What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review

"A banana in the tailpipe": a qualitative study of patient flow in the healthcare system

BACKGROUND

Suboptimal patient flow and impaired hospital access can lead to adverse outcomes, including lower care quality, higher mortality risk, and patient dissatisfaction. Despite awareness, optimizing patient flow remains an area requiring further development. This study aimed to comprehensively identify factors hindering patient flow in a large healthcare system and explore potential solutions, using a qualitative approach for context-specific insights.

METHODS

This qualitative study followed COREQ guidelines. We conducted four focus group discussions (FGDs) involving 23 healthcare workers (HCWs) and patients selected through purposive sampling. The data were analysed using the directed content analysis method, ensuring rigor through methods such as credibility, dependability, authenticity, and transferability. The study also mapped qualitative findings to outcomes from our recent umbrella review (UR) to enhance comprehensiveness.

RESULTS

Patient flow challenges were categorized into population (patients and providers), capacity, and process. Population challenges included community-based care, staffing issues, and inequities in access. The capacity challenges involved inefficient resource allocation, resource constraints, and patient volume growth. The process challenges included bed management, modernization struggles, private hospital issues, funding model problems, information sharing gaps, coordination challenges, transition issues, particularly delayed discharges from inpatient wards, and problems in healthcare management and patient communication. The solutions focused on human factors, infrastructure, and management, organization, and policy. FGDs identified new challenges and solutions were not covered in the recent UR.

DISCUSSION

The participants' insights highlight the critical necessity for systemic improvements, which include enhancing infrastructure, communication, and collaboration. These improvements include early identification of discharge barriers, facilitating community discharge, addressing diverse patient needs, optimizing prehospital services, and improving patient communication. Shifting the focus from traditional emergency department processes to a system-wide approach is crucial. The comparative mapping between FGDs and the UR insights into both common and specific challenges and solutions enriches discussions on healthcare reform.

Frailty-aware Care in the Emergency Department

Older adults living with frailty are a growing population that will increasingly present to the emergency department (ED). This is a population that is at increased risk of adverse health outcomes and most EDs are not designed with their needs in mind. Instead of characterizing patients based on chronologic age or existing triage tools, frailty assessment offers an accurate, feasible, and patient-centered approach to improving care, and should be performed in the ED.

Association between chronic respiratory diseases and frailty in Chinese elderly: a population-based longitudinal study

BACKGROUND

Chronic respiratory diseases (CRDs) have been shown to be associated with frailty, but these findings have not yet reached a consensus. The aim of this study was to investigate the association between CRDs and frailty in the elderly using a nationally representative data from China.

METHODS

Data from the China Health and Retirement Longitudinal Study (CHARLS) were analysed, including 3309 frailty-free participants followed for three waves from 2011. Frailty was assessed using the physical frailty phenotype scale, and CRDs were conformed by self-reported physician diagnoses. Cox proportional hazard models were used to examine the association between baseline CRDs and subsequent frailty.

RESULTS

Among participants (mean age 67.07 years, 51.53% male), 497 (15.02%) had CRDs. During a mean follow-up of 46 months, 273 (8.25%) participants developed frailty. The incidence rate of frailty was significantly higher in the CRDs group (37.17% per 1000 person-years vs 18.41% per 1000 person-years, p<0.01). Adjusted for covariables, participants with CRDs had a 44% higher risk of developing frailty (HR = 1.44, 95% CI: 1.08 to 1.91). Specifically, asthma only (HR=1.89, 95% CI: 1.07 to 3.33) and asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) (HR=1.79, 95% CI: 1.19 to 2.69) were associated with a higher risk of frailty among the elderly, while COPD only was not (HR=1.11, 95% CI: 0.73 to 1.65).

CONCLUSION

This study shows a significant association between CRDs, particularly asthma only and ACO, and frailty in the elderly. We need to pay attention to the frailty status of CRDs patients and consider routine screening among them in both clinical practice and community settings. Active treatment and control of CRDs are necessary to avoid frailty caused by primary lung disease progression or exacerbation.

Revisits and frailty in older patients in the emergency department - a prospective observational multicenter study

BACKGROUND

An increased number of revisits may signal that the immediate medical needs of patients seeking care at Emergency Departments (EDs) are not being met. The prevalence and characteristics of revisits to the EDs in Sweden among older patients, and its association to frailty, are unknown. We aimed to investigate the prevalence of ED revisits among patients over 65 years of age, living with or without frailty, and its association with rate of admission, and mortality; in the Swedish ED setting.

METHODS

This was a prospective, multicentre study of patients over 65 years of age with an index visit to one of three Swedish EDs during May-Nov 2021. Frailty was assessed in conjunction with standard triage, using the 9-level Clinical Frailty Scale (CFS) with a CFS score of 5 to 8 as cut-off for identifying frailty. For all patients who made a revisit within 90 days of their index visit, we collected information about the revisit, admission, and mortality.

RESULTS

A total of 1835 patients made an index visit which were included, and out of those, 595 patients made a revisit within 90 days of the index visit. Patients living with frailty (CFS 5 to 8) were more likely to make a revisit to the ED at 8 to 30 days (17% vs. 11%, diff 6%, 95% CI 2-10%, p < 0.001) and at 31 to 90 days (19% vs. 12%, diff 7%, 95% CI 3-10%, p < 0.001) and be admitted to in-hospital care during their revisit (57% vs. 47%, diff 10%, 95% CI, 1-18%, p < 0.05), compared to patients living without frailty. Results also show that patients living with frailty had a higher overall mortality rate (17% vs. 5%, diff 12%, 95% CI 7-18%, p < 0.001). However, among patients living without frailty, making a revisit slightly increased the mortality rate compared to those who did not (5% vs. 2%, diff 3%, 95% CI 1-10%, p < 0.05).

CONCLUSIONS

Patients living with frailty make more revisits, are more often admitted to in-hospital care, and have a higher overall mortality rate than patients not living with frailty. Frailty, assessed with the CFS may be a simple and useful indicator of increased risk of adverse events, including revisits, in the ED.

Scoping review of the effectiveness of 10 high-impact initiatives (HIIs) for recovering urgent and emergency care services

INTRODUCTION

Prolonged ambulance response times and unacceptable emergency department (ED) wait times are significant challenges in urgent and emergency care systems associated with patient harm. This scoping review aimed to evaluate the evidence base for 10 urgent and emergency care high-impact initiatives identified by the National Health Service (NHS) England.

METHODS

A two-stage approach was employed. First, a comprehensive search for reviews (2018-2023) was conducted across PubMed, Epistemonikos and Google Scholar. Additionally, full-text searches using Google Scholar were performed for studies related to the key outcomes. In the absence of sufficient review-level evidence, relevant available primary research studies were identified through targeted MEDLINE and HMIC searches. Relevant reviews and studies were mapped to the 10 high-impact initiatives. Reviewers worked in pairs or singly to identify studies, extract, tabulate and summarise data.

RESULTS

The search yielded 20 771 citations, with 48 reviews meeting the inclusion criteria across 10 sections. In the absence of substantive review-level evidence for the key outcomes, primary research studies were also sought for seven of the 10 initiatives. Evidence for interventions improving ambulance response times was generally scarce. ED wait times were commonly studied using ED length of stay, with some evidence that same day emergency care, acute frailty units, care transfer hubs and some in-patient flow interventions might reduce direct and indirect measures of wait times. Proximal evidence existed for initiatives such as urgent community response, virtual hospitals/hospital at home and inpatient flow interventions (involving flow coordinators), which did not typically evaluate the NHS England outcomes of interest.

CONCLUSIONS

Effective interventions were often only identifiable as components within the NHS England 10 high-impact initiative groupings. The evidence base remains limited, with substantial heterogeneity in urgent and emergency care initiatives, metrics and reporting across different studies and settings. Future research should focus on well-defined interventions while remaining sensitive to local context.

AEGIS-AcutE Geriatric Intervention Study: pilot study of frontline acute geriatric assessment to improve quality of care in emergency department

INTRODUCTION

Due to the increasing number of older patients in emergency departments (EDs) with frailty, cognitive impairment and multimorbidity, there is a need for geriatric expertise in EDs.

METHODS

This retrospective study is of older patients visiting Turku University Hospital ED between 2 January and 31 December 2022. Patients aged 75 years of older were screened for frailty using Triage Risk Screening Tool (TRST) and Clinical Frailty Scale (CFS). Nonacute, frail patients (CFS ≥4) suitable for Targeted Geriatric Assessment (TGA) (n = 1096) were scanned for the risk of delirium, cognitive impairment, change in functional status, falls, malnutrition and depression. A comprehensive patient record was made with recommendations for future care.

RESULTS

TRST was completed in 70% of the ED visits, and two-thirds of those were considered high-risk. Among the patients assessed by the geriatric team (TGA), nonspecific complaint (38%) and falls (35%) were the main reasons for ED admission. Cognitive impairment was present in over 60% and orthostatic hypotension in 40% of the patients. The 72-hour revisit rate for TGA-patients was 2.3%. For the real-life control group, the 72-hour revisit rate was 4.6% (P = .001). Thirty-day revisit rates were 10% and 16%, respectively (P < .001). The need for rehabilitation, cognitive evaluation and intensifying home care were the main recommendations for future care.

CONCLUSIONS

TGA approach provides structured and accurate information on older patients' background. This may lead to more precise diagnostics, a thorough consideration of hospital intake and a secure discharge from the ED. Ensuring continuity of care may help to reduce readmissions to EDs.

Patient flow in emergency departments: a comprehensive umbrella review of solutions and challenges across the health system

BACKGROUND

Globally, emergency departments (EDs) are overcrowded and unable to meet an ever-increasing demand for care. The aim of this study is to comprehensively review and synthesise literature on potential solutions and challenges throughout the entire health system, focusing on ED patient flow.

METHODS

An umbrella review was conducted to comprehensively summarise and synthesise the available evidence from multiple research syntheses. A comprehensive search strategy was employed in four databases alongside government or organisational websites in March 2023. Gray literature and reports were also searched. Quality was assessed using the JBI critical appraisal checklist for systematic reviews and research syntheses. We summarised and classified findings using qualitative synthesis, the Population-Capacity-Process (PCP) model, and the input/throughput/output (I/T/O) model of ED patient flow and synthesised intervention outcomes based on the Quadruple Aim framework.

RESULTS

The search strategy yielded 1263 articles, of which 39 were included in the umbrella review. Patient flow interventions were categorised into human factors, management-organisation interventions, and infrastructure and mapped to the relevant component of the patient journey from pre-ED to post-ED interventions. Most interventions had mixed or quadruple nonsignificant outcomes. The majority of interventions for enhancing ED patient flow were primarily related to the 'within-ED' phase of the patient journey. Fewer interventions were identified for the 'post-ED' phase (acute inpatient transfer, subacute inpatient transfer, hospital at home, discharge home, or residential care) and the 'pre-ED' phase. The intervention outcomes were aligned with the aim (QAIM), which aims to improve patient care experience, enhance population health, optimise efficiency, and enhance staff satisfaction.

CONCLUSIONS

This study found that there was a wide range of interventions used to address patient flow, but the effectiveness of these interventions varied, and most interventions were focused on the ED. Interventions for the remainder of the patient journey were largely neglected. The metrics reported were mainly focused on efficiency measures rather than addressing all quadrants of the quadruple aim. Further research is needed to investigate and enhance the effectiveness of interventions outside the ED in improving ED patient flow. It is essential to develop interventions that relate to all three phases of patient flow: pre-ED, within-ED, and post-ED.

The Association of Frailty and Neighborhood Disadvantage with Emergency Department Visits and Hospitalizations in Older Adults

BACKGROUND

Risk stratification and population management strategies are critical for providing effective and equitable care for the growing population of older adults in the USA. Both frailty and neighborhood disadvantage are constructs that independently identify populations with higher healthcare utilization and risk of adverse outcomes.

OBJECTIVE

To examine the joint association of these factors on acute healthcare utilization using two pragmatic measures based on structured data available in the electronic health record (EHR).

DESIGN

In this retrospective observational study, we used EHR data to identify patients aged ≥ 65 years at Atrium Health Wake Forest Baptist on January 1, 2019, who were attributed to affiliated Accountable Care Organizations. Frailty was categorized through an EHR-derived electronic Frailty Index (eFI), while neighborhood disadvantage was quantified through linkage to the area deprivation index (ADI). We used a recurrent time-to-event model within a Cox proportional hazards framework to examine the joint association of eFI and ADI categories with healthcare utilization comprising emergency visits, observation stays, and inpatient hospitalizations over one year of follow-up.

KEY RESULTS

We identified a cohort of 47,566 older adults (median age = 73, 60% female, 12% Black). There was an interaction between frailty and area disadvantage (P = 0.023). Each factor was associated with utilization across categories of the other. The magnitude of frailty's association was larger than living in a disadvantaged area. The highest-risk group comprised frail adults living in areas of high disadvantage (HR 3.23, 95% CI 2.99-3.49; P < 0.001). We observed additive effects between frailty and living in areas of mid- (RERI 0.29; 95% CI 0.13-0.45; P < 0.001) and high (RERI 0.62, 95% CI 0.41-0.83; P < 0.001) neighborhood disadvantage.

CONCLUSIONS

Considering both frailty and neighborhood disadvantage may assist healthcare organizations in effectively risk-stratifying vulnerable older adults and informing population management strategies. These constructs can be readily assessed at-scale using routinely collected structured EHR data.

Extended use of point-of-care technology versus usual care for in-home assessment by acute community nurses in older adults with signs of potential acute respiratory disease: an open-label randomised controlled trial protocol

BACKGROUND

Due to ageing-related physiological changes, diagnosing older adults is challenging. Delayed disease recognition may lead to adverse health outcomes and increased hospitalisation, necessitating the development of new initiatives for timely diagnosis and treatment of older adults. Point-of-care technology, such as focused lung ultrasound scan and bedside analysis of blood samples (leucocytes with differential count, electrolytes, and creatinine) conducted in the patients' home, may support clinical decision-making, and potentially reduce acute hospital admissions. We present the protocol for a randomized controlled trial, which aims at assessing the effect of focused lung ultrasound scan and bedside blood analysis during in-home assessments among older adults with signs of potential acute respiratory disease on hospital admissions.

METHOD

We will use a parallel open-label, individually randomised controlled trial design in an acute community healthcare setting. The trial will initiate on October 2022 and is expected to end one year later. The study population will include older adults (65 + year), with at least one of the following inclusion criteria: Cough, dyspnoea, fever, fall, or rapid functional decline. Expected study sample will comprise 632 participants. Participants in the control group will receive usual care, while the intervention group will undergo extended point-of-care technology (focused lung ultrasound scan and bedside venous blood analysis), in addition to usual care. The primary outcome is acute hospital admission within 30 days follow-up. Secondary outcomes include readmissions, mortality, length of hospital stay, hospital-free days, complications during hospital admission, treatment initiations or changes, functional level, re-referrals to the acute community healthcare service, and contacts to the primary care physician. A tertiary outcome is the diagnostic accuracy of Acute Community Nurses for conducting focused lung ultrasound compared with a specialist. Outcomes will be analysed as intention-to-treat.

DISCUSSION

To our knowledge, this is the first randomised controlled trial examining the effect of extended use of point-of-care technology conducted in an in-home setting. We expect that the results may contribute to the development of new interventions aiming to improve timely diagnostics, treatment decisions, and reduce acute hospital admissions.

TRIAL REGISTRATION

www.

CLINICALTRIALS

org NCT05546073 (Date of registration: September 19th, 2022).

Frailty assessment tools in the emergency department: A geriatric emergency department guidelines 2.0 scoping review

Objective

Given the aging population and growing burden of frailty, we conducted this scoping review to describe the available literature regarding the use and impact of frailty assessment tools in the assessment and care of emergency department (ED) patients older than 60 years.

Methods

A search was made of the available literature using the Covidence system using various search terms. Inclusion criteria comprised peer-reviewed literature focusing on frailty screening tools used for a geriatric population (60+ years of age) presenting to EDs. An additional search of PubMed, EBSCO, and CINAHL for articles published in the last 5 years was conducted toward the end of the review process (January 2023) to search specifically for literature describing interventions for frailty, yielding additional articles for review. Exclusion criteria comprised articles focusing on an age category other than geriatric and care environments outside the emergency care setting.

Results

A total of 135 articles were screened for inclusion and 48 duplicates were removed. Of the 87 remaining articles, 20 were deemed irrelevant, leaving 67 articles for full-text review. Twenty-eight were excluded for not meeting inclusion criteria, leaving 39 full-text studies. Use of frailty screening tools were reported in the triage, care, and discharge decision-making phases of the ED care trajectory, with varying reports of usefulness for clinical decision-making.

Conclusion

The literature reports tools, scales, and instruments for identifying frailty in older patients at ED triage; multiple frailty scores or tools exist with varying levels of utilization. Interventions for frailty directed at the ED environment were scant. Further research is needed to determine the usefulness of frailty identification in the context of emergency care, the effects of care delivery interventions or educational initiatives for front-line medical professionals on patient-oriented outcomes, and to ensure these initiatives are acceptable for patients.

Core requirements of frailty screening in the emergency department: an international Delphi consensus study

INTRODUCTION

Frailty is associated with adverse outcomes among patients attending emergency departments (EDs). While multiple frailty screens are available, little is known about which variables are important to incorporate and how best to facilitate accurate, yet prompt ED screening. To understand the core requirements of frailty screening in ED, we conducted an international, modified, electronic two-round Delphi consensus study.

METHODS

A two-round electronic Delphi involving 37 participants from 10 countries was undertaken. Statements were generated from a prior systematic review examining frailty screening instruments in ED (logistic, psychometric and clinimetric properties). Reflexive thematic analysis generated a list of 56 statements for Round 1 (August-September 2021). Four main themes identified were: (i) principles of frailty screening, (ii) practicalities and logistics, (iii) frailty domains and (iv) frailty risk factors.

RESULTS

In Round 1, 13/56 statements (23%) were accepted. Following feedback, 22 new statements were created and 35 were re-circulated in Round 2 (October 2021). Of these, 19 (54%) were finally accepted. It was agreed that ideal frailty screens should be short (<5 min), multidimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2-4 weeks before presentation. Screening should ideally be routine, prompt (<4 h after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use and social factors were identified as the most important variables to include.

CONCLUSIONS

Although a clear consensus was reached on important requirements of frailty screening in ED, and variables to include in an ideal screen, more research is required to operationalise screening in clinical practice.

Use of Artificial Intelligence in the Identification and Management of Frailty: A Scoping Review Protocol

INTRODUCTION

Rapid population ageing and associated health issues such as frailty are a growing public health concern. While early identification and management of frailty may limit adverse health outcomes, the complex presentations of frailty pose challenges for clinicians. Artificial intelligence (AI) has emerged as a potential solution to support the early identification and management of frailty. In order to provide a comprehensive overview of current evidence regarding the development and use of AI technologies including machine learning and deep learning for the identification and management of frailty, this protocol outlines a scoping review aiming to identify and present available information in this area. Specifically, this protocol describes a review that will focus on the clinical tools and frameworks used to assess frailty, the outcomes that have been evaluated and the involvement of knowledge users in the development, implementation and evaluation of AI methods and tools for frailty care in clinical settings.

METHODS AND ANALYSIS

This scoping review protocol details a systematic search of eight major academic databases, including Medline, Embase, PsycInfo, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ageline, Web of Science, Scopus and Institute of Electrical and Electronics Engineers (IEEE) Xplore using the framework developed by Arksey and O'Malley and enhanced by Levac et al and the Joanna Briggs Institute. The search strategy has been designed in consultation with a librarian. Two independent reviewers will screen titles and abstracts, followed by full texts, for eligibility and then chart the data using a piloted data charting form. Results will be collated and presented through a narrative summary, tables and figures.

ETHICS AND DISSEMINATION

Since this study is based on publicly available information, ethics approval is not required. Findings will be communicated with healthcare providers, caregivers, patients and research and health programme funders through peer-reviewed publications, presentations and an infographic.

REGISTRATION DETAILS

OSF Registries (https://doi.org/10.17605/OSF.IO/T54G8).

Prevalence of frailty and associated factors in older adults seeking care at Swedish emergency departments

BACKGROUND

Internationally, prolonged length of stay for older adults in the emergency department (ED) is associated with increased risk of in-hospital adverse events. In Sweden patients 65 years and older account for 35% of emergency visits, and according to consensus from an international expert group, all persons over 70 should be screened for frailty. This is not routinely done in Swedish EDs, and therefore, knowledge about prevalence, characteristics and clinical outcomes associated with frailty is limited.

AIM

To describe the prevalence of frailty and associated factors in older adults seeking care at Swedish EDs.

METHODS

The study has a cross-sectional design. Data was collected at three hospital-based EDs, varying in level and size of setting, for one month. Patients age 70 and older presenting at the EDs and agreed to participate were screened for frailty using the FRail Elderly Support researcH group (FRESH) instrument. Data were analysed using descriptive statistics to assess the distribution of patient characteristics and clinical outcomes. Multivariate logistic regression was used to model the association between frailty and demographic characteristics, and Cox regression was used to model the association between frailty and clinical outcomes.

RESULTS

A total of 3101 patients were eligible for inclusion; of these, 984 (32%) were included and screened for frailty. Of the final sample, 57.3% were assessed as frail. Characteristics significantly associated with frailty were living in a residential care facility, age (> 80 years), being a woman and arriving with emergency medical service (EMS). There was a significant association between frailty and admittance to in-hospital care.

CONCLUSION

Our study shows a high prevalence of frailty in older people. Factors associated with frailty were living in a residential care facility, age ≥ 80 years, being a woman and arriving with EMS to the ED and being admitted to in-hospital care. Frailty screening should be incorporated in the triage system to identify frail patients who need tailored interventions. More studies using the FRESH instrument are needed to further confirm our findings and to develop the methods for screening for frailty in the ED.

Is the clinical frailty scale feasible to use in an emergency department setting? A mixed methods study

BACKGROUND

The Clinical Frailty Scale (CFS) is a frailty assessment tool used to identify frailty in older patients visiting the emergency department (ED). However, the current understanding of how it is used and accepted in ED clinical practice is limited. This study aimed to assess the feasibility of CFS in an ED setting.

METHODS

This was a prospective, mixed methods study conducted in three Swedish EDs where CFS had recently been introduced. We examined the completion rate of CFS assessments in relation to patient- and organisational factors. A survey on staff experience of using CFS was also conducted. All quantitative data were analysed descriptively, while free text comments underwent a qualitative content analysis.

