Geriatric support in the emergency department: a national survey in Belgium

Optimizing older patient care in emergency departments: a comprehensive survey of current practices and challenges in Northern Italy

BACKGROUND

The progressive aging of the population and the increasing complexity of health issues contribute to a growing number of older individuals seeking emergency care. This study aims to assess the state of the art of care provided to older people in the Emergency Departments of Lombardy, the most populous region in Italy, counting over 2 million people aged 65 years and older.

METHODS

An online cross-sectional survey was developed and disseminated among emergency medicine physicians and physicians affiliated to the Lombardy section of the Italian Society of Geriatrics and Gerontology (SIGG), during June and July 2023. The questionnaire covered hospital profiles, geriatric consultation practices, risk assessment tools, discharge processes and perspectives on geriatric emergency care.

RESULTS

In this mixed method research, 219 structured interviews were collected. The majority of physicians were employed in hospitals, with 54.7% being geriatricians. Critical gaps in older patient's care were identified, including the absence of dedicated care pathways, insufficient awareness of screening tools, and a need for enhanced professional training.

CONCLUSIONS

Tailored protocols and geriatric educational programs are crucial for improving the quality of emergency care provided to older individuals. These measures might also help relieve the burden on the Emergency Departments, thereby potentially enhancing overall efficiency and ensuring better outcomes.

A survey on the availability of geriatric-friendly protocols, equipment and physical environment across emergency departments in Flanders, Belgium

BACKGROUND

The acquisition of geriatric-friendly resources is an important part of adapting emergency department (ED) care to the needs of vulnerable older patients. The aim of this study was to explore the availability of geriatric-friendly protocols, equipment and physical environment criteria in EDs and to identify related improvement opportunities.

METHODS

The head nurse of 63 EDs in Flanders and Brussels Capital Region was invited to complete a survey in collaboration with the chief physician of the ED. The questionnaire was inspired by the American College of Emergency Physicians Geriatric ED Accreditation Program and explored the availability, relevance and feasibility of geriatric-friendly protocols, equipment and physical environment. Descriptive analyses were performed. A region-wide improvement opportunity was defined as a resource that was never to occasionally (0-50%) available on Flemish EDs and was scored (rather or very) relevant by at least 75% of respondents.

RESULTS

A total of 32 questionnaires were analysed. The response rate was 50.8%. All surveyed resources were available in at least one ED. Eighteen out of 52 resources (34.6%) were available in more than half of EDs. Ten region-wide improvement opportunities were identified. These comprised seven protocols and three physical environment characteristics: 1) a geriatric approach initiated from physical triage, 2) elder abuse, 3) discharge to residential facility, 4) frequent geriatric pathologies, 5) access to geriatric specific follow-up clinics, 6) medication reconciliation, 7) minimising 'nihil per os' designation, 8) a large-face, analogue clock in each patient room, 9) raised toilet seats and 10) non-slip floors.

CONCLUSIONS

Currently available resources supporting optimal ED care for older patients in Flanders are very heterogeneous. Researchers, clinicians and policy makers need to define which geriatric-friendly protocols, equipment and physical environment criteria should become region-wide minimum operational standards. Findings of this study are relevant to facilitate the development process of this endeavour.

Models of comprehensive care for older persons with chronic diseases: a systematic review with a focus on effectiveness

INTRODUCTION

Ageing entails a variety of physiological changes that increase the risk of chronic non-communicable diseases. The prevalence of these diseases leads to an increase in the use of health services. The care models implemented by health systems should provide comprehensive long-term healthcare. We conducted this systematic review to determine whether any model of care for older persons have proven to be effective.

METHODS

A systematic review of literature was carried out to identify randomised clinical trials that have assessed how effective a care model for older patients with chronic diseases. A searches electronic databases such as MEDLINE, Turning Research Into Practice Database, Cochrane Library and Cochrane Central Register of controlled Trials was conducted from January 1966 to January 2021. Two independent reviewers assessed the eligibility of the studies. Interventions were identified and classified according to the taxonomies developed by the Cochrane Effective Practice and Organisation of Care and Cochrane Consumers and Communication groups.

