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.

Elderly patients with non-specific complaints at the emergency department have a high risk for admission and 30-days mortality.

BACKGROUND: Older adults have complex medical needs that causes increased use of resources at the emergency department (ED). The prevalence of non-specific complaint (NSC) as a chief-complaint in the ED is common among older adults and is not prioritized even though possibly having worse clinical outcome. The objective was to study hospital admission and mortality for older adults visiting the ED with NSC compared to specific complaints such as dyspnea, chest pain and abdominal pain. METHODS: A retrospective observational study of older adults visiting the ED with NSC and specific complaints; dyspnea, chest pain and abdominal pain was performed. Chief-complaint were collected from electronic medical records. Fatigue, confusion, non-specific complaints, generalized weakness and risk of falling were defined as non-specific complaint (NSC) when registered as chief-complaint at the ED. Admission rate and 30-days mortality were the primary outcomes. RESULTS: A total of 4927 patients were included in the study based on chief-complaint; patients with chest pain 1599 (32%), dyspnea 1343 (27%), abdominal pain 1460 (30%) and NSC 525 (11%). Patients with dyspnea and NSC had the highest hospital admission rate 79% vs 70% compared to patients with chest pain (63%) and abdominal pain (61%) (p = < 0.001). Patients with NSC had a mean LOS 4.7 h at the ED which was significantly higher compared to chest pain, dyspnea and abdominal pain. Mean bed-days for the whole population was 4.2 days compared to patients with NSC who had a mean LOS of 5.6 days. NSC and dyspnea were both associated with the highest 30-day mortality. CONCLUSION: Older patients who present with NSC at the ED are associated with a high risk for admission and 30-days mortality. In addition, patients with NSC have a longer LOS at the ED, a high admission rate and the highest number of bed-days once admitted. This study indicates that ED staff should be more vigilant when an elderly patient presents with NSC at the ED. Further studies and guidelines are needed to improve the management of these individuals.

Lack of patient and primary care physician follow-up in geriatric emergency department patients with head trauma from a fall.

STUDY OBJECTIVE: Falls are the leading cause of injuries in the US for older adults. Follow-up after an ED-related fall visit is essential to initiate preventive strategies in these patients who are at very high risk for recurrent falls. It is currently unclear how frequently follow-up occurs and whether preventive strategies are implemented. Our objective is to determine the rate of follow-up by older adults who sustain a fall related head injury resulting in an ED visit, the rate and type of risk assessment and adoption of preventive strategies. METHODS: This 1-year prospective observational study was conducted at two South Florida hospitals. All older ED patients with an acute head injury due to a fall were identified. Telephone surveys were conducted 14 days after ED presentation asking about PCP follow-up and adoption of fall prevention strategies. Clinical and demographic characteristics were compared between patients with and without follow up. RESULTS: Of 4951 patients with a head injury from a fall, 1527 met inclusion criteria. 905 reported follow-up with their PCP. Of these, 72% reported receiving a fall assessment and 56% adopted a fall prevention strategy. Participants with PCP follow-up were significantly more likely to have a history of cancer or hypertension. CONCLUSION: Only 60% of ED patients with fall-related head injury follow-up with their PCP. Further, 72% received a fall assessment and only 56% adopted a fall prevention strategy. These data indicate an urgent need to promote PCP fall assessment and adoption of prevention strategies in these patients.

A consensus statement on minimum operational standards for geriatric emergency care in Belgium: a modified Delphi study.