RESULTS

A total of 4235 visits were analysed, and CFS assessments were performed in 47%. The completion rate exceeded 50% for patients over the age of 80. Patients with low triage priority were assessed to a low degree (24%). There was a diurnal variation with the highest completion rates seen for arrivals between 6 and 12 a.m. (58%). The survey response rate was 48%. The respondents rated the perceived relevance and the ease of use of the CFS with a median of 5 (IQR 2) on a scale with 7 being the highest. High workload, forgetfulness and critical illness were ranked as the top three barriers to assessment. The qualitative analysis showed that CFS assessments benefit from a clear routine and a sense of apparent relevance to emergency care.

CONCLUSION

Most emergency staff perceived CFS as relevant and easy to use, yet far from all older ED patients were assessed. The most common barrier to assessment was high workload. Measures to facilitate use may include clarifying the purpose of the assessment with explicit follow-up actions, as well as formulating a clear routine for the assessment.

REGISTRATION

The study was registered on ClinicalTrials.gov 2021-06-18 (identifier: NCT04931472).

Identifying models of care to improve outcomes for older people with urgent care needs: a mixed methods approach to develop a system dynamics model

Background

We aimed to understand urgent and emergency care pathways for older people and develop a decision support tool using a mixed methods study design.

Objective(s), study design, settings and participants

Work package 1 identified best practice through a review of reviews, patient, carer and professional interviews. Work package 2 involved qualitative case studies of selected urgent and emergency care pathways in the Yorkshire and Humber region. Work package 3 analysed linked databases describing urgent and emergency care pathways identifying patient, provider and pathway factors that explain differences in outcomes and costs. Work package 4 developed a system dynamics tool to compare emergency interventions.

Results

A total of 18 reviews summarising 128 primary studies found that integrated social and medical care, screening and assessment, follow-up and monitoring of service outcomes were important. Forty patient/carer participants described emergency department attendances; most reported a reluctance to attend. Participants emphasised the importance of being treated with dignity, timely and accurate information provision and involvement in decision-making. Receiving care in a calm environment with attention to personal comfort and basic physical needs were key. Patient goals included diagnosis and resolution, well-planned discharge home and retaining physical function. Participants perceived many of these goals of care were not attained. A total of 21 professional participants were interviewed and 23 participated in focus groups, largely confirming the review evidence. Implementation challenges identified included the urgent and emergency care environment, organisational approaches to service development, staff skills and resources. Work package 2 involved 45 interviews and 30 hours of observation in four contrasting emergency departments. Key themes relating to implementation included: intervention-related staff: frailty mindset and behaviours resources: workforce, space, and physical environment operational influences: referral criteria, frailty assessment, operating hours, transport. context-related links with community, social and primary care organisation and management support COVID-19 pandemic. approaches to implementation service/quality improvement networks engaging staff and building relationships education about frailty evidence. The linked databases in work package 3 comprised 359,945 older people and 1,035,045 observations. The most powerful predictors of four-hour wait and transfer to hospital were age, previous attendance, out-of-hours attendance and call handler designation of urgency. Drawing upon the previous work packages and working closely with a wide range of patient and professional stakeholders, we developed an system dynamics tool that modelled five evidence-based urgent and emergency care interventions and their impact on the whole system in terms of reducing admissions, readmissions, and hospital related mortality.

Limitations

Across the reviews there was incomplete reporting of interventions. People living with severe frailty and from ethnic minorities were under-represented in the patient/carer interviews. The linked databases did not include patient reported outcomes. The system dynamics model was limited to evidence-based interventions, which could not be modelled conjointly.

Conclusions

We have reaffirmed the poor outcomes frequently experienced by many older people living with urgent care needs. We have identified interventions that could improve patient and service outcomes, as well as implementation tools and strategies to help including clinicians, service managers and commissioners improve emergency care for older people.

Future work

Future work will focus on refining the system dynamics model, specifically including patient-reported outcome measures and pre-hospital services for older people living with frailty who have urgent care needs.

Study registrations

This study is registered as PROSPERO CRD42018111461. WP 1.2: University of Leicester ethics: 17525-spc3-ls:healthsciences, WP 2: IRAS 262143, CAG 19/CAG/0194, WP 3: IRAS 215818, REC 17/YH/0024, CAG 17/CAG/0024.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme [project number 17/05/96 (Emergency Care for Older People)] and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 14. See the NIHR Journals Library website for further project information.

Frailty in Patients with Chronic Graft-versus-Host Disease

Frailty is an increasingly recognized clinical diagnosis associated with high risk of disability and mortality. Frailty in patients after hematopoietic cell transplantation (HCT) is associated with increased nonrelapse mortality (NRM) and decreased overall survival (OS). Frailty has not been studied extensively in patients with chronic graft-versus-host disease (cGVHD). The objectives of the present study were to assess the prevalence and clinical correlates of frailty and the association of frailty with NRM and OS in patients enrolled in the Chronic GVHD Consortium. Patients were characterized as frail if they met the Fried definition of ≥3 of the following criteria at enrollment: unintentional weight loss, exhaustion, slow walking speed, low physical activity, and weakness. Frailty was assessed retrospectively using surrogate measures for the 5 domains of frailty. Frailty, cGVHD organ scores, and patient-reported outcomes were measured at the time of enrollment. The study included 399 patients from 9 centers in the United States, with 32% characterized as frail and 68% as not frail. The median duration of follow-up from enrollment was 9 years (interquartile range, 7 to 11 years). Frail patients were more likely to be older (P = .004), to have a lower Karnofsky Performance Status (P < .001), to have severe cGVHD (P < .001), and to have gastrointestinal (P < .001), liver (P = .04), or lung cGVHD (P = .002). In a multivariable analysis, older age, increased cGVHD global severity, and thrombocytopenia were statistically significantly associated with frailty when cGVHD organ involvement was excluded. A separate analysis excluding cGVHD severity and including organ involvement showed that lung and liver cGVHD and older age were associated with frailty. Neither corticosteroid use at the time of enrollment nor the maximum recorded dose of corticosteroids before enrollment was associated with frailty. Frail patients had higher NRM than nonfrail patients (P < .001), with a 10-year cumulative incidence of 41% (95% confidence interval [CI], 32% to 49%) versus 22% (95% CI, 17% to 28%). Reciprocally, frailty also was associated with a significantly lower OS (P < .001), with a 10-year OS of 43% (95% CI, 35% to 53%) in frail patients versus 63% (95% CI, 57% to 69%) in nonfrail patients. In multivariable analysis that included the individual domains of frailty, weakness, low physical activity, and slow walking speed were associated with survival. Frail patients also had worse scores on various measures of patient-reported outcomes, including the Short Form (SF)-36, the Lee Symptom Scale, and the trial outcome of the Functional Assessment of Cancer Therapy-Bone Marrow Transplantation (FACT-BMT) index score. Frail patients with cGVHD have significantly worse outcomes than nonfrail patients. Such clinical features as older age and lung and liver cGVHD are associated with frailty. Earlier clinical recognition of frailty in patients with cGVHD may prompt interventions to counteract frailty that could be beneficial for this population.