RESULTS

Of the 4952 bibliographic references that were screened, 577 were potentially eligible and the final sample included 25 studies that evaluated healthcare models in older people with chronic diseases. In the 25 care models, the most frequently implemented interventions were educational, and those based on the provision of healthcare. Only 22% of the outcomes of interventions were identified as being effective, whereas 21% were identified as being partially effective; thus, more than 50% of the outcomes were identified as being ineffective.

CONCLUSIONS

It was not possible to determine a care model as effective. The interventions implemented in the models are variable. The most effective outcomes were focused on improving the patient-healthcare professional relationship in the early stages of the intervention. The interventions addressed in the studies were similar to public health interventions as their main objectives focused on promoting health. Most studies were of low methodological quality.

Optimizing pharmacotherapy on geriatric hospital units in Belgium - a national survey

OBJECTIVE

Inappropriate prescribing remains highly prevalent on geriatric units. The aim of this investigation, initiated by the Belgian College for Geriatrics, was to evaluate the implementation of strategies to optimize pharmacotherapy on geriatric units in Belgium.

METHODS

A literature search was performed to identify strategies to support the appropriate use of medications in very old inpatients. These strategies were subsequently validated based on Delphi consensus rounds and a national survey was developed. Experts were selected by the research team in collaboration with the Belgian College for Geriatrics. The survey was sent to the heads of the geriatric departments of all Belgian hospitals (n = 100).

RESULTS

After 3 months a response rate of 55% was achieved. Strategies that were implemented more frequently were the use of electronic prescribing (85%), performing a structured medication review (69%) and providing patient education (76%). In a minority (24%) of hospitals, a clinical pharmacist was directly involved in the multidisciplinary geriatric team. Implementation of clinical decisions support systems (CDSS) was reported by 36% of the hospitals. Educational strategies for healthcare professionals and strategies to optimize transitional care were variable.

CONCLUSION

Taking into account the current body of evidence, strategies that include transitional care components, CDSS or ward-based clinical pharmacy services should be further promoted on Belgian geriatric units.

Opportunities for Using Health Information Technology for Elderly Care in the Emergency Departments: A Qualitative Study

INTRODUCTION

Recently, several technologies have been developed for being used in the field of geriatric emergency medicine. As a large number of elderly patients visit emergency departments, the use of health information technology in this department can help to improve patient care and control the outcome of diseases. The present study aimed to identify opportunities for using various health information technologies for elderly care in the emergency department.

METHODS

This qualitative study was conducted in 2020. The participants included geriatricians, geriatric nurses, emergency medicine specialists, and nurses who worked in the emergency department. In total, 33 semi-structured interviews were conducted, and data were analyzed by using framework analysis method and MAXQDA software.

RESULTS

The findings of the qualitative study included four main themes, nine subthemes, and 20 categories. The main themes were the common process of elderly care in the emergency departments, data required for elderly care in the emergency departments, the elderly treatment team, and current information technologies used in the emergency departments for elderly care. Overall, the results showed that there was no specific workflow for elderly care in the emergency departments; the great workload of this department prevents the clinicians to conduct cognitive and functional assessments; geriatricians were not involved in the care process; and none of the current information systems were designed specifically for elderly patients. It seems that using specific heath information technology for elderly care in the emergency department can help to overcome current challenges.

CONCLUSION

Identifying opportunities for using health information technologies for geriatric patients in the emergency department can lead to better use of financial, physical, and human resources, and improve staff performance. These systems can be designed and used for different purposes such as reducing work load, readmissions, and hospitalization. Improving access to data and better collaboration between different specialties are other benefits of using these systems. However, more research is required to evaluate the effectiveness of technology in this area.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Factors to improve quality for older patients in the emergency department: a qualitative study of patient trajectory

BACKGROUND

Managing older people in the emergency department remains a challenge. We aimed to identify the factors influencing the care quality of older patients in the emergency department, to fine-tune future interventions for older people, considering the naturalistic context of the ED.

METHODS

This is a qualitative study of some 450 h of observations performed in three emergency departments selected for their diverse contexts. We performed seventy observations of older patient trajectories admitted to the emergency department. Themes were extracted from the material using an inductive reasoning approach, to highlight factors positively or negatively influencing management of patient's trajectories, in particular those presenting with typically geriatric syndromes.

