Lowell W. Gerson

Quality Indicators for Geriatric Emergency Care

OBJECTIVES Emergency departments (EDs), similar to other health care environments, are concerned with improving the quality of patient care. Older patients comprise a large, growing, and particularly vulnerable subset of ED users. The project objective was to develop ED-specific quality indicators for older patients to help practitioners identify quality gaps and focus quality improvement efforts. METHODS The Society for Academic Emergency Medicine (SAEM) Geriatric Task Force, including members representing the American College of Emergency Physicians (ACEP), selected three conditions where there are quality gaps in the care of older patients: cognitive assessment, pain management, and transitional care in both directions between nursing homes and EDs. For each condition, a content expert created potential quality indicators based on a systematic review of the literature, supplemented with expert opinion when necessary. The original candidate quality indicators were modified in response to evaluation by four groups: the Task Force, the SAEM Geriatric Interest Group, and audiences at the 2007 SAEM Annual Meeting and the 2008 American Geriatrics Society Annual Meeting. RESULTS The authors offer 6 quality indicators for cognitive assessment, 6 for pain management, and 11 for transitions between nursing homes and EDs. CONCLUSIONS These quality indicators will help researchers and clinicians target quality improvement efforts. The next steps will be to test the feasibility of capturing the quality indicators in existing medical records and to measure the extent to which each quality indicator is successfully met in current emergency practice.

Difficulty in predicting bacteremia in elderly emergency patients

STUDY OBJECTIVES To characterize the clinical presentation and identify factors predictive of bacteremia in elderly patients. DESIGN Retrospective review of emergency department charts, hospital records, and microbiology reports. SETTING Community teaching hospital with annual ED census of 65,000 adults. PARTICIPANTS Seven hundred fifty elderly patients (aged 65 to 99 years) who were evaluated by the emergency physician, had blood cultures obtained in the ED, and were hospitalized with a suspected infectious process during a 12-month period. MEASUREMENTS Records were analyzed for demographic information, underlying diseases, clinical presentation, laboratory findings, sources of infection, and causative organisms. Using contingency tables, 79 patients with positive blood cultures were compared with a random sample of 136 patients with sterile blood cultures to identify clinical variables significantly (P less than .05) associated with bacteremia. Logistic regression analysis was performed with significant factors to develop a model to predict bacteremia. Sensitivity, specificity, and predictive values were calculated for the model. MAIN RESULTS The prevalence of bacteremia was 10.6%. Escherichia coli was the most commonly isolated pathogen (29% of cases), and the urinary tract was the most common source of infection (44.3% of cases). Logistic regression analysis showed that altered mental status (odds ratio, 2.88; 95% confidence interval [Cl], 1.52 to 5.50), vomiting (odds ratio, 2.63; 95% Cl, 1.16 to 6.15), and WBC band forms of more than 6% (0.06) (odds ratio, 3.50; 95% Cl, 1.58 to 5.27) were independent predictors of bacteremia. The presence of at least one of these three factors had a sensitivity of 0.85 (95% Cl, 0.75 to 0.92) and a specificity of 0.46 (95% Cl, 0.38 to 0.55) for predicting bacteremia in the study group. The positive predictive value was 0.16 (95% Cl, 0.12 to 0.19) and the negative predictive value was 0.96 (95% Cl, 0.94 to 0.98) for the ED patient group that met inclusion criteria. CONCLUSION Elderly patients fail to manifest identifiable clinical features indicative of bloodstream infection. The sensitivity and specificity of the best statistical model for identifying bacteremic elderly patients suggest that clinical indicators alone are unreliable predictors of bacteremia in the geriatric ED population studied.

Emergency Medical Service Utilization by the Elderly

The growing number of aged in the United States will continue to increase the demand for medical services, including emergency care. In a medium-sized city, 22% of 14,400 emergency medical service responses were to patients over 65 years of age. Of the elderly, those over 75 years were more likely to call EMS than were those between 65 and 74 years old. Men used the service more often than did women. Men were more likely to suffer a cardiac condition; women, an injury. Elderly patients were 1.7 times more likely to require paramedic-accompanied transportation to hospital.