Frailty Screening in the Emergency Department: Comparing the Variable Indicative of Placement Risk, Clinical Frailty Scale and PRISMA-7

Prompt recognition of frailty in the emergency department (ED) is important to identify patients at higher risk of adverse outcomes. Despite this, few studies examine the diagnostic accuracy of screening instruments for frailty, instead focusing on predictive validity. We compared three commonly used, short frailty screens to an independent comprehensive geriatric assessment (CGA) in an urban University Hospital ED. Consecutive attendees aged ≥70 years were screened by trained raters, blind to the CGA, with the Variable Indicative of Placement risk (VIP), 3 and 4-item versions, Clinical Frailty Scale (CFS) and PRISMA-7. Accuracy was measured from the area under the ROC curve (AUROC). In total, 197 patients were included, median age 79 (±10); 46% were female. Half (49%) were confirmed as frail after CGA. All instruments differentiated frail from non-frail states, although the CFS (AUROC: 0.91) and PRISMA-7 (AUROC: 0.90) had higher accuracy compared to the VIP-4 (AUROC: 0.84) and VIP-3 (AUROC: 0.84). The CFS was significantly more accurate than the VIP-3 (p = 0.026) or VIP-4 (p = 0.047). There was no significant difference between the CFS and PRISMA-7 (p = 0.90). The CFS and PRISMA-7 were more accurate and should be considered in preference to the VIP (3 or 4-item versions) to identify frailty in EDs.

Inter-rater reliability of the Clinical Frailty Scale by staff members in a Swedish emergency department setting

INTRODUCTION

As frailty among the elderly is receiving increasing attention in emergency departments (EDs) around the world, the use of frailty assessment tools is growing. An often used such tool is the Clinical Frailty Scale (CFS), whose inter-rater reliability has been sparingly investigated in ED settings. No inter-rater reliability study regarding CFS has previously been performed within the Scandinavian ED context. The primary aim of this study was to evaluate the inter-rater reliability of the CFS in a Swedish ED setting.

METHODS

This was a prospective observational study conducted at three Swedish EDs. Patients ≥65 years were independently assessed with CFS by their responsible physician, registered nurse, and assistant nurse. Demographic information for each assessor was collected, along with frailty status (frail/not frail) on the basis of clinical judgment. Inter-rater reliability was calculated using intraclass correlation coefficient (ICC), whereas agreement of frailty assessed by CFS (dichotomized between frail/not frail, cutoff at ≥5 points) versus solely by clinical judgment was calculated by using cross-tabulation.

RESULTS

One-hundred patients were included. We found inter-rater reliability to be moderate to good (ICC 0.78, 95% confidence interval [CI] 0.72-0.84), regardless of whether the care team included an emergency physician (ICC 0.74, 95% CI 0.62-0.83) or an intern/resident from another specialty (ICC 0.83, 95% CI 0.74-0.89). The agreement of clinically judged frailty compared to frailty according to CFS was 84%. In the opposing cases, staff tended to assess patients as frail to a higher extent using clinical judgment than by applying CFS on the same patient.

CONCLUSIONS

The CFS appears to have a moderate to good inter-rater reliability when used in a clinical ED setting. When guiding clinical decisions, we advise that the CFS score should be discussed within the team. Further research needs to be performed on the accuracy of clinical judgment to identify frailty in ED patients.

The effectiveness of interventions to reduce adverse outcomes among older adults following Emergency Department discharge: umbrella review

BACKGROUND

Population ageing is increasing rapidly worldwide. Older adults are frequent users of health care services including the Emergency Department (ED) and experience a number of adverse outcomes following an ED visit. Adverse outcomes include functional decline, unplanned hospital admission and an ED revisit. Given these adverse outcomes a number of interventions have been examined to improve the outcomes of older adults following presentation to the ED. The aim of this umbrella review was to evaluate the effectiveness of ED interventions in reducing adverse outcomes in older adults discharged from the ED.

METHODS

Systematic reviews of randomised controlled trials investigating ED interventions for older adults presenting to the ED exploring clinical, patient experience and healthcare utilisation outcomes were included. A comprehensive search strategy was employed in eleven databases and the PROSPERO register up until June 2020. Grey literature was also searched. Quality was assessed using the A MeaSurement Tool to Assess Systematic Reviews 2 tool. Overlap between systematic reviews was assessed using a matrix of evidence table. An algorithm to assign the Grading of Recommendations Assessment, Development and Evaluation to assess the strength of evidence was applied for all outcomes.

RESULTS

Nine systematic reviews including 29 randomised controlled trials were included. Interventions comprised of solely ED-based or transitional interventions. The specific interventions delivered were highly variable. There was high overlap and low methodological quality of the trials informing the systematic reviews. There is low quality evidence to support ED interventions in reducing functional decline, improving patient experience and improving quality of life. The quality of evidence of the effectiveness of ED interventions to reduce mortality and ED revisits varied from very low to moderate. Results were presented narratively and summary of evidence tables created.

CONCLUSION

Older adults are the most important emerging group in healthcare for several economic, social and political reasons. The existing evidence for the effectiveness of ED interventions for older adults is limited. This umbrella review highlights the challenge of synthesising evidence due to significant heterogeneity in methods, intervention content and reporting of outcomes. Higher quality intervention studies in line with current geriatric medicine research guidelines are recommended, rather than the publication of further systematic reviews.

TRIAL REGISTRATION

UMBRELLA REVIEW REGISTRATION: PROSPERO ( CRD42020145315 ).

Patients' experiences of being treated for acute illness at home as an alternative to hospital admission: a qualitative study in Denmark

OBJECTIVE

We aimed to investigate the experiences of Danish patients treated at home for an acute illness instead of being hospitalised.

DESIGN

This study had a qualitative design inspired by the methodology of interpretive description. Data were collected through semistructured interviews.

SETTING

Home treatment was conducted by a team of nurses (n=10-15) supported by physiotherapists and physicians, all affiliated with an emergency department, located in the capital region of Denmark. Interviews were conducted between August 2020 and April 2021.

PARTICIPANTS

Twenty-one patients, aged 34-94 years, narrated their experiences of being treated at home for an acute illness.

RESULTS

The overarching theme in our analyses was that 'being the centre of the nurses' attention provided safety, patient involvement and quality of life during home treatment'. The following six themes emerged from analyses: (1) exclusive attention facilitates involvement and activity; (2) hospitals are for the sick; (3) maintaining a meaningful everyday life; (4) the hospital exudes productivity and busyness; (5) family relations and roles are maintained; (6) and concerns of deterioration.

CONCLUSIONS

From a patient's perspective, home treatment made sense and was perceived as a quality improvement. Being the centre of nurses' attention induced a sense of safety, involvement and enhanced quality of life among patients during the treatment course for an acute illness.

Frailty and adverse outcomes in older adults being discharged from the emergency department: A prospective cohort study

BACKGROUND

A growing number of frail older adults are treated in the emergency department (ED) and discharged home. There is an unmet need to identify older adults that are predisposed to functional decline and repeat ED visits so as to target them with proactive interventions.

METHODS

A prospective cohort study was conducted in patients 75 years or older who were being discharged from the ED. The objective was to test the value of frailty screening tests, namely 5-meter gait speed and handgrip strength, to predict repeat ED visits at 1 and 6 months and functional decline at 1 month using multivariable logistic regression.

RESULTS

After excluding 7 patients lost to follow-up, 150 patients were available for analysis. The mean age was 81.1 ± 4.9 years with 51% females, 13% arriving by ambulance, and 67% having at least two comorbid conditions. At ED discharge, 41% of patients were found to have slow gait speed, whereas 23% had weak handgrip strength. After adjustment, only slow gait speed was independently associated with functional decline at 1 month (odds ratio [OR] 1.39 per 0.1 meters/second decrement, 95% confidence interval [CI], 1.12 to 1.72) and repeat ED visits at 6 months (OR 1.20 per 0.1 meters/second decrement, 95% CI, 1.01 to 1.42).

CONCLUSIONS

Gait speed can be feasibly measured at the time of ED discharge to identify frail older adults at risk for early functional decline and subsequent return to the ED. Conversely, grip strength was not found to be associated with functional decline or ED visits.

