Article

Emergency geriatric assessment: A novel comprehensive screen tool for geriatric patients in the emergency department

Acknowledgements

The authors wish to acknowledge the contributions of all research staff at the clinical sites for their efforts towards conducting the parent study.

Rosanne Naunheim, MD

Washington University Barnes JewishMedical Center, St. Louis, MO,

United States E-mail address: [email protected]

Tracey Covassin, PhD, ATC

Sport Concussion Laboratory, Michigan State University, East Lansing, MI,

United States E-mail address: [email protected]

Arnaud Jacquin, PhD BrainScope Company, Inc., Bethesda, MD, United States Corresponding author at: BrainScope Company, Inc., Room 1220, 1115

Broadway, New York, NY 10010, United States.

E-mail address: [email protected]

Daniel Hanley, MD

Brain Injury Outcomes – The Johns Hopkins Medical Institutions, Baltimore,

MD, United States E-mail address: [email protected]

Edward Michelson, MD

Department of Emergency Medicine, Texas Tech University Health Sciences

Center, El Paso, TX, United States

14 April 2017

geriatric assessment: A novel “>http://dx.doi.org/10.1016/j.ajem.2017.07.007

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  • Emergency geriatric assessment: A novel comprehensive screen tool for geriatric patients in the emergency department

    To the Editor,

    The geriatric population is rapidly increasing all over the world, es- pecially in developed countries. The emergency department (ED) is

    the most common place that the elderly use when they suffer from an illness [1-4]. Because of their frailty and complex conditions, the geriat- ric population also has a higher rate of revisiting the ED or readmission than the younger population [1-4]. The problems in the elderly are typ- ically multidimensional in nature, and include physical, psychological, and socioeconomic factors [5,6]. Thus, delivering a multidimensional as- sessment (comprehensive geriatric assessment, CGA) and the subse- quent management by multidisciplinary specialist care teams are widely recognized as being beneficial for the elderly [7]. In recent years, some studies in the United Kingdom showed that early CGA in the ED could reduce both admission and readmission rates [6,8]. How- ever, a CGA may require 20-30 min, and therefore may be difficult to conduct in the busy ED. Hospice and palliative care (HPC) are also im- portant issues in the geriatric population [9]; however, they are not in- cluded in the CGA, which intends to screen for geriatric syndromes. Therefore, we developed a novel model entitled, “emergency geriatric assessment (EGA),” based on the modified CGA with the addition of items for HPC. We intended to screen geriatric ED patients comprehen- sively and initiate subsequent interventions to both improve the quality of care and reduce ED visits in this population.

    First, we constructed a draft EGA using the core components in the

    CGA [6,7,8,10,11] and items from HPC [12] by a critical literature review and expert committee (Fig. 1). The core components in the CGA were for screening geriatric syndromes as follows: (1) delirium; (2) depres- sion; (3) dementia; (4) activities of daily living; (5) vision; (6) hearing;

    (7) sleep; (8) falls; (9) polypharmacy; (10) pain; (11) pressure ulcers;

    (12) incontinence or retention; (13) instrument or restriction; (14) nu- trition; (15) use of medical resources; (16) Advance care planning; (17) caregiver; (18) socioeconomic status; and (19) family meeting [6,7,8, 10,11]. The items for HPC were as follows: (20) life period; (21) need for comfort care; and (22) long-term bedridden care [12]. Second, we invited 10 older adults for a geriatric FoCUS group meeting to help us im- prove the understanding and appropriateness of the items in the EGA. Third, we invited 10 experts including nurses, emergency physicians, geriatricians, and HPC specialists to help revise the draft EGA. Fourth, using the revised EGA, we conducted a prospective study to recruit con- venient samples from the geriatric patients in the ED in the Chi-Mei Medical Center (CMMC) between September 1, 2016, and November 31, 2016, for assessing the reliability of the EGA. Geriatric patients, who were waiting for admission, or being observed in the observation unit, were eligible for this study. Individuals were excluded if they:

    Fig. 1. Flowchart of this study. EGA, emergency geriatric assessment; ED, emergency department.

    (1) had an acute stroke; (2) had an acute myocardial infarction; or (3) were awaiting surgical intervention and admission (Fig. 2 for the En- glish version and Supplement Table 1 for the Chinese version). Trained experienced nurse practitioners or nurses performed the EGA for eligi- ble geriatric patients in a convenient manner. Consultations with the geriatrician or HPC specialist suggested in the EGA, depended on the EGA results combined with the specific condition of the patient. This study was conducted strictly under the Declaration of Helsinki. We

    used the Kuder-Richardson Formula 20 (KR-20) for testing the internal consistency reliability and the content validity index (CVI) for testing the validity of the EGA. All statistical analyzes used SAS 9.4 for Windows (SAS Institute, Cary, NC, USA). The significance level was set at 0.05 (two-tailed).

