Healthcare risk stratification model for emergency departments based on drugs, income and comorbidities: the DICER-score.

BACKGROUND: During the last decade, the progressive increase in age and associated chronic comorbidities and polypharmacy. However, assessments of the risk of emergency department (ED) revisiting published to date often neglect patients' pharmacotherapy plans, thus overseeing the Drug-related problems (DRP) risks associated with the therapy burden. The aim of this study is to develop a predictive model for ED revisit, hospital admission, and mortality based on patient's characteristics and pharmacotherapy. METHODS: Retrospective cohort study including adult patients visited in the ED (triage 1, 2, or 3) of multiple hospitals in Catalonia (Spain) during 2019. The primary endpoint was a composite of ED visits, hospital admission, or mortality 30 days after ED discharge. The study population was randomly split into a model development (60%) and validation (40%) datasets. The model included age, sex, income level, comorbidity burden, measured with the Adjusted Morbidity Groups (GMA), and number of medications. Forty-four medication groups, associated with medication-related health problems, were assessed using ATC codes. To assess the performance of the different variables, logistic regression was used to build multivariate models for ED revisits. The models were created using a "stepwise-forward" approach based on the Bayesian Information Criterion (BIC). Area under the curve of the receiving operating characteristics (AUCROC) curve for the primary endpoint was calculated. RESULTS: 851.649 patients were included; 134.560 (15.8%) revisited the ED within 30 days from discharge, 15.2% were hospitalized and 9.1% died within 30 days from discharge. Four factors (sex, age, GMA, and income level) and 30 ATC groups were identified as risk factors and combined into a final score. The model showed an AUCROC values of 0.720 (95%CI:0.718-0.721) in the development cohort and 0.719 (95%CI.0.717-0.721) in the validation cohort. Three risk categories were generated, with the following scores and estimated risks: low risk: 18.3%; intermediate risk: 40.0%; and high risk: 62.6%. CONCLUSION: The DICER score allows identifying patients at high risk for ED revisit within 30 days based on sociodemographic, clinical, and pharmacotherapeutic characteristics, being a valuable tool to prioritize interventions on discharge.

Frailty and mortality: Utility of Frail-VIG index in ED short-stay units for older adults.

BACKGROUND: Frailty assessment allows the identification of patients at risk of death. The aim here was to study the ability of Frail-VIG Index (FI-VIG) in order to discriminate frailty groups of older adults and garner its correlation with mortality in an Emergency-Department Short-Stay Unit (ED-SSU). METHODS: Our observational, single-center, prospective study consecutively included patients over 65-years-old admitted between March 1, 2021, and April 30, 2021. RESULTS: 302 patients were included (56 % women), mean age 83 ± 8 years, and 39.1 % of them had a functional disability whilst 16.5 % of them had dementia. A total of 174 patients (58 %) met the frailty criteria (FI-VIG ≥ 0.2): 111 (63.8 %) had mild frailty (FI-VIG 0.2-0.36), 52 (29.9 %) had moderate frailty (FI-VIG 0.36-0.55), and 11 (6.3 %) had advanced frailty (FI-VIG > 0.55). Mortality at 30 days, 6 months, and 1 year was analyzed: no frailty was 6.3 %, 10.8 %, and 12.5 %, respectively; mild frailty was 10.8 %, 22.5 %, and 22.5 %, respectively; moderate frailty was 25 %, 34.6 %, and 42.3 %, respectively; advanced frailty was 36.4 %, 54.5 %, and 3.6 %, respectively. This shows the significant differences between the groups (1-year mortality p < 0.001). Mild frailty vs. non-frail HR was 2.47 (95 %CI 1.12-5.46), moderate frailty vs. non-frail HR was 6.93 (95 %CI 3.16-15.23), and advanced frailty vs. non-frail HR was 11.29 (95 %CI 3.54-36.03). The mean test time was 7 min. CONCLUSIONS: There was a strong correlation between frailty degree and mortality at 1, 6, and 12 months. FI-VIG is fast and easy-to-use in this setting. It is routine implementation in ED-SSUs could enable early risk stratification.

