Enhancing healthcare access for an older population: The age-friendly emergency department.

Healthcare systems face significant challenges in meeting the unique needs of older adults, particularly in the acute setting. Age-friendly healthcare is a comprehensive approach using the 4Ms framework-what matters, medications, mentation, and mobility-to ensure that healthcare settings are responsive to the needs of older patients. The Age-Friendly Emergency Department (AFED) is a crucial component of a holistic age-friendly health system. Our objective is to provide an overview of the AFED model, its core principles, and the benefits to older adults and healthcare clinicians. The AFED optimizes the delivery of emergency care by integrating age-specific considerations into various aspects of (1) ED physical infrastructure, (2) clinical care policies, and (3) care transitions. Physical infrastructure incorporates environmental modifications to enhance patient safety, including adequate lighting, nonslip flooring, and devices for sensory and ambulatory impairment. Clinical care policies address the physiological, cognitive, and psychosocial needs of older adults while preserving focus on emergency issues. Care transitions include communication and involving community partners and case management services. The AFED prioritizes collaboration between interdisciplinary team members (ED clinicians, geriatric specialists, nurses, physical/occupational therapists, and social workers). By adopting an age-friendly approach, EDs have the potential to improve patient-centered outcomes, reduce adverse events and hospitalizations, and enhance functional recovery. Moreover, healthcare clinicians benefit from the AFED model through increased satisfaction, multidisciplinary support, and enhanced training in geriatric care. Policymakers, healthcare administrators, and clinicians must collaborate to standardize guidelines, address barriers to AFEDs, and promote the adoption of age-friendly practices in the ED.

Risk factors and risk stratification approaches for delirium screening: A Geriatric Emergency Department Guidelines 2.0 systematic review.

OBJECTIVE: As part of the Geriatric Emergency Department (ED) Guidelines 2.0 project, we conducted a systematic review to find risk factors or risk stratification approaches that can be used to identify subsets of older adults who may benefit from targeted ED delirium screening. METHODS: An electronic search strategy was developed with a medical librarian, conducted in April 2021 and November 2022. Full-text studies of patients ≥65 years assessed for prevalent delirium in the ED were included. Risk of bias was assessed using the McMaster University Clarity Group tool. Outcomes measures pertained to the risk stratification method used. Due to heterogeneity of patient populations, risk stratification methods, and outcomes, a meta-analysis was not conducted. RESULTS: Our search yielded 1878 unique citations, of which 13 were included. Six studies developed a novel delirium risk score with or without evaluation of specific risk factors, six studies evaluated specific risk factors only, and one study evaluated an existing nondelirium risk score for association with delirium. The most common risk factor was history of dementia, with odds ratios ranging from 3.3 (95% confidence interval [CI] 1.2-8.9) to 18.33 (95% CI 8.08-43.64). Other risk factors that were consistently associated with increased risk of delirium included older age, use of certain medications (such as antipsychotics, antidepressants, and opioids, among others), and functional impairments. Of the studies that developed novel risk scores, the reported area under the curve ranged from 0.77 to 0.90. Only two studies reported potential impact of the risk stratification tool on screening burden. CONCLUSIONS: There is significant heterogeneity, but results suggest that factors such as dementia, age over 75, and functional impairments should be used to identify older adults who are at highest risk for ED delirium. No studies evaluated implementation of a risk stratification method for delirium screening or evaluated patient-oriented outcomes.

Emergency department communication with diverse caregivers and persons living with dementia: A qualitative study.

BACKGROUND: Research to date has detailed numerous challenges in emergency department (ED) communication with persons living with dementia (PLWD) and their caregivers. However, little is known about communication experiences of individuals belonging to minoritized racial and ethnic groups, who are disproportionately impacted by dementia and less likely to be included in dementia research. METHODS: We conducted semi-structured interviews with 29 caregivers of PLWD from two urban academic hospital EDs with distinct patient populations. The first site is an ED in the Northeast serving a majority White, English-speaking, and insured population. The second site is an ED in the South serving a majority Black and/or Hispanic, Spanish-speaking, and underinsured population. Interviews lasted an average of 25 min and were digitally recorded and transcribed. We used an inductive approach to analyze interview transcripts for dominant themes and compared themes between sites. RESULTS: Our sample included caregivers of diverse racial and ethnic backgrounds. Caregivers cared for PLWD who spoke English, Spanish, Arabic, Chinese, and Vietnamese. We identified three themes. First, caregiver advocacy was central to experiences of ED communication, particularly when PLWD primarily spoke a non-English language. Second, routine care plans did not address what mattered most to participants and PLWD. Participants felt that care arose from protocols and did not address what mattered most to them. Third, White English-speaking caregivers in Site 1 more commonly expected ED staff to engage them in care decision-making than Black, Hispanic, Asian, and Middle Eastern caregivers in Site 2. CONCLUSION: Language barriers amplify the higher intensity care needed by PLWD in the ED. Strategies should be developed for communicating with PLWD and caregivers about what matters most in their ED care.