The Role of Frailty in Predicting 3 and 6 Months Functional Decline in Hospitalized Older Adults: Findings from a Secondary Analysis

Frailty represents one of the most relevant geriatric syndromes in the 21st century and is a predictor of adverse outcomes in hospitalized older adult, such as, functional decline (FD). This study aimed to examine if frailty, evaluated with the Frailty Index (FI), can predict FD during and after hospitalization (3 and 6 months). Secondary data analysis of a prospective cohort study of 101 hospitalized older adults was performed. The primary outcome was FD at discharge, 3 and 6 months. The FI was created from an original database using 40 health deficits. Functional decline models for each time-point were examined using a binary logistic regression. The prevalence of frailty was 57.4% with an average score of 0.25 (±0.11). Frail patients had significant and higher values for functional decline and social support for all time periods and more hospital readmission in the 3 month period. Multivariable regression analysis showed that FI was a predictor of functional decline at discharge (OR = 1.07, 95% CI = 1.02–1.14) and 3-month (OR = 1.05, 95% CI = 1.01–1.09) but not 6-month (OR = 1.03, 95% CI = 0.99–1.09) follow-up. Findings suggest that frailty at admission of hospitalized older adults can predict functional decline at discharge and 3 months post-discharge.

Emergency room evaluation and recommendations for older emergency department users: results of the ER2 experimental study

PURPOSE

The study aims to examine whether the use of "emergency room evaluation and recommendations" (ER²) tool in daily ED practice reduces the length of stay in ED and hospital, and hospital admission in older patients visiting ED on stretcher.

METHODS

A total of 3931 older patients visiting ED of the Jewish General Hospital (Montreal, Quebec, Canada) on stretcher were recruited in this non-randomized, pre-post intervention, single arm, prospective and longitudinal open-label trial. ED staff and patients were blinded of the ER² score and patients received usual ED care over the observational phase, whereas ED staff were informed about the ER² score and patients had usual care plus interventions based on tailor-made geriatric recommendations during the interventional phase. The length of stay in ED and in hospital, and hospital admission were the outcomes.

RESULTS

The ER² recommendations were associated with increased length of stay in ED (β = 2.94 with P ≤ 0.001) and decreased length of stay in hospital (β = - 2.07 with P = 0.011). No effect was found for hospital admission (Odd Ratio (OR) = 0.92 with P = 0.182).

CONCLUSION

Emergency room evaluation and recommendations (ER²) tool had mixed effects. Shorter hospital stay has been reported for older ED users hospitalized, but increased ED stay and no effects on hospital admission were found.

Effectiveness of interventions to reduce adverse outcomes among older adults following emergency department discharge: Protocol for an overview of systematic reviews

Background: Older adults are frequent users of Emergency departments (ED) and this trend will continue due to population ageing and the associated increase in healthcare needs. Older adults are vulnerable to adverse outcomes following ED discharge. A number of heterogeneous interventions have been developed and implemented to improve clinical outcomes among this cohort. A growing number of systematic reviews have synthesised evidence regarding ED interventions using varying methodologies. This overview aims to synthesise the totality of evidence in order to evaluate the effectiveness of interventions to reduce adverse outcomes in older adults discharged from the ED. Methods: To identify relevant reviews, the following databases will be searched: Cochrane Database of Systematic reviews, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Databases of Abstracts of Reviews of Effects, PubMed, MEDLINE, Epistemonikos, Ageline, Embase, PEDro, Scopus, CINAHL and the PROSPERO register. The search for grey literature will include Open Grey and Grey Literature Reports. Systematic reviews of randomised controlled trials will be analysed to assess the effect of ED interventions on clinical and process outcomes in older adults. Methodological quality of the reviews will be assessed using the Assessment of Multiple Systematic Reviews 2 tool. The review will be reported in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Summary of findings will include a hierarchical rank of interventions based on estimates of effects and the quality of evidence. Discussion: This overview is required given the number of systematic reviews published regarding the effectiveness of various ED interventions for older adults at risk of adverse outcomes following discharge from the ED. There is a need to examine the totality of evidence using rigorous analytic techniques to inform best care and potentially develop a hierarchy of treatment options. PROSPERO registration: CRD42020145315 (28/04/2020).

Effectiveness of interventions to reduce adverse outcomes among older adults following emergency department discharge: Protocol for an overview of systematic reviews

Background: Older adults are frequent users of Emergency departments (ED) and this trend will continue due to population ageing and the associated increase in healthcare needs. Older adults are vulnerable to adverse outcomes following ED discharge. A number of heterogeneous interventions have been developed and implemented to improve clinical outcomes among this cohort. A growing number of systematic reviews have synthesised evidence regarding ED interventions using varying methodologies. This overview aims to synthesise the totality of evidence in order to evaluate the effectiveness of interventions to reduce adverse outcomes in older adults discharged from the ED. Methods: To identify relevant reviews, the following databases will be searched: Cochrane Database of Systematic reviews, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Databases of Abstracts of Reviews of Effects, PubMed, MEDLINE, Epistemonikos, Ageline, Embase, PEDro, Scopus, CINAHL and the PROSPERO register. The search for grey literature will include Open Grey and Grey Literature Reports. Systematic reviews of randomised controlled trials will be analysed to assess the effect of ED interventions on clinical and process outcomes in older adults. Methodological quality of the reviews will be assessed using the Assessment of Multiple Systematic Reviews 2 tool. The review will be reported in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Summary of findings will include a hierarchical rank of interventions based on estimates of effects and the quality of evidence. Discussion: This overview is required given the number of systematic reviews published regarding the effectiveness of various ED interventions for older adults at risk of adverse outcomes following discharge from the ED. There is a need to examine the totality of evidence using rigorous analytic techniques to inform best care and potentially develop a hierarchy of treatment options. PROSPERO registration: CRD42020145315 (28/04/2020).

Feasibility and accuracy of ED frailty identification in older trauma patients: a prospective multi-centre study

BACKGROUND

The burden of frailty on older people is identifiable by its adverse effect on mortality, morbidity and long term functional and health outcomes. In patients suffering from a traumatic injury there is increasing evidence that it is frailty rather than age that impacts greatest on these outcomes and that early identification can guide frailty specific care. The aim of this study was to evaluate the feasibility of nurse-led assessment of frailty in older trauma patients in the ED in patients admitted to major trauma centres.

METHODS

Patients age 65 years and over attending the Emergency Departments (ED) of five Major Trauma Centres following traumatic injury were enrolled between June 2019 and March 2020. Patients were assessed for frailty whilst in the ED using three different screening tools (Clinical Frailty Scale [CFS], Program of Research to Integrate Services for the Maintenance of Autonomy 7 [PRIMSA7], and the Trauma Specific Frailty Index [TSFI]) to compare feasibility and accuracy. Accuracy was determined by agreement with geriatrician assessment of frailty. The primary outcome was identification of frailty in the ED using three different assessment tools.

RESULTS

We included 372 patients whose median age was 80, 53.8% of whom were female. The most common mechanism of injury was fall from less than 2 m followed by falls greater than 2 m. Completion rates for the tools were variable, 31.9% for TSFI, compared to 93% with PRISMA7 and 98.9% with the CFS. There was substantial agreement when using CFS between nurse defined frailty and geriatrician defined frailty. Agreement was moderate using PRISMA7 and slight using TSFI.

CONCLUSIONS

This prospective study has demonstrated that screening for frailty in older major trauma patients within the Emergency Department is feasible and accurate using CFS.

TRIAL REGISTRATION

ISRCTN, ISRCTN10671514 . Registered 22 October 2019.