Drug-Related Problems in Elderly Patients Attended to by Emergency Services.

The progressive aging and comorbidities of the population have led to an increase in the number of patients with polypharmacy attended to in the emergency department. Drug-related problems (DRPs) have become a major cause of admission to these units, as well as a high rate of short-term readmissions. Anticoagulants, antibiotics, antidiabetics, and opioids have been shown to be the most common drugs involved in this issue. Inappropriate polypharmacy has been pointed out as one of the major causes of these emergency visits. Different ways of conducting chronic medication reviews at discharge, primary care coordination, and phone contact with patients at discharge have been shown to reduce new hospitalizations and new emergency room visits due to DRPs, and they are key elements for improving the quality of care provided by emergency services.

Factores asociados con mortalidad a corto plazo en personas que viven en residencias atendidas en servicios de urgencias: resultados del estudio multicéntrico Caregency / Factors associated with short-term mortality after emergency department care of residents living in aged care homes: findings from the multicenter Caregency study

Objetivo: Evaluar la frecuencia y los factores asociados con la mortalidad a corto plazo de personas que viven en residencias tras ingreso en urgencias.Método: Análisis retrospectivo multicéntrico de una muestra aleatoria de admisiones de personas $ 65 años que viven en residencias en cinco servicios de urgencias de Cataluña, a lo largo de 2017. Se analizaron características sociodemográficas, el estado funcional y cognitivo previo, multimorbilidad, nivel de triaje de las urgencias, duración de la estancia en urgencias, hospitalización y mortalidad a corto plazo (en urgencias o en los 30 días posteriores al alta). Se utilizó un análisis de regresión multivariante para investigar los factores asociados con la mortalidad a corto plazo. Resultados: Se analizaron 2.444 admisiones en urgencias, con una edad media de 85,9 (DE 7,1) años, 67,7% mujeres. La mortalidad a corto plazo (15,5%) se asoció con una edad > 90 años (OR 1,50; IC 95%: 1,5-1,95), un índice de Charlson > 2 (OR 1,47; IC 95%: 1,14-1,90), y un grado de dependencia moderado (OR 1,50; IC 95%: 1,03-2,20) y grave (OR 2,56; IC 95%: 1,84-3,55). También se asoció con un mayor nivel de triaje de la urgencia, duración de la estancia en urgencias e ingreso en planta de hospitalización. Conclusiones: Los ancianos residentes con las características descritas podrían beneficiarse especialmente de intervenciones dirigidas a la prevención de traslados potencialmente innecesarios a urgencias y a la implementación de una atención integral geriátrica dentro de los servicios de urgencias, a fin de garantizar una buena calidad de los cuidados en fases finales de la vida. (AU)

Objectives: To evaluate short-term mortality in people transferred from aged care homes for treatment in a hospital emergency department (ED) and to analyze factors associated with mortality. Methods: Multicenter study of a random sample of retrospective data of patients treated in 5 EDs in Catalonia in 2017. The patients were over the age of 65 years and lived in residential care facilities. In addition to short-term mortality (in the ED or within 30 days of discharge), we analyzed sociodemographic characteristics, prior functional and cognitive status, multimorbidity, triage level on arrival, length of stay in the ED, and hospital admission. Odds ratios (ORs) for factors associated with short-term mortality were calculated by multivariate regression analysis. Results: A total of 2444 ED admissions were analyzed. The patients’ mean (SD) age was 85.9 (7.1) years, and 67.7% were women. Short-term mortality (in 15.5%) was associated with age >90 years (OR, 1.50; 95% CI, 1.5-1.95 years), a Charlson index >2 (OR, 1.47; 95% CI, 1.14-1.90), and dependency assessed as moderate (OR, 1.50; 95% CI, 1.03-2.20) or severe (OR, 2.56; 95% CI, 1.84-3.55). Other associated factors were a higher level of urgency on triage, duration of ED stay, and hospital admission. Conclusions: Aged residents with the characteristics associated with short-term mortality could benefit from interventions for potentially avoiding unnecessary transfers to an ED, and from the implementation of comprehensive geriatric care within the ED. This could be useful to support good quality of care at the end of life. (AU)

Cost-effectiveness analysis of implementing a secondary prevention programme in those patients who visited an emergency department for drug-related problems.

