Ellen Burkett

Profiles of older patients in the emergency department: findings from the interRAI Multinational Emergency Department Study.

STUDY OBJECTIVE We examine functional profiles and presence of geriatric syndromes among older patients attending 13 emergency departments (EDs) in 7 nations. METHODS This was a prospective observational study of a convenience sample of patients, aged 75 years and older, recruited sequentially and mainly during normal working hours. Clinical observations were drawn from the interRAI Emergency Department Screener, with assessments performed by trained nurses. RESULTS A sample of 2,282 patients (range 98 to 549 patients across nations) was recruited. Before becoming unwell, 46% were dependent on others in one or more aspects of personal activities of daily living. This proportion increased to 67% at presentation to the ED. In the ED, 26% exhibited evidence of cognitive impairment, and 49% could not walk without supervision. Recent falls were common (37%). Overall, at least 48% had a geriatric syndrome before becoming unwell, increasing to 78% at presentation to the ED. This pattern was consistent across nations. CONCLUSION Functional problems and geriatric syndromes affect the majority of older patients attending the ED, which may have important implications for clinical protocols and design of EDs.

Methodology for developing quality indicators for the care of older people in the Emergency Department

BackgroundCompared with younger people, older people have a higher risk of adverse health outcomes when presenting to emergency departments. As the population ages, older people will make up an increasing proportion of the emergency department population. Therefore it is timely that consideration be given to the quality of care received by older persons in emergency departments, and to consideration of those older people with special needs. Particular attention will be focused on important groups of older people, such as patients with cognitive impairment, residents of long term care and patients with palliative care needs. This project will develop a suite of quality indicators focused on the care of older persons in the emergency department.Methods/designFollowing input from an expert panel, an initial set of structural, process, and outcome indicators will be developed based on thorough systematic search in the scientific literature. All initial indicators will be tested in eight emergency departments for their validity and feasibility. Results of the data from the field studies will be presented to the expert panel at a second meeting. A suite of Quality Indicators for the older emergency department population will be finalised following a formal voting process.DiscussionThe predicted burgeoning in the number of older persons presenting to emergency departments combined with the recognised quality deficiencies in emergency department care delivery to this population, highlight the need for a quality framework for the care of older persons in emergency departments. Additionally, high quality of care is associated with improved survival & health outcomes of elderly patients. The development of well-selected, validated and economical quality indicators will allow appropriate targeting of resources (financial, education or quality management) to improve quality in areas with maximum potential for improvement.

Appraisal of the quality of care of older adults with cognitive impairment in the emergency department.

The medical records of 273 patients 75 years and older were reviewed to evaluate quality of emergency department (ED) care through the use of quality indicators. One hundred fifty records contained evidence of an attempt to carry out a cognitive assessment. Documented evidence of cognitive impairment (CI) was reported in 54 cases. Of these patients, 30 had no documented evidence of an acute change in cognitive function from baseline; of 26 patients discharged home with preexisting CI (i.e., no acute change from baseline), 15 had no documented evidence of previous consideration of this issue by a health care provider; and 12 of 21 discharged patients who screened positive for cognitive issues for the first time were not referred for outpatient evaluation. These findings suggest that the majority of older adults in the ED are not receiving a formal cognitive assessment, and more than half with CI do not receive quality of care according to the quality indicators for geriatric emergency care. Recommendations for improvement are discussed.

Trends and predicted trends in presentations of older people to Australian emergency departments: effects of demand growth, population aging and climate change