Patient Characteristics of Persons Dead on Arrival Received in a Danish Emergency Department: A Retrospective Review of Health Records

INTRODUCTION

In addition to treating living patients, emergency nurses are also responsible for receiving and caring for persons who are dead on arrival and their relatives. There is limited knowledge about the dead on arrival patient and family population as well as care practice for the dead and their relatives. The first step in improving care for dead on arrival persons is to know the size and characteristics of the population. Therefore, the aim of this study was to describe the size and characteristics of the dead on arrival population in a Danish emergency department.

METHODS

A retrospective review of health records was undertaken for all consecutive dead on arrival persons received in 1 Danish emergency department between January 2018 and December 2019.

RESULTS

A total of 719 dead on arrival persons were included, 350 in 2018 and 369 in 2019. Males accounted for 64%. The mean age was 71 years with a range from 18 to 102 years. The place of death was 80% at home, and more than half (54%) were found either dead or dying by a spouse, cohabitant, or son/daughter. In most cases, the cause of death was described as unknown (92%), whereas suicide and accidents accounted for 8%.

DISCUSSION

The population of dead on arrival persons in a Danish emergency department were mainly men, found dying or dead by relatives and brought in from home. Additional research and development are warranted regarding care practices for dead on arrival and their families in the emergency department.

Prognosis tools for short-term adverse events in older emergency department users: result of a Québec observational prospective cohort

Background

The “Program of Research on the Integration of Services for the Maintenance of Autonomy” (PRISMA-7) and “Emergency room evaluation and recommendations” (ER²) are both clinical tools used in Québec Emergency Departments (EDs) for screening of older ED users at higher risk of poor outcomes, such as prolonged length of stay (LOS) in EDs and in hospital. The study aimed to: 1) examine whether the PRISMA-7 and ER² risk levels were associated with length of stays in ED and hospital, as well as hospital admission; and 2) compare the criteria performance (i.e., sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios and area under receiver operating characteristic curve) of the PRISMA-7 and ER2 high-risk levels for these three ED adverse events in Québec older patients visiting ED on a stretcher.

Methods

A total of 1905 older patients who visited the ED of the Jewish General Hospital (Montreal, Québec, Canada) on stretchers were recruited in this prospective observational cohort. Upon their ED arrival, PRISMA-7 and ER² were performed. The outcomes were LOS in ED and in hospital, and hospital admission.

Results

The PRISMA-7 and ER² risk levels were associated with length of stay in ED and hospital as well as with hospital admission. Prolonged stays and higher hospitalization rates were associated with high-risk levels, whereas those in low-risk level groups had significantly shorter LOS and a lower rate of hospital admission (P < 0.006). While performance measures were poor for both assessment tools, ER² had a greater prognostic testing accuracy compared with PRISMA-7.

Conclusion

PRISMA-7 and ER² were both associated with incidental short-term ED adverse events but their overall prognostic testing accuracy was low, suggesting that they cannot be used as prognostic tools for this purpose.

Improving outcomes for older people in the emergency department: a review of reviews

Background

There has been a recognised trend of increasing use of emergency and urgent care and emergency departments (EDs) by older people, which is marked by a substantial evidence base reporting interventions for this population and guidance from key organisations. Despite this, outcomes for this population remain suboptimal. A plethora of reviews in this area provides challenges for clinicians and commissioners in determining which interventions and models of care best meet people’s needs. The aim of this review was to identify effective ED interventions which have been reported for older people, and to provide a clear summary of the myriad reviews and numerous intervention types in this area.

Methods

A review of reviews, reporting interventions for older people, either initiated or wholly delivered within the ED.

Results

A total of 15 review articles describing 83 primary studies met our content and reporting standards criteria. The majority (n=13) were systematic reviews (four using meta-analysis.) Across the reviews, 26 different outcomes were reported with inconsistency. Follow-up duration varied within and across the reviews. Based on how authors had reported results, evidence clusters were developed: (1) staff-focused reviews, (2) discharge intervention reviews, (3) population-focused reviews and (4) intervention component reviews.

Conclusions

The evidence base describing interventions is weak due to inconsistent reporting, differing emphasis placed on the key characteristics of primary studies (staff, location and outcome) by review authors and varying quality of reviews. No individual interventions have been found to be more promising, but interventions initiated in the ED and continued into other settings have tended to result in more favourable patient and health service outcomes. Despite many interventions reported within the reviews being holistic and patient focused, outcomes measured were largely service focused.

PROSPERO registration number

PROSPERO CRD42018111461.

Characterising the evidence base for advanced clinical practice in the UK: a scoping review protocol

INTRODUCTION

A global health workforce crisis, coupled with ageing populations, wars and the rise of non-communicable diseases is prompting all countries to consider the optimal skill mix within their health workforce. The development of advanced clinical practice (ACP) roles for existing non-medical cadres is one potential strategy that is being pursued. In the UK, National Health Service (NHS) workforce transformation programmes are actively promoting the development of ACP roles across a wide range of non-medical professions. These efforts are currently hampered by a high level of variation in ACP role development, deployment, nomenclature, definition, governance and educational preparation across the professions and across different settings. This scoping review aims to support a more consistent approach to workforce development in the UK, by identifying and mapping the current evidence base underpinning multiprofessional advanced level practice in the UK from a workforce, clinical, service and patient perspective.

METHODS AND ANALYSIS

This scoping review is registered with the Open Science Framework (https://osf.io/tzpe5). The review will follow Joanna Briggs Institute guidance and involves a multidisciplinary and multiprofessional team, including a public representative. A wide range of electronic databases and grey literature sources will be searched from 2005 to the present. The review will include primary data from any relevant research, audit or evaluation studies. All review steps will involve two or more reviewers. Data extraction, charting and summary will be guided by a template derived from an established framework used internationally to evaluate ACP (the Participatory Evidence-Informed Patient-Centred Process-Plus framework).

DISSEMINATION

The review will produce important new information on existing activity, outcomes, implementation challenges and key areas for future research around ACP in the UK, which, in the context of global workforce transformations, will be of international, as well as local, significance. The findings will be disseminated through professional and NHS bodies, employer organisations, conferences and research papers.

Frailty: implications for clinical practice and public health

Frailty is an emerging global health burden, with major implications for clinical practice and public health. The prevalence of frailty is expected to rise alongside rapid growth in the ageing population. The course of frailty is characterised by a decline in functioning across multiple physiological systems, accompanied by an increased vulnerability to stressors. Having frailty places a person at increased risk of adverse outcomes, including falls, hospitalisation, and mortality. Studies have shown a clear pattern of increased health-care costs and use associated with frailty. All older adults are at risk of developing frailty, although risk levels are substantially higher among those with comorbidities, low socioeconomic position, poor diet, and sedentary lifestyles. Lifestyle and clinical risk factors are potentially modifiable by specific interventions and preventive actions. The concept of frailty is increasingly being used in primary, acute, and specialist care. However, despite efforts over the past three decades, agreement on a standard instrument to identify frailty has not yet been achieved. In this Series paper, we provide an overview of the global impact and burden of frailty, the usefulness of the frailty concept in clinical practice, potential targets for frailty prevention, and directions that need to be explored in the future.

Interventions to manage use of the emergency and urgent care system by people from vulnerable groups: a mapping review

Background

The NHS currently faces increasing demands on accident and emergency departments. Concern has been expressed regarding whether the needs of vulnerable groups are being handled appropriately or whether alternative methods of service delivery may provide more appropriate emergency and urgent care services for particular groups.

Objective

Our objective was to identify what interventions exist to manage use of the emergency and urgent care system by people from a prespecified list of vulnerable groups. We aimed to describe the characteristics of these interventions and examine service delivery outcomes (for patients and the health service) resulting from these interventions.