RESULTS

Four themes were developed: no geriatric flow routine; risk of discontinuity of care; unmet basic needs and patient-centered care; complex older patients are unwelcome in EDs.

CONCLUSIONS

The overall process of care was based on an organ- and flow-centered paradigm, which ignored older people's specific needs and exposed them to discontinuity of care. Their basic needs were neglected and, when their management slowed the emergency department flow, older people were perceived as unwelcome. Findings of our study can inform the development of interventions about the influence of context and organizational factors.

Profile of geriatric presentations at the emergency department of a rural district hospital in South Africa

INTRODUCTION

the geriatric population is increasing in South Africa and globally. According to Statistics South Africa (STATSSA), people aged 60 years or older constitute approximately 8.4%-9.3% of the population in the Free State province, South Africa, the majority of which are rural dwellers. Elderly patients constitute a high percentage of patients presenting at the emergency department (ED) and it has been suggested that understanding the pattern of geriatric morbidities presenting at the ED can help prepare the healthcare workers and the healthcare system to confront the challenges of delivering acute geriatric care. In this present study, we compiled the profile of geriatric patients that presented at the ED of Botshabelo district hospital (BDH), Free State province, South Africa, with the aim of formulating evidence-based strategies to improving quality of service and patient outcome.

METHODS

this was a descriptive, retrospective cross-sectional clinical audit of all geriatric cases (≥ 65 years), that presented at the ED of BDH from January 1st 2017, to March 31st 2017.

RESULTS

geriatric cases accounted for 25% of the total adult ED presentation at BDH. The majority (66.6%, n=197) of the patients were female and the mean age at presentation was 75 years. The majority (63.5%) of cases were self-referred and trauma (fracture) was the most frequently diagnosed morbidity. More than half (53.7%) of the cases were classified as priority 2 (P2) and the average waiting time was 86 ± 93 minutes. Less than half of the patients (48.3%; n=143) were admitted for further management, while 36.1% (n=107) of them were discharged from the ED. The remaining 46 cases (15.5%) were referred to a tertiary hospital for further management.

CONCLUSION

it is crucial that healthcare facilities in South Africa recognise the special needs of elderly patients due to the growing aging population. Compiling the profile of geriatric cases presenting at ED can help identify crucial area of need and help prepare the healthcare workers and the healthcare system to confront challenges of delivering acute geriatric care. Findings presented herein will assist in formulating evidence-based strategies to improve geriatric patient outcome at the ED in BDH.

Effects of a geriatric education program for emergency physicians: a mixed-methods study

Emergency physicians (EPs) often regard care for older adults as complex, while they lack sufficient geriatric skills. This study evaluates the effect of a geriatric education program on EPs' geriatric knowledge, attitude and medical practice when treating older adults. A mixed-methods study was performed on EPs from two Dutch hospitals. Effects were measured by pre-post tests of EPs' (n = 21) knowledge of geriatric syndromes and attitudes toward older adults, and by a retrospective pre-post analysis of 100 records of patients aged 70 years or more. Six EPs were purposively sampled and interviewed after completion of the education program. The program significantly improved EPs' geriatric knowledge. EPs indicated that the program improved their ability and attentiveness to recognize frailty and geriatric syndromes. The program also significantly improved EPs' attention for the older patient's social history and circumstances (P = 0.04) but did not have a significant effect on medical decision making. EPs valued especially the case-based teaching and indicated that the interactive setting helped them to better understand and retain knowledge. Combined quantitative and qualitative data suggest that EPs benefit from geriatric emergency teaching. Future enhancement and evaluation of the geriatric education program is needed to confirm benefits to clinical practice and patient outcomes.

Ability of Emergency Department Physicians Using a Functional Autonomy-Assessing Version of the Triage Risk Screening Tool to Detect Frail Older Patients Who Require Mobile Geriatric Team Consultation

OBJECTIVES

Frailty in older people associates with poor outcomes. Screening by ED physicians would greatly facilitate detection of frail older patients but our previous attempt to introduce routine ED-physician screening with Short Emergency Geriatric Assessment (SEGA), a 13-item frailty tool that French geriatricians use to identify frail patients, failed due to its length and complexity. A national committee recently generated a new version of the fast and simple 5-item Triage Risk Screening Tool (TRST) in which a subjective item ('nurse concern') was replaced by an item assessing basic activities of daily living. The ability of ED physicians using this French-TRST to accurately detect frail patients who require comprehensive geriatric assessment was assessed.