Frailty assessment tools in the emergency department: A geriatric emergency department guidelines 2.0 scoping review.

Objective: Given the aging population and growing burden of frailty, we conducted this scoping review to describe the available literature regarding the use and impact of frailty assessment tools in the assessment and care of emergency department (ED) patients older than 60 years. Methods: A search was made of the available literature using the Covidence system using various search terms. Inclusion criteria comprised peer-reviewed literature focusing on frailty screening tools used for a geriatric population (60+ years of age) presenting to EDs. An additional search of PubMed, EBSCO, and CINAHL for articles published in the last 5 years was conducted toward the end of the review process (January 2023) to search specifically for literature describing interventions for frailty, yielding additional articles for review. Exclusion criteria comprised articles focusing on an age category other than geriatric and care environments outside the emergency care setting. Results: A total of 135 articles were screened for inclusion and 48 duplicates were removed. Of the 87 remaining articles, 20 were deemed irrelevant, leaving 67 articles for full-text review. Twenty-eight were excluded for not meeting inclusion criteria, leaving 39 full-text studies. Use of frailty screening tools were reported in the triage, care, and discharge decision-making phases of the ED care trajectory, with varying reports of usefulness for clinical decision-making. Conclusion: The literature reports tools, scales, and instruments for identifying frailty in older patients at ED triage; multiple frailty scores or tools exist with varying levels of utilization. Interventions for frailty directed at the ED environment were scant. Further research is needed to determine the usefulness of frailty identification in the context of emergency care, the effects of care delivery interventions or educational initiatives for front-line medical professionals on patient-oriented outcomes, and to ensure these initiatives are acceptable for patients.

A protocol to determine the acceptability and feasibility of a pilot intervention emergency department virtual observation unit fall prevention program.

BACKGROUND: As a third of all community dwellers aged 65+ fall each year, falls are common reasons for older adults to present to an Emergency Department (ED). Although EDs should assess patients' multifactorial fall risks to prevent future fall-related injuries, this frequently does not occur. We describe our protocol to determine the feasibility, acceptability, and safety of a pilot ED Virtual Observation Unit (VOU) Falls program. METHODS: To ensure standardized conduct and reporting, the Standard Protocol Items for Intervention Trials (SPIRIT) guidelines will be used. The VOU is a program where patients are sent home from the ED but are part of a virtual observation unit in that they can call on-call ED physicians while they are being treated for conditions such as cellulitis, congestive heart failure, or pneumonia. A paramedic conducts daily visits with the patient and facilitates a telemedicine consult with an ED physician. VOU nursing staff conduct daily assessments of patients via telemedicine. The ED VOU Falls program is one of the VOU pathways and is a multi-component fall prevention program for fall patients who present after an ED visit. The paramedic conducts a home safety evaluation, a Timed Up and Go Test (TUG). During the VOU visit, the ED physician conducts a telemedicine visit, while the paramedic is visiting the home, to review patients' fall-risk-increasing drugs and their TUG test. We will determine feasibility by calculating rates of patient enrollment refusal, and adherence to fall-risk prevention recommendations using information from 3-month follow-up telephone calls, as well as qualitative interviews with the paramedics. We will determine the acceptability of the ED VOU Falls program based on patient and provider surveys using a Likert scale. We will ask VOU nursing staff to report any safety issues encountered while the patient is in the ED VOU Falls program (e.g., tripping hazards). We will use the chi-square test or Fisher's exact test for categorical variables, Student's t-test for continuous variables, and Mann-Whitney for nonparametric data. We will review interview transcripts and generate codes. Codes will then be extracted and organized into concepts to generate an overall theme following grounded theory methods. This is a pilot study; hence, results cannot be extrapolated. However, a definite trial would be the next step in the future to determine if such a program could be implemented as part of fall prevention interventions. DISCUSSION: This study will provide insights into the feasibility and acceptability of a novel ED VOU Falls program with the aim of ultimately decreasing falls. In the future, such a program could be implemented as part of fall prevention interventions.

Differences in code status practice patterns among emergency clinicians working in Japan and the United States.

