Person-centred decisions in emergency care for older people living with frailty: principles and practice.

Older people living with frailty are frequent users of emergency care and have multiple and complex problems. Typical evidence-based guidelines and protocols provide guidance for the management of single and simple acute issues. Meanwhile, person-centred care orientates interventions around the perspectives of the individual. Using a case vignette, we illustrate the potential pitfalls of applying exclusively either evidence-based or person-centred care in isolation, as this may trigger inappropriate clinical processes or place undue onus on patients and families. We instead advocate for delivering a combined evidence-based, person-centred approach to healthcare which considers the person's situation and values, apparent problem and available options.

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.

Transitions of care for older adults discharged home from the emergency department: an inductive thematic content analysis of patient comments.

OBJECTIVE: Improving care transitions for older adults can reduce emergency department (ED) visits, adverse events, and empower community autonomy. We conducted an inductive qualitative content analysis to identify themes emerging from comments to better understand ED care transitions. METHODS: The LEARNING WISDOM prospective longitudinal observational cohort includes older adults (≥ 65 years) who experienced a care transition after an ED visit from both before and during COVID-19. Their comments on this transition were collected via phone interview and transcribed. We conducted an inductive qualitative content analysis with randomly selected comments until saturation. Themes that arose from comments were coded and organized into frequencies and proportions. We followed the Standards for Reporting Qualitative Research (SRQR). RESULTS: Comments from 690 patients (339 pre-COVID, 351 during COVID) composed of 351 women (50.9%) and 339 men (49.1%) were analyzed. Patients were satisfied with acute emergency care, and the proportion of patients with positive acute care experiences increased with the COVID-19 pandemic. Negative patient comments were most often related to communication between health providers across the care continuum and the professionalism of personnel in the ED. Comments concerning home care became more neutral with the COVID-19 pandemic. CONCLUSION: Patients were satisfied overall with acute care but reported gaps in professionalism and follow-up communication between providers. Comments may have changed in tone from positive to neutral regarding home care over the COVID-19 pandemic due to service slowdowns. Addressing these concerns may improve the quality of care transitions and provide future pandemic mitigation strategies.

Developing a Geriatric Emergency Department: People, Processes, and Place.

Older patients' ED visits rose 30% over 5 years and EDs are now examining geriatric emergency department (GED) models of care. The 3 Ps model focuses on the GED's People, Processes, and the Place to provide a framework for GED development. Key resources include the: GED Collaborative, GED Guidelines, and Geriatric Emergency Department Accreditation process. Core to a GED's operation is its care processes including: (1) General approaches; (2) Screening for high-risk conditions; (3) Enhanced assessment; (4) Workflow alterations; and (5) Transitions. This article provides practical guidance to EDs seeking to enhance the ED experience of older people and improve the quality of their outcomes.

Pharmacological Management of Agitation and Delirium in Older Adults: a Survey of Practices in Canadian Emergency Departments.

Agitation is a common presenting symptom of delirium for older adults in the emergency department (ED). No medications have been found to reduce delirium severity, symptoms, or mortality, yet they may cause harm. Guidelines suggest using medications only when patients are posing a risk of harm, situations which may arise frequently in the ED. We sought to characterize prescribing patterns of medications for agitation by ED physicians in Canadian hospitals. In this multicenter study, we surveyed physicians in Vancouver, Toronto, and Sherbrooke. Descriptive statistics were used to summarize group characteristics and starting doses were compared to order sets. Fisher exact tests were used for demographic comparison. Ordinal linear regression models were run to identify a relationship between starting dose of medications and location. Of the 137 physicians invited, 77 (56%) completed the survey. Use of order sets was greatest in Sherbrooke and least in Vancouver. The most common medications used across sites were haloperidol, lorazepam, and quetiapine. Benzodiazepines were used across all sites but were used significantly more frequently in Vancouver than the other sites. Practice location was a significant predictor of starting dose of haloperidol, with Sherbrooke and Toronto having a lower starting dose than Vancouver. Higher use of order sets correlated with lower and more consistent starting doses. Benzodiazepines are used across EDs in Canada despite little evidence for efficacy in delirium and risk of harm. Implementation of order sets may be a useful way to standardize ED management of older adults experiencing hyperactive delirium.

Understanding why delirium is often missed in older emergency department patients: a qualitative descriptive study.