Geriatric Emergency Department guidelines

INTRODUCTION According to the 2010 Census, more than 40 million Americans were over the age of 65, which was “more people than in any previous census.” In addition, “between 2000 and 2010, the population 65 years and over increased at a faster rate than the total U.S. population.” The census data also demonstrated that the population 85 and older is growing at a rate almost three times the general population. The subsequent increased need for health care for this burgeoning geriatric population represents an unprecedented and overwhelming challenge to the American health care system as a whole and to emergency departments (EDs) specifically. Geriatric EDs began appearing in the United States in 2008 and have become increasingly common. The ED is uniquely positioned to play a role in improving care to the geriatric population. As an ever-increasing access point for medical care, the ED sits at a crossroads between inpatient and outpatient care (Figure 1). Specifically, the ED represents 57% of hospital admissions in the United States, of which almost 70% receive a non-surgical diagnosis. The expertise which an ED staff can bring to an encounter with a geriatric patient can meaningfully impact not only a patient’s condition, but can also impact the decision to utilize relatively expensive inpatient modalities, or less expensive outpatient treatments. Emergency medicine experts recognize similar challenges around the world. Geriatric ED core principles have been described in the United Kingdom. Furthermore, as the initial site of care for both inpatient and outpatient events, the care provided in the ED has the opportunity to “set the stage” for subsequent care provided. More accurate diagnoses and improved therapeutic measures can not only expedite and improve inpatient care and outcomes, but can effectively guide the allocation of resources towards a patient population that, in general, utilizes significantly more resources per event than younger populations. Geriatric ED patients

High Yield Research Opportunities in Geriatric Emergency Medicine: Prehospital Care, Delirium, Adverse Drug Events, and Falls

Emergency services constitute crucial and frequently used safety nets for older persons, an emergency visit by a senior very often indicates high vulnerability for functional decline and death, and interventions via the emergency system have significant opportunities to change the clinical course of older patients who require its services. However, the evidence base for widespread employment of emergency system-based interventions is lacking. In this article, we review the evidence and offer crucial research questions to capitalize on the opportunity to optimize health trajectories of older persons seeking emergency care in four areas: prehospital care, delirium, adverse drug events, and falls.

Research priorities for high-quality geriatric emergency care: medication management, screening, and prevention and functional assessment.

BACKGROUND Geriatric adults represent an increasing proportion of emergency department (ED) users and can be particularly vulnerable to acute illnesses. Health care providers have recently begun to focus on the development of quality indicators (QIs) to define a minimal standard of care. OBJECTIVES The original objective of this project was to develop additional ED-specific QIs for older patients within the domains of medication management, screening and prevention, and functional assessment, but the quantity and quality of evidence were insufficient to justify unequivocal minimal standards of care for these three domains. Accordingly, the authors modified the project objectives to identify key research opportunities within these three domains that can be used to develop QIs in the future. METHODS Each domain was assigned one or two content experts who created potential QIs based on a systematic review of the literature, supplemented by expert opinion. Candidate QIs were then reviewed by four groups: the Society for Academic Emergency Medicine (SAEM) Geriatric Task Force, the SAEM Geriatric Interest Group, and audiences at the 2008 SAEM Annual Meeting and the 2009 American Geriatrics Society Annual Meeting, using anonymous audience response system technology as well as verbal and written feedback. RESULTS High-quality evidence based on patient-oriented outcomes was insufficient or nonexistent for all three domains. The participatory audiences did not reach a consensus on any of the proposed QIs. Key research questions for medication management (three), screening and prevention (two), and functional assessment (three) are presented based on proposed QIs that the majority of participants accepted. CONCLUSIONS In assessing a minimal standard of care by which to systematically derive geriatric QIs for medication management, screening and prevention, and functional assessment, compelling clinical research evidence is lacking. Patient-oriented research questions that are essential to justify and characterize future QIs within these domains are described.

