study uses emergency department (ED) data collected over the course of a year, containing information about 31,491 patient visits. The measured variables are treatment time, waiting time, number of tests, number of medical procedures, number of specialties involved and the patient’s length of stay on the ED. To examine the multivariate differences between different patient groups, the data set is split into eighteen age groups and a MANOVA analysis is conducted to compare group means. The results show that older patients tend to have a longer stay on the ED. They also require more medical tests, have higher resource utilization and admission rates to the hospital. When the patients are grouped according to life stages (<18, 18-39, 40-64 and ≥65), each life stage shows significantly different characteristics across all variables. To understand where these differences start, age bins of five years are analyzed and almost none of the consecutive groups are significantly different in any variable. A significant difference between all groups is observed when age interval of the bins is increased to 10 years. This indicates that although age has an effect on the patient’s treatment, a clear age threshold that identifies the group of elderly patients is not observable from emergency room variables. The results of this study show no clear age boundary between young and old patients. In other words, we could not find support for favoring the often-used age boundary of 65 over other boundaries (e.g. 60 or 70) to distinguish the group of elderly patients on the ED.
Collapse
Affiliation(s)
- Caro Fuchs
- Eindhoven University of Technology, School of Industrial Engineering, Eindhoven, The Netherlands
- * E-mail:
| | - Bilge Çelik
- Eindhoven University of Technology, School of Industrial Engineering, Eindhoven, The Netherlands
| | - Steffie H. A. Brouns
- Department of Internal Medicine, Máxima Medical Center, Eindhoven, the Netherlands
| | - Uzay Kaymak
- Eindhoven University of Technology, School of Industrial Engineering, Eindhoven, The Netherlands
| | - Harm R. Haak
- Department of Internal Medicine, Máxima Medical Center, Eindhoven, the Netherlands
- Department of Internal Medicine, Division of General Internal Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Ageing and Long-Term Care, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
6
|
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
|
7
|
Understanding why older adults choose to seek non-urgent care in the emergency department: the patient's perspective. CAN J EMERG MED 2018; 21:243-248. [PMID: 29843840 DOI: 10.1017/cem.2018.378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Older adults make up a significant proportion of patients seeking care in the ED, with about 25% of these visits classified as "non-urgent." This study explored older adults' understandings, expectations of and self-reported reasons for seeking care and treatment provided in the ED. METHODS This qualitative study involved semi-structured interviews with CTAS 4-5 patients conducted at randomly selected times and days during ED visits at three Saskatoon facilities in 2016. Thematic analysis was used to analyze interview data. RESULTS 115 patients over age 65 years (mean age 79.1 years) were interviewed. While the majority had independently or with family made the decision to attend the ED, almost one-third of patients (31.6%) reported that they had been referred to the ED by general practitioners or specialists. Few respondents indicated the visit was the result of their general practitioner not being available. Most participants cited comprehensiveness and convenience of diagnostic and treatment services in a single location as the primary motivation for seeking treatment in the ED, which was especially important to those in poor health, without family supports, or with functional limitations, personal mobility and/or transportation challenges. Other common motivations were availability of after-hours care and perceived higher quality care compared to primary care. CONCLUSIONS Accessibility to comprehensive care, availability, quality of care and positive past experiences were key considerations for older adults seeking treatment of non-urgent concerns. Older adults will likely continue to use EDs for non-urgent medical care until trusted, "one-stop" settings that better addresses the needs of this population are more widely available.
Collapse
|
8
|
Guidance when Applying the Canadian Triage and Acuity Scale (CTAS) to the Geriatric Patient: Executive Summary. CAN J EMERG MED 2018; 19:S28-S37. [PMID: 28756798 DOI: 10.1017/cem.2017.363] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
9
|
Émond M, Boucher V, Carmichael PH, Voyer P, Pelletier M, Gouin É, Daoust R, Berthelot S, Lamontagne ME, Morin M, Lemire S, Minh Vu TT, Nadeau A, Rheault M, Juneau L, Le Sage N, Lee J. Incidence of delirium in the Canadian emergency department and its consequences on hospital length of stay: a prospective observational multicentre cohort study. BMJ Open 2018. [PMID: 29523559 PMCID: PMC5855334 DOI: 10.1136/bmjopen-2017-018190] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE We aim to determine the incidence of delirium and describe its impacts on hospital length of stay (LOS) among non-delirious community-dwelling older adults with an 8-hour exposure to the emergency department (ED) environment. DESIGN This is a prospective observational multicentre cohort study (March-July 2015). Patients were assessed two times per day during their entire ED stay and up to 24 hours on hospital ward. SETTING The study took place in four Canadian EDs. PARTICIPANTS 338 included patients: (1) aged ≥65 years; (2) who had an ED stay ≥8 hours; (3) were admitted to hospital ward and (4) were independent/semi-independent. MAIN OUTCOMES AND MEASURES The primary outcomes of this study were incident delirium in the ED or within 24 hours of ward admission and ED and hospital LOS. Functional and cognitive status were assessed using validated Older Americans Resources and Services and the modified Telephone Interview for Cognitive Status tools. The Confusion Assessment Method was used to detect incident delirium. Univariate and multivariate analyses were conducted to evaluate outcomes. RESULTS Mean age was 76.8 (±8.1), 17.7% were aged >85 years old and 48.8% were men. The mean incidence of delirium was 12.1% (n=41). Median IQR ED LOS was 32.4 (24.5-47.9) hours and hospital LOS was 146.6 (75.2-267.8) hours. Adjusted mean hospital LOS was increased by 105.4 hours (4.4 days) (95% CI 25.1 to 162.0, P<0.001) for patients who developed an episode of delirium compared with non-delirious patient. CONCLUSIONS An incident delirium was observed in one of eight independent/semi-independent older adults after an 8-hour ED exposure. An episode of delirium increases hospital LOS by 4 days and therefore has important implications for patients and could contribute to ED overcrowding through a deleterious feedback loop.