BACKGROUND: As emergency department (ED) leaders started integrating geriatric emergency guidelines on a facultative basis, important variations have emerged between EDs in care for older patients. The aim of this study was to establish a consensus on minimum operational standards for Geriatric ED care in Belgium. METHODS: A two-stage modified Delphi study was conducted. Twenty panellists were recruited from Dutch and French speaking regions in Belgium to join an interdisciplinary expert panel. In the first stage, an online survey was conducted to identify and define all possible elements of geriatric emergency care. In the second stage, an online survey and online expert panel meeting were organized consecutively to determine which elements should be recognized as minimum operational standards. RESULTS: Between March 2020 and February 2021, the expert panel developed a broad consensus including ten statements focusing on the target population, specific goals, availability of geriatric practitioners and quality assurance. Additionally, the expert panel also determined which protocols, materials and accommodation criteria should be available in conventional EDs (39 standards) and in observational EDs (57 standards). CONCLUSIONS: This study presents a consensus on minimum operational standards for geriatric emergency care in two ED types: the conventional ED and the observational ED. These findings may serve as a starting point towards broadly supported minimum standards of care stipulated by legislation in Belgium or other countries.

A survey on the availability of geriatric-friendly protocols, equipment and physical environment across emergency departments in Flanders, Belgium.

BACKGROUND: The acquisition of geriatric-friendly resources is an important part of adapting emergency department (ED) care to the needs of vulnerable older patients. The aim of this study was to explore the availability of geriatric-friendly protocols, equipment and physical environment criteria in EDs and to identify related improvement opportunities. METHODS: The head nurse of 63 EDs in Flanders and Brussels Capital Region was invited to complete a survey in collaboration with the chief physician of the ED. The questionnaire was inspired by the American College of Emergency Physicians Geriatric ED Accreditation Program and explored the availability, relevance and feasibility of geriatric-friendly protocols, equipment and physical environment. Descriptive analyses were performed. A region-wide improvement opportunity was defined as a resource that was never to occasionally (0-50%) available on Flemish EDs and was scored (rather or very) relevant by at least 75% of respondents. RESULTS: A total of 32 questionnaires were analysed. The response rate was 50.8%. All surveyed resources were available in at least one ED. Eighteen out of 52 resources (34.6%) were available in more than half of EDs. Ten region-wide improvement opportunities were identified. These comprised seven protocols and three physical environment characteristics: 1) a geriatric approach initiated from physical triage, 2) elder abuse, 3) discharge to residential facility, 4) frequent geriatric pathologies, 5) access to geriatric specific follow-up clinics, 6) medication reconciliation, 7) minimising 'nihil per os' designation, 8) a large-face, analogue clock in each patient room, 9) raised toilet seats and 10) non-slip floors. CONCLUSIONS: Currently available resources supporting optimal ED care for older patients in Flanders are very heterogeneous. Researchers, clinicians and policy makers need to define which geriatric-friendly protocols, equipment and physical environment criteria should become region-wide minimum operational standards. Findings of this study are relevant to facilitate the development process of this endeavour.

Older patients referred for geriatric consultation in the emergency department: characteristics and healthcare utilization.

BACKGROUND: Comprehensive geriatric assessment (CGA) is difficult to perform in the emergency department (ED) environment and performance of screening tools in identifying vulnerable older ED patients who are best candidates for a geriatric consultation remain questionable. AIM: To determine the characteristics of older patients referred for a geriatric consultation by ED staff and to investigate these patients' subsequent healthcare utilization. METHODS: Secondary analysis of data previously collected for a prospective observational study of patients aged 75 + years visiting the ED of an academic hospital in Switzerland over four months (Michalski-Monnerat et al., J Am Geriatr Soc 68(12):2914-20, 2020). Socio-demographic, health, functional (basic activities of daily living; BADL), cognitive, and affective status data were collected at admission by a research nurse using a standardized brief geriatric assessment. Information on geriatric consultations, hospitalization, discharge destination, and 30-day readmission were retrieved from hospital database. Bivariable and multivariable analyses were performed using this data set collected previously. RESULTS: Thirty-two (15.8%) of the 202 enrolled patients were referred for a geriatric consultation. Compared to the others, they were older (84.9 ± 5.4 vs 82.9 ± 5.4 years, p = .03), more impaired in BADL (4.8 ± 1.6 vs 5.5 ± 1.0, p = .01), with more comorbid conditions (5.3 ± 1.5 vs 4.5 ± 1.9, p = .03), more frequently admitted after a fall (43.7% vs 19.4%, p = .01), and hospitalized over the previous 6-month period (53.1% vs 30.6%, p = .02). Multivariable analyses that adjusted for variables significantly associated with outcomes in bivariable analysis found that being admitted after a fall (AdjOR 4.0, 95%CI 1.7-9.4, p < .01) and previously hospitalized (AdjOR 2.7, 95% CI 1.2-6.2, p = .02) remained associated with increased odds of consultation, whereas the inverse association with BADL performance remained (AdjOR 0.7, 95%CI 0.5-0.9, p = .01). Patients referred for geriatric consultation had higher odds of hospitalization (84.4% vs 49.4%; AdjOR 5.9, 95%CI 2.1-16.8, p < .01), but similar odds of home discharge when admitted, and of 30-day readmission. CONCLUSION: About one in six older ED patients were referred for a geriatric consultation who appeared to be those most vulnerable, as suggested by their increased hospitalization rate. Alternative strategies are needed to enhance access to geriatric consultation in the ED.

