A randomized trial exploring the effect of a telephone call follow-up on care plan compliance among older adults discharged home from the emergency department.

OBJECTIVES: Older patients discharged from the emergency department (ED) have difficulty comprehending discharge plans and are at high risk of adverse outcomes. The authors investigated whether a postdischarge telephone call-mediated intervention by a nurse would improve discharge care plan adherence, specifically by expediting post-ED visit physician follow-up appointments and/or compliance with medication changes. The second objectives were to determine if this telephone call intervention would reduce return ED visits and/or hospitalizations within 35 days of the index ED visit and to determine potential cost savings of this intervention. METHODS: This was a 10-week randomized, controlled trial among patients aged 65 and older discharged to home from an academic ED. At 1 to 3 days after each patient's index ED visit, a trained nurse called intervention group patients to review discharge instructions and assist with discharge plan compliance; placebo call group patients received a patient satisfaction survey call, while the control group patients were not called. Data collection calls occurred at 5 to 8 days and 30 to 35 days after the index ED visits for all three groups. Chi-square or Fisher's exact tests were performed for categorical data and the Kruskal-Wallis test examined group differences in time to follow-up. RESULTS: A total of 120 patients completed the study. Patients were 60% female and 72% white, with a mean age of 75 years (standard deviation [SD] ± 7.58 years). Intervention patients were more likely to follow up with medical providers within 5 days of their ED visits than either the placebo or the control group patients (54, 20, and 37%, respectively; p = 0.04). All groups performed well in medication acquisition and comprehension of medication indications and dosage. There were no differences in return visits to the ED or hospital within 35 days of the index ED visit for intervention patients, compared to placebo or control group patients (22, 33, and 27%, respectively; p = 0.41). An economic analysis showed an estimated 70% chance that this intervention would reduce total costs. CONCLUSIONS: Telephone call follow-up of older patients discharged from the ED resulted in expedited follow-up for patients with their primary care physicians. Further study is warranted to determine if these results translate into improved patient outcomes, decreased return ED visits or hospital admissions, and cost savings resulting from this intervention.

Predictive value of initial triage vital signs for critically ill older adults.

INTRODUCTION: Triage of patients is critical to patient safety, yet no clear information exists as to the utility of initial vital signs in identifying critically ill older emergency department (ED) patients. The objective of this study is to evaluate a set of initial vital sign thresholds as predictors of severe illness and injury among older adults presenting to the ED. METHODS: We reviewed all visits by patients aged 75 and older seen during 2007 at an academic ED serving a large community of older adults. Patients' charts were abstracted for demographic and clinical information including vital signs, via automated electronic methods. We used bivariate analysis to investigate the relationship between vital sign abnormalities and severe illness or injury, defined as intensive care unit (ICU) admission or ED death. In addition, we calculated likelihood ratios for normal and abnormal vital signs in predicting severe illness or injury. RESULTS: 4,873 visits by patients aged 75 and above were made to the ED during 2007, and of these 3,848 had a complete set of triage vital signs. For these elderly patients, the sensitivity and specificity of an abnormal vital sign taken at triage for predicting death or admission to an ICU were 73% (66,81) and 50% (48,52) respectively (positive likelihood ratio 1.47 (1.30,1.60); negative likelihood ratio 0.54 (0.30,0.60). CONCLUSION: Emergency provider assessment and triage scores that rely primarily on initial vital signs are likely to miss a substantial portion of critically ill older adults.

Computer-facilitated review of electronic medical records reliably identifies emergency department interventions in older adults.

OBJECTIVES: An estimated 14% to 25% of all scientific studies in peer-reviewed emergency medicine (EM) journals are medical records reviews. The majority of the chart reviews in these studies are performed manually, a process that is both time-consuming and error-prone. Computer-based text search engines have the potential to enhance chart reviews of electronic emergency department (ED) medical records. The authors compared the efficiency and accuracy of a computer-facilitated medical record review of ED clinical records of geriatric patients with a traditional manual review of the same data and describe the process by which this computer-facilitated review was completed. METHODS: Clinical data from consecutive ED patients age 65 years or older were collected retrospectively by manual and computer-facilitated medical record review. The frequency of three significant ED interventions in older adults was determined using each method. Performance characteristics of each search method, including sensitivity and positive predictive value, were determined, and the overall sensitivities of the two search methods were compared using McNemar's test. RESULTS: For 665 patient visits, there were 49 (7.4%) Foley catheters placed, 36 (5.4%) sedative medications administered, and 15 (2.3%) patients who received positive pressure ventilation. The computer-facilitated review identified more of the targeted procedures (99 of 100, 99%), compared to manual review (74 of 100 procedures, 74%; p < 0.0001). CONCLUSIONS: A practical, non-resource-intensive, computer-facilitated free-text medical record review was completed and was more efficient and accurate than manually reviewing ED records.