Collapse
Affiliation(s)
- Marcel Émond
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
- Département de médecine d’urgence, CHU de Québec-Université Laval, Québec, Canada
- Medicine, Université Laval, Québec, Canada
- Centre d’excellence sur le vieillissement de Québec, Québec, Canada
- Centre de recherche sur les soins et les services de première ligne de l’Université Laval, Québec, Canada
| | - Valérie Boucher
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
- Medicine, Université Laval, Québec, Canada
- Centre d’excellence sur le vieillissement de Québec, Québec, Canada
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale, Québec, Canada
| | | | - Philippe Voyer
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
- Centre d’excellence sur le vieillissement de Québec, Québec, Canada
- Nursing, Université Laval, Québec, Canada
| | - Mathieu Pelletier
- Medicine, Université Laval, Québec, Canada
- Centre Intégré de Santé et de Services Sociaux de Lanaudière, Joliette, Canada
| | - Émilie Gouin
- Centre Hospitalier Régional de Trois-Rivières, Trois-Rivières, Canada
| | - Raoul Daoust
- Centre de recherche de l’Hôpital du Sacré-Cœur de Montréal, Montréal, Canada
- Medicine, Université de Montréal, Montréal, Canada
| | - Simon Berthelot
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
- Département de médecine d’urgence, CHU de Québec-Université Laval, Québec, Canada
- Medicine, Université Laval, Québec, Canada
| | - Marie-Eve Lamontagne
- Medicine, Université Laval, Québec, Canada
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale, Québec, Canada
| | - Michèle Morin
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
- Medicine, Université Laval, Québec, Canada
| | - Stéphane Lemire
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
- Medicine, Université Laval, Québec, Canada
- Centre d’excellence sur le vieillissement de Québec, Québec, Canada
| | - Thien Tuong Minh Vu
- Centre de recherche du Centre hospitalier de l’Université de Montréal, Montréal, Canada
- Centre hospitalier de l’Université de Montréal, Montréal, Canada
- Institut de gériatrie de l’Université de Montréal, Montréal, Canada
| | - Alexandra Nadeau
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
- Medicine, Université Laval, Québec, Canada
- Centre d’excellence sur le vieillissement de Québec, Québec, Canada
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale, Québec, Canada
| | | | - Lucille Juneau
- Centre Intégré Universitaire de Services Sociaux et de Santé de la Capitale-Nationale, Québec, Canada
| | - Natalie Le Sage
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
- Département de médecine d’urgence, CHU de Québec-Université Laval, Québec, Canada
- Medicine, Université Laval, Québec, Canada
| | - Jacques Lee
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Sunnybrook Health Sciences Center, Toronto, Canada
| |
Collapse
|
10
|
Mohd Mokhtar MA, Pin TM, Zakaria MI, Hairi NN, Kamaruzzaman SB, Vyrn CA, Hua PPJ. Utilization of the emergency department by older residents in Kuala Lumpur, Malaysia. Geriatr Gerontol Int 2014; 15:944-50. [PMID: 25311907 DOI: 10.1111/ggi.12369] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2014] [Indexed: 11/28/2022]
Abstract
AIM To determine the pattern of utilization of emergency department (ED) services by older patients in Kuala Lumpur, Malaysia, compared with younger patients in the same setting. METHODS The sociodemographics, clinical characteristics and resource utilization of consecutive patients attending the adult ED at the University Malaya Medical Center were recorded during a typical week. RESULTS A total of 1649 patients were included in the study; 422/1649 (25.6%) were aged ≥60 years and 1077 (74.4%) were aged <60 years. Older adult patients were more likely to be diagnosed with ischemic heart disease (12.6% vs 2.5%, P < 0.001), and more likely to require investigations such as electrocardiogram (68.1% vs 16.6%, P < 0.001) or chest X-rays (67.6% vs 24.0%, P < 0.001) than their younger counterparts. Logistic regression methods showed that older adults remained an independent predictor of hospital admission (OR 2.75, 95% CI 2.11-3.57). CONCLUSION The ratio of older adult patients attending our ED over the proportion of older people in the general population was 26:6, which is far higher than reported in previous published studies carried out in other countries. Older ED attenders are also more likely to require investigations, procedures and hospital admissions. With the rapidly aging population in Malaysia, reconfiguration of resources will need to occur at a compatible rate in order to ensure that the healthcare needs of our older adults are met.
Collapse
Affiliation(s)
- Mohd Amin Mohd Mokhtar
- Faculty of Medicine, MARA University of Technology, Batu Caves, Selangor Darul Ehsan, Malaysia
| | - Tan Maw Pin
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mohd Idzwan Zakaria
- Academic Unit of Trauma and Emergency Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Noran Naqiah Hairi
- Julius Center University of Malaya, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Shahrul Bahiyah Kamaruzzaman
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chin Ai Vyrn
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Philip Poi Jun Hua
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| |
Collapse
|
11
|
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]
|
12
|
Shankar KN, Bhatia BK, Schuur JD. Toward patient-centered care: a systematic review of older adults' views of quality emergency care. Ann Emerg Med 2013; 63:529-550.e1. [PMID: 24051211 DOI: 10.1016/j.annemergmed.2013.07.509] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 07/22/2013] [Accepted: 07/30/2013] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE Observers have cited a quality gap between the current emergency care and the needs of elderly adults in the emergency setting. The Institute of Medicine identified patient-centeredness as a vital aim of quality health care. To develop a patient-centered approach in the emergency setting, we must first understand the elderly patients' views of their emergency care. Thus, we performed a systematic review to synthesize the current knowledge about the elderly patient's preferences and views of their emergency care. METHODS Systematic review of qualitative studies and surveys addressing the elderly patients' views of their emergency care using PUBMED and CINAHL. Using meta-ethnography, we identified 6 broad themes about the elderly's perspectives of hospital-based emergency care. RESULTS Of the 81 articles initially identified, our final review included 28 articles. We developed 6 themes of quality emergency care: (1) role of health care providers; (2) content of communication and patient education; (3) barriers to communication; (4) wait times; (5) physical needs in the emergency care setting; and (6) general elder care needs. Key findings were that emergency staff should (1) assume a leadership role with both the medical and social needs; (2) initiate communication frequently; (3) minimize potential barriers to communication; (4) check on patients during prolonged periods of waiting; (5) attend to distress caused by physical discomforts in the emergency care setting; and (6) address general elder care needs, including the care transition and involvement of caregivers when necessary. CONCLUSION Current qualitative research on the views of the elderly patient to hospital-based emergency care reveals common themes that should be considered in efforts to improve delivery of care to the elderly patient.
Collapse
Affiliation(s)
- Kalpana N Shankar
- Department of Emergency Medicine, Boston Medical Center, Boston, MA.
| | | | - Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
13
|
Kessler C, Williams MC, Moustoukas JN, Pappas C. Transitions of Care for the Geriatric Patient in the Emergency Department. Clin Geriatr Med 2013. [DOI: 10.1016/j.cger.2012.10.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
14
|
Hoon LS, Mackey S, Hong-Gu H. Elderly patients' experiences of care received in the emergency department: a systematic review. ACTA ACUST UNITED AC 2012; 10:1363-1409. [PMID: 27820308 DOI: 10.11124/01938924-201210230-00001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Elderly patients admitted into the emergency department present with high levels of illness acuity and severity, accompanied by multiple and complex medical and psychosocial issues, creating challenges for health care professionals to provide appropriate care. OBJECTIVE To determine the best available evidence on elderly patients' experiences of care received in the emergency department. INCLUSION CRITERIA The review considered studies that included male and female patients of all ethnic groups who were 65 years old and above, and admitted to the emergency department with urgent and non-urgent health-related issues. Both quantitative and qualitative studies were included. The phenomena of interest were the experiences of elderly patients in the emergency department. SEARCH STRATEGY A three-step search strategy was utilised in this review. The following databases were searched for articles published in English before year 2010: CINAHL, Medline, Scopus, PsycINFO, Mednar and Cochrane library. METHODOLOGICAL QUALITY Each paper was assessed independently by two reviewers for methodological quality prior to inclusion in the review using standardised critical appraisal checklists from the Joanna Briggs Institute. DATA COLLECTION Data were extracted using standardised data extraction tools from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (MAStARI) for descriptive/case series, and Qualitative Assessment and Review Instrument (QARI) for interpretive and critical research. DATA SYNTHESIS The findings from the quantitative study were presented in a narrative summary. The findings from the qualitative papers were pooled using JBI-QARI, involving the aggregation of findings to generate a set of statements that represent that aggregation. RESULTS A total of five papers were included in this review. The quantitative evidence demonstrated elderly patients' satisfaction level with care received in the emergency department was related to the length of waiting time and the information and pain management received. Two syntheses were generated from 12 unequivocal or credible findings from the qualitative evidence: 1) Health care professionals should be aware of the intolerable factors of the waiting experiences and appreciate the positive attitudes of elderly patients at the emergency department in order to improve the care provided; 2) There is a need for improvement for nursing staff to deliver the appropriate attention needed by elderly patients and meet their expectations to deliver professional and competent nursing care. CONCLUSIONS This review found that elderly patients had negative experiences, which mainly occurred during the waiting period and were related to long waiting time and physical environment. They were generally satisfied with the care they received from nurses. However, they expressed the need for more physiological, psychological and information support IMPLICATIONS FOR PRACTICE: Waiting time should be shortened for elderly patients. Patients' physiological and psychological needs should be paid more attention. The physical environment and facility design of the emergency department should be made more patient friendly. Complete information and clear answers to questions should be provided. IMPLICATIONS FOR RESEARCH Future studies are needed to better understand elderly patients' needs and their experiences of care at the emergency department; to develop strategies that may improve elderly patients' experiences; to compare the experiences and satisfaction levels of those who have shorter versus longer periods of waiting time; and to explore health care professionals' perception of the care provided to elderly patients in the emergency department.
Collapse
Affiliation(s)
- Lim Siew Hoon
- 1. Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore National University Hospital Centre for Evidence Based Nursing: A collaborating centre of the Joanna Briggs Institute
| | | | | |
Collapse
|
15
|
Hoon LS, Mackey S, Hong-Gu H. Elderly patientsʼ experiences of care received in the emergency department: a systematic review. ACTA ACUST UNITED AC 2012. [DOI: 10.11124/jbisrir-2012-52] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
16
|
Foo CL, Siu VWY, Tan TL, Ding YY, Seow E. Geriatric assessment and intervention in an emergency department observation unit reduced re-attendance and hospitalisation rates. Australas J Ageing 2011; 31:40-6. [DOI: 10.1111/j.1741-6612.2010.00499.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
17
|
Carpenter CR, DesPain B, Keeling TN, Shah M, Rothenberger M. The Six-Item Screener and AD8 for the detection of cognitive impairment in geriatric emergency department patients. Ann Emerg Med 2011; 57:653-61. [PMID: 20855129 PMCID: PMC3213856 DOI: 10.1016/j.annemergmed.2010.06.560] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Revised: 05/25/2010] [Accepted: 06/24/2010] [Indexed: 01/10/2023]
Abstract
STUDY OBJECTIVE We evaluate the diagnostic test characteristics of the Six-Item Screener and the AD8 to detect cognitive dysfunction in adults older than 65 years and using the emergency department (ED) for any reason. METHODS We conducted an observational cross-sectional cohort study at a single academic urban university-affiliated hospital. Subjects were consenting, non--critically ill, English-speaking adults older than 65 years and receiving care in the ED. We quantitatively assessed the diagnostic test characteristics of the Six-Item Screener and AD8 by using the Mini-Mental State Examination score less than 24 as the criterion standard for cognitive dysfunction. RESULTS The prevalence of cognitive dysfunction was 35%, but only 6% of charts noted a pre-existing deficit. The Six-Item Screener was superior to either the caregiver-administered AD8 or the patient-administered AD8 for the detection of cognitive dysfunction. CONCLUSION The Six-Item Screener was superior to the caregiver- or patient-administered AD8 to identify older adults at increased risk for occult cognitive dysfunction.
Collapse
Affiliation(s)
- Christopher R Carpenter
- Division of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
| | | | | | | | | |
Collapse
|
18
|
Carpenter CR, Bassett ER, Fischer GM, Shirshekan J, Galvin JE, Morris JC. Four sensitive screening tools to detect cognitive dysfunction in geriatric emergency department patients: brief Alzheimer's Screen, Short Blessed Test, Ottawa 3DY, and the caregiver-completed AD8. Acad Emerg Med 2011; 18:374-84. [PMID: 21496140 DOI: 10.1111/j.1553-2712.2011.01040.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cognitive dysfunction, including dementia and delirium, is prevalent in geriatric emergency department (ED) patients, but often remains undetected. One barrier to reliable identification of acutely or chronically impaired cognitive function is the lack of an acceptable screening tool. While multiple brief screening instruments have been derived, ED validation trials have not previously demonstrated tools that are appropriately sensitive for clinical use. OBJECTIVES The primary objective was to evaluate and compare the Ottawa 3DY (O3DY), Brief Alzheimer's Screen (BAS), Short Blessed Test (SBT), and caregiver-completed AD8 (cAD8) diagnostic test performance for cognitive dysfunction in geriatric ED patients using the Mini Mental Status Exam (MMSE) as the criterion standard. A secondary objective was to assess the diagnostic accuracy for the cAD8 (which is an informant-based instrument) when used in combination with the other performance-based screening tools. METHODS In an observational cross-sectional cohort study at one urban academic university-affiliated medical center, trained research assistants (RAs) collected patients' responses on the Confusion Assessment Method for the Intensive Care Unit, BAS, and SBT. When available, reliable caregivers completed the cAD8. The MMSE was then obtained. The O3DY was reconstructed from elements of the MMSE and the BAS. Consenting subjects were non-critically ill, English-speaking adults over age 65 years, who had not received potentially sedating medications prior to or during cognitive testing. Using an MMSE score of ≤23 as the criterion standard for cognitive dysfunction, the sensitivity, specificity, likelihood ratios, and receiver operating characteristic (ROC) area under the curve (AUC) were computed. Venn diagrams were constructed to quantitatively compare the degree of overlap among positive test results between the performance-based instruments. RESULTS The prevalence of cognitive dysfunction for the 163 patients enrolled with complete data collection was 37%, including 5.5% with delirium. Dementia was self-reported in 3%. Caregivers were available to complete the cAD8 for 56% of patients. The SBT, BAS, and O3DY each demonstrated 95% sensitivity, compared with 83% sensitivity for the cAD8. The SBT had a superior specificity of 65%. No combination of instruments with the cAD8 significantly improved diagnostic accuracy. The SBT provided the optimal overlap with the MMSE. CONCLUSIONS The SBT, BAS, and O3DY are three brief performance-based screening instruments to identify geriatric patients with cognitive dysfunction more rapidly than the MMSE. Among these three instruments, the SBT provides the best diagnostic test characteristics and overlap with MMSE results. The addition of the cAD8 to the other instruments does not enhance diagnostic accuracy.
Collapse
Affiliation(s)
- Christopher R Carpenter
- Division of Emergency Medicine, Washington University in St. Louis School of Medicine, MO, USA.
| | | | | | | | | | | |
Collapse
|
19
|
McCusker J, Verdon J, Veillette N, Berg K, Emond T, Belzile E. Standardized Screening and Assessment of Older Emergency Department Patients: A Survey of Implementation in Quebec. Can J Aging 2010; 26:49-57. [PMID: 17430804 DOI: 10.3138/g236-p856-815w-3863] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
ABSTRACTCost-effective methods have been developed to help busy emergency department (ED) staff cope with the growing number of older patients, including quick screening and assessment tools to identify those at high risk and note their specific needs. This survey, from a sample of key informants from all EDs (n=111) in the province of Quebec (participation rate of 88.2%), investigated the implementation of these tools and barriers to implementation. Questionnaires (administered either by telephone or by self-completion) included characteristics of the ED, characteristics of the respondent, use of tools, and method of implementation. Barriers to the implementation of these tools included lack of resources for screening and follow-up, misunderstandings of the difference between screening and assessment tools, and need for adaptation of the tools to the local context. Education of staff and pre-implementation adaptation and testing are needed for successful implementation.
Collapse
Affiliation(s)
- Jane McCusker
- Department of Clinical Epidemiology and Community Studies, St. Mary's Hospital Centre, Montreal, QC.
| | | | | | | | | | | |
Collapse
|
20
|
Sheppard LA, Anaf S, Gordon J. Patient satisfaction with physiotherapy in the emergency department. Int Emerg Nurs 2010; 18:196-202. [PMID: 20869660 DOI: 10.1016/j.ienj.2009.11.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Revised: 11/08/2009] [Accepted: 11/15/2009] [Indexed: 10/19/2022]
Abstract
STUDY AIM This research aims to explore patient satisfaction with ED physiotherapy within the Australian context by providing a qualitative perspective with in-depth exploration of the factors underlying patients' satisfaction. The physiotherapist was part of the Emergency Department Allied Health Team of social worker and occupational therapist. METHODS A qualitative, interpretive, field-based study using face-to-face interviews were carried out post-physiotherapy treatment within the emergency department, followed-up 2-3 weeks later with telephone interviews. RESULTS Twenty two participants took part in the face-to-face interviews and 15 in the follow-up interviews. Of the 22 participants who took part in the initial interviews 19 were over 65 years of age, with a mean age of 78 years. Within the category 'Physiotherapy in the emergency department' the themes were; expectations, bedside manner, physiotherapy management (i.e. assessment, advice, hands-on, exercise, follow-up/referral) and satisfaction. The physiotherapist at the Australian emergency department appeared to make an impact on patients' experiences in the emergency department through his thorough subjective assessment of the patients' home environment, coping skills and social supports, his assessment of functional mobility, his provision of exercises, advice and hands-on treatment, as well as his involvement in organising follow-up or referral to other services. The physiotherapist's bedside manner shaped patients' perceptions throughout their assessment and treatment, reassuring and comforting patients within the emergency environment. CONCLUSION Participants were satisfied with the experience of attending the physiotherapist in the emergency department and commented the blend of skills of the physiotherapists enhanced the service provision and self reported patient outcomes.
