A comparison of palliative care and rapid emergency screening (P-CaRES) tool, broad and narrow criteria, and surprise questions to predict survival of older emergency department patients.

BACKGROUND: Palliative care is a form of medical care designed to enhance the quality of life of patients with life-threatening conditions. This study was conducted to compare the accuracy of predicted survival the 1 and 3-month survival rate of Broad and narrow criteria, Surprise questions (SQ), and Palliative Care and Rapid Emergency Screening (P-CaRES) after admission to the emergency department (ED). METHODS: This prospective cohort study was conducted at an urban teaching hospital in Thailand. Patients aged ≥ 65 years admitted to the ED were classified according to their emergency severity index (ESI) (Level: 1-3). We collected data on SQ, P-CaRES, and broad and narrow criteria. A survival data of participants were collected at 1 and 3 months after admission to the ED. The survival rate was calculated using the Kaplan-Meier and log-rank tests. RESULTS: A total of 269 patients completed the study. P-CaRES positive and P-CaRES negative patients had 1-month survival rates of 81% and 94.8%, respectively (P = 0.37), and at 3-month survival rates of 70.7% and 90.1%, respectively (P < 0.001). SQ (not surprised) had a 1-month survival rate of 79.3%, while SQ (surprised) had a 97% survival rate (P = 0.01), and SQ (not surprised) had a 75.4% survival rate at 3-months, while SQ (surprised) had a 96.3% survival rate (P = 0.01). Broad and narrow criteria that were positive and negative had 1-month survival rates of 88.1% and 92.5%, respectively (P = 0.71), while those that were positive and negative had 3-month survival rates of 78.6% and 87.2%, respectively (P = 0.19). The hazard ratio (HR) of SQ (not surprised) at 1 month was 3.22( 95%CI:1.16-8.89). The HR at 3 months of P-CaRES (positive) was 3.31 with a 95% confidence interval (CI): 1.74 - 6.27, while the HR for SQ (not surprise) was 7.33, 95% CI: 3.03-19.79; however, broad and narrow criteria had an HR of 1.78, 95% CI:0.84-3.77. CONCLUSIONS: Among older adults who visited the ED, the SQ were good prognosis tools for predicting 1 and 3-month survival, and P-CaRES were good prognostic tools for predicting 3-month survival.

Disaster preparedness among Thai elderly emergency department patients: a survey of patients' perspective.

BACKGROUND: In disaster situations, the elderly are considered to be a particularly vulnerable population. Preparedness is the key to reduce post-disaster damage. There is limited research in middle-income countries on how well elderly emergency department (ED) patients are prepared for disaster situations. The objective of this study was to determine the attitudes and behavior of elderly ED patients toward disaster preparedness. METHODS: This study was a cross-sectional face-to-face survey at one urban teaching hospital in Bangkok, Thailand between August 1st and September 30th, 2016. Patients aged 60 and older who presented to the ED were included to this study. We excluded patients who had severe dementia [defined as Short Portable Mental State Questionnaires (SPMSQ) > 8], were unable to speak Thai, had severe trauma and/or needed immediate resuscitation. The survey instruction was adapted from previous disaster surveys. This study was approved by the Vajira Institutional Review Board (IRB). RESULTS: A total of 243 patients were enrolled. Most of them were female [154 patients (63.4%)]. The median age was 72 [Interquartile range (IQR) 66-81] years and the most common underlying diseases were hypertension [148 patients (60.9%)] and diabetes [108 patients (44.4%)]. The majority of patients [172 patients (72.4%)] reported that they had had some teaching about disaster knowledge from a healthcare provider and had experienced a disaster [138 patients (56.8%)]. While 175/197 (81.8%) patients who had underlying diseases reported that they had a medication supply for disaster situations, only 61 (25.1%) patients had an emergency toolbox for disasters. Most patients (159, 65.4%) did not know the emergency telephone number, and 133 (54.7%) patients reported transportation limitations. CONCLUSIONS: While most Thai elderly ED patients reported having a medication supply for disaster situations, many lacked comprehensive plans for a disaster situation. Work needs to be done to improve the quality of preparedness in disaster situations among elderly patients. Future research should focus on preparedness knowledge regarding evacuation, and shelter/residence for older patients.

Is there such a thing as a mechanical fall?

