The ability of acute care providers to cope with the influx of frail older patients is increasingly stressed, and changes need to be made to improve care provided to older adults. Our purpose was to conduct a scoping review to map and synthesize the literature addressing frailty in the acute care setting in order to understand how to tackle this challenge. We also aimed to highlight the current gaps in frailty research. This scoping review included original research articles with acutely-ill Emergency Medical Services (EMS) or hospitalized older patients who were identified as frail by the authors. We searched Medline, CINAHL, Embase, PsycINFO, Eric, and Cochrane from January 2000 to September 2015. Our database search initially resulted in 8658 articles and 617 were eligible. In 67% of the articles the authors identified their participants as frail but did not report on how they measured frailty. Among the 204 articles that did measure frailty, the most common disciplines were geriatrics (14%), emergency department (14%), and general medicine (11%). In total, 89 measures were used. This included 13 established tools, used in 51% of the articles, and 35 non-frailty tools, used in 24% of the articles. The most commonly used tools were the Clinical Frailty Scale, the Frailty Index, and the Frailty Phenotype (12% each). Most often (44%) researchers used frailty tools to predict adverse health outcomes. In 74% of the cases frailty predicted the outcome examined, typically mortality and length of stay. Most studies (83%) were conducted in non-geriatric disciplines and two thirds of the articles identified participants as frail without measuring frailty. There was great variability in tools used and more recently published studies were more likely to use established frailty tools. Overall, frailty appears to be a good predictor of adverse health outcomes. For frailty to be implemented in clinical practice frailty tools should help formulate the care plan and improve shared decision making. How this will happen has yet to be determined.

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What do we know about frailty in the acute care setting? A scoping review.

OBJECTIVE As aging progresses, clinical characteristics of elderly patients in the emergency department (ED) vary by age. We aimed to study differences among elderly patients in the ED by age group. METHODS For 2 years, patients aged 65 and older were enrolled in the study and classified into three groups: youngest-old, ages 65 to 74 years; middle-old, 75 to 84 years; and oldest-old, ≥85 years. Participants' sex, reason for ED visit, transfer from another hospital, results of treatment, type of admission, admission department and length of stay were recorded. RESULTS During the study period, a total 64,287 patients visited the ED; 11,236 (17.5%) were aged 65 and older, of whom 14.4% were 85 and older. With increased age, the female ratio (51.5% vs. 54.9% vs. 69.1%, P<0.001), medical causes (79.5% vs. 81.3% vs. 81.7%, P=0.045), and admission rate (35.3% vs. 42.8% vs. 48.5%, P<0.001) increased. Admissions to internal medicine (57.5% vs. 59.3% vs. 64.7%, P<0.001) and orthopedic surgery (8.5% vs. 11.6% vs. 13.8%, P< 0.001) also increased. The ratio of admission to intensive care unit showed no statistical significance (P=0.545). Patients over age 85 years had longer stays in the ED (330.9 vs. 378.9 vs. 407.2 minutes, P<0.001), were discharged home less (84.4% vs. 78.9% vs. 71.5%, P<0.001), and died more frequently (6.3% vs. 10.4% vs. 13.0%, P<0.001). CONCLUSION With increased age, the proportion of female patients and medical causes increased. Rates of admission and death increased with age and older patients had longer ED and hospital stays.

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Differences in youngest-old, middle-old, and oldest-old patients who visit the emergency department.

Introduction The elderly, who suffer from multiple chronic diseases, represent a substantial proportion of Emergency Department (ED) frequent users, thus contributing to ED overcrowding, although they could benefit from other health care facilities, if those were available. The aim of this study was to evaluate and characterize hospital visits of older patients (age 65 or greater) to the ED of a university teaching hospital in Rome from the 1st of January to the 31st of December 2014, in order to identify clinical and social characteristics potentially associated with “elderly frequent users”. Material and Methods A retrospective study was performed during the calendar year 2014 (1st January 2014 – 31st December 2014) analyzing all ED admissions to the University Hospital of Rome Tor Vergata. Variables collected included age, triage code, arrival data, discharge diagnosis, and visit outcome. We performed a risk analysis using univariate binary logistic regression models. Results A total number of 38,016 patients accessed the ED, generating 46,820 accesses during the study period, with an average of 1.23 accesses for patient. The elderly population represented a quarter of the total ED population and had an increased risk of frequent use (OR 1.5: CI 1.4–1.7) and hospitalization (OR 3.8: CI 3.7–4). Moreover, they showed a greater diagnostic complexity, as demonstrated by the higher incidence of yellow and red priority codes compared to other ED populations (OR 3.1: CI 2.9–3.2). Discussion Older patients presented clinical and social characteristics related to the definition of “elderly frail frequent users”. The fact that a larger number of hospitalizations occurred in such patients is indirect evidence of frailty in this specific population, suggesting that hospital admissions may be an inappropriate response to frailty, especially when continued care is not established. Conclusion Enhancement of continuity of care, establishment of a tracking system for those who are at greater risk of visiting the ED and evaluating fragile individuals should be the highest priority in addressing ED frequent usage by the elderly.