Objectives The aim of the present study was to describe trends in and age and gender distributions of presentations of older people to Australian emergency departments (EDs) from July 2006 to June 2011, and to develop ED utilisation projections to 2050. Methods A retrospective analysis of data collected in the National Non-admitted Patient Emergency Department Care Database was undertaken to assess trends in ED presentations. Three standard Australian Bureau of Statistics population growth models, with and without adjustment for current trends in ED presentation growth and effects of climate change, were examined with projections of ED presentations across three age groups (0-64, 65-84 and ≥85 years) to 2050. Results From 2006-07 to 2010-11, ED presentations increased by 12.63%, whereas the Australian population over this time increased by only 7.26%. Rates of presentation per head of population were greatest among those aged ≥85 years. Projections of ED presentations to 2050 revealed that overall ED presentations are forecast to increase markedly, with the rate of increase being most marked for older people. Conclusion Growth in Australian ED presentations from 2006-07 to 2010-11 was greater than that expected from population growth alone. The predicted changes in demand for ED care will only be able to be optimally managed if Australian health policy, ED funding instruments and ED models of care are adjusted to take into account the specific care and resource needs of older people. What is known about the topic? Rapid population aging is anticipated over coming decades. International studies and specific local-level Australian studies have demonstrated significant growth in ED presentations. There have been no prior national-level Australian studies of ED presentation trends by age group. What does this paper add? The present study examined national ED presentation trends from July 2006 to June 2011, with specific emphasis on trends in presentation by age group. ED presentation growth was found to exceed population growth in all age groups. The rate of ED presentations per head of population was highest among those aged ≥85 years. ED utilisation projections to 2050, using standard Australian Bureau of Statistics population modelling, with and without adjustment for current ED growth, were developed. The projections demonstrated linear growth in ED presentation for those aged 0-84 years, with growth in ED presentations of the ≥85 year age group demonstrating marked acceleration after 2030. What are the implications for practitioners? Growth in ED presentations exceeding population growth suggests that current models of acute health care delivery require review to ensure that optimal care is delivered in the most fiscally efficient manner. Trends in presentation of older people emphasise the imperative for ED workforce planning and education in care of this complex patient cohort, and the requirement to review funding models to incentivise investment in ED avoidance and substitutive care models targeting older people.

Frailty, thy name is…

Department of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia, Emergency Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia, Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia, Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA, Emergency Department, Liverpool Hospital, Sydney, New South Wales, Australia, and Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia

Is delirium the medical emergency we know least about

EmergencyDepartment, Hornsby and Royal North ShoreHospitals, Sydney, NewSouthWales, Australia, EmergencyDepartment, Princess Alexandra Hospital, Brisbane, Queensland, Australia, Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA, and Harry Perkins Institute for Medical Research, The University of Western Australia, Perth, Western Australia, Australia

Approach to death in the older emergency department patient

Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia, Harry Perkins Institute for Medical Research, Perth, Western Australia, Australia, Washington University in St Louis School of Medicine, St Louis, MO, USA, Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia, Princess Alexandra Hospital, Brisbane, Queensland, Australia, Hornsby and Royal North Shore Hospitals, Sydney, New South Wales, Australia, School of Medicine, The University of Sydney, Sydney, New South Wales, Australia, and The University of Notre Dame, Fremantle, Western Australia, Australia

Abuse of the older person: is this the case you missed last shift?

School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia, Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia, Department of Emergency Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA, The Hills Local Area Command, New South Wales Police Force, Sydney, New South Wales, Australia, Emergency Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia, Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia, Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute for Medical Research, Perth, Western Australia, Australia, Emergency Department, Liverpool Hospital, Sydney, New South Wales, Australia, School of Medicine, The University of Sydney, Sydney, New South Wales, Australia, and Division of Emergency Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, New York, USA

Major trauma in the older patient: Evolving trauma care beyond management of bumps and bruises

Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA, Department of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia, Harry Perkins Institute for Medical Research, Centre for Clinical Research in Emergency Medicine, Perth, Western Australia, Australia, Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia, Department of Emergency Medicine, Faculty of Health and Medicine, The University of Newcastle, Newcastle, New South Wales, Australia, Department of Emergency Medicine, Liverpool Hospital, Liverpool, New South Wales, Australia, Department of Emergency Medicine, School of Medicine, The University of Sydney, Sydney, New South Wales, Australia, Department of Surgery, Brigham and Women’s Hospital, Harvard University School of Medicine, Boston, Massachusetts, USA, Princess Alexandra Hospital, Brisbane, Queensland, Australia, and Department of Emergency Medicine, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia

Avoiding anchoring bias by moving beyond ‘mechanical falls’ in geriatric emergency medicine: ACUTE GERIATRICS

Guruprasad NAGARAJ, Carolyn HULLICK , Glenn ARENDTS , Ellen BURKETT, Keith D HILL and Christopher R CARPENTER 8 Hornsby Ku-ring-gai Hospital, Sydney, New South Wales, Australia, Royal North Shore Hospital, Sydney, New South Wales, Australia, Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia, School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia, Department of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia, Princess Alexandra Hospital, Brisbane, Queensland, Australia, School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia, and Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA