Functional Assessment of Older Adults in an Emergency Department

Strategies to improve care for older adults who present to the emergency department: a systematic review

BACKGROUND

The aim of this systematic review was to examine the relationship between strategies to improve care delivery for older adults in ED and evaluation measures of patient outcomes, patient experience, staff experience, and system performance.

METHODS

A systematic review of English language studies published since inception to December 2022, available from CINAHL, Embase, Medline, and Scopus was conducted. Studies were reviewed by pairs of independent reviewers and included if they met the following criteria: participant mean age of ≥ 65 years; ED setting or directly influenced provision of care in the ED; reported on improvement interventions and strategies; reported patient outcomes, patient experience, staff experience, or system performance. The methodological quality of the studies was assessed by pairs of independent reviewers using The Joanna Briggs Institute critical appraisal tools. Data were synthesised using a hermeneutic approach.

RESULTS

Seventy-six studies were included in the review, incorporating strategies for comprehensive assessment and multi-faceted care (n = 32), targeted care such as management of falls risk, functional decline, or pain management (n = 27), medication safety (n = 5), and trauma care (n = 12). We found a misalignment between comprehensive care delivered in ED for older adults and ED performance measures oriented to rapid assessment and referral. Eight (10.4%) studies reported patient experience and five (6.5%) reported staff experience.

CONCLUSION

It is crucial that future strategies to improve care delivery in ED align the needs of older adults with the purpose of the ED system to ensure sustainable improvement effort and critical functioning of the ED as an interdependent component of the health system. Staff and patient input at the design stage may advance prioritisation of higher-impact interventions aligned with the pace of change and illuminate experience measures. More consistent reporting of interventions would inform important contextual factors and allow for replication.

Process quality indicators for musculoskeletal injuries in the emergency department

OBJECTIVES

Measuring quality of care for musculoskeletal injuries presenting to the ED is important given their prevalence, variations in care, the associated morbidity and financial impacts and pressure to achieve time-based performance measures. Process quality indicators (QIs) provide a quantitative method to measure the actions taken during healthcare delivery. This study aimed to develop a set of process QIs to measure the quality of care for musculoskeletal injuries in the ED.

METHODS

A multiphase mixed-methods study was undertaken from 2015 to 2018, commencing with a systematic review to identify existing musculoskeletal QIs. This review, along with current evidence regarding musculoskeletal injury management in the ED, informed an expert panel who developed a preliminary set of process QIs. The preliminary set was field tested at eight EDs in Queensland, Australia, to determine the validity, reliability, feasibility and usefulness of each QI. Prospective observational data collection and retrospective chart audits were used to score the process QIs. These results were presented to the expert panel who determined a final QI set.

RESULTS

A total of 633 patients were recruited and 36 process QIs included in the final set. The QIs covered important domains of pain assessment and management, history taking and physical examination, appropriateness and timeliness of imaging, fracture management, mobility, patient information and discharge considerations including safety and referrals. The best performing QIs included the use of opioid sparing analgesics and avoiding prescription of 'just in case' opioids at discharge. The poorest performing QIs included the completion of spinal red flag questioning and referrals for fragility fractures.

CONCLUSION

An evidence and best practice-based set of QIs has been developed to allow EDs to assess and quantify the quality of care for musculoskeletal presentations. This will allow EDs to compare and benchmark, leading to the optimisation of care for patients.

Mobility assessments of geriatric emergency department patients: A systematic review

Objectives

We wished to determine the impact of emergency department (ED) mobility assessments for older patients on hospitalization, return visits, future falls, and frailty.

Methods

We searched MEDLINE, Embase, CINAHL, Cochrane Library, PEDro, and OTseeker (September 2016). Two independent reviewers identified studies of patients ≥65 years with ED physical mobility assessments and outcomes of hospitalization, return to ED, falls, and frailty. Language was not restricted. Only clinical trials and observational studies were included.

Results

We identified 1,365 unique citations. Nine studies (six cohort and three cross-sectional) met full inclusion criteria. Patients (n=2,513) with mean age 75-85 years, admitted to hospital and discharged, underwent these ED evaluations: Timed Up and Go (TUG), Get Up and Go, tandem walk, and a gait assessment. Study quality was moderate to poor. Tandem walk did not predict falls at 90 days. TUG was not associated with return to the ED/hospitalization at 90 days. Get Up and Go was associated with hospital admission but not return to ED visits at 1 or 3 months. Due to clinical heterogeneity in study populations and outcomes, a meta-analysis was not undertaken.

Conclusions

Despite multiple guidelines recommending a mobility assessment prior to ED discharge for older patients, we found that such assessments were neither associated with nor predictive of adverse outcomes. Robust research is required to guide clinicians on the utility of physical mobility assessments in older ED patients.

Can consultant geriatrician led comprehensive geriatric assessment in the emergency department reduce hospital admission rates? A systematic review

Objective

economic and demographic pressures are driving a need to reassess the way in which we care for older patients presenting to emergency departments (EDs). This systematic review seeks to assess the extent to which performing comprehensive geriatric assessment (CGA) in the ED can reduce admission rates.

Design

systematic search of both published and unpublished literature to identify studies reporting admission rates following the introduction of consultant geriatrician led teams performing CGA in the ED. Changes in inpatient length of stay and subsequent readmission rates were identified as secondary outcome measures.

Results

five studies with a total of 28,434 participants were included. All of the studies reported statistically significant reductions in admission rates (ranging between 2.6 and 19.7%). However, variation in the degree of changes leads to uncertainty as to the financial viability of the intervention. No studies have yet examined the clinical effects of performing CGA within the ED. The results were far more varied with regards to inpatient length of stay and readmission rates, indicating that complex local factors, such as the design of community support services, may play an important role.

Conclusion

consultant geriatrician led teams performing CGA within the ED can reduce admissions rates among older patients. It is unclear as to what impact such interventions have upon readmission rates or inpatient length of stay. Future research is needed to assess the clinical outcomes and financial viability of such admissions avoidance teams.

PROSPERO registration number

CRD42016038840.

Timed Up and Go predicts functional decline in older patients presenting to the emergency department following minor trauma†

Background

there is no standardised test for assessing mobility in the Emergency Department (ED).

Objective

we wished to evaluate the relationship between the Timed Up and Go (TUG) and frailty, functional decline and falls in community dwelling elders that present to the ED following minor trauma.

Methods

this was a secondary analysis of a prospective cohort study conducted at eight Canadian hospitals. Evaluations included: TUG; Study of Osteoporotic Fractures Frailty Index; Older American Resources and Service Functional Scale; and self-reported falls. Of note, 3- and 6-month follow-up was conducted. Generalised linear model with log-binomial distribution was utilised. Relative risks (RR) and 95% CI were calculated.

Results

TUG scores were available for 911/2918 patients, mean age 76.2 (SD 7.8) and 57.9% female. There was an association between TUG scores and frailty (P < 0.05) and functional decline at 3 (P < 0.05) and 6 (P < 0.05) months but not self-reported falls. For TUG scores 10-19 seconds, 20-29 seconds and ≥30 seconds, respectively: (i) frailty RR (95% CI): 1.8 (1.3-2.4), 3.0 (2.2-4.2) and 3.7 (2.6-5.1); (ii) functional decline RR (95% CI): 2.7 (1.1-6.4), 5.5 (2.1-14.3) and 8.9 (3.0-25.8); (iii) falls RR (95% CI): 0.9 (0.5-1.5), 1.3 (0.6-2.5) and 1.1 (0.4-3.5).

Conclusion

in community dwelling elders presenting to the ED following minor trauma, TUG scores were associated with frailty and strongly associated with functional decline at 3 and 6 months post injury. TUG scores were not associated with self-reported falls. Use of the TUG in the ED will help identify frail patients at risk of functional decline.

National survey of family physicians to define functional decline in elderly patients with minor trauma

Background

Failing to assess elderly patients for functional decline at the time around a minor injury may result in adverse health outcomes. This study was conducted to define what constitutes clinically significant functional decline and the sensitivity required for a clinical decision instrument to identify such functional decline after an injury in previously independent elderly patients.

Methods

After a thorough development process, a survey questionnaire was administered to a random sample of 178 family physicians. The surveys were distributed using a modified Dillman technique.

Results

From 143 eligible surveys, we received 67 completed surveys (response rate, 46.9 %). Respondents indicated that a drop of at least 3 points on the 28-point Older Americans Resources and Services (OARS) ADL Scale was considered clinically significant by 90 % of physicians. Ninety percent (90 %) of physicians would be satisfied with a sensitivity of 90 % or more for a clinical decision instrument to detect patients at risk of functional decline at 6 months following an injury. The majority of family physicians do not routinely assess the majority of the tasks on the OARS scale for injured elderly patients.

Conclusions

A high proportion of physicians (90 %) would consider a drop of 3 points on the OARS ADL Scale as significant to define functional decline and would be satisfied with a sensitivity of 90 % for a clinical decision instrument to detect such a decline. Any instrument to identify patients at elevated risk for subsequent decline should consider these outcome measures to be clinically useful.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0520-1) contains supplementary material, which is available to authorized users.

Management of Patients Aged ≥85 Years With ST-Elevation Myocardial Infarction

Guidelines mandate urgent revascularization in patients presenting with ST-elevation myocardial infarction (STEMI) irrespective of age. Whether this strategy is optimal in patients aged ≥85 years remains uncertain. We aimed to assess the clinical characteristics and outcomes of patients aged ≥85 years with STEMI stratified by their management strategy. We analyzed baseline clinical characteristics of 101 consecutive patients aged ≥85 years who presented with STEMI to a tertiary Australian hospital. Patients were stratified based on whether they underwent invasive management with urgent coronary angiography ± percutaneous coronary intervention or conservative management. Our primary outcome was long-term mortality. Independent predictors of conservative management and long-term mortality were assessed by multivariate logistic regression and Cox proportional hazard modeling respectively. Of the 101 patients included, 45 underwent invasive management. Independent predictors of having conservative management were older age, anterior STEMI, and cognitive impairment (all p <0.01). Patients managed invasively had lower in-hospital (13.3% vs 32.1%, p = 0.03), 30-day (13.3% vs 37.5%, p <0.01), 12-month (22.2% vs 57.1%, p <0.01), and long-term (40.0% vs 75.0%, p <0.01) mortality. Invasive management was an independent predictor of lower long-term mortality (hazard ratio 0.29, 95% CI 0.11 to 0.76, p <0.01). In conclusion, patients aged ≥85 years with STEMI who were older, had cognitive impairment or presented with anterior ST-elevation were more likely to be managed conservatively. Those who underwent invasive management had reasonable short- and long-term outcomes.

Description de la pratique des ergothérapeutes du Québec en salle d'urgence

Introduction. Les ergothérapeutes interviennent à l'urgence, mais on ne connaît pas l'ampleur et la nature de cette pratique. Objectif. Décrire la pratique professionnelle des ergothérapeutes du Québec à l'urgence. Méthodologie. Questionnaire postal aux membres de l'Ordre des ergothérapeutes du Québec portant sur le contexte général de pratique, la nature des interventions, les outils d'évaluation, les modèles de pratique et la satisfaction au travail à l'urgence. Résultats. Les ergothérapeutes oeuvrant à l'urgence pratiquent dans plusieurs régions socio-administratives du Québec depuis un maximum de 11 ans. Ils consacrent plus de 90% du temps à la clientèle âgée et sont intégrés à des équipes interdisciplinaires. Ils évaluent diverses sphères du fonctionnement et 75% utilisent des outils maison. Les difficultés rencontrées affectent le deux tiers des répondants qui se disent neutres ou insatisfaits par rapport à cette pratique. Conséquences pour la pratique. Les répondants ont confirmé l'émergence de l'ergothérapie à l'urgence et la nécessité d'être mieux outillé pour faire face aux difficultés rencontrées dans leur pratique.

National Survey of Geriatricians to Define Functional Decline in Elderly People with Minor Trauma

Background

This study was designed to determine a clinically significant point drop in function to define functional decline and the required sensitivity for a clinical decision tool to identify elderly patients at high risk of functional decline following a minor injury.

Methods

After a rigorous development process, a survey questionnaire was administered to a random sample of 178 geriatricians selected from those registered in a national medical directory. The surveys were distributed using a modified Dillman technique.

Results

We obtained a satisfactory response rate of 70.5%. Ninety percent of the geriatricians required a sensitivity of 90% or less for a clinical decision tool to identify injured seniors at high risk of functional decline 6 months post injury. Our results indicate that 90% of the respondents considered a drop in function of at least 2 points in activities of daily living (ADL) as clinically significant when considering all 14 ADL items. Considering only the 7 basic ADL items, 90% of physicians considered a 1 point drop as clinically significant.

Conclusions

A tool with a sensitivity of 90% to detect patients at risk of functional decline at 6 months post minor injury would meet or exceed the sensitivity required by 90% of geriatric specialists. These findings clearly define what is a clinically significant decline following a “minor injury.”

National Survey of Emergency Physicians to Define Functional Decline in Elderly Patients with Minor Trauma

BACKGROUND

There are a number of screening tools to predict return to the emergency department (ED) in elderly trauma patients, but none exist to specifically screen for functional decline after a minor injury. The objective of this study was to identify outcome measures for a possible future clinical decision rule to be used in the ED to identify previously independent patients at high risk of functional decline at six months post minor injury.

METHODS

After a rigorous development process, a survey instrument was administered to a random sample of 178 emergency physicians using the Dillman's Tailored Design Method.

RESULTS

Of 156 eligible surveys, we received 81 completed surveys (response rate 51.9%). Considering all 14 activities of daily living (ADL) items, 90% of physicians deemed a minimal clinically important difference (MCID) in function to be at least three points on the 28-point Older Americans Resources and Services (OARS) ADL Scale as clinically significant. A tool with a sensitivity of 93% to detect patients at risk of functional decline at six months post injury would meet or exceed the sensitivity deemed to be required by 90% of physicians. The majority of emergency physicians do not assess elderly injured patients for the majority of the tasks.

CONCLUSIONS

A drop of three points on the 28-point OARS ADL Scale would be deemed clinically important by the vast majority of emergency physicians. Further, a sensitivity of 93% for a clinical decision tool would satisfy the MCID requirements of the vast majority of emergency physicians. There appears to be a gap between physician knowledge and actual practice. We intend to use these findings in the development of a clinical decision rule to identify high-risk elderly trauma patients.

Caring for depressed elderly in the emergency department: establishing links between sub-acute, primary, and community care

Elderly patients presenting to St. Vincent's Health Emergency Department (ED) constitute approximately one third of presentations. A significant proportion of these involve preexisting conditions including depression that, within elderly patients, is associated with social isolation, physical and mental health problems, and barriers to accessing community services. It is also often overlooked as a clinical diagnosis among the elderly. This study aimed to assess the efficacy of a brief depression screening tool and examine the change over time in quality of life and social factors for elderly patients who present to ED. Patients aged 65 years and over were screened for depression using a short form of the Geriatric Depression Scale (GDS-15). Participants were randomized into control (usual care) and intervention (an assertive outreach community management program) groups and assessed in relation to depression, quality of life, and social support/functioning at recruitment and 6 weeks post discharge. Approximately one in four participants experienced mild to moderate depression that was related to medical factors and associated reduced mobility. This study suggests that an assertive outreach program, with the inclusion of community intervention and links to social supports and services, could improve the management of depression in the elderly and associated health outcomes.

Continuing professional development for occupational therapy emergency department services

AIM

To explore continuing professional development (CPD) resources and needs of Australian emergency department occupational therapists.

METHOD

Australian websites and occupational therapy newsletters were searched to identify CPD resources/opportunities. Occupational therapists with recent clinical experience in Australian emergency departments were surveyed on strengths, weaknesses, opportunities and threats to their service, research information needs, supervision/mentor arrangements and quality assurance activity.

RESULTS

No Australian CPD opportunities were identified; 1.3% of the 2008 OT AUSTRALIA conference topics were emergency department specific. Forty-one Australian hospitals employed a total of 51 occupational therapists of whom 30 responded. Half were supervised by occupational therapists; 20 had occupational therapy mentors; 23 perceived that they were very independent; seven did quality assurance projects; 25 had unmet research needs; 27 thought their service was effective; and service strengths, weaknesses, opportunities and threats to service could be identified by most occupational therapists.

CONCLUSION

Australian occupational therapists in emergency departments need specialised CPD opportunities. The information needs and strengths, weaknesses, opportunities and threats provide a CPD topic planning guide.

Occupational therapy in emergency departments: Australian practice

BACKGROUND

Some emergency departments (EDs) in the UK, North America and Australia have provided occupational therapy (OT) services for over 10 years; however, little is known about practice patterns as previous literature has focussed on single programmes or the generic contribution of allied health multidisciplinary teams to ED throughput and safe discharge.

AIM

To describe practice patterns of OT services in Australian EDs.

METHOD

Of 129 Australian public hospital EDs, 41 were identified to have offered OT services in the past 5 years (32%). Using snowball sampling an investigator designed survey was sent to 51 occupational therapists who were identified to have worked in these EDs in the past 5 years.

FINDINGS

30 subjects (58% response rate) from 21 sites participated. Mean age 30.4, 29 females, one male and an average of 9-year clinical experience. OT service was usually provided within multidisciplinary or interdisciplinary teams by full-time employed staff and patients were overwhelmingly Australian Triage Scale level 4 or 5 and were over 65 years. Few standardized assessment or outcome measures were used. The OT role was consistently focussed on functional assessment and provision of interventions such as equipment prescription, patient education and referral to community and support services to ensure safe discharge or inform inpatient admission decisions.

Evaluation of occupational therapy interventions for elderly patients in Swedish acute care: a pilot study

The aim was to evaluate whether occupational therapy interventions in acute care could improve the elderly patient's perception of ability to manage at home after discharge. A pilot study was performed, including 22 patients in the experimental group and 19 in the control group. Occupational therapy interventions were conducted in the experimental group concerning personal care, information, prescription of assistive devices, planning of discharge, and reporting to primary care or community care. The control group was given no occupational therapy interventions. Structured interviews were performed on discharge and at a follow-up in about 14 weeks after discharge. The two groups were comparable concerning gender, age, days of care, and diagnoses. Patients in the experimental group scored lower on mental health and were more anxious on discharge. However, there was no difference between the groups in managing at home after discharge. Patients in the control group had greater need of further contacts with healthcare after discharge. Due to the small sample interpretations must be made with caution. The findings indicate that occupational therapy interventions in acute care might have a positive effect from the perspective of the elderly patient. These results need to be confirmed in a larger study.

Psychosocial profile of elderly patients discharged from a community hospital

Social workers have historically been an advocate for vulnerable groups. One such vulnerable group is elderly patients who have been shown to have multiple, chronic health problems. The current fiscal environment favors shortened lengths of stay, potentially leaving these vulnerable patients at risk for adverse outcomes upon discharge, especially for those discharged home as opposed to institutional settings. The purpose of the study was to characterize the biopsychosocial risks for adverse outcomes in the elderly patients discharged home from Guelph General Hospital (Ontario, Canada). The objectives were to (1) estimate the number of elderly people who indicate biopsychosocial risk for adverse outcomes, (2) determine the specific risks and their severity, and (3) estimate the number of readmissions to hospital within three months after discharge. Standardized, self-reported scales were used to measure risks in elderly patients at discharge from acute care medical and surgical units. The sample included 62 patients with a mean age of 79 years. At discharge almost 40% of the patients were considered at risk for adverse outcomes, 11% indicated depression, 45% indicated psychological distress, 13% showed cognitive impairment, and 62.5% (35/56) had at least one nutritional concern. Over the three-month follow-up period, there were 23 readmissions, 8 ED visits (not mutually exclusive), and 7 outpatient visits. The mortality rate over the three-month period was 5% (3/62). Many elderly patients who were discharged from hospital to home experienced several challenges medically, psychologically and some also experienced social adversities. The implication is that these patients may benefit from a more comprehensive discharge plan than is currently practiced that addresses their challenges.

Functional assessment of older patients in the emergency department: comparison between standard instruments, medical records and physicians' perceptions

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.

Comprehensive geriatric assessment: making the most of the aging years

The elderly population is the most rapidly growing segment of our population. This group utilizes the highest proportion of medical care of any age group. Comprehensive geriatric assessment involves the evaluation of the physical, psychosocial and environmental factors that impact on the well-being of older individuals. The use of an organized approach with objective measurements helps target key areas of functional status. Important areas include the evaluation of activities of daily living, cognition, mood, social supports, gait and falls, nutrition, sensory impairments, incontinence, polypharmacy, elder abuse, pressure sores, pain, and advance directives. The provision of primary and secondary prevention is also increasingly important for older individuals. The components of a successful geriatric assessment program are outlined, with suggestions to improve compliance.