Review methods

We conducted an initial mapping review to assess the quantity and nature of the published research evidence relating to seven vulnerable groups (socioeconomically deprived people and families, migrants, ethnic minority groups, the long-term unemployed/inactive, people with unstable housing situations, people living in rural/isolated areas and people with substance abuse disorders). Databases, including MEDLINE and the Cumulative Index to Nursing and Allied Health Literature, and other sources were searched between 2008 and 2018. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion. In addition, we searched for UK interventions and initiatives by examining press reports, commissioning plans and casebooks of ‘good practice’. We carried out a detailed intervention analysis, using an adapted version of the TIDieR (Template for Intervention Description and Replication) framework for describing interventions, and an analysis of current NHS practice initiatives.

Results

We identified nine different types of interventions: care navigators [three studies – moderate GRADE (Grading of Recommendations, Assessment, Development and Evaluations)], care planning (three studies – high), case finding (five studies – moderate), case management (four studies – high), front of accident and emergency general practice/front-door streaming model (one study – low), migrant support programme (one study – low), outreach services and teams (two studies – moderate), rapid access doctor/paramedic/urgent visiting services (one study – low) and urgent care clinics (one systematic review – moderate). Few interventions had been targeted at vulnerable populations; instead, they represented general population interventions or were targeted at frequent attenders (who may or may not be from vulnerable groups). Interventions supported by robust evidence (care navigators, care planning, case finding, case management, outreach services and teams, and urgent care clinics) demonstrated an effect on the general population, rather than specific population effects. Many programmes mixed intervention components (e.g. case finding, case management and care navigators), making it difficult to isolate the effect of any single component. Promising UK initiatives (front of accident and emergency general practice/front-door streaming model, migrant support programmes and rapid access doctor/paramedic/urgent visiting services) lacked rigorous evaluation. Evaluation should therefore focus on the clinical effectiveness and cost-effectiveness of these initiatives.

Conclusions

The review identified a limited number of intervention types that may be useful in addressing the needs of specific vulnerable populations, with little evidence specifically relating to these groups. The evidence highlights that vulnerable populations encompass different subgroups with potentially differing needs, and also that interventions seem particularly context sensitive. This indicates a need for a greater understanding of potential drivers for varying groups in specific localities.

Limitations

Resources did not allow exhaustive identification of all UK initiatives; the examples cited are indicative.

Future work

Research is required to examine how specific vulnerable populations differentially benefit from specific types of alternative service provision. Further exploration, using primary mixed-methods data and potentially realist evaluation, is required to explore what works for whom under what circumstances. Rigorous evaluation of UK initiatives is required, including a specific need for economic evaluations and for studies that incorporate effects on the wider emergency and urgent care system.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Emergency Department Interventions for Older Adults: A Systematic Review

OBJECTIVES

To evaluate the effect of emergency department (ED) interventions on clinical, utilization, and care experience outcomes for older adults.

DESIGN

A conceptual model informed, protocol-based systematic review.

SETTING

Emergency Department (ED).

PARTICIPANTS

Older adults 65 years of age and older.

METHODS AND MEASUREMENT

Medline, Embase, CINAHL, and PsycINFO were searched for English-language studies published through December 2017. Studies evaluating the use of one or more eligible intervention strategies (discharge planning, case management, medication safety or management, and geriatric EDs including those that cited the 2014 Geriatric ED Guidelines) with adults 65 years of age and older were included. Studies were classified by the number of intervention strategies used (ie, single strategy or multi-strategy) and key intervention components present (ie, assessment, referral plus follow-up, and contact both before and after ED discharge ["bridge"]). The effect of ED interventions on clinical (functional status, quality of life [QOL]), patient experience, and utilization (hospitalization, ED return visit) outcomes was evaluated.

RESULTS

A total of 2000 citations were identified; 17 articles describing 15 unique studies (9 randomized and 6 nonrandomized) met eligibility criteria and were included in analyses. ED interventions showed a mixed pattern of effects. Overall, there was a small positive effect of ED interventions on functional status but no effects on QOL, patient experience, hospitalization at or after the initial ED index visit, or ED return visit.

CONCLUSION

Studies using two or more intervention strategies may be associated with the greatest effects on clinical and utilization outcomes. More comprehensive interventions, defined as those with all three key intervention components present, may be associated with some positive outcomes.

Screening for older inpatients at risk for long length of stay: which clinical tool to use?

Background

Screening for inpatients at risk for long length of stay (LOS) is the first step of an effective hospital care plan for older inpatients. This study aims, in older adults admitted to a geriatric acute care ward, to examine and compare the 6-item brief geriatric assessment (BGA) and the “Programme de Recherche sur l’Intégration des Services pour le Maintien de l’Autonomie” (PRISMA-7) risk levels with long LOS, and to establish their performance criteria (i.e., sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios) for LOS.

Methods

Based on an observational, retrospective, cohort design, 166 inpatients aged ≥75 admitted to a geriatric acute care ward of a McGill University-affiliated hospital (Montreal, Quebec, Canada) were recruited. The risk levels of the 6-item BGA (low, moderate and high) and the PRISMA-7 (low versus high) were calculated from a baseline assessment. The LOS was subsequently calculated in number of days.

Results

Only the 6-item BGA high risk level was associated with a long LOS (Odds ratio = 1.1 with P = 0.028 and Hazard ratio = 2.1 with P = 0.004). Kaplan-Meier distributions showed that there was no significant difference in the delay of hospital discharge between the low and high-risk level reported by the PRISMA-7 (P = 0.381), whereas the 6-item BGA three risk levels differed significantly (P = 0.008), with individuals at high risk levels being discharged later when compared to those with low (P = 0.001) and moderate (P = 0.019) risk levels. Both tools’ performance criteria were poor (i.e., < 0.70), except for PRISMA-7’s sensitivity which was 100%.

Conclusion

The 6-item BGA risk levels were associated with LOS, low risk-level being associated with short LOS and high-risk level with long LOS, but no association was reported with the PRISMA-7 risk levels. Both tools had poor performance criteria for long LOS, suggesting that they cannot be used as prognostic tools with current scientific knowledge.

Which frailty scale for patients admitted via Emergency Department? A cohort study

OBJECTIVES

To determine the prevalence of frailty in Emergency Departments (EDs); examine the ability of frailty to predict poor outcomes post-discharge; and identify the most appropriate instrument for routine ED use.

METHODS

In this prospective study we simultaneously assessed adults 65+yrs admitted and/or spent one night in the ED using Fried, the Clinical Frailty Scale (CFS), and SUHB (Stable, Unstable, Help to walk, Bedbound) scales in four Australian EDs for rapid recognition of frailty between June 2015 and March 2016.

RESULTS

899 adults with complete follow-up data (mean (SD) age 80.0 (8.3) years; female 51.4%) were screened for frailty. Although different scales yielded vastly different frailty prevalence (SUHB 9.7%, Fried 30.4%, CFS 43.7%), predictive discrimination of poor discharge outcomes (death, poor self-reported health/quality of life, need for community services post-discharge, or reattendance to ED after the index hospitalization) for all identical final models was equivalent across all scales (AUROC 0.735 for Fried, 0.730 for CFS and 0.720 for SUHB).

CONCLUSION

This study confirms that screening for frailty in older ED patients can inform prognosis and target discharge planning including community services required. The CFS was as accurate as the Fried and SUHB in predicting poor outcomes, but more practical for use in busy clinical environments with lower level of disruption. Given the limitations of objectively measuring frailty parameters, self-report and clinical judgment can reliably substitute the assessment in EDs. We propose that in a busy ED environment, frailty scores could be used as a red flag for poor follow-up outcome.