THE ASSOCIATION BETWEEN SYSTOLIC BLOOD PRESSURE AND HEART RATE IN EMERGENCY DEPARTMENT PATIENTS: A MULTICENTER COHORT STUDY.

BACKGROUND: Guidelines and textbooks assert that tachycardia is an early and reliable sign of hypotension, and an increased heart rate (HR) is believed to be an early warning sign for the development of shock, although this response may change by aging, pain, and stress. OBJECTIVE: To assess the unadjusted and adjusted associations between systolic blood pressure (SBP) and HR in emergency department (ED) patients of different age categories (18-50 years; 50-80 years; > 80 years). METHODS: A multicenter cohort study using the Netherlands Emergency department Evaluation Database (NEED) including all ED patients ≥ 18 years from three hospitals in whom HR and SBP were registered at arrival to the ED. Findings were validated in a Danish cohort including ED patients. In addition, a separate cohort was used including ED patients with a suspected infection who were hospitalized from whom measurement of SBP and HR were available prior to, during, and after ED treatment. Associations between SBP and HR were visualized and quantified with scatterplots and regression coefficients (95% confidence interval [CI]). RESULTS: A total of 81,750 ED patients were included from the NEED, and a total of 2358 patients with a suspected infection. No associations were found between SBP and HR in any age category (18-50 years: -0.03 beats/min/10 mm Hg, 95% CI -0.13-0.07, 51-80 years: -0.43 beats/min/10 mm Hg, 95% CI -0.38 to -0.50, > 80 years: -0.61 beats/min/10 mm Hg, 95% CI -0.53 to -0.71), nor in different subgroups of ED patient. No increase in HR existed with a decreasing SBP during ED treatment in ED patients with a suspected infection. CONCLUSION: No association between SBP and HR existed in ED patients of any age category, nor in ED patients who were hospitalized with a suspected infection, even during and after ED treatment. Emergency physicians may be misled by traditional concepts about HR disturbances because tachycardia may be absent in hypotension.

Measuring health-related quality of life of older people with frailty receiving acute care: feasibility and psychometric performance of the EuroQol EQ-5D.

