What matters most in acute care: an interview study with older people living with frailty.

BACKGROUND: Healthcare outcome goals are central to person-centred acute care, however evidence among older people is scarce. Older people who are living with frailty have distinct requirements for healthcare delivery and have distinct risk for adverse outcomes from healthcare. There is insufficient evidence for whether those living with frailty also have distinct healthcare outcome goals. This study explored the nature of acute care outcome goals in people living with frailty. METHODS: Healthcare outcome goals were explored using semi-structured patient interviews. Participants aged over 65 with Clinical Frailty Score 5-8 (mild to very severe frailty) were recruited during their first 72 hours in a UK hospital. Purposive, maximum variation sampling was guided by lay partners from a Patient and Public Involvement Forum specialising in ageing-related research. Qualitative analysis used a blended approach based on framework and constant comparative methodologies for the identification of themes. Findings were validated through triangulation with participant, lay partner, and technical expert review. RESULTS: The 22 participants were aged 71 to 98 and had mild to very severe frailty. One quarter were living with dementia. Most participants had reflected on their situation and considered their outcome goals. Theme categories (and corresponding sub-categories) were 'Autonomy' (information, control, and security) and 'Functioning' (physical, psychosocial, and relief). A novel 'security' theme was identified, whereby participants sought to feel safe in their usual living place and with their health problems. Those living with milder frailty were concerned to maintain ability to support loved ones, while those living with most severe frailty were concerned about burdening others. CONCLUSIONS: Outcome goals for acute care among older participants living with frailty were influenced by the insecurity of their situation and fear of deterioration. Patients may be supported to feel safe and in control through appropriate information provision and functional support.

What older people want from emergency care: a systematic review.

OBJECTIVES: To evaluate the expectations and preferred outcomes from emergency care among older people or their caregivers. METHODS: A review protocol was registered. Medline, Embase, CINAHL, PsychInfo, BNI, AgeInfo and the Cochrane Database of Systematic Reviews were searched in their full date ranges to September 2018. Included articles were hand-searched for further citations. Citations were screened for (1) older people aged over 65 years, (2) ED settings and (3) reporting expectations or preferred outcomes for emergency care (as opposed to experience or satisfaction). Quality appraisal and data extraction of eligible articles were undertaken by two reviewers. Themes were synthesised through content analysis and described narratively. RESULTS: Older people wished to have prompt waiting times, efficient care, clear communication and comfortable environments. They had additional and unique expectations for holistic care and support in decision-making. The ED provoked a sense of vulnerability among older people who were likely to have had frailty. CONCLUSION: The lack of dominant themes among included studies suggests that older people should be treated as individuals rather than a homogenous group. Establishing individuals' preferred outcomes could improve person-centred care. PROSPERO REGISTRATION NUMBER: CRD42018107050.

The effect of relative hypotension on 30-day mortality in older people receiving emergency care.

Research has observed increased mortality among older people attending the emergency department (ED) who had systolic pressure > 7 mmHg lower than baseline primary care values. This study aimed to (1) assess feasibility of identifying this 'relative hypotension' using readily available ED data, (2) externally validate the 7 mmHg threshold, and (3) refine a threshold for clinically important relative hypotension. A single-centre retrospective cohort study linked year 2019 data for ED attendances by people aged over 64 to hospital discharge vital signs within the previous 18 months. Frailty and comorbidity scores were calculated. Previous discharge ('baseline') vital signs were subtracted from initial ED values to give individuals' relative change. Cox regression analysis compared relative hypotension > 7 mmHg with mean time to mortality censored at 30 days. The relative hypotension threshold was refined using a fully adjusted risk tool formed of logistic regression models. Receiver operating characteristics were compared to NEWS2 models with and without incorporation of relative systolic. 5136 (16%) of 32,548 ED attendances were linkable with recent discharge vital signs. Relative hypotension > 7 mmHg was associated with increased 30-day mortality (HR 1.98; 95% CI 1.66-2.35). The adjusted risk tool (AUC: 0.69; sensitivity: 0.61; specificity: 0.68) estimated each 1 mmHg relative hypotension to increase 30-day mortality by 2% (OR 1.02; 95% CI 1.02-1.02). 30-day mortality prediction was marginally better with NEWS2 (AUC: 0.73; sensitivity: 0.59; specificity: 0.78) and NEWS2 + relative systolic (AUC: 0.74; sensitivity: 0.63; specificity: 0.75). Comparison of ED vital signs with recent discharge observations was feasible for 16% individuals. The association of relative hypotension > 7 mmHg with 30-day mortality was externally validated. Indeed, any relative hypotension appeared to increase risk, but model characteristics were poor. These findings are limited to the context of older people with recent hospital admissions.

A systematic review and recommendations for prom instruments for older people with frailty in emergency care.

INTRODUCTION: The current service metrics used to evaluate quality in emergency care do not account for specific healthcare outcome goals for older people living with frailty. These have previously been classified under themes of 'Autonomy' and 'Functioning'. There is no person-reported outcome measure (PROM) for older people with frailty and emergency care needs. This study aimed to identify and co-produce recommendations for instruments potentially suitable for use in this population. METHODS: In this systematic review, we searched six databases for PROMs used between 2010 and 2021 by older people living with frailty receiving acute hospital care. Studies were reviewed against predefined eligibility criteria and appraised for quality using the COSMIN Risk of Bias checklist. Data were extracted to map instrument constructs against an existing framework of acute healthcare outcome goals. Instrument face and content validity were assessed by lay collaborators. Recommendations for instruments with potential emergency care suitability were formed through co-production. RESULTS: Of 9392 unique citations screened, we appraised the full texts of 158 studies. Nine studies were identified, evaluating nine PROMs. Quality of included studies ranged from 'doubtful' to 'very good'. Most instruments had strong evidence for measurement properties. PROMs mainly assessed 'Functioning' constructs, with limited coverage of 'Autonomy'. Five instruments were considered too burdensome for the emergency care setting or too specific for older people living with frailty. CONCLUSIONS: Four PROMs were recommended as potentially suitable for further validation with older people with frailty and emergency care needs: COOP/WONCA charts, EuroQol, McGill Quality of Life (Expanded), and Palliative care Outcome Scale.

The effect of hypertonic saline dextran on whole blood coagulation.

Hypertonic saline dextran (RescueFlow) is being promoted for resuscitation from hypovolaemia following injury. We studied the in vitro effect on coagulation of serial dilutions of blood with this fluid. There was a mild procoagulant effect up to a dilution of 11% and an anticoagulant effect above this level, which rapidly increased so that coagulation was grossly deranged at a 15% dilution. Although the clinical significance of these findings is not yet known, it may suggest that for hypertonic saline dextran there is little to separate the top of the therapeutic window from the threshold of potentially serious adverse effects.