DESIGN

Prospective cross-sectional study on diagnostic accuracy relative to the gold standard, namely, geriatrician-administered SEGA.

SETTING

Tertiary-care hospital, France.

SUBJECTS AND MEASUREMENTS

The participants were 498 ≥75-year-old patients who visited the ED in 2018-2019 and were administered French-TRSTs by first ED physicians and then geriatricians, followed by SEGA, all within 24 hours. Diagnostic accuracy variables were calculated. Geriatrician-TRST was used to identify TRST items that associated with ED physician misclassification of frail patients.

RESULTS

Emergency-TRST was significantly less sensitive than Geriatrician-TRST (88% vs. 93%; p=0.04) and tended to have lower negative predictive value (66% vs. 77%; p=0.09). Emergency-TRSTs rated four French-TRST items less well than Geriatrician-TRSTs.

CONCLUSIONS

As a substitute for SEGA in the ED, the French-TRST performed quite well overall but the ED physicians detected frail patients less well than the geriatricians. Modifications of the French-TRST that may improve the diagnostic performance of ED physicians are discussed.

Comparison of Frailty Screening Instruments in the Emergency Department

Early identification of frailty through targeted screening can facilitate the delivery of comprehensive geriatric assessment (CGA) and may improve outcomes for older inpatients. As several instruments are available, we aimed to investigate which is the most accurate and reliable in the Emergency Department (ED). We compared the ability of three validated, short, frailty screening instruments to identify frailty in a large University Hospital ED. Consecutive patients aged ≥70 attending ED were screened using the Clinical Frailty Scale (CFS), Identification of Seniors at Risk Tool (ISAR), and the Programme on Research for Integrating Services for the Maintenance of Autonomy 7 item questionnaire (PRISMA-7). An independent CGA using a battery of assessments determined each patient’s frailty status. Of the 280 patients screened, complete data were available for 265, with a median age of 79 (interquartile ±9); 54% were female. The median CFS score was 4/9 (±2), ISAR 3/6 (±2), and PRISMA-7 was 3/7 (±3). Based upon the CGA, 58% were frail and the most accurate instrument for separating frail from non-frail was the PRISMA-7 (AUC 0.88; 95% CI:0.83–0.93) followed by the CFS (AUC 0.83; 95% CI:0.77–0.88), and the ISAR (AUC 0.78; 95% CI:0.71–0.84). The PRISMA-7 was statistically significantly more accurate than the ISAR (p = 0.008) but not the CFS (p = 0.15). Screening for frailty in the ED with a selection of short screening instruments, but particularly the PRISMA-7, is reliable and accurate.

Unplanned Readmission prevention by Geriatric Emergency Network for Transitional care (URGENT): protocol of a prospective single centre quasi-experimental study

BACKGROUND

International guidelines recommend adapting the classic emergency department (ED) management model to the needs of older adults in order to ameliorate post-ED outcomes among this vulnerable group. To improve the care for older ED patients and especially prevent unplanned ED readmissions, the URGENT care model was developed.

METHODS

The URGENT care model is a nurse-led, comprehensive geriatric assessment based care model in the ED with geriatric follow-up after ED discharge. A prospective single centre quasi-experimental study (sequential design with two cohorts) is used to evaluate its effectiveness on unplanned ED readmission compared to usual ED care. Secondary outcome measures are hospitalization rate, ED length of stay, in-hospital length of stay, higher level of care, functional decline and mortality.

DISCUSSION

URGENT builds on previous research with adaptations tailored to the local context and addresses the needs of older patients in the ED with a special focus on transition of care. Although the selected approaches have been tested in other settings, evidence on this type of innovative care models in the ED setting is inconclusive.

TRIAL REGISTRATION

The study protocol is registered retrospectively with ISRCTN ( ISRCTN91449949 ).