BACKGROUND: Although outcome goals for acute healthcare among older people living with frailty often include Health-Related Quality of Life (HRQoL) and other patient-reported outcome measures (PROMs), current quality metrics usually focus on waiting times and survival. Lay and patient review have identified the EuroQol EQ-5D as a candidate measure for this setting. This research appraised the EQ-5D for feasibility, psychometric performance, and respondents' outcomes in the acute frailty setting. METHODS: People aged 65 + with Clinical Frailty Scale (CFS) 5-8 were recruited from eight UK hospitals' emergency care and acute admissions settings. They completed the five-level EQ-5D and the EQ-VAS. Feasibility was assessed with completion times and completeness. For reliability, response distributions and internal consistency were analysed. Finally, EQ-Index values were compared with demographic characteristics and service outcomes for construct validity. RESULTS: The 232 participants were aged 65-102. 38% responded in emergency departments and 62% in admissions wards. Median completion time was 12 (IQR, 11) minutes. 98% responses were complete. EQ-5D had acceptable response distribution (SD 1.1-1.3) and internal consistency (Cronbach's alpha 0.69). EQ-VAS demonstrated a midpoint response pattern. Median EQ-Index was 0.574 (IQR, 0.410) and was related positively with increasing age (p = 0.010) and negatively with CFS (p < 0.001). Participants with higher CFS had more frequent problems with mobility, self-care, and usual activities. CONCLUSIONS: Administration of the EQ-5D was feasible in these emergency and acute frailty care settings. EQ-5D had acceptable properties, while EQ-VAS appeared problematic. Participants with more severe frailty had also poorer HRQoL.

Association between emergency department modifiable risk factors and subsequent delirium among hospitalized older adults.

STUDY OBJECTIVE: To evaluate the association between potential emergency department (ED)-based modifiable risk factors and subsequent development of delirium among hospitalized older adults free of delirium at the time of ED stay. METHODS: Observational cohort study of patients aged ≥75 years who screened negative for delirium in the ED, were subsequently admitted to the hospital, and had delirium screening performed within 48 h of admission. Potential ED-based risk factors for delirium included ED length of stay (LOS), administration of opioids, benzodiazepines, antipsychotics, or anticholinergics, and the placement of urinary catheter while in the ED. Odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CIs) were calculated. RESULTS: Among 472 patients without delirium in the ED (mean age 84 years, 54.2% females), 33 (7.0%) patients developed delirium within 48 h of hospitalization. The ED LOS of those who developed delirium was similar to those who did not develop delirium (312.1 vs 325.6 min, MD -13.5 min, CI -56.1 to 29.0). Patients who received opioids in the ED were as likely to develop delirium as those who did not receive opioids (7.2% vs 6.9%: OR 1.04, CI 0.44 to 2.48). Patients who received benzodiazepines had a higher risk of incident delirium, the difference was clinically but not statistically significant (37.3% vs 6.5%, OR 5.35, CI 0.87 to 23.81). Intermittent urinary catheterization (OR 2.05, CI 1.00 to 4.22) and Foley placement (OR 3.69, CI 1.55 to 8.80) were associated with a higher risk of subsequent delirium. After adjusting for presence of dementia, only Foley placement in the ED remained significantly associated with development of in-hospital delirium (adjusted OR 3.16, CI 1.22 to 7.53). CONCLUSION: ED LOS and ED opioid use were not associated with higher risk of incident delirium in this cohort. Urinary catheterization in the ED was associated with an increased risk of subsequent delirium. These findings can be used to design ED-based initiatives and increase delirium prevention efforts.

Translator use not associated with longer time to pain medication in initial evaluation of low-severity geriatric trauma.

OBJECTIVES: Determine whether geriatric victims of blunt trauma who preferred to communicate in a language other than English waited longer for pain medication or received more imaging studies than English-speaking patients with the same age and injuries. Secondary outcomes were the type of medication administered and number of imaging studies. METHODS: We conducted a retrospective analysis of all trauma activations to a single academic urban medical center from January 2019 to October 2019. We included all hemodynamically stable patients older than 65, with head or torso trauma after a low energy injury, and on at least one medication that was an anti-coagulant, anti-platelet, or chemotherapeutic. RESULTS: We identified 1,153 unique patients (17, 379 radiologic studies) performed from January 2019 to October 2019, with a median of 5 (4-6) radiologic studies per patient. We excluded 419 patients for whom the language used was not reported (n = 7), no imaging was not reported (n = 16), or no medication was recorded as given (n = 409), leaving 734 patients for further analysis. Of those 734 patients, 460 preferred to communicate in English, 84 in Mandarin Chinese, 64 in Spanish, 37 in Cantonese Chinese, and 35 in Korean, and 29 in Russian. Across all languages patient age and Injury Severity Score (ISS) were comparable. Those who preferred to communicate in Spanish, Russian, or Korean were more likely to be female than those who preferred English, Mandarin, or Cantonese, but this tendency was not statistically significant (χ2-test; p = 0.051, 0.15 after Bonferroni correction). We did not find a statistically significant association between preferred language and time to medication, fraction of opioids used as first-line pain medication, or number of imaging studies performed. Across all patients, the most common medications administered were acetaminophen (524/734, 71%), any opioid (111/734, 15%), followed by local infiltration or nerve block with lidocaine (49/734, 6.7%). CONCLUSIONS: A retrospective analysis of patients with low-risk blunt trauma found no relationship between preferred language, time to pain medication, use of opioids or number of imaging studies.