OBJECTIVE: To evaluate the cost-effectiveness of a secondary prevention programme in patients admitted to the emergency department due to drug-related problems (DRPs). METHODS: A decision model compared costs and outcomes of patients with DRPs admitted to the emergency department. Model variables and costs, along with their distributions, were obtained from the trial results and literature. The study was performed from the perspective of the National Health System including only direct costs. KEY FINDINGS: The implementation of a secondary prevention programme for DRPs reduces costs associated with emergency department revisits, with an annual net benefit of €87 639. Considering a mortality rate attributable to readmission of 4.7%, the cost per life-years gained (LYG) with the implementation of this programme was €2205. In the short term, the reduction in the number of revisits following the programme implementation was the variable that most affected the model, with the benefit threshold value corresponding to a relative reduction of 12.4% of the number of revisits of patients with DRPs to obtain benefits. CONCLUSIONS: Implementing a secondary prevention programme is cost-effective for patients with DRPs admitted to the emergency department. Implementation costs will be exceeded by reducing revisits to the emergency department.

Factors associated with short-term mortality after emergency department care of residents living in aged care homes: findings from the multicenter Caregency study. / Factores asociados con mortalidad a corto plazo en personas que viven en residencias atendidas en servicios de urgencias: resultados del estudio multicéntrico Caregency.

OBJECTIVES: To evaluate short-term mortality in people transferred from aged care homes for treatment in a hospital emergency department (ED) and to analyze factors associated with mortality. MATERIAL AND METHODS: Multicenter study of a random sample of retrospective data of patients treated in 5 EDs in Catalonia in 2017. The patients were over the age of 65 years and lived in residential care facilities. In addition to short-term mortality (in the ED or within 30 days of discharge), we analyzed sociodemographic characteristics, prior functional and cognitive status, multimorbidity, triage level on arrival, length of stay in the ED, and hospital admission. Odds ratios (ORs) for factors associated with short-term mortality were calculated by multivariate regression analysis. RESULTS: A total of 2444 ED admissions were analyzed. The patients' mean (SD) age was 85.9 (7.1) years, and 67.7% .were women. Short-term mortality (in 15.5%) was associated with age >90 years (OR, 1.50; 95% CI, 1.5-1.95 years), a Charlson index >2 (OR, 1.47; 95% CI, 1.14-1.90), and dependency assessed as moderate (OR, 1.50; 95% CI, 1.03- 2.20) or severe (OR, 2.56; 95% CI, 1.84-3.55). Other associated factors were a higher level of urgency on triage, duration of ED stay, and hospital admission. CONCLUSION: Aged residents with the characteristics associated with short-term mortality could benefit from interventions for potentially avoiding unnecessary transfers to an ED, and from the implementation of comprehensive geriatric care within the ED. This could be useful to support good quality of care at the end of life.

OBJETIVO: Evaluar la frecuencia y los factores asociados con la mortalidad a corto plazo de personas que viven en residencias tras ingreso en urgencias. METODO: Análisis retrospectivo multicéntrico de una muestra aleatoria de admisiones de personas $ 65 años que viven en residencias en cinco servicios de urgencias de Cataluña, a lo largo de 2017. Se analizaron características sociodemográficas, el estado funcional y cognitivo previo, multimorbilidad, nivel de triaje de las urgencias, duración de la estancia en urgencias, hospitalización y mortalidad a corto plazo (en urgencias o en los 30 días posteriores al alta). Se utilizó un análisis de regresión multivariante para investigar los factores asociados con la mortalidad a corto plazo. RESULTADOS: Se analizaron 2.444 admisiones en urgencias, con una edad media de 85,9 (DE 7,1) años, 67,7% mujeres. La mortalidad a corto plazo (15,5%) se asoció con una edad > 90 años (OR 1,50; IC 95%: 1,5-1,95), un índice de Charlson > 2 (OR 1,47; IC 95%: 1,14-1,90), y un grado de dependencia moderado (OR 1,50; IC 95%: 1,03-2,20) y grave (OR 2,56; IC 95%: 1,84-3,55). También se asoció con un mayor nivel de triaje de la urgencia, duración de la estancia en urgencias e ingreso en planta de hospitalización. CONCLUSIONES: Los ancianos residentes con las características descritas podrían beneficiarse especialmente de intervenciones dirigidas a la prevención de traslados potencialmente innecesarios a urgencias y a la implementación de una atención integral geriátrica dentro de los servicios de urgencias, a fin de garantizar una buena calidad de los cuidados en fases finales de la vida.