OBJECTIVES: Unrecognized delirium is associated with significant adverse outcomes. Despite decades of effort and educational initiatives, validated screening tools have not improved delirium recognition in the emergency department (ED). There remains a fundamental knowledge gap of why it is consistently missed. The objective of this study was to explore the perceptions of ED physicians and nurses regarding factors contributing to missed delirium in older ED patients. METHODS: We conducted a qualitative descriptive study at two academic tertiary care EDs in Toronto, Canada. Emergency physicians and nurses were interviewed by a trained qualitative researcher using a semi-structured interview guide. We coded transcripts with an iteratively developed codebook. Interviews were conducted until thematic saturation occurred. Thematic data analysis occurred in conjunction with data collection to continuously monitor emerging themes and areas for further exploration. RESULTS: We interviewed 26 ED physicians and nurses. We identified key themes at four levels: clinical practice, provider attitudes, systematic processes, and education. The four themes include: (1) there are varied approaches to delirium recognition and infrequent use of screening tools; (2) delirium assessment is perceived as overly time consuming and of lower priority than other symptoms and syndromes; (3) it is unclear whose responsibility it is to recognize delirium; and (4) there is a need for a deeper or "functional" understanding of delirium that includes its consequences. CONCLUSIONS: Our findings demonstrate a need for ED leadership to identify clear team roles for delirium recognition, standardize use of delirium screening tools, and prioritize delirium as a symptom of an acute medical emergency.

RéSUMé: OBJECTIFS: Le délire non reconnu est associé à des résultats négatifs importants. Malgré des décennies d'efforts et d'initiatives éducatives, les outils de dépistage validés n'ont pas amélioré la reconnaissance du délire au service des urgences (SU). Il reste une lacune fondamentale dans la connaissance des raisons pour lesquelles elle est systématiquement manquée. L'objectif de cette étude était d'explorer les perceptions des médecins et des infirmières de l'urgence au sujet des facteurs contribuant au délire manqué chez les patients âgés des urgences. MéTHODES: Nous avons mené une étude qualitative descriptive dans deux urgences universitaires de soins tertiaires à Toronto, au Canada. Les médecins et les infirmières des urgences ont été interrogés par un chercheur qualitatif formé à l'aide d'un guide d'entretien semi-structuré. Nous avons codé les transcriptions à l'aide d'un livre de codes développé de manière itérative. Les entretiens ont été menés jusqu'à saturation thématique. L'analyse thématique des données s'est déroulée conjointement avec la collecte des données afin de surveiller continuellement les thèmes émergents et les domaines à explorer davantage. RéSULTATS: Nous avons interrogé 26 médecins et infirmières des urgences. Nous avons identifié des thèmes clés à quatre niveaux : la pratique clinique, les attitudes des prestataires, les processus systématiques et l'éducation. Les quatre thèmes abordés sont les suivants : 1) les approches de la reconnaissance du délire sont variées et les outils de dépistage peu utilisés ; 2) l'évaluation du délire est perçue comme prenant trop de temps et moins prioritaire que d'autres symptômes et syndromes ; 3) il n'est pas clair à qui revient la responsabilité de reconnaître le délire ; et 4) il est nécessaire d'avoir une compréhension plus profonde ou "fonctionnelle" du délire, qui inclut ses conséquences. CONCLUSIONS: Nos résultats démontrent la nécessité pour les responsables des urgences de définir clairement les rôles de l'équipe pour la reconnaissance du delirium, de normaliser l'utilisation des outils de dépistage du delirium et d'accorder la priorité au delirium en tant que symptôme d'une urgence médicale aiguë.

Prevalence, management and outcomes of unrecognized delirium in a National Sample of 1,493 older emergency department patients: how many were sent home and what happened to them?

BACKGROUND: Retrospective studies estimate Emergency Department (ED) delirium recognition at <20%; few prospective studies have assessed delirium recognition and outcomes for patients with unrecognized delirium. OBJECTIVES: To prospectively measure delirium recognition by ED nurses and physicians, document their confidence in diagnosis and disposition, actual dispositions, and patient outcomes. METHODS: Prospective observational study of people ≥65 years. We assessed delirium using the Confusion Assessment Method, then asked ED staff if the patient had delirium, confidence in their assessment, if the patient could be discharged, and contacted patients 1 week postdischarge. We report proportions and 95% confidence intervals (Cls). RESULTS: We enrolled 1,493 participants; mean age was 77.9 years; 49.2% were female, 79 (5.3%, 95% CI 4.2-6.5%) had delirium. ED nurses missed delirium in 43/78 cases (55.1%, 95% CI 43.4-66.4%). Nurses considered 12/43 (27.9%) patients with unrecognized delirium safe to discharge. Median confidence in their delirium diagnosis for patients with unrecognized delirium was 7.0/10. Physicians missed delirium in 10/20 (50.0%, 95% CI 27.2-72.8) cases and considered 2/10 (20.0%) safe to discharge. Median confidence in their delirium diagnosis for patients with unrecognized delirium was 8.0/10. Fifteen patients with unrecognized delirium were sent home: 6.7% died at 1 week follow-up vs. none in those with recognized delirium and 1.1% in the rest of the cohort. CONCLUSION: Delirium recognition by nurses and physicians was sub-optimal at ~50% and may be associated with increased mortality. Research should explore root causes of unrecognized delirium, and novel strategies to systematically improve delirium recognition and patient outcomes.