    A total of 118 geriatric patients in the ED were enrolled in this study (Table 1). The mean +- standard deviation was 78.0 +- 9.0 years (range: 65-98 years). The percentage of Males and females was 47.5% and 52.5%,

    Fig. 2. English version of emergency geriatric assessment (EGA).

    Fig. 2. (continued.)

    respectively. Overall, the internal consistency reliability by KR-20 was

    0.86 in the 118 patients, which showed good internal consistency for the EGA. We invited 10 experts to rate each item of the EGA based on rel- evance, clarity, and simplicity. The item CVI ranged from 0.9 to 1.0, and the total CVI was 0.95, indicating adequate content validity.

    We developed the EGA strictly based on our literature review, the ex- pert committee, and a geriatric focus meeting at CMMC. The 22 items in- cluded the core components of CGA for geriatric syndromes and additional items for HPC. The EGA has good reliability and validity and

    potentially may become a solution for comprehensively screening prob- lems in geriatric ED patients. Both the results of the EGA and subsequent referral to multidisciplinary specialist care teams may help solve under- lying problems in geriatric patients, reduce the rate of Hospital visits, im- prove the quality of care, and decrease medical expenditures eventually. Further evaluation of its practicality, comparison of predictive value for geriatric syndromes with CGA, and generalizability are needed.

    Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2017.07.008.

    Table 1

    Demographic characteristics of geriatric patients in the observation unit of the emergency department.

    Variable Total (n = 118)

    Age (years) 78 +- 9

    Age subgroup (years)

    65-74 46 (39%)

    75-84 41 (34.7%)

    >= 85 31 (26.3%)

    Sex

    Males 56 (47.5%)

    Females 62 (52.5%)

    Medical decisions

    By self 28 (23.7%)

    Assistance by others 90 (76.3%) Ability to care for self

    By self 5 (4.2%)

    Assistance by others 113 (95.8%) Data is expressed as number (percent) or mean +- standard deviation.

    Disclosure statement

    The authors declare no conflicts of interest.

    Funding

    No sources of funding were used.

    Acknowledgments

    The authors would like to thank Miss Jui-Chi Lee and all the nurses who participated in performing the EGA in patients and Mr. Po-Chang Huang for statistical assistance.

    Tzu-Chieh Weng, MD

    Holistic Care Unit, Department of Internal Medicine, Chi-Mei Medical

    Center, Tainan, Taiwan

    Chien-Chin Hsu, MD, PhD

    Department of Emergency Medicine, Chi-Mei Medical Center,

    Tainan, Taiwan Department of Biotechnology, Southern Taiwan University of Science and

    Technology, Tainan, Taiwan

    Hung-Jung Lin, MD, MBA

    Department of Emergency Medicine, Chi-Mei Medical Center,

    Tainan, Taiwan Department of Biotechnology, Southern Taiwan University of Science and

    Technology, Tainan, Taiwan Department of Emergency Medicine, Taipei Medical University, Taipei,

    Taiwan

    Chien-Cheng Huang, MD

    Bachelor Program of Senior Service, Southern Taiwan University of Science

    and Technology, Tainan, Taiwan Department of Geriatrics and Gerontology, Chi-MeiMedical Center,

    Tainan, Taiwan Department of Emergency Medicine, Chi-Mei Medical Center,

    Tainan, Taiwan Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan Department of occupational medicine, Chi-Mei Medical Center,

    Tainan, Taiwan Corresponding author at: Department of Emergency Medicine, Chi-Mei Medical Center, 901 Zhonghua Road, Yongkang District,

    Tainan City 710, Taiwan.

    E-mail address: [email protected]

    Ya-Ting Ke, RN, MSN Department of Nursing, Chi-Mei Medical Center, Tainan, Taiwan Graduate Institute of Nursing, Kaohsiung Medical University,

    Kaohsiung City, Taiwan Bachelor Program of Senior Service, Southern Taiwan University of Science

    and Technology, Tainan, Taiwan

    http://dx.doi.org/10.1016/j.ajem.2017.07.008

    15 June 2017

    An-Chi Peng, RN Department of Nursing, Chi-Mei Medical Center, Tainan, Taiwan Graduate Institute of Nursing, Kaohsiung Medical University,

    Kaohsiung City, Taiwan

    Yi-Min Shu, RN, MSN

    Department of Nursing, Chi-Mei Medical Center, Tainan, Taiwan

    Min-Hsien Chung, MD

    Department of Emergency Medicine, Chi-Mei Medical Center, Liouying,

    Tainan, Taiwan

    Kang-Ting Tsai, MD

    Department of Geriatrics and Gerontology, Chi-MeiMedical Center,

    Tainan, Taiwan Graduate Institute of Medical Sciences, College of Health Sciences, Chang

    Jung Christian University, Tainan, Taiwan

    Ping-Jen Chen, MD

    Bachelor Program of Senior Service, Southern Taiwan University of Science

    and Technology, Tainan, Taiwan Department of Geriatrics and Gerontology, Chi-MeiMedical Center,

    Tainan, Taiwan Palliative Care Center, Chi-Mei Medical Center, Tainan, Taiwan

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