Video-telehealth to support clinical assessment and management of acutely unwell older people in Residential Aged Care: a pre-post intervention study.

BACKGROUND: Older people living in Residential Aged Care (RAC) are at high risk of clinical deterioration. Telehealth has the potential to provide timely, patient-centred care where transfer to hospital can be a burden and avoided. The extent to which video telehealth is superior to other forms of telecommunication and its impact on management of acutely unwell residents in aged care facilities has not been explored previously. METHODS: In this study, video-telehealth consultation was added to an existing program, the Aged Care Emergency (ACE) program, aiming at further reducing Emergency Department (ED) visits and hospital admissions. This controlled pre-post study introduced video-telehealth consultation as an additional component to the ACE program for acutely unwell residents in RACs. Usual practice is for RACs and ACE to liaise via telephone. During the study, when the intervention RACs called the ED advanced practice nurse, video-telehealth supported clinical assessment and management. Five intervention RACs were compared with eight control RACs, all of whom refer to one community hospital in regional New South Wales, Australia. Fourteen months pre-video-telehealth was compared with 14 months post-video-telehealth using generalized linear mixed models for hospital admissions after an ED visit and ED visits. One thousand two hundred seventy-one ED visits occurred over the 28-month study period with 739 subsequent hospital admissions. RESULTS: There were no significant differences in hospital admission or ED visits after the introduction of video-telehealth; adjusted incident rate ratios (IRR) were 0.98 (confidence interval (CI) 0.55 to 1.77) and 0.89 (95% CI 0.53 to 1.47) respectively. CONCLUSIONS: Video-telehealth did not show any incremental benefit when added to a structured hospital avoidance program with nursing telephone support. TRIAL REGISTRATION: The larger Aged Care Emergency evaluation is registered with ANZ Clinical Trials Registry, ACTRN12616000588493.

Implementing a multidisciplinary rapid geriatric observation unit for non-critical older patients referred to hospital: observational study on real-world data.

BACKGROUND: Geriatric rapid observation units may represent an alternative to hospitalization in older patients with non-critical acute illness. AIMS: To describe the characteristics and outcomes of patients admitted to a geriatric observation unit called URGe (Unità Geriatrica Rapida), implemented in an Italian hospital and characterized by multidisciplinary medical staff with geriatric expertise, fast-track access to diagnostic resources, regular use of point-of-care ultrasound and predicted length of stay (LOS) < 72 h. METHODS: The medical records of patients admitted to URGe during a 3-month period (452 subjects, 247 F and 205 M, median age 82 years, IQR 77-87) were retrospectively examined. The primary study endpoint was transferral from URGe to regular wards. Baseline covariates included demographics, comprehensive geriatric assessment, acute illnesses, comorbidities, vital signs and routine laboratory tests. RESULTS: Despite elevated burden of multimorbidity (median number of chronic diseases 4, IQR 2-5) and frailty (median Rockwood Clinical Frailty Scale score 4, IQR 3-6), only 137 patients (30.3%) required transferral from URGe to regular wards. The main factors positively associated with this outcome were Rockwood score, fever, cancer and red cell distribution width (P < 0.05 on multivariate logistic regression model). The rate of complications (mortality, delirium, and falls) during URGe stay was low (0.5%, 7% and 2%, respectively). Overall duration of hospital stay was lower than that of a group of historical controls matched by age, sex, main diagnosis, multimorbidity and frailty. CONCLUSIONS: The URGe model of acute geriatric care is feasible, safe and has the potential of reducing unnecessary hospitalizations of older patients.