Learning Integrated Health System to Mobilize Context-Adapted Knowledge With a Wiki Platform to Improve the Transitions of Frail Seniors From Hospitals and Emergency Departments to the Community (LEARNING WISDOM): Protocol for a Mixed-Methods Implementation Study.

BACKGROUND: Elderly patients discharged from hospital experience fragmented care, repeated and lengthy emergency department (ED) visits, relapse into their earlier condition, and rapid cognitive and functional decline. The Acute Care for Elders (ACE) program at Mount Sinai Hospital in Toronto, Canada uses innovative strategies, such as transition coaches, to improve the care transition experiences of frail elderly patients. The ACE program reduced the lengths of hospital stay and readmission for elderly patients, increased patient satisfaction, and saved the health care system over Can $4.2 million (US $2.6 million) in 2014. In 2016, a context-adapted ACE program was implemented at one hospital in the Centre intégré de santé et de services sociaux de Chaudière-Appalaches (CISSS-CA) with a focus on improving transitions between hospitals and the community. The quality improvement project used an intervention strategy based on iterative user-centered design prototyping and a "Wiki-suite" (free web-based database containing evidence-based knowledge tools) to engage multiple stakeholders. OBJECTIVE: The objectives of this study are to (1) implement a context-adapted CISSS-CA ACE program in four hospitals in the CISSS-CA and measure its impact on patient-, caregiver-, clinical-, and hospital-level outcomes; (2) identify underlying mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly; and (3) identify underlying mechanisms by which the Wiki-suite contributes to context-adaptation and local uptake of knowledge tools. METHODS: Objective 1 will involve staggered implementation of the context-adapted CISSS-CA ACE program across the four CISSS-CA sites and interrupted time series to measure the impact on hospital-, patient-, and caregiver-level outcomes. Objectives 2 and 3 will involve a parallel mixed-methods process evaluation study to understand the mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly and by which our Wiki-suite contributes to adaptation, implementation, and scaling up of geriatric knowledge tools. RESULTS: Data collection started in January 2019. As of January 2020, we enrolled 1635 patients and 529 caregivers from the four participating hospitals. Data collection is projected to be completed in January 2022. Data analysis has not yet begun. Results are expected to be published in 2022. Expected results will be presented to different key internal stakeholders to better support the effort and resources deployed in the transition of seniors. Through key interventions focused on seniors, we are expecting to increase patient satisfaction and quality of care and reduce readmission and ED revisit. CONCLUSIONS: This study will provide evidence on effective knowledge translation strategies to adapt best practices to the local context in the transition of care for elderly people. The knowledge generated through this project will support future scale-up of the ACE program and our wiki methodology in other settings in Canada. TRIAL REGISTRATION: ClinicalTrials.gov NCT04093245; https://clinicaltrials.gov/ct2/show/NCT04093245. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17363.

Using volunteers to improve the experience of older patients in the emergency department.

OBJECTIVES: The Maximizing Aging Using Volunteer Engagement in the Emergency Department (MAUVE + ED) program connects specially trained volunteers with older patients whose personal and social needs are not always met within the busy ED environment. The objective of this study was to describe the development and implementation of the MAUVE + ED program. METHODS: Volunteers were trained to identify and approach older patients at risk for adverse outcomes, including poor patient experience, and invite such patients to participate in the program. The program is available to all patients >65 years, and those with confusion, patients who were alone, those with mobility issues, and patients with increased length of stay in the ED. Volunteers documented their activities after each patient encounter using a standardized paper-based data collection form. RESULTS: Over the program's initial 6-month period, the MAUVE + ED volunteers reported a total of 896 encounters with 718 unique patients. The median time (interquartile range [IQR]) a MAUVE volunteer spent with a patient was 10 minutes (IQR = 5, 20), with a range of 1 to 130 minutes. The median number of patients seen per shift was 7 (IQR = 6, 9), with a range of 1 to 16 patients per shift. The most common activities the volunteer assisted with were therapeutic activities/social visits (n = 859; 95.9%), orientation activities (n = 501; 55.9%), and hydration assistance (n = 231; 25.8%). The least common were mobility assistance (n = 36; 4.0%), and vision/hearing assistance (n = 13; 1.5%). CONCLUSIONS: Preliminary data suggest the MAUVE + ED volunteers were able to provide additional care to older adults and their families/carers in the ED.

