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Fabio SalviU.O.C. Geriatria – Accettazione Geriatrica d’Urgenza

INRCA – POR Ancona

NUOVI MODELLI ORGANIZZATIVI:

IL PRONTO SOCCORSO GERIATRICO

GERIATRIC EMERGENCY MEDICINE

Emergenze-Urgenze nel Paziente

AnzianoVerona 16-17 maggio 2014

GERIATRIC EMERGENCY MEDICINE

Emergenze-Urgenze nel Paziente

AnzianoVerona 16-17 maggio 2014

OUTLINE

GERIATRIC EMERGENCY DEPARTMENT• Why• How• What experiences• What evidence• What alternatives

Roberts DC et al. Ann Emerg Med 2008

The overall trend in the rate of ED visits for the 65- to 74-year-old group showed a 34% increase in visit rate per populationthroughout the study period

Albert M et al. Adv Data 2013

THE ITALIAN PICTURE

2000 2002 2003 2004 20052001 2006

17.7 18.1 18.2 18.7 19.2 19.7 19.6

0

10

20

30

40

500-14 15-44 45-64 65+

Salvi F et al. Intern Emerg Med 2007

2007/2008

2009

20.8 21.0

2012 = 22.1%

THE MARCHE REGION PICTURE

0

10

20

30

40

50

0-14 15-44 45-64 65+

23.9

Salvi F et al. Aging Clin Exp Res 2013

Aminzadeh F, Dalziel WB. Ann Emerg Med 2002

• More likely