OBJECTIVE: This study aimed to examine self-reported code-status practice patterns among emergency clinicians from Japan and the U.S. METHODS: A cross-sectional questionnaire was distributed to emergency clinicians from one academic medical center and four general hospitals in Japan and two academic medical centers in the U.S. The questionnaire was based on a hypothetical case involving a critically ill patient with end-stage lung cancer. The questionnaire items assessed whether respondent clinicians would be likely to pose questions to patients about their preferences for medical procedures and their values and goals. RESULTS: A total of 176 emergency clinicians from Japan and the U.S participated. After adjusting for participants' backgrounds, emergency clinicians in Japan were less likely to pose procedure-based questions than those in the U.S. Conversely, emergency clinicians in Japan showed a statistically higher likelihood of asking 10 out of 12 value-based questions. CONCLUSION: Significant differences were found between emergency clinicians in Japan and the U.S. in their reported practices on posing procedure-based and patient value-based questions. PRACTICE IMPLICATIONS: Serious illness communication training based in the U.S. must be adapted to the Japanese context, considering the cultural characteristics and practical responsibilities of Japanese emergency clinicians.

Delirium detection in the emergency department: A diagnostic accuracy meta-analysis of history, physical examination, laboratory tests, and screening instruments.

INTRODUCTION: Geriatric emergency department (ED) guidelines emphasize timely identification of delirium. This article updates previous diagnostic accuracy systematic reviews of history, physical examination, laboratory testing, and ED screening instruments for the diagnosis of delirium as well as test-treatment thresholds for ED delirium screening. METHODS: We conducted a systematic review to quantify the diagnostic accuracy of approaches to identify delirium. Studies were included if they described adults aged 60 or older evaluated in the ED setting with an index test for delirium compared with an acceptable criterion standard for delirium. Data were extracted and studies were reviewed for risk of bias. When appropriate, we conducted a meta-analysis and estimated delirium screening thresholds. RESULTS: Full-text review was performed on 55 studies and 27 were included in the current analysis. No studies were identified exploring the accuracy of findings on history or laboratory analysis. While two studies reported clinicians accurately rule in delirium, clinician gestalt is inadequate to rule out delirium. We report meta-analysis on three studies that quantified the accuracy of the 4 A's Test (4AT) to rule in (pooled positive likelihood ratio [LR+] 7.5, 95% confidence interval [CI] 2.7-20.7) and rule out (pooled negative likelihood ratio [LR-] 0.18, 95% CI 0.09-0.34) delirium. We also conducted meta-analysis of two studies that quantified the accuracy of the Abbreviated Mental Test-4 (AMT-4) and found that the pooled LR+ (4.3, 95% CI 2.4-7.8) was lower than that observed for the 4AT, but the pooled LR- (0.22, 95% CI 0.05-1) was similar. Based on one study the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is the superior instrument to rule in delirium. The calculated test threshold is 2% and the treatment threshold is 11%. CONCLUSIONS: The quantitative accuracy of history and physical examination to identify ED delirium is virtually unexplored. The 4AT has the largest quantity of ED-based research. Other screening instruments may more accurately rule in or rule out delirium. If the goal is to rule in delirium then the CAM-ICU or brief CAM or modified CAM for the ED are superior instruments, although the accuracy of these screening tools are based on single-center studies. To rule out delirium, the Delirium Triage Screen is superior based on one single-center study.

A Qualitative Study of Emergency Department Delirium Prevention Initiatives.

Background: Delirium is a serious but preventable syndrome of acute brain failure. It affects 15% of patients presenting to emergency care and up to half of hospitalized patients. The emergency department (ED) often represents the entry point for hospital care for older adults and as such is an important site for delirium prevention. Objective: We sought to characterize delirium prevention initiatives in EDs in the United States and Canada. Methods: We conducted qualitative interviews with 16 ED administrators representing 14 EDs with delirium prevention initiatives. We used a combined deductive-inductive approach to code responses about involved staff, target patient population, and delirium prevention activities. Results: ED delirium prevention initiatives were largely driven by bedside nurses and occurred on an ad hoc basis, rather than systematically. Due to resource limitations, three EDs targeted older adults with high-risk conditions for delirium, rather than all patients age 65 and over. The most common delirium prevention interventions were offering assistive sensory devices (hearing amplifiers, reading glasses), having a toileting protocol, and offering patients food and drink. Conclusions: As minimal evidence exists about effective ED delirium prevention practices, low-cost and low-risk activities outlined by study participants are reasonable to use to improve patient experience and staff satisfaction.