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Frequent Use of Emergency Departments by the Elderly Population When Continuing Care Is Not Well Established

Aim To explore the experiences and perceptions of recent nursing graduates working in emergency departments during the COVID-19 outbreak. Background Overcrowding in emergency departments has been one of the most prominent issues arising in these units for more than 20 years. However, it has become even more problematic due to the novelty of the coronavirus pandemic, which has forced hospitals to recruit larger numbers of beginner nursing staff as the number of quarantined health professionals increases. Methods Sixteen semi-structured interviews were conducted in Spanish emergency departments, which were analysed and synthesized using content analysis. Results Three major themes emerged from the data analysis: (a) Fears and concerns, (b) Organisational issues and (c) Support for novice nurses. Conclusions Our findings may help to understand how shadowing periods as a learning programme for nurses, continuing professional development, evidence-based apps and better planning are needed to ensure both novice nurses' confidence in emergency departments and expert emergency room nurses' ability to cope with complications in critical situations. Implications for nursing management Training periods that include shadowing expert emergency room nurses, along with evidence-based technology, provide an opportunity to support novice nurses' transition into the workplace. These measures would provide a safety net and would increase novice nurses' confidence as well as high-quality care.

Novice nurse's transitioning to emergency nurse during COVID-19 pandemic: A qualitative study.

Early identification of frailty through targeted screening can facilitate the delivery of comprehensive geriatric assessment (CGA) and may improve outcomes for older inpatients. As several instruments are available, we aimed to investigate which is the most accurate and reliable in the Emergency Department (ED). We compared the ability of three validated, short, frailty screening instruments to identify frailty in a large University Hospital ED. Consecutive patients aged ≥70 attending ED were screened using the Clinical Frailty Scale (CFS), Identification of Seniors at Risk Tool (ISAR), and the Programme on Research for Integrating Services for the Maintenance of Autonomy 7 item questionnaire (PRISMA-7). An independent CGA using a battery of assessments determined each patient’s frailty status. Of the 280 patients screened, complete data were available for 265, with a median age of 79 (interquartile ±9); 54% were female. The median CFS score was 4/9 (±2), ISAR 3/6 (±2), and PRISMA-7 was 3/7 (±3). Based upon the CGA, 58% were frail and the most accurate instrument for separating frail from non-frail was the PRISMA-7 (AUC 0.88; 95% CI:0.83–0.93) followed by the CFS (AUC 0.83; 95% CI:0.77–0.88), and the ISAR (AUC 0.78; 95% CI:0.71–0.84). The PRISMA-7 was statistically significantly more accurate than the ISAR (p = 0.008) but not the CFS (p = 0.15). Screening for frailty in the ED with a selection of short screening instruments, but particularly the PRISMA-7, is reliable and accurate.

Comparison of Frailty Screening Instruments in the Emergency Department

Background Emergency Departments (EDs) are playing an increasingly important role in the care of older adults. Characterizing ED usage will facilitate the planning for care delivery more suited to the complex health needs of this population. Methods In this retrospective cross-sectional study, administrative and clinical data were extracted from four study sites. Visits for patients aged 65 years or older were characterized using standard descriptive statistics. Results We analyzed 34,454 ED visits by older adults, accounting for 21.8% of the total ED visits for our study time period. Overall, 74.2% of patient visits were triaged as urgent or emergent. Almost half (49.8%) of visits involved diagnostic imaging, 62.1% involved lab work, and 30.8% involved consultation with hospital services. The most common ED diagnoses were symptom- or injury-related (25.0%, 17.1%. respectively). Length of stay increased with age group (Mann-Whitney U;p < .0001), as did the proportion of visits involving diagnostic testing and consultation (χ2; p < .0001). Approximately 20% of older adults in our study population were admitted to hospital following their ED visit. Conclusions Older adults have distinct patterns of ED use. ED resource use intensity increases with age. These patterns may be used to target future interventions involving alternative care for older adults.