Perceptions of emergency care by the elderly: Results of multicenter focus group interviews

STUDY OBJECTIVE To determine the elderlys perception of emergency care and to identify specific problems and solutions. DESIGN Focus group interviews. SETTING AND TYPE OF PARTICIPANTS Community senior citizen centers in Boston; Los Angeles; Pittsburgh; Youngstown, Ohio; and Norwalk, Connecticut. Senior citizens who had had emergency care in the past year participated. MEASUREMENT AND RESULTS Participants were satisfied with their overall medical care. Long waits were a hardship for patients and their families. The elderly are not familiar with the process of emergency care. They were frightened by their injury or illness. Their anxiety was not allayed until they were informed of the nature of their illness and what their treatment and disposition was to be. The emergency department environment frequently made them uncomfortable. There was considerable confusion caused by the billing process. CONCLUSIONS The elderly would benefit from prior or concurrent education regarding emergency care. Staff should be more sensitive to the anxiety felt by the elderly, should explain the reasons for delays in care, and what to expect. Patients should be informed of the nature and seriousness of their illness as soon as possible. Family and friends may be encouraged to stay with patients. The billing process needs to be clarified and simplified.

Response error in self-reported current smoking frequency by black and white established smokers

As compared with white smokers, black smokers, although they report using fewer cigarettes per day, are at higher risk for most smoking-related diseases. Among black smokers serum cotinine levels are also higher in proportion to cigarettes per day; this observation has led to suggestions of bias in self-reporting. The purpose of this study was to evaluate and compare the extent of errors in self-reported smoking patterns among black and white established smokers. Ninety-seven white and 66 black smokers participated in structured telephone interviews, filled out two self-administered questionnaires one week apart, and collected all of their cigarette butts for a week. Group differences in the validity of self-reported smoking patterns were assessed by comparison with cigarette butt counts and the measured butt lengths. Both black and white smokers significantly overestimated smoking on our measure of smoking frequency (both P < 0.001); the group difference in bias was not significant (P = 0.13). There was no evidence that underreporting was more common among blacks than among whites (P = 0.67). Test-retest reliability was not significantly different in the two groups (P = 0.09). Both groups performed poorly when asked to categorize their smoking frequency according to the cutpoints of the Fagerström Test for Nicotine Dependence. Black smokers smoked more of each cigarette and smoked longer cigarettes, but they smoked fewer total millimeters of cigarettes per day (all P < 0.001). Contrary to an earlier report, the disproportionately high cotinine levels could not be attributed to reporting error.

Comparison of Intramuscular Triamcinolone and Oral Prednisone in the Outpatient Treatment of Acute Asthma: A Randomized Controlled Trial

STUDY OBJECTIVE To determine whether a one-time dose of triamcinolone diacetate, 40 mg intramuscular (i.m.), given to adult patients treated in the emergency department for mild to moderate exacerbation of asthma would decrease the rate of relapse during the following week, compared with a nontapering course of oral prednisone, 40 mg/day over 5 days. METHODS A randomized, double-blind, controlled clinical trial was conducted at two university-affiliated community teaching hospitals with a combined annual census of 97,000. Patients were eligible if they were between the ages of 18 and 50 years, had an initial peak expiratory flow rate of less than 350 L/minute, and were to be discharged from the ED taking steroids. Patients were randomly assigned to receive either triamcinolone (40 mg i.m.) and placebo tablets or a placebo injection and prednisone (40 mg/day orally for 5 days). Patients were instructed to use a beta-agonist metered-dose inhaler, to continue other routine medications, to complete symptom diary cards, and to return in 7 to 10 days for follow-up. The main outcome measure was relapse, which was defined as an unscheduled visit to a physicians office or ED for worsening or persistent symptoms within 7 days of the initial ED visit. RESULTS A total of 168 patients were initially enrolled; 6 patients were withdrawn for protocol violations and 8 because they could not be contacted for follow-up. A total of 154 patients were available for outcome analysis, 78 in the triamcinolone group and 76 in the prednisone group. There were no differences between the two patient groups with regard to demographics, smoking history, weight, or symptom severity. Mean initial peak flows were 244+/-64 L/minute for the triamcinolone group and 245+/-83 L/minute for the prednisone group. Fifty percent of the study patients were current smokers. The relapse rates were 9.0% (7/78) in the triamcinolone group and 14.5% (11/76) in the prednisone group (P=.29). The absolute difference in relapse rates was 5.5% (95% confidence interval [CI], 4.6% to 15.6%). There was no difference in symptom frequency or severity between the two groups during the first 5 days of outpatient treatment. Analysis between the groups stratified for smoking showed no difference in relapse rate between smokers and nonsmokers. CONCLUSION A single dose of triamcinolone diacetate, 40 mg i.m., produced a relapse rate similar to that of prednisone, 40 mg/day orally for 5 days, after ED treatment of mild to moderate exacerbations of asthma. Intramuscular triamcinolone would appear to be an attractive alternative when compliance with a daily oral regimen is of concern.