OBJECTIVES: The term mechanical falls is commonly used in the emergency department (ED), yet its definition and clinical implications are not established. It may be used to attribute falls to extrinsic factors in the environment exonerating clinicians from conducting a thorough assessment of the fall's underlying intrinsic causes. We conducted this study to determine how clinicians assess "mechanical" and "nonmechanical" falls; we explored conditions, fall evaluation, and outcomes associated with these diagnoses. METHODS: This study was a secondary analysis of a retrospective study at 1 urban ED. Data were obtained from medical records of patients aged 65 years and older who presented to the ED for a fall. We compared the associated conditions/causes, the ED fall evaluation, mortality, ED revisits, subsequent hospitalizations, and recurrent falls between the 2 terms. RESULTS: We had a sample size of 350 patients: 218 (62.3%) with "mechanical falls" and 132 (37.7%) with nonmechanical falls. There was little difference among associated conditions between the 2 fall labels other than mechanical falls had more associated environmental causes but fewer syncope causes. However, more than a quarter of nonmechanical falls had associated environmental factors as well. Similarly, there was little difference in the fall evaluation, ED revisit rates, recurrent falls, subsequent hospitalizations, and death between the 2 groups. CONCLUSIONS: The term mechanical fall is unclear, inconsistently used, and not associated with a discrete fall evaluation and does not predict outcomes. We propose eliminating the term because it inaccurately implies that a benign etiology for an older person's fall exists.

Revisits within 48 Hours to a Thai Emergency Department.

Objective. Emergency department (ED) revisits are a common ED quality measure. This study was undertaken to ascertain the contributing factors of revisits within 48 hours to a Thai ED and to explore physician-related, illness-related, and patient-related factors behind those revisits. Methods. This study was a chart review from one tertiary care, urban Thai hospital from October 1, 2009, to September 31, 2010. We identified patients who returned to the ED within 48 hours for the same or related complaints after their initial discharge. Three physicians classified revisit as physician-related, illness-related, and patient-related factors. Results. Our study included 172 ED patients' charts. 86/172 (50%) were male and the mean age was 38 ±â€Š5.6 (SD) years. The ED revisits contributing factors were physician-related factors [86/172 (50.0%)], illness-related factors [61/172 (35.5%)], and patient-related factor [25/172 (14.5%)], respectively. Among revisits classified as physician-related factors, 40/86 (46.5%) revisits were due to misdiagnosis and 36/86 (41.9%) were due to suboptimal management. Abdominal pain [27/86 (31.4%)] was the majority of physician-related chief complaints, followed by fever [16/86 (18.6%)] and dyspnea [15/86 (17.4%)]. Conclusion. Misdiagnosis and suboptimal management contributed to half of the 48-hour repeat ED visits in this Thai hospital.

Knowledge and practices of Thai emergency physicians regarding the care of delirious elderly patients.

BACKGROUND: The Society for Academic Emergency Medicine (SAEM) Geriatric Emergency Medicine Task Force recommends assessment of delirium for all elderly emergency department (ED) patients. Little is known about emergency physicians' (EPs) opinions regarding care of delirious elderly patients. We sought to determine the knowledge and practice experience of members of the Thai Association for Emergency Medicine regarding the care of delirious elderly ED patients. METHODS: We surveyed all Thai emergency physicians from July to September 2013 using a brief online survey as this does not include any non-trained physician working in the private/provincial/community EDs, still a significant part of the ED workforce in Thailand. RESULTS: We had a response rate of 50% (239/474) of which 95% (228/239) completed the survey. Respondents largely reported that <10% of their patients experience delirium. Eighty-five percent of the respondents recognized delirium as a problem that required active intervention, and 76% of the respondents thought it was underdiagnosed in the ED. Only 24% of the respondents reported routinely screening delirium in the ED and 16% reported using a specific screening tool for delirium assessment. Forty-two percent of the respondents reported treating delirium with a long acting benzodiazepine and 29% reported using haloperidol. Forty percent of respondents thought that oversedation was the most common complication associated with drug treatment of delirium. CONCLUSIONS: Basic knowledge and perceptions surrounding the recognition, diagnosis, and treatment of delirium in elderly ED patients by Thai EPs vary. Most of the Thai EPs consider delirium in the ED an emergency condition, while far fewer screen for this condition. Future research and quality improvement should determine which single screening tool is appropriate for EPs in regular practice as well as how to standardize delirium management in the ED.