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Emergency Department Utilization by Older Adults: a Descriptive Study

Performance-based financial incentives for diabetes care: an effective strategy?

Background Psoriasis has a profound negative effect on quality of life that is often underappreciated by health care professionals and the public. Objective We sought to assess the perception of the burden of psoriasis relative to other medical conditions in first-year medical students, and to determine if wearing a temporary tattoo simulating psoriasis during a teaching exercise would change their perceptions. Methods Participants completed a questionnaire assessing their perception of the impact of psoriasis and other common medical conditions (visual analog scale). Participants then wore a temporary tattoo of a psoriatic lesion for 24 hours and completed the same questionnaire after this exercise. Results Of 91 students approached, 61 completed the study. At baseline, psoriasis (mean = 23.6) and eczema (mean = 23.3) were perceived as having the lowest physical burden of diseases queried ( P P P  = .0005) and psoriasis (physical: mean = 37.8, P  = .0014; mental: mean = 68.6, P  = .0293) was significantly increased. Limitations The exercise did not simulate the chronic nature of psoriasis or the scaling and pruritic characteristics of psoriatic lesions. The survey instrument used to assess empathy has not been previously validated and statistical analysis was limited by small sample size and the absence of a control group. Conclusions Temporary tattoos are a novel and effective method of teaching medical students about the psychological burden of psoriasis.

https://www.jaad.org/article/S0190-9622(11)00812-7/pdf

Teaching empathy to undergraduate medical students using a temporary tattoo simulating psoriasis.

Objective: As older adults become increasingly reliant on emergency departments (EDs) for care, there is an interest in determining what types of ED visits by this population may be preventable, or amenable to other forms of care. The aim of this project was to explore the concept of preventable ED visits by older adults. Methods: We conducted a literature search to identify definitions of “preventable” or “avoidable” ED visits. We then applied a definition of preventable ED visits to an administrative data set consisting of ED visit data extracted from four sites in Halifax, Nova Scotia, Canada. Visits for patients 65 years of age or older were eligible for inclusion. Visits were categorized using triage level and discharge diagnosis. Results: Four methods of defining preventable ED visits were identified in our literature search: 1) Ambulatory Care Sensitive Conditions (ACSCs) (N = 7), 2) Low Acuity/low intensity visits (N = 5), 3) New York University (NYU) (Billings) Algorithm (N = 3) and 4) hospital admission vs. non-admission (N = 1). We categorized 34,454 ED visits from our dataset using a modified definition of preventable ED visits that included ACSCs (15.3%) as well as low acuity visits that required no testing or hospital admission (9.9%). Conclusions: Our results suggest that approximately 25% of ED visits by older adults may be preventable or amenable to other forms of care. This data may be useful in the planning of care delivery appropriate for the needs of this population.

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Defining potentially preventable emergency department visits for older adults

Medical schools recognize that they have an important social mandate beyond their primary role to educate future physicians. The instantiation of social accountability (SA) within faculties of medicine requires intentional, effective partnering with diverse internal and external stakeholders. Despite early, promising academic work in the field of SA in medical education, there remains a lack of conceptual clarity about what SA could and should entail, and a lack of practical direction regarding how it could be implemented. The paper describes the development of an innovative SA framework that incorporates both pragmatic-evaluation and collaborative-enhancement components. The framework consists of five distinct phases, uses a deliberative engagement methodology, and is meaningfully informed by a set of four SA Lenses: Diversity, Inclusion and Cultural Responsiveness; Equity; Community / Stakeholder Engagement and Partnering; and Justice-Fairness and Sustainability. In addition to using the framework to evaluate and enhance the social accountability statuses of a variety of the medical school’s operational components, Dalhousie Faculty of Medicine leaders are committed to applying the framework’s SA Lenses to important decision-making processes, such as the revision of the medical school’s strategic directions and the allocation of limited resources to address important, emerging medical education issues and challenges.

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Lesley P. Latham

Papers

Emergency Department Utilization by Older Adults: a Descriptive Study

Performance-based financial incentives for diabetes care: an effective strategy?

Teaching empathy to undergraduate medical students using a temporary tattoo simulating psoriasis.

Defining potentially preventable emergency department visits for older adults

Introducing a Collaborative E2 (Evaluation & Enhancement) Social Accountability Framework for Medical Schools