Short-term Functional Decline and Service Use in Older Emergency Department Patients With Blunt Injuries

BACKGROUND Injuries are a common reason for emergency department (ED) visits by older patients. Although injuries in older patients can be serious, 75% of these patients are discharged home after their ED visit. These patients may be at risk for short-term functional decline related to their injuries or treatment. OBJECTIVES The objectives were to determine the incidence of functional decline in older ED patients with blunt injuries not requiring hospital admission for treatment, to describe their care needs, and to determine the predictors of short-term functional decline in these patients. METHODS This institutional review board-approved, prospective, longitudinal study was conducted in two community teaching hospital EDs with a combined census of 97,000 adult visits. Eligible patients were > or = 65 years old, with blunt injuries <48 hours old, who could answer questions or had a proxy. We excluded those too ill to participate; skilled nursing home patients; those admitted for surgery, major trauma, or acute medical conditions; patients with poor baseline function; and previously enrolled patients. Interviewers collected baseline data and the used the Older Americans Resources and Services (OARS) questionnaire to assess function and service use. Potential predictors of functional decline were derived from prior studies of functional decline after an ED visit and clinical experience. Follow-up occurred at 1 and 4 weeks, when the OARS questions were repeated. A three-point drop in activities of the daily living (ADL) score defined functional decline. Data are presented as means and proportions with 95% confidence intervals (CIs). Logistic regression was used to model potential predictors with functional decline at 1 week as the dependent variable. RESULTS A total of 1,186 patients were evaluated for eligibility, 814 were excluded, 129 refused, and 13 were missed, leaving 230 enrolled patients. The mean (+/-SD) age was 77 (+/-7.5) years, and 70% were female. In the first week, 92 of 230 patients (40%, 95% CI = 34% to 47%) had functional decline, 114 of 230 (49%, 95% CI = 43% to 56%) had new services initiated, and 76 of 230 had an unscheduled medical contact (33%, 95% CI = 27% to 39%). At 4 weeks, 77 of 219 had functional decline (35%, 95% CI = 29% to 42%), 141 of 219 had new services (65%, 95% CI = 58% to 71%), and 123 of 219 had an unscheduled medical contact (56%, 95% CI = 49% to 63%), including 15% with a repeated ED visit and 11% with a hospital admission. Family members provided the majority of new services at both time periods. Significant predictors of functional decline at 1 week were female sex (odds ratio [OR] = 2.2, 95% CI = 1.1 to 4.5), instrumental ADL dependence (IADL; OR = 2.5, 95% CI = 1.3 to 4.8), upper extremity fracture or dislocation (OR = 5.5, 95% CI = 2.5 to 11.8), lower extremity fracture or dislocation (OR = 4.6, 95% CI = 1.4 to 15.4), trunk injury (OR = 2.4, 95% CI = 1.1 to 5.3), and head injury (OR = 0.48, 95% CI = 0.23 to 1.0). CONCLUSIONS Older patients have a significant risk of short-term functional decline and other adverse outcomes after ED visits for injuries not requiring hospitalization for treatment. The most significant predictors of functional decline are upper and lower extremity fractures.