Collapse
Affiliation(s)
- Lorraine A Sheppard
- University of South Australia, School of Health Sciences, Adelaide, South Australia, Australia.
| | | | | |
Collapse
|
21
|
Hoon LS, Mackey S, Hong-Gu H. Elderly patients' experiences of care in the emergency department: a systematic review. JBI LIBRARY OF SYSTEMATIC REVIEWS 2010; 8:1-25. [PMID: 27820353 DOI: 10.11124/01938924-201008341-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
|
22
|
Abstract
In this paper we report the role that a sense of significance plays in the experiences of older patients in urgent care settings, and explore the factors that influence these experiences. The paper draws on findings from a UK study in which 69 patients and 27 relatives from 31 English NHS Trusts were interviewed about their urgent care experiences using semi-structured qualitative interviews. Key among the findings was that older patients experienced a diminished sense of their individual significance. Some questioned the legitimacy of their presence in the urgent care setting and believed that they mattered little in relation to other patients and the other tasks which health professionals were undertaking. The three key features of this diminished sense of significance were: the primacy of technical, medical care; an imbalance of power; and the subordination of patients’ non-medical needs. These features suggest that interventions to enhance care delivery that promotes a sense of significance will need to target practitioners and the wider organisational culture.
Collapse
Affiliation(s)
- Jackie Bridges
- School of Community and Health Sciences, City University London, UK,
| | - Peter Nugus
- Centre for Clinical Governance Research, Faculty of Medicine, University of New South Wales, Sydney, Australia
| |
Collapse
|
23
|
Foo CL, Chan KC, Goh HK, Seow E. Profiling Acute Presenting Symptoms of Geriatric Patients Attending an Urban Hospital Emergency Department. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2009. [DOI: 10.47102/annals-acadmedsg.v38n6p515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective: To study the profile of geriatric patients warded to the emergency department (ED) of an Asian acute care general hospital and determine if they are ‘more ill’, more likely to have atypical presentations and have a higher utilisation of healthcare resources when compared to a younger group of patients.
Materials and Methods: This is a retrospective chart review of consecutive patients aged 45 years and above presenting to the study ED over a period of 4 weeks from 4 June 2006 to 1 July 2006. The following data were obtained: (i) demographics, (ii) mode of arrival and triage acuity, (iii) presence of co-morbidities, (iv) investigations ordered in the ED, (v) clinical symptoms and diagnoses, (vi) disposition, (vii) length of hospital stay, (viii) injuries and outcomes of elderly fallers. The study population was divided into 2 groups – a study group with patients aged 65 years and above, and a control group with patients aged 45 to 64.
Results: There were 2847 patients in the study group and these were compared against 2875 in the control group. Those 65 years and above had greater representation in the ED population compared to the general population. In the study group, the proportion of females, the number arriving by ambulance and the likelihood of having a higher triage acuity increased with age. The elderly had higher rates of co-morbidities. They also had a higher resource utilisation rate. Falls was their commonest presenting complaint.
Conclusion: It is crucial that EDs recognise the special needs of elderly patients due to the growing ageing population. Healthcare policy makers when allocating resources should take into account the profile of elderly patients presenting to an ED and their resource utilisation.
Key words: Elderly, Presentation, Symptomology
Collapse
|
24
|
Duaso E, Tomás S, Rodríguez-Carballeira M, Cuadra L, Llonch M, Ruiz D. [Geriatric assessment in the emergency departments of acute hospitals]. Rev Esp Geriatr Gerontol 2009; 44 Suppl 1:10-14. [PMID: 19524119 DOI: 10.1016/j.regg.2009.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Accepted: 01/29/2009] [Indexed: 05/27/2023]
Abstract
Elderly people use often and in an appropriate way the Emergency Department (ED). However, we don't dispose of evidences that demonstrate utility of a specific model of geriatric assessment (GA) applied in ED. Nowadays; GA in ED should be used being adapted to the environment and with some clear objectives that allow to carry out a multidimensional diagnosis and to establish therapeutic priorities. GA contributes benefits in the continuity of care on the part of the Primary Attention when elderly people are discharged from an ED.
Collapse
Affiliation(s)
- Enric Duaso
- Ambito de Geriatría, Consorci Sanitari de Terrassa, Terrassa, Barcelona, España.
| | | | | | | | | | | |
Collapse
|
25
|
Ballabio C, Bergamaschini L, Mauri S, Baroni E, Ferretti M, Bilotta C, Vergani C. A comprehensive evaluation of elderly people discharged from an Emergency Department. Intern Emerg Med 2008; 3:245-9. [PMID: 18421427 DOI: 10.1007/s11739-008-0151-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2007] [Accepted: 03/17/2008] [Indexed: 11/29/2022]
Abstract
Elderly people make extensive use of the Emergency Department (ED). After discharge from the ED, these patients are at high risk of short-term adverse outcomes such as functional decline, readmission to the ED, hospitalization and death. We investigated whether a comprehensive geriatric evaluation (CGE) and follow-up of the elderly discharged from the ED can provide them with better diagnosis and treatment, and thus reduce adverse outcomes. Out of 423 elderly patients over 75 years of age discharged from an ED we evaluated 222 of them. The patients were evaluated and treated, based on testing for physical, functional, cognitive and emotional status. A comparison was made between scale scores at baseline and 3 months later. We observed a significant improvement in physical and emotional status in all the studied patients, a significant improvement in behavioural status in the elderly patients with cognitive dysfunction, and a reduction of distress in the caregivers of the elderly patients with cognitive dysfunction and behavioural disturbances. We also found that the rate of ED readmission or hospitalization was lower than in the 3 months preceding the CGE. The experience of older patients with the ED system can be greatly improved if their complex needs are given due attention by developing interdisciplinary programs between emergency physicians, geriatricians, and primary care physicians.
Collapse
Affiliation(s)
- Claudia Ballabio
- Department of Internal Medicine, University of Milan, Geriatric Medicine Unit, Ospedale Maggiore Policlinico, IRCCS, Via Pace 9, 20122, Milan, Italy
| | | | | | | | | | | | | |
Collapse
|
26
|
Wilber ST, Burger B, Gerson LW, Blanda M. Reclining Chairs Reduce Pain from Gurneys in Older Emergency Department Patients: A Randomized Controlled Trial. Acad Emerg Med 2008. [DOI: 10.1111/j.1553-2712.2005.tb00846.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
27
|
Vidal Ó, Manuel Romero J, Ginestà C, Badiella L, Valentini M, José Espert J, Benarroch G, García-Valdecasas JC. Factores asociados con la satisfacción en el cuidado y la asistencia en el departamento de cirugía de urgencias de los pacientes mayores de 65 años. Cir Esp 2008; 83:260-5. [DOI: 10.1016/s0009-739x(08)70565-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
28
|
Unsal A, Ayranci U, Alper Cevik A, Metintas S, Arslantas D, Unluoglu I. Use of emergency departments by elderly patients in a city of Western Turkey. Eur J Emerg Med 2007; 14:125-9. [PMID: 17473604 DOI: 10.1097/mej.0b013e3280111f99] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the reasons behind the demographic characteristics of patients presented to emergency departments. METHODS The entire patient records of all the hospitals' emergency departments in the city of Eskisehir were retrospectively assessed in this study. The study was conducted between the years 1998 and 2000. Data were evaluated using chi2, t-tests, and percent rates. RESULTS Of 608,528 patients visiting the emergency departments, 79 123 (13.0%) were elderly patients. The treatment and discharge rate was 78.3%. Mean admission rate was 21.2%. The death rate during the visits was 0.4%. The proportion of the five most frequently seen diseases was 41.9%. CONCLUSION Demographical trends show that emergency department visits by elderly patients would increase in time. So, in Turkey, emergency department staff should be trained to provide for the special needs of this population in emergency departments.
Collapse
Affiliation(s)
- Alaettin Unsal
- Medical Faculty Public Health Department, Osmangazi University, Meselik-Eskisehir, Turkey
| | | | | | | | | | | |
Collapse
|
29
|
Rodríguez-Molinero A, López-Diéguez M, Tabuenca AI, de la Cruz JJ, Banegas JR. Functional assessment of older patients in the emergency department: comparison between standard instruments, medical records and physicians' perceptions. BMC Geriatr 2006; 6:13. [PMID: 16952319 PMCID: PMC1569831 DOI: 10.1186/1471-2318-6-13] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Accepted: 09/04/2006] [Indexed: 11/24/2022] Open
Abstract
Background We evaluated the accuracy of physician recognition of functional status impairment in older emergency departments (ED) patients. In particular, we evaluated the accuracy of medical records (a comparison of the information in the medical record with the functional status based on proxy interviews), and the accuracy of physician knowledge (a comparison of the information obtained from the responsible physician with the functional status based on proxy interviews). Methods Cross-sectional study on 101 frail older patients selected at random from among those attending ED, their ED physicians, and respondents. The study was conducted at ED in four general university teaching hospitals in a city, from July through November 2003. Functional data shown on patients' medical records were compared against functional data obtained from respondents (family members), using Kendall's Tau-b statistic. In addition patients' Katz Indices (which assesses six basic activities of daily living – basic ADL) based on interviews with ED physicians were compared against those obtained from respondents, using the coefficient of concordance weighted kappa (κ). Each patient and his respondent were paired with a single physician. Results The correlation between information on dependence for basic ADL obtained from medical records and that furnished by respondents, was 0.41 (95% CI 0.27–0.55). Concordance between the respective Katz Indices obtained from physicians and respondents was 0.47 (95% CI 0.38–0.57). Conclusion Older subjects' functional status is not properly assessed by emergency department physicians.
Collapse
Affiliation(s)
| | - María López-Diéguez
- Department of Preventive Medicine and Public Health. Universidad Autónoma de Madrid, Madrid, Spain
| | - Ana I Tabuenca
- Department of Preventive Medicine and Public Health. Universidad Autónoma de Madrid, Madrid, Spain
| | - Juan J de la Cruz
- Department of Preventive Medicine and Public Health. Universidad Autónoma de Madrid, Madrid, Spain
| | - José R Banegas
- Department of Preventive Medicine and Public Health. Universidad Autónoma de Madrid, Madrid, Spain
| |
Collapse
|
30
|
Fan J, Worster A, Fernandes CMB. Predictive validity of the Triage Risk Screening Tool for elderly patients in a Canadian emergency department. Am J Emerg Med 2006; 24:540-4. [PMID: 16938591 DOI: 10.1016/j.ajem.2006.01.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2005] [Revised: 01/06/2006] [Accepted: 01/15/2006] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We sought to externally evaluate the predictive validity of the Triage Risk Screening Tool (TRST) for elderly patients in a Canadian setting. METHODS A prospective, observational cohort study of a convenience sample of patients more than 64 years old was assessed using the TRST before discharge. The composite outcome of any emergency department (ED) revisit, hospital admission, or long-term care placement at 30 and 120 days was measured. Likelihood ratios (LRs) and 95% confidence intervals (CIs) were calculated. MAIN FINDINGS Of 218 patients screened, 120 patients were enrolled. At 30 and 120 days, the positive LRs were 1.4 (95% CI, 0.9-2.0) and 1.4 (95% CI, 1.0-1.9), respectively. The negative LRs were 0.7 (95% CI, 0.4-1.3) and 0.7 (95% CI, 0.4-1.0), respectively. CONCLUSION The TRST cannot be used as a single diagnostic test to predict whether Canadian ED elders will have an ED revisit, hospital admission, or long-term care placement at 30 or 120 days.
Collapse
Affiliation(s)
- Jerome Fan
- Department of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada L8N 3Z5
| | | | | |
Collapse
|
31
|
McCusker J, Verdon J. Do geriatric interventions reduce emergency department visits? A systematic review. J Gerontol A Biol Sci Med Sci 2006; 61:53-62. [PMID: 16456194 DOI: 10.1093/gerona/61.1.53] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hospital emergency departments (EDs) serve an aging population with an increased burden on health resources. Few studies have examined the effects of comprehensive geriatric assessment interventions on ED use. This study aimed to systematically review the literature and compare the effects of these interventions on ED visits. METHODS Relevant articles were identified through electronic databases and a search of reference lists and personal files. Inclusion criteria included: original research (written in English or French) on interventions conducted in noninstitutionalized populations 60 years old or older, not restricted to a particular medical condition, in which ED visits were a study outcome. Data were abstracted and checked by the first author and a research assistant using a standard protocol. RESULTS Twenty-six relevant studies were identified, reported in 28 articles, with study samples obtained from EDs (9), hospitals (4), outpatient or primary care settings (10), home care (4), and community (1). The study designs included 17 randomized controlled trials, 3 trials with nonrandom allocation, 4 before-after studies, 1 quasi-experimental time-series study, and 1 cross-sectional study. Hospital-based interventions (mostly short-term assessment and/or liaison) had little overall effect on ED utilization, whereas many interventions in outpatient and/or primary care or home care settings (including geriatric assessment and management and case management) reduced ED utilization. Heterogeneity in study methods, measures of comorbidity, functional status, and ED utilization precluded meta-analysis of the results. CONCLUSION Further research, using improved methodologies and standardized measures, is needed to address the effects of innovative geriatric interventions on ED visits.
Collapse
Affiliation(s)
- Jane McCusker
- Department of Clinical Epidemiology and Community Studies, St. Mary's Hospital Center, 3830 Lacombe Ave., Room 2508, Montreal, QC H3T 1M5.
| | | |
Collapse
|
32
|
Enguidanos SM, Brumley RD. Risk of medication errors at hospital discharge and barriers to problem resolution. Home Health Care Serv Q 2006; 24:123-35. [PMID: 16236663 DOI: 10.1300/j027v24n01_09] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Medication errors are common among older adults, particularly among those who are at heightened risk due to transfer between care settings. Determining accurate medications for hospitalized patients is a complicated process. This paper presents findings from a small pilot study conducted to identify medication documentation problems at the point of hospital discharge among older adults and the problems encountered in developing new technological systems to address these problems. A prospective study was conducted within a managed care medical center that included patient and physician surveys and chart reviews. A review of 104 medical records revealed several problems in the documentation of patient medication including legibility, use of medical abbreviations and incomplete and missing entries. While patients overall were satisfied with medications communication efforts at discharge, physicians surveyed reported that these methods were inadequate in transmitting medication lists to primary care physicians, patients and other care providers. Patients reported taking more drugs than what were listed in the medical record. These findings led to the development, testing, and implementation of an electronic medication sheet. Despite the success in developing this new system, few physicians engaged in its use, with most preferring to continue with their standard discharge practices of written communication.
Collapse
|
33
|
Guttman A, Afilalo M, Guttman R, Colacone A, Robitaille C, Lang E, Rosenthal S. An Emergency Department–Based Nurse Discharge Coordinator for Elder Patients: Does It Make a Difference? Acad Emerg Med 2004. [DOI: 10.1111/j.1553-2712.2004.tb01920.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
34
|
Kihlgren AL, Nilsson M, Skovdahl K, Palmblad B, Wimo A. Older patients awaiting emergency department treatment. Scand J Caring Sci 2004; 18:169-76. [PMID: 15147480 DOI: 10.1111/j.1471-6712.2004.00266.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aim of this study was to describe, through observations and interviews with patients >/=75 years old and the relatives who accompanied them to the hospital, the conditions at the emergency department (ED) and the events that took place during the waiting period. Twenty older patients were studied, together with their relatives. A modification of a comparative design, the interpretative method 'grounded theory', was utilized. Open, nonparticipant observations were carried out; from the time patients were admitted until the time they were discharged. Patients were observed through all stages, for example, in the reception area, in the examination room, and in the X-ray department. The observations were supplemented with field notes and interviews with the older patients as they left the ED. The selective coding developed into six core-variables that were the focus of the material. These were: unpleasant waiting, unnecessary waiting, lack of good routines during the waiting stage, suffering during the waiting stage, bad feelings during the waiting stage and nursing care during the waiting stage. The way, in which nursing care was carried out, which in this context is discussed in terms of praxis and poieses, appeared to be of major importance for the older peoples' experiences when visiting the ED.
Collapse
|
35
|
Dendukuri N, McCusker J, Belzile E. The Identification of Seniors At Risk Screening Tool: Further Evidence of Concurrent and Predictive Validity. J Am Geriatr Soc 2004; 52:290-6. [PMID: 14728643 DOI: 10.1111/j.1532-5415.2004.52073.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the validity of the Identification of Seniors at Risk (ISAR) screening tool for detecting severe functional impairment and depression and predicting increased depressive symptoms and increased utilization of health services. SETTING Four university-affiliated hospitals in Montreal. DESIGN Data from two previous studies were available: Study 1, in which the ISAR scale was developed (n=1,122), and Study 2, in which it was used to identify patients for a randomized trial of a nursing intervention (n=1,889 with administrative data, of which 520 also had clinical data). PARTICIPANTS Patients aged 65 and older who were to be released from an emergency department (ED). MEASUREMENTS Baseline validation criteria included premorbid functional status in both studies and depression in Study 2 only. Increase in depressive symptoms at 4-month follow-up was assessed in Study 2. Information on health services utilization during the 5 months after the ED visit (repeat ED visits and hospitalization in both studies, visits to community health centers in Study 2) was available by linkage with administrative databases. RESULTS Estimates of the area under the receiver operating characteristic curve (AUC) for concurrent validity of the ISAR scale for severe functional impairment and depression ranged from 0.65 to 0.86. Estimates of the AUC for predictive validity for increased depressive symptoms and high utilization of health services ranged from 0.61 to 0.71. CONCLUSION The ISAR scale has acceptable to excellent concurrent and predictive validity for a variety of outcomes, including clinical measures and utilization of health services.
Collapse
Affiliation(s)
- Nandini Dendukuri
- Department of Clinical Epidemiology and Community Studies, St. Mary's Hospital, Montreal, Canada.
| | | | | |
Collapse
|
36
|
Moons P, Arnauts H, Delooz HH. Nursing issues in care for the elderly in the emergency department: an overview of the literature. ACCIDENT AND EMERGENCY NURSING 2003; 11:112-20. [PMID: 12633630 DOI: 10.1016/s0965-2302(02)00163-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Emergency care is an important link in the chain of care for geriatric patients. Due to the specific physiological, psychological, and social needs of elderly people, the type and quantity of emergency care are different for this group of patients than for other age groups. Consequently, they have a significant impact on the health care system. Doctors and nurses working in an emergency department must be aware of this specific situation and adjust the care that they provide accordingly. Appropriate communication between health care providers and patients, a sound assessment of functional status and cognitive ability, and specific attention to verbal and written discharge guidelines are indispensable.
Collapse
Affiliation(s)
- Philip Moons
- Research Associate, Centre for Health Services and Nursing Research, Katholieke Universiteit Leuven, Kapucijnenvoer 35/4, B-3000, Leuven, Belgium.
| | | | | |
Collapse
|
37
|
Grief CL. Patterns of ED use and perceptions of the elderly regarding their emergency care: a synthesis of recent research. J Emerg Nurs 2003; 29:122-6. [PMID: 12660693 DOI: 10.1067/men.2003.65] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The research literature reveals that the emergency care rendered to elderly patients may be of poor quality. Research examining elderly patients' ED use and their perceptions of their ED experiences was analyzed and synthesized, revealing gaps in the research and identifying areas for future research. METHODS A computerized search was made of 3 databases (medline, HealthSTAR, and CINAHL). Each of the studies was systematically evaluated with use of the Nursing Practice Research Analysis Tool. RESULTS Despite increased length of stay, more diagnostic tests, and higher expenses, the elderly have a higher rate of recidivism and are dissatisfied with their outcomes upon leaving the emergency department. Several areas that need to be explored further include quality of services rendered from the elderly ED patient's perspective; whether ageism exists within the emergency department; and the consequences of that ageism on the quality of care provided. DISCUSSION The elderly are being cared for by ED personnel who have limited geriatric education within an environment that is antithetical to their needs. Research and endeavors that concentrate on improving the care of the elderly ED patient must be given top priority.
Collapse
Affiliation(s)
- C Lynne Grief
- College of Nursing, University of South Florida, and Emergency Care Center, Sarasota Memorial Healthcare System, Sarasota, FL, USA.
| |
Collapse
|
38
|
Huang JA, Weng RH, Tsai WC, Hu WH, Yang DY. Analysis of emergency department utilization by elderly patients under National Health Insurance. Kaohsiung J Med Sci 2003; 19:113-20. [PMID: 12751871 DOI: 10.1016/s1607-551x(09)70458-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Elderly persons are thought to use emergency departments (EDs) disproportionately. This phenomenon has implications for policy-making as the population of the elderly continues to increase. This study aimed to characterize national ED utilization by elderly patients (> or = 65 years old), compared with that by younger patients (15-64 years old). The sample was selected from the National Health Insurance Research Database for the year 2000. There were 519,003 visits to adult EDs in the 12 medical centers sampled. The study used a secondary data analysis and included 14 variables. The elderly accounted for 28.5% of all adult ED visits. Compared with younger patients, a greater proportion of elderly patients were male (61.6% vs. 47.7%, p < 0.001), had chronic diseases (11.9% vs. 8.0%, p < 0.001), were major cases (6.7% vs. 4.1%, p < 0.001), made no co-payment (38.5% vs. 5.8%, p < 0.001), were frequent users of outpatient services (28.4% vs. 9.9%, p < 0.001), were higher-level emergencies (60.0% vs. 43.7%, p < 0.001), had longer stays in the ED (14.0% vs. 4.7%, p < 0.001), and had higher costs per visit (NT dollars 4,814 +/- 6,046 vs. 2,779 +/- 5,533, p < 0.001). In addition, elderly patients used 40.8% of total adult ED costs. Older patients have distinct patterns of ED use, and use emergency services at a higher rate than younger patients. ED staff should be knowledgeable about the unique and complex presentations of older ED patients.
Collapse
Affiliation(s)
- Jin-An Huang
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.
| | | | | | | | | |
Collapse
|
39
|
Nydén K, Petersson M, Nyström M. Unsatisfied basic needs of older patients in emergency care environments - obstacles to an active role in decision making. J Clin Nurs 2003; 12:268-74. [PMID: 12603560 DOI: 10.1046/j.1365-2702.2003.00737.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Little attention is paid in Emergency Care Units (ECUs) in Sweden to the special needs of older people. The aim of this study was thus to analyse older people's basic needs in the emergency care environment. The study was carried out with a life-world interpretative approach, and the theoretical framework for interpretation was Abraham Maslow's theory of motivation and personality. Seven informants aged between 65 and 88 years, with various experiences of being patients with urgent as well as non-urgent health-related problems, were interviewed about their experiences of ECU care. Their basic needs at the lower levels of Maslow's hierarchy were well-represented in the data. Higher needs, such as desire to know and understand, appeared to be totally neglected. Safety needs dominated the whole situation. Our conclusion is that standards of care must be developed in Sweden to make older patients feel safer and more secure in ECUs. Furthermore, the principles of nursing care for older patients need to be defined in order to encourage them to take an active part in their own health process.
Collapse
Affiliation(s)
- Kristoffer Nydén
- Department of Surgury, Sahlgrenska University Hospital, Ostra, Sweden
| | | | | |
Collapse
|
40
|
Mion LC, Palmer RM, Meldon SW, Bass DM, Singer ME, Payne SMC, Lewicki LJ, Drew BL, Connor JT, Campbell JW, Emerman C. Case finding and referral model for emergency department elders: a randomized clinical trial. Ann Emerg Med 2003; 41:57-68. [PMID: 12514683 DOI: 10.1067/mem.2003.3] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Elderly emergency department patients have complex medical needs and limited social support. A transitional model of care adapted from hospitals was tested for its effectiveness in the ED in reducing subsequent service use. METHODS A randomized clinical trial was conducted at 2 urban, academically affiliated hospitals. Participants were 650 community-residing individuals 65 years or older who were discharged home after an ED visit. Main outcomes were service use rates, defined as repeat ED visits, hospitalizations, or nursing home admissions, and health care costs at 30 and 120 days. Intervention consisted of comprehensive geriatric assessment in the ED by an advanced practice nurse and subsequent referral to a community or social agency, primary care provider, and/or geriatric clinic for unmet health, social, and medical needs. Control group participants received usual and customary ED care. RESULTS The intervention had no effect on overall service use rates at 30 or 120 days. However, the intervention was effective in lowering nursing home admissions at 30 days (0.7% versus 3%; odds ratio 0.21; 95% confidence interval [CI] 0.05 to 0.99) and in increasing patient satisfaction with ED discharge care (3.41 versus 3.03; mean difference 0.37; 95% CI 0.13 to 0.62). The intervention was more effective for high-risk than low-risk elders. CONCLUSION An ED-based transitional model of care reduced subsequent nursing home admissions but did not decrease overall service use for older ED patients. Further studies are needed to determine the best models of care for this setting and for at-risk patients.
Collapse
Affiliation(s)
- Lorraine C Mion
- Geriatric Nursing Program, Division of Nursing, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
McCusker J, Verdon J, Caplan GA, Meldon SW, Jacobs P. Older persons in the emergency medical care system. J Am Geriatr Soc 2002; 50:2103-5. [PMID: 12473035 DOI: 10.1046/j.1532-5415.2002.50635.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
42
|
Aminzadeh F, Dalziel WB. Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med 2002; 39:238-47. [PMID: 11867975 DOI: 10.1067/mem.2002.121523] [Citation(s) in RCA: 701] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE We sought to synthesize the literature on patterns of use of emergency services among older adults, risk factors associated with adverse health outcomes, and effectiveness of intervention strategies targeting this population. METHODS Relevant articles were identified by means of an English-language search of MEDLINE, HealthSTAR, CINAHL, Current Contents, and Cochrane Library databases from January 1985 to January 2001. This search was supplemented with literature from reference sections of the retrieved publications. A qualitative approach was used to synthesize the literature. RESULTS Compared with younger persons, older adults use emergency services at a higher rate, their visits have a greater level of urgency, they have longer stays in the emergency department, they are more likely to be admitted or to have repeat ED visits, and they experience higher rates of adverse health outcomes after discharge. The risk factors commonly associated with the negative outcomes are age, functional impairment, recent hospitalization or ED use, living alone, and lack of social support. Comprehensive geriatric screening and coordinated discharge planning initiatives designed to improve clinical outcomes in older emergency patients have provided inconclusive results. CONCLUSION Older ED patients have distinct patterns of service use and care needs. The current disease-oriented and episodic models of emergency care do not adequately respond to the complex care needs of frail older patients. More research is needed to determine the effectiveness of screening and intervention strategies targeting at-risk older ED patients.
Collapse
Affiliation(s)
- Faranak Aminzadeh
- Regional Geriatric Assessment Program of Ottawa Carleton, Geriatric Outreach Team, Nepean, Ontario, Canada.
| | | |
Collapse
|
43
|
McCusker J, Verdon J, Tousignant P, de Courval LP, Dendukuri N, Belzile E. Rapid emergency department intervention for older people reduces risk of functional decline: results of a multicenter randomized trial. J Am Geriatr Soc 2001; 49:1272-81. [PMID: 11890484 DOI: 10.1046/j.1532-5415.2001.49254.x] [Citation(s) in RCA: 179] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To determine the effectiveness of a two-stage (screening and nursing assessment) intervention for older patients in the emergency department (ED) who are at increased risk of functional decline and other adverse outcomes. DESIGN Controlled trial, randomized by day of ED visit, with follow-up at 1 and 4 months. SETTING Four university-affiliated hospitals in Montreal. PARTICIPANTS Patients age 65 and older expected to be released from the ED to the community with a score of 2 or more on the Identification of Seniors At Risk (ISAR) screening tool and their primary family caregivers. One hundred seventy-eight were randomized to the intervention, 210 to usual care. INTERVENTION The intervention consisted of disclosure of results of the ISAR screen, a brief standardized nursing assessment in the ED, notification of the primary care physician and home care providers, and other referrals as needed. The control group received usual care, without disclosure of the screening result. MEASUREMENTS Patient outcomes assessed at 4 months after enrollment included functional decline (increased dependence on the Older American Resources and Services activities of daily living scale or death) and depressive symptoms (as assessed by the short Geriatric Depression Scale). Caregiver outcomes, also assessed at baseline and 4 months, included the physical and mental summary scales of the Medical Outcomes Study Short Form-36. Patient and caregiver satisfaction with care were assessed 1 month after enrollment. RESULTS The intervention increased the rate of referral to the primary care physician and to home care services. The intervention was associated with a significantly reduced rate of functional decline at 4 months, in both unadjusted (odds ratio (OR) = 0.60, 95% confidence interval (CI) = 0.36-0.99) and adjusted (OR = 0.53, 95% CI = 0.31-0.91) analyses. There was no intervention effect on patient depressive symptoms, caregiver outcomes, or satisfaction with care. CONCLUSION A two-stage ED intervention, consisting of screening with the ISAR tool followed by a brief, standardized nursing assessment and referral to primary and home care services, significantly reduced the rate of subsequent functional decline.
Collapse
Affiliation(s)
- J McCusker
- Department of Clinical Epidemiology and Community Studies, St. Mary's Hospital, Montreal, Quebec, Canada
| | | | | | | | | | | |
Collapse
|
44
|
Mion LC, Palmer RM, Anetzberger GJ, Meldon SW. Establishing a case-finding and referral system for at-risk older individuals in the emergency department setting: the SIGNET model. J Am Geriatr Soc 2001; 49:1379-86. [PMID: 11890500 DOI: 10.1046/j.1532-5415.2001.49270.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Older emergency department (ED) patients have complex medical, social, and physical problems. We established a program at four ED sites to improve case finding of at-risk older adults and provide comprehensive assessment in the ED setting with formal linkage to community agencies. The objectives of the program are to (1) improve case finding of at-risk older ED patients, (2) improve care planning and referral for those returning home, and (3) create a coordinated network of existing medical and community services. The four sites are a 1,000-bed teaching center, a 700-bed county teaching hospital, a 400-bed community hospital, and a health maintenance organization (HMO) ED site. Ten community agencies also participated in the study: four agencies associated with the hospital/HMO sites, two nonprofit private agencies, and four public agencies. Case finding is done using a simple screening assessment completed by the primary or triage nurse. A geriatric clinical nurse specialist (GCNS) further assesses those considered at risk. Patients with unmet medical, social, or health needs are referred to their primary physicians or to outpatient geriatric evaluation and management centers and to community agencies. After 18 months, the program has been successfully implemented at all four sites. Primary nurses screened over 70% (n = 28,437) of all older ED patients, GCNSs conducted 3,757 comprehensive assessments, participating agency referrals increased sixfold, and few patients refused the GCNS assessment or subsequent referral services. Thus, case finding and community linkage programs for at-risk older adults are feasible in the ED setting.