Development of an Emergency Revisit Score for Patients With Drug-Related Problems.

Background: Drug-related problems (DRPs) are a frequent reason for emergency departments (EDs) visits. However, data about the risk factors associated with EDs revisits are limited. Objective: To develop and validate a predictive model indicating the risk factors associated with EDs revisit within 30 days of the first visit. Methods: A retrospective cohort study was conducted involving patients who attended an ED for DRPs related to cardiovascular drugs. A 30-day prediction model was created in a derivation cohort by logistic regression. An integer score proportional to the regression coefficient was assigned to the variables with P < .100 in the multivariate analysis. Results: 581 patients (mean age: 80.0 [12.6] years) were included, 133 (22.9%) revisited the ED within 30 days from discharge. Six factors (chronic kidney disease, chronic heart failure, visit to an ED in the preceding 3 months, high anticholinergic burden, DRPs associated with heparin, and safety-related DRPs) were identified as risk factors and combined into a final score, termed the DREAMER score. The model reached an area under the receiver operating curve values of 0.72 (95% confidence interval [CI] = 0.67-0.77) in the referral cohort and 0.71 (95% CI = 0.65-0.74) in the validation cohort (P = .273). Three risk categories were generated, with the following scores and estimated risks: low risk (0-8 points): 11.6%; intermediate risk (9-14 points): 21.3%; and high risk (>14 points): 41.2%. Conclusion and Relevance: The DREAMER score identifies patients at high risk for ED revisit within 30 days from the first visit for a DRPs, being a useful tool to prioritize interventions on discharge.

Anticholinergic burden in patients treated for constipation in an emergency department. / Carga anticolinérgica en pacientes atendidos por estreñimiento en un servicio de ugencias.

OBJECTIVES: To evaluate the anticholinergic burden on discharge of patients treated for constipation in an emergency department (ED) and to assess the effect on emergency revisiting within 30 days. MATERIAL AND METHODS: Observational retrospective cohort study. We collected cases with a discharge diagnosis of constipation after ED treatment between September 2018 and June 2019 and recorded information on all drugs taken and the anticholinergic burden of treatment. A revisit to the ED within 30 days was the primary outcome. RESULTS: We included 104 patients. A high anticholinergic burden of treatment was identified in 47 (56.6%), an intermediate burden in 30 (36.1%), and a low burden in 6 (7.2%). Twenty-nine (27.9%) patients revisited the ED within 30 days of discharge. An intermediate anticholinergic burden (23 patients [31.1%] vs 4 [13.3%]; P = .061) and high burden (19 [40.4%] vs 8 [14.1%]; P = .002] was associated with revisiting within 30 days in the univariate analysis. On multivariate analysis, a high anticholinergic burden was independently associated with a higher rate of revisiting than a low burden: adjusted odds ratio (aOR), 4.21; 95% CI, 1.07-16.5; P = .039. An intermediate load was not associated with more revisits, however: aOR, 1.27; 95% CI, 0.25-6.41; P = .776. Prescription of long-term treatment with laxatives on discharge did not reduce revisiting withing 30-days in the group with a high anticholinergic load (OR, 0.86; 95% CI, 0.48-3.27; P = .526), but it did have an effect in patients an intermediate burden (OR, 0.13; 95% CI, 0.02-0.99; P = .049). CONCLUSION: The prescription of drugs leading to a high anticholinergic burden was a factor associated with ED revisits within 30 days in patients treated for constipation.

OBJETIVO: Evaluar la frecuencia e impacto de la carga anticolinérgica del tratamiento en la reconsulta a los 30 días en los pacientes atendidos por estreñimiento en un servicio de urgencias (SU). METODO: Estudio observacional de cohortes retrospectivo. Se incluyeron por oportunidad pacientes que fueron dados de alta con diagnóstico de estreñimiento desde un SU entre septiembre 2018 y junio 2019. Se recogieron los fármacos y su carga anticolinérgica. La variable de resultado fue la reconsulta por cualquier causa a los 30 días. RESULTADOS: Se incluyeron 104 pacientes, 47 (56,6%) se clasificaron como tratamiento con alta carga colinérgica, 30 (36,1%) intermedia y 6 (7,2%) baja. Veintinueve (27,9%) pacientes sufrieron una reconsulta a urgencias en los primeros 30 días tras el alta. Los pacientes con fármacos con una carga anticolinérgica alta tuvieron una mayor frecuencia de reconsultas a 30 días [19/47 (40,4%) vs 8/57 (14,1%); p = 0,002]. Tras el análisis multivarible, en comparación con aquellos con tratamiento con baja carga anticolinérgica, el tener una alta carga (ORa = 4,21; IC 95% 1,07-16,5; p = 0,039), pero no intermedia (ORa = 1,27; IC 95% 0,25-6,41; p = 0,776), se asoció de forma independiente con una mayor reconsulta a los 30 días. La prescripción de laxantes crónicos al alta no redujo la reconsulta a 30 días en el grupo con alta carga anticolinérgica (OR = 0,86; IC 95% 0,48-3,27; p = 0,526), pero sí en aquellos con carga intermedia (OR = 0,13; IC 95% 0,02-0,99; p = 0,049). CONCLUSIONES: La prescripción de fármacos con alta carga anticolinérgica fue un factor asociado con reconsulta a los 30 días en los pacientes atendidos por estreñimiento en urgencias.

Carga anticolinérgica en pacientes atendidos por estreñimiento en un servicio de ugencias / Anticholinergic burden in patients treated for constipation in an emergency department

OBJETIVO: Evaluar la frecuencia e impacto de la carga anticolinérgica del tratamiento en la reconsulta a los 30 días en los pacientes atendidos por estreñimiento en un servicio de urgencias (SU). MÉTODO: Estudio observacional de cohortes retrospectivo. Se incluyeron por oportunidad pacientes que fueron dados de alta con diagnóstico de estreñimiento desde un SU entre septiembre 2018 y junio 2019. Se recogieron los fármacos y su carga anticolinérgica. La variable de resultado fue la reconsulta por cualquier causa a los 30 días. RESULTADOS: Se incluyeron 104 pacientes, 47 (56,6%) se clasificaron como tratamiento con alta carga colinérgica, 30 (36,1%) intermedia y 6 (7,2%) baja. Veintinueve (27,9%) pacientes sufrieron una reconsulta a urgencias en los primeros 30 días tras el alta. Los pacientes con fármacos con una carga anticolinérgica alta tuvieron una mayor frecuencia de reconsultas a 30 días [19/47 (40,4%) vs 8/57 (14,1%); p = 0,002]. Tras el análisis multivarible, en comparación con aquellos con tratamiento con baja carga anticolinérgica, el tener una alta carga (ORa = 4,21; IC 95% 1,07-16,5; p = 0,039), pero no intermedia (ORa = 1,27; IC 95% 0,25-6,41; p = 0,776), se asoció de forma independiente con una mayor reconsulta a los 30 días. La prescripción de laxantes crónicos al alta no redujo la reconsulta a 30 días en el grupo con alta carga anticolinérgica (OR = 0,86; IC 95% 0,48-3,27; p = 0,526), pero sí en aquellos con carga intermedia (OR = 0,13; IC 95% 0,02-0,99; p = 0,049). CONCLUSIONES: La prescripción de fármacos con alta carga anticolinérgica fue un factor asociado con reconsulta a los 30 días en los pacientes atendidos por estreñimiento en urgencias