Nursing home revenue source and information availability during the emergency department evaluation of nursing home residents.

OBJECTIVES: Lack of access to medical information for nursing home residents during emergency department (ED) evaluation is a barrier to quality care. We hypothesized that the quantity of information available in the ED differs based on the funding source of the resident's nursing home. DESIGN: Cross-sectional observational study. SETTING: Single academic ED. PARTICIPANTS: Participants were 128 skilled nursing facility (SNF) residents age 65 or older from 12 SNFs. MEASUREMENTS: Emergency physicians documented knowledge of 9 essential information items. SNFs were categorized as accepting or not accepting Medicaid. RESULTS: Questionnaires were completed for 128 patients, of whom 95 (74%) were from 1 of 8 Medicaid-funded SNFs and 33 (26%) were from 1 of 4 SNFs not accepting Medicaid. Patients from SNFs accepting Medicaid were younger (79 versus 87, P < .001) and less frequently white (62% versus 97%, P < .001). The mean number of 9 possible information items available was lower for patients from SNFs that accept Medicaid (7.13 versus 8.15, P < .001). Emergency providers also reported lower satisfaction regarding access to information for residents from SNFs that accept Medicaid (P < .05). The association between residence in an SNF that accepts Medicaid and lower ED information scores remained after linear regression with clustering by SNF controlling for age, gender, and race. The most common source of information for residents from both types of SNFs was transfer papers from the SNF. CONCLUSION: Less information is available to ED providers for patients from SNFs that accept Medicaid than for residents from SNFs that do not accept Medicaid. Further study is needed to examine this information gap.

Implementation of a Web-based system to improve the transitional care of older adults.

We constructed a bidirectional Web-based system to transmit critical patient information in real time between referring nursing homes and a university hospital emergency department (ED) to facilitate the care of patients referred to our ED. Our model was inexpensive, improved measures of information transfer, and increased provider satisfaction.

Accuracy of the Emergency Severity Index triage instrument for identifying elder emergency department patients receiving an immediate life-saving intervention.

OBJECTIVES: The study objective was to determine the sensitivity and specificity of the Emergency Severity Index (ESI) triage instrument for the identification of elder patients receiving an immediate life-saving intervention in the emergency department (ED). METHODS: The authors reviewed medical records for consecutive patients 65 years or older who presented to a single academic ED serving a large community of elders during a 1-month period. ESI triage scores were compared to actual ED course with attention to the occurrence of an immediate life-saving intervention. The sensitivity and specificity of an ESI triage level of 1 for the identification of patients receiving an immediate intervention was calculated. For 50 cases, the triage nurse ESI designation was compared to the triage level determined by an expert triage nurse based on retrospective record review. RESULTS: Of 782 consecutive patients 65 years or older who presented to the ED, 18 (2%) had an ESI level of 1, 176 (23%) had an ESI level of 2, 461 (60%) had an ESI level of 3, 100 (13%) had an ESI level of 4, and 18 (2%) had an ESI level of 5. Twenty-six patients received an immediate life-saving intervention. ESI triage scores for these 26 individuals were as follows: ESI 1, 11 patients; ESI 2, nine patients; and ESI 3, six patients. The sensitivity of ESI to identify patients receiving an immediate intervention was 42.3% (95% confidence interval [CI]=23.3% to 61.3%); the specificity was 99.2% (95% CI=98.0% to 99.7%). For 17 of 50 cases in which actual triage nurse and expert nurse ESI levels disagreed, undertriage by the triage nurses was more common than overtriage (13 vs. 4 patients). CONCLUSIONS: The ESI triage instrument identified fewer than half of elder patients receiving an immediate life-saving intervention. Failure to follow established ESI guidelines in the triage of elder patients may contribute to apparent undertriage.