Collapse
Affiliation(s)
- L C Mion
- Division of Nursing, Cleveland Clinic Foundation, Ohio 44195, USA
| | | | | | | |
Collapse
|
45
|
Nerney MP, Chin MH, Jin L, Karrison TG, Walter J, Mulliken R, Miller A, Hayley DC, Friedmann PD. Factors associated with older patients' satisfaction with care in an inner-city emergency department. Ann Emerg Med 2001; 38:140-5. [PMID: 11468608 DOI: 10.1067/mem.2001.114304] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVES We sought to assess older patients' satisfaction with care in the emergency department and to identify factors associated with global satisfaction with care. METHODS We performed a prospective cohort study of 778 patients 65 years of age and older presenting to an urban academic ED between 1995 and 1996, of whom 79% were black and 63% were female. A baseline survey at presentation to the ED asked for demographic information, medical history, and health-related quality of life information. A follow-up satisfaction survey asked patients to rate the care they received in the ED on a 5-point Likert scale (1=excellent, 5=poor). Overall satisfaction with care, dichotomized into responses of "excellent" versus all others, was the primary dependent variable in our bivariate analyses. RESULTS Of respondents, 40% rated their ED care as "excellent." Variables significantly correlated with high satisfaction include having the perception of time spent in the ED as not "too long," having the emergency physicians and nurses clearly answer patients' questions, having a relationship of trust with an ED staff member, being told why tests were done, feeling involved in decisions about care as much as they wanted, having pain addressed fully, having a perception of greater health status, and having fewer comorbid conditions at the time of the ED visit. Results may be applicable only to urban academic EDs and may be limited by time elapsed between ED visits and follow-up surveys. CONCLUSION To improve quality of care for older adults in the ED, physicians should be more attentive to older patients' concerns and questions, recognize and aggressively treat pain, and reduce the patients' perception of a long waiting time.
Collapse
Affiliation(s)
- M P Nerney
- Section of General Internal Medicine, Department of Health Studies, University of Chicago, 5841 South Maryland Avenue, Chicago, IL, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
46
|
McCusker J, Bellavance F, Cardin S, Belzile E, Verdon J. Prediction of hospital utilization among elderly patients during the 6 months after an emergency department visit. Ann Emerg Med 2000; 36:438-45. [PMID: 11054196 DOI: 10.1067/mem.2000.110822] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE A simple screening tool, Identification of Seniors at Risk (ISAR), developed for administration in the emergency department for patients 65 years and older, predicts adverse health outcomes during the 6 months after the ED visit. In this study, we investigated whether the ISAR tool can also predict acute care hospital utilization in the same population. METHODS Patients 65 years and older who visited the EDs of 4 acute care Montreal hospitals during the weekday shift over a 3-month period were enrolled. At the initial (index) ED visit, 27 self-report screening questions (including the 6 ISAR items) were administered. The number of acute care hospital days during the 6 months after the index visit were abstracted from the provincial hospital discharge database. High utilization was defined as the top decile of the distribution of acute care hospital days. RESULTS Among 1,620 patients with linked data, a score of 2+ on the ISAR tool predicted high hospital utilization with a sensitivity of 73% and a specificity of 51%; the area under the receiver operating characteristic curve was 0.68. The ISAR tool also performed well in subgroups defined by disposition (admitted versus discharged) and by age (65 to 74 years versus 75 years and older). CONCLUSION The ISAR tool, a 6-item self-report questionnaire, can be used in the ED to identify elderly patients who will experience high acute care hospital utilization as well as adverse health outcomes.
Collapse
Affiliation(s)
- J McCusker
- Department of Clinical Epidemiology and Community Studies, St. Mary's Hospital, Montreal,Quebec, Canada.
| | | | | | | | | |
Collapse
|
47
|
Affiliation(s)
- K S Hayes
- Wichita State University, Wichita, Kans., USA.
| |
Collapse
|
48
|
Jones JS, Young MS, LaFleur RA, Brown MD. Effectiveness of an Organized Follow-up System for Elder Patients Released from the Emergency Department. Acad Emerg Med 2000. [DOI: 10.1111/j.1553-2712.2000.tb03847.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
49
|
McCusker J, Bellavance F, Cardin S, Trépanier S, Verdon J, Ardman O. Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool. J Am Geriatr Soc 1999; 47:1229-37. [PMID: 10522957 DOI: 10.1111/j.1532-5415.1999.tb05204.x] [Citation(s) in RCA: 397] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To develop a self-report screening tool to identify older people in the emergency department (ED) of a hospital at increased risk of adverse health outcomes, including: death, admission to a nursing home or long-term hospitalization, or a clinically significant decrease in functional status. DESIGN Prospective (6-month) follow-up study of a cohort of ED patients aged 65 and older. SETTING The EDs of four acute-care hospitals in Montreal, Quebec, Canada. PARTICIPANTS Community-dwelling patients aged 65 and older who came to the EDs during the weekday shift over a 3-month recruitment period. Patients were excluded if they could not be interviewed either because of their medical condition or because of cognitive impairment and no other informant was available. MEASUREMENTS Measures ascertained at the ED visit included: 27 self-report screening questions on social, physical, and mental risk factors; medical history; use of hospital services, medications, and alcohol; and the Older American Resources and Services (OARS) activities of daily living (ADL) scale. At follow-up, the OARS scale was readministered by telephone, and other adverse health outcomes were ascertained. RESULTS Among 1673 patients who completed the follow-up measures, 488 (29.2%) had an adverse health outcome. Scale development and selection methods included logistic regression, receiver operating characteristic curves, and expert judgment. The proposed screening tool (ISAR) comprises six self-report questions on functional dependence (premorbid and acute change), recent hospitalization, impaired memory and vision, and polymedication. The tool performed well in the total cohort aged 65 and older, and in sub-groups defined by disposition (admitted or released from ED), language of questionnaire administration (French or English), information source (patient or other), and other characteristics. CONCLUSIONS The ISAR is a short self-report questionnaire that can quickly identify older patients in the ED at increased risk of several adverse health outcomes and those with current disability.
Collapse
Affiliation(s)
- J McCusker
- Department of Clinical Epidemiology and Community Studies, St. Mary's Hospital, McGill University, Montreal, Quebec, Canada
| | | | | | | | | | | |
Collapse
|
50
|
Hayes KS. Adding medications in the emergency department: effect on knowledge of medications in older adults. J Emerg Nurs 1999; 25:178-82. [PMID: 10346838 DOI: 10.1016/s0099-1767(99)70201-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Older adults constitute 20% of the ED population. Of older patients discharged from the emergency department, 40% receive at least one new medication to add to their already complex medication regimen. The purpose of this study was to determine the effect of increasing medication complexity on knowledge of newly prescribed medications for older adults discharged from the emergency department. METHODS The complexity of self-administered medications after ED treatment was measured with the Medication Complexity Index to determine its potential influence on the patient's knowledge of medication. The Knowledge of Medication Subtest, a measure of the effectiveness of medication teaching, was administered by telephone interview 48 to 72 hours after ED discharge. RESULTS Sixty rural ED patients ranging in age from 60 to 98 years completed the study. Higher medication complexity after the addition of medications in the emergency department was associated with less knowledge of their medications (r = 0.37, P =. 004). DISCUSSION The increase in medication complexity that results from ED therapeutic intervention may decrease knowledge of medications. A heightened emphasis should be placed on effective medication teaching, counseling, and follow-up for older adult ED patients.
Collapse
Affiliation(s)
- K S Hayes
- Wichita State University, Kansas, USA
| |
Collapse
|