Emergency department use and length of stay by younger and older adults: Nottingham cohort study in the emergency department (NOCED).

BACKGROUND: Younger and older adults attending the Emergency Department (ED) are a heterogeneous population. Longer length of ED stay is associated with adverse outcomes and may vary by age. AIMS: To evaluate the associations between age and (1) clinical characteristics and (2) length of ED stay among adults attending ED. METHODS: The NOttingham Cohort study in the Emergency Department (NOCED)-a retrospective cohort study-comprises new consecutive ED attendances by adults ≥ 18 years, at a secondary/tertiary care hospital, in 2019. Length of ED stay was dichotomised as < 4 and ≥ 4 h. The associations between age and length of ED stay were analysed by binary logistic regression and adjusted for socio-demographic and clinical factors including triage acuity. RESULTS: 146,636 attendances were analysed; 75,636 (51.6%) resulted in a length of ED stay ≥ 4 h. Attendances of adults aged 65 to 74 years, 75 to 84 years and ≥ 85 years, respectively, had an increased risk (odds ratio (95% confidence interval) of length of ED stay ≥ 4 h of 1.52 (1.45-1.58), 1.65 (1.58-1.72), and 1.84 (1.75-1.93), compared to those of adults 18 to 64 years (all p < 0.001). These findings remained consistent in the subsets of attendances leading to hospital admission and those leading to discharge from ED. DISCUSSION AND CONCLUSION: In this real-world cohort study, older adults were more likely to have a length of ED stay ≥ 4 h, with the oldest old having the highest risk. ED target times should take into account age of attendees.

Dutch emergency physicians insufficiently educated in geriatric emergency medicine: results of a nationwide survey.

BACKGROUND: Emergency physicians (EPs) provide care to older adults with complex health problems. Treating these patients is challenging for many EPs, which might originate from modest geriatric education. OBJECTIVE: Our aim was to assess EPs' self-perceived needs regarding geriatric emergency medicine (GEM) education, factors determining these needs and the utilization of this education. Our secondary aim was to assess emergency department (ED) managers' view and support for GEM education. METHODS: All EPs and ED managers in the Netherlands received a survey by e-mail. The questionnaires focused on EPs' needs in GEM education, EPs' utilization of GEM education and managerial support for GEM education. We used descriptive statistics to analyse needs, utilization of- and support for GEM education. Regression analyses were used to identify factors associated with EPs' need for GEM education. RESULTS: EPs reported to need better training in diagnosing, treating and communicating with older adults. Seventy percent of EPs reported no GEM education program in their hospital, and 83% reported no utilization of GEM education outside their hospital. EPs working in EDs with a possibility for geriatric consultation, and EPs aware of actual GEM education programs, had lower educational needs. Of responding managers, 86.2% reported the care for older adults as an important topic; lack of finances and time were obstacles to provide GEM education for EPs. CONCLUSION: EPs in the Netherlands feel insufficiently educated to treat older adults. ED managers largely recognize this educational challenge. This nationwide survey underlines the need to prioritize GEM education for EPs.

Silver Book II: an international framework for urgent care of older people in the first 72 hours from illness or injury.

The new edition of the Silver Book, Silver Book II, provides a framework for the urgent care of older people in the first 72 hours from illness or injury. It incorporates principles of geriatric medicine, quality improvement (including patient reported outcome measures) and interdisciplinary care in a balanced, practical and evidence-rich manual on unscheduled and emergent care for older adults. Silver Book II shows how frailty, comprehensive geriatric assessment and shared decision-making can be locally adapted according to national practice and policy across the world. The challenge for all providers is adapting our models of care to meet the changing needs of older patients and their caregivers as well as changes in the delivery of medical care in the 21st century.