OBJECTIVES: To evaluate the anticholinergic burden on discharge of patients treated for constipation in an emergency department (ED) and to assess the effect on emergency revisiting within 30 days. METHODS: Observational retrospective cohort study. We collected cases with a discharge diagnosis of constipation after ED treatment between September 2018 and June 2019 and recorded information on all drugs taken and the anticholinergic burden of treatment. A revisit to the ED within 30 days was the primary outcome. RESULTS: We included 104 patients. A high anticholinergic burden of treatment was identified in 47 (56.6%), an intermediate burden in 30 (36.1%), and a low burden in 6 (7.2%). Twenty-nine (27.9%) patients revisited the ED within 30 days of discharge. An intermediate anticholinergic burden (23 patients [31.1%] vs 4 [13.3%]; P = .061) and high burden (19 [40.4%] vs 8 [14.1%]; P = .002] was associated with revisiting within 30 days in the univariate analysis. On multivariate analysis, a high anticholinergic burden was independently associated with a higher rate of revisiting than a low burden: adjusted odds ratio (aOR), 4.21; 95% CI, 1.07-16.5; P = .039. An intermediate load was not associated with more revisits, however: aOR, 1.27; 95% CI, 0.25-6.41; P = .776. Prescription of long-term treatment with laxatives on discharge did not reduce revisiting withing 30-days in the group with a high anticholinergic load (OR, 0.86; 95% CI, 0.48-3.27; P = .526), but it did have an effect in patients an intermediate burden (OR, 0.13; 95% CI, 0.02-0.99; P = .049). CONCLUSION: The prescription of drugs leading to a high anticholinergic burden was a factor associated with ED revisits within 30 days in patients treated for constipation

Aprender, desaprender y reaprender para asistir ancianos en urgencias: el secreto del cambio / Learn, unlearn, and learn again: the secret to changing how elderly patients are attended in the emergency department

El importante cambio demográfico, con el incremento de personas ancianas con multimorbilidad y dependencia funcional, conlleva un aumento de presión sobre los servicios de urgencias (SUH). En esta población, la atención clásica desarrollada en los SUH no es resolutiva, comporta riesgos para las personas, implica tasas altas de ingreso y contribuye a aumentar la saturación del propio SUH. Las sociedades científicas recomiendan incorporar estrategias de valoración geriátrica en el SUH a cargo de equipos multidisciplinares, y procurar entornos seguros. Una organización de este estilo requiere de un profundo cambio del propio servicio, de sus profesionales y de las conexiones con el entorno post-hospitalario. Exponemos la experiencia del SUH de un hospital terciario y los mecanismos utilizados para conseguir ese cambio. El objetivo es garantizar que el equipo del SUH lleve a cabo unos cuidados y un diagnóstico y tratamiento correctos de los procesos urgentes en la población anciana, tome decisiones ajustadas a las necesidades clínicas, sociales, funcionales, a los deseos del paciente y su familia, y elija el entorno de tratamiento mejor en cada caso. Todo ello son cambios imprescindibles para atender adecuadamente una nueva demanda, conseguir resultados óptimos para los pacientes y para el funcionamiento del SUH y del hospital

The demographic shift toward ever greater numbers of older patients with multiple conditions and functional dependency has increased pressure on emergency departments (EDs). The traditional approach to emergency treatment does not resolve problems in this population, creates risk, leads to high admission rates, and collapses the ED itself. Medical associations recommend that multidisciplinary teams incorporate geriatric assessment strategies and procure safe care enviroments. Implementing such recommendations will require profound changes in ED processes and staff and in connections between the ED and the community the patient is discharged to. This paper describes the processes we used in our tertiary-care hospital to achieve the necessary level of change. Our aims were to ensure that the ED staff provides correct diagnoses and treatments for elderly patients; bases decisions on the patients’ clinical, social and functional needs and the preferences of both patient and family; and arranges for the most appropriate treatment environment in each case. All these changes were essential for properly addressing new care demands while achieving optimal patient outcomes and contributing to better ED and hospital performance

Learn, unlearn, and learn again: the secret to changing how elderly patients are attended in the emergency department. / Aprender, desaprender y reaprender para asistir ancianos en urgencias: el secreto del cambio.