Geriatric Emergency Medicine Fellowships: Current State of Specialized Training for Emergency Physicians in Optimizing Care for Older Adults.

Improving emergency department (ED) care for older adults is a critical issue in emergency medicine. Institutions throughout the United States and Canada have recognized the growing need for a workforce of emergency physician (EP) leaders focused on clinical innovation, education, and research and have developed specialized fellowship training in geriatric emergency medicine (GEM). We describe here the overview, structure, and curricula of these fellowships as well as successes and challenges they have encountered. Seven GEM fellowships are active in the United States and Canada, with five offering postresidency training only, one offering fellowship training during residency only, and one offering both. The backbone of the curriculum for all fellowships is the achievement of core competencies in various aspects of GEM, and each includes clinical rotations, teaching, and a research project. Evaluation strategies and feedback have allowed for significant curricular changes as well as customization of the fellowship experience for individual fellows. Key successes include an improved collaborative relationship with geriatrics faculty that has led to additional initiatives and projects and former fellows already becoming regional and national leaders in GEM. The most critical challenges have been ensuring adequate funding and recruiting new fellows each year who are interested in this clinical area. We believe that interest in GEM fellowships will grow and that opportunities exist to combine GEM fellowship training with a focus in research, administration, or health policy to create unique new types of highly impactful specialized training. Future research may include exploring former fellows' postfellowship experiences, careers, accomplishments, and contributions to GEM to better understand the impact of GEM fellowships.

Elder Abuse in the Out-of-Hospital and Emergency Department Settings: A Scoping Review.

This scoping review aimed to synthesize the available evidence on the epidemiology, patient- and caregiver-associated factors, clinical characteristics, screening tools, prevention, interventions, and perspectives of health care professionals in regard to elder abuse in the out-of-hospital or emergency department (ED) setting. Literature search was performed with MEDLINE, EMBASE, the Cumulative Index of Nursing and Allied Health, PsycINFO, and the Cochrane Library. Studies were eligible if they were observational or experimental and reported on elder abuse in the out-of-hospital or ED setting. A qualitative approach, performed independently by 2 reviewers, was used to synthesize and report the findings. A total of 413 citations were retrieved, from which 55 studies published between 1988 and 2019 were included. The prevalence of elder abuse reported during the ED visit was lower than reported in the community. The most commonly detected type of elder abuse was neglect, and then physical abuse. The following factors were more common in identified cases of elder abuse: female sex, cognitive impairment, functional disability, frailty, social isolation, and lower socioeconomic status. Psychiatric and substance use disorders were more common among victims and their caregivers. Screening tools have been proposed, but multicenter validation and influence of screening on patient-important outcomes were lacking. Health care professionals reported being poorly trained and acknowledged numerous barriers when caring for potential victims. There is insufficient knowledge, limited training, and a poorly organized system in place for elder abuse in the out-of-hospital and ED settings. Studies on the processes and effects of screening and interventions are required to improve care of this vulnerable population.

Examining the relationship between triage acuity and frailty to inform the care of older emergency department patients: Findings from a large Canadian multisite cohort study.

BACKGROUND: The 2016 Canadian Triage and Acuity Scale (CTAS) updates introduced frailty screening within triage to more accurately code frail patients who may deteriorate waiting for care. The relationship between triage acuity and frailty is not well understood, but may help inform which supplemental geriatric assessments are beneficial to support care in the emergency department (ED). Our objectives were to investigate the relationship between triage acuity and frailty, and to compare their associations with a series of patient outcomes. METHODS: We conducted a secondary analysis of the Canadian cohort from a multinational prospective study. Data were collected on ED patients 75 years of age and older from eight ED sites across Canada between November 2009 and April 2012. Triage acuity was assigned using the CTAS, whereas frailty was measured using an ED frailty index. Spearman rank and binary logistic regression were used to examine associations. RESULTS: A total of 2,153 ED patients were analyzed. No association was found between the CTAS and ED frailty index scores assigned to patients (r = .001; p = 0.99). The ED frailty index was associated with hospital admission (odds ratio [OR] = 1.5; 95% confidence interval [CI] = 1.4-1.6), hospital length of stay (OR = 1.4; 95% CI = 1.2-1.6), future hospitalization (OR = 1.1; 95% CI = 1.05-1.2), and ED recidivism (OR = 1.1; 95% CI = 1.04-1.2). The CTAS was associated with hospital admission (e.g., CTAS 2 v. 5; OR = 6; 95% CI = 3.3-11.4). CONCLUSION: Our findings demonstrate that frailty and triage acuity are independent but complementary measures. EDs may benefit from comprehensive frailty screening post-triage, as frailty and its associated geriatric syndromes drive outcomes separate from traditional measures of acuity.