Structure and processes of emergency observation units with a geriatric focus: a scoping review.

BACKGROUND: Combining observation principles and geriatric care concepts is considered a promising strategy for risk-stratification of older patients with emergency care needs. We aimed to map the structure and processes of emergency observation units (EOUs) with a geriatric focus and explore to what extent the comprehensive geriatric assessment (CGA) approach was implemented in EOUs. METHODS: The revised scoping methodology framework of Arksey and O'Malley was applied. Manuscripts reporting on dedicated areas within hospitals for observation of older patients with emergency care needs were eligible for inclusion. Electronic database searches were performed in MEDLINE, EMBASE and CINAHL in combination with backward snowballing. Two researchers conducted data charting independently. Data-charting forms were developed and iteratively refined. Data inconsistencies were judged by a third researcher or discussed in the research team. Quality assessment was conducted with the Methodological Index for Non-Randomized Studies. RESULTS: Sixteen quantitative studies were included reporting on fifteen EOUs in seven countries across three continents. These units were located in the ED, immediately next to the ED or remote from the ED (i.e. hospital-based). All studies reported that staffing consisted of at least three healthcare professions. Observation duration varied between 4 and 72 h. Most studies focused on medical and functional assessment. Four studies reported to assess a patients' medical, functional, cognitive and social capabilities. If deemed necessary, post-discharge follow-up (e.g. community/primary care services and/or outpatient clinics) was provided in eleven studies. CONCLUSION: This scoping review documented that the structure and processes of EOUs with a geriatric focus are very heterogeneous and rarely cover all elements of CGA. Further research is necessary to determine how complex care principles of 'observation medicine' and 'CGA' can ideally be merged and successfully implemented in clinical care.

Implementation of the acutely presenting older patient (APOP) screening program in routine emergency department care : A before-after study.

OBJECTIVE: The aim of this study was to evaluate the effects of implementation of the acutely presenting older patient (APOP) screening program for older patients in routine emergency department (ED) care shortly after implementation. METHODS: We conducted an implementation study with before-after design, using the plan-do-study-act (PDSA) model for quality improvement, in the ED of a Dutch academic hospital. All consecutive patients ≥ 70 years during 2 months before and after implementation were included. The APOP program comprises screening for risk of functional decline, mortality and cognitive impairment, targeted interventions for high-risk patients and education of professionals. Outcome measures were compliance with interventions and impact on ED process, length of stay (LOS) and hospital admission rate. RESULTS: Two comparable groups of patients (median age 77 years) were included before (n = 920) and after (n = 953) implementation. After implementation 560 (59%) patients were screened of which 190 (34%) were high-risk patients. Some of the program interventions for high-risk patients in the ED were adhered to, some were not. More hospitalized patients received comprehensive geriatric assessment (CGA) after implementation (21% before vs. 31% after; p = 0.002). In 89% of high-risk patients who were discharged to home, telephone follow-up was initiated. Implementation did not influence median ED LOS (202 min before vs. 196 min after; p = 0.152) or hospital admission rate (40% before vs. 39% after; p = 0.410). CONCLUSION: Implementation of the APOP screening program in routine ED care did not negatively impact the ED process and resulted in an increase of CGA and telephone follow-up in older patients. Future studies should investigate whether sustainable changes in management and patient outcomes occur after more PDSA cycles.

Feasibility and acceptability of the 'Acutely Presenting Older Patient' screener in routine emergency department care.