The demographic shift toward ever greater numbers of older patients with multiple conditions and functional dependency has increased pressure on emergency departments (EDs). The traditional approach to emergency treatment does not resolve problems in this population, creates risk, leads to high admission rates, and collapses the ED itself. Medical associations recommend that multidisciplinary teams incorporate geriatric assessment strategies and procure safe care enviroments. Implementing such recommendations will require profound changes in ED processes and staff and in connections between the ED and the community the patient is discharged to. This paper describes the processes we used in our tertiary-care hospital to achieve the necessary level of change. Our aims were to ensure that the ED staff provides correct diagnoses and treatments for elderly patients; bases decisions on the patients' clinical, social and functional needs and the preferences of both patient and family; and arranges for the most appropriate treatment environment in each case. All these changes were essential for properly addressing new care demands while achieving optimal patient outcomes and contributing to better ED and hospital performance.

El importante cambio demográfico, con el incremento de personas ancianas con multimorbilidad y dependencia funcional, conlleva un aumento de presión sobre los servicios de urgencias (SUH). En esta población, la atención clásica desarrollada en los SUH no es resolutiva, comporta riesgos para las personas, implica tasas altas de ingreso y contribuye a aumentar la saturación del propio SUH. Las sociedades científicas recomiendan incorporar estrategias de valoración geriátrica en el SUH a cargo de equipos multidisciplinares, y procurar entornos seguros. Una organización de este estilo requiere de un profundo cambio del propio servicio, de sus profesionales y de las conexiones con el entorno post-hospitalario. Exponemos la experiencia del SUH de un hospital terciario y los mecanismos utilizados para conseguir ese cambio. El objetivo es garantizar que el equipo del SUH lleve a cabo unos cuidados y un diagnóstico y tratamiento correctos de los procesos urgentes en la población anciana, tome decisiones ajustadas a las necesidades clínicas, sociales, funcionales, a los deseos del paciente y su familia, y elija el entorno de tratamiento mejor en cada caso. Todo ello son cambios imprescindibles para atender adecuadamente una nueva demanda, conseguir resultados óptimos para los pacientes y para el funcionamiento del SUH y del hospital.

Una oportunidad de mejora en las caídas de ancianos: el urgenciólogo y la ortogeriatría / Opportunity for emergency medicine and geriatric-orthopedic specialists to improve the emergency department care of elderly patients

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Development of a comprehensive, multidisciplinary program of care for frailty in an emergency department.

PURPOSE: Frailty and multi-morbidity have been associated with increased pressure on Emergency Departments (ED), higher hospital admissions and more risks for patients arising from the ED stay. The advantages of developing specific attention to frailty in ED have been highlighted. The benefits of these approaches are related to patients but also to organizations. The aim is to present how a Program of Care for Frailty (PCF) in an ED impacts on patient flows. METHODS: Setting: A tertiary, teaching, 550-bed urban hospital, with 80,000 adult patients/year ED attendances (43% ≥ 65 years). The three main axes of the program are (1) an ED geriatrization, implementing multidisciplinary comprehensive geriatric assessment performed by ED professionals (physician, nurses, social worker, pharmacist); (2) an elder-friendly area (EFA) inside the ED was built; (3) The ED integration in a collaborative network with others healthcare providers in the territory for a shared urgent care. RESULTS: Between 2011 and 2017, we observe a progressive increase in ED activity (+ 8.1%), in patient's age (40.9% vs 42.8% ≥ 65 years), and an increase in ambulance arrivals (+ 25.1%). The admission rate was rising until 2014 (10.8-12%). In 2014, the ED geriatrization began and networking was reinforced, and a decrease in the rate of admission (11.3%) is observed. CONCLUSIONS: Despite a progressive increase in ED activity and older people, we have observed a decrease in hospital admissions in parallel with the Program of Care for Frailty development. Systematic application of similar programs in distinct EDs would have an impact on the overall health system.