BACKGROUND: risk stratification tools for older patients in the emergency department (ED) have rarely been implemented successfully in routine care. OBJECTIVE: to evaluate the feasibility and acceptability of the 'Acutely Presenting Older Patient' (APOP) screener, which identifies older ED patients at the highest risk of adverse outcomes within 2 minutes at presentation. DESIGN AND SETTING: 2-month prospective cohort study, after the implementation of the APOP screener in ED routine care in the Leiden University Medical Center. SUBJECTS: all consecutive ED patients aged ≥70 years. METHODS: feasibility of screening was assessed by measuring the screening rate and by identifying patient- and organisation-related determinants of screening completion. Acceptability was assessed by collecting experienced barriers of screening completion from triage-nurses. RESULTS: we included 953 patients with a median age of 77 (IQR 72-82) years, of which 560 (59%) patients were screened. Patients had a higher probability of being screened when they had a higher age (OR 1.03 (95%CI 1.01-1.06), P = 0.017). Patients had a lower probability of being screened when they were triaged very urgent (OR 0.55 (0.39-0.78), P = 0.001) or when the number of patients upon arrival was high (OR 0.63 (0.47-0.86), P = 0.003). Experienced barriers of screening completion were patient-related ('patient was too sick'), organisation-related ('ED was too busy') and personnel-related ('forgot to complete screening'). CONCLUSION: with more than half of all older patients screened, feasibility and acceptability of screening in routine ED care is very promising. To further improve screening completion, solutions are needed for patients who present with high urgency and during ED rush hours.

The GAP-ED Project: Improving Care for Elderly Patients Presenting to the Emergency Department.

BACKGROUND: Older adults presenting to the emergency department (ED) represent a highly vulnerable patient population with complex conditions and multiple comorbidities. The introduction of a Geriatric and Palliative (GAP)-ED partnership may be an effective strategy to avoid unneeded admissions and improve outcomes for this population. OBJECTIVES: The primary objective was to decrease 30-day revisit and hospitalization rates in this population through identifying patients that could be safely sent home with connection to community resources. Secondary outcomes included achieving high patient and family satisfaction scores assessed through follow-up interviews. METHODS: The GAP-ED intervention included the placement of a Specialist in the ED to coordinate care for older adults presenting to the ED who were likely to be discharged home. Independent t-tests and chi-squared tests were used to assess for changes in outcomes between the intervention group and a blocked matched historical usual-care group. RESULTS: There was no significant difference in 30-day ED revisits between the two groups, but there was a statistically significant reduction in hospital admissions from these 30-day revisits. Patient and family satisfaction with the presence of the GAP-ED Specialist was high. CONCLUSION: The implementation of a GAP-ED partnership and use of a GAP-ED Specialist is an effective means of reducing hospitalization in older adults revisiting the ED.

Utility of a Medical Alert Protection System compared to telephone follow-up only for home-alone elderly presenting to the ED - A randomized controlled trial.

OBJECTIVE: Medical Alert Protection Systems (MAPS) are a form of assistive technology designed to support independent living in the care of elderly patients in the community. We aimed to investigate the utility of using such a device (eAlert! System) in elderly patients presenting to an Emergency Department (ED). METHODS: Elderly patients presenting to an ED were randomized to receive MAPS or telephone follow-up only (control arm). All patients were followed up at one-week, one-month and six-month post-intervention. A confidence scale (at 1week, 1month and 6months) and EQ-5D score (at 6months) were also administered. RESULTS: 106 and 91 participants enrolled in the MAPS and control arms respectively. Within both individual arms, there were significant reductions in the median number of ED visits and median number of admissions in the six month periods before, compared to after intervention (p<0.01 for both). However, the reductions were not significantly different between the two arms. Among participants who have had one or more admissions during the six months period post intervention, the MAPS arm had significantly lower median total length of stay (8days, Interquartile Range [IQR]=(4, 14)) compared to the control arm (15days, IQR=(3, 25), p=0.045). The median health state score for health state was significantly higher in the MAPS arm (70 IQR=(60,80) versus 60 IQR=(50,70), p=0.008). CONCLUSION: In this population of elderly ED patients, the use of a MAPS decreased length of stay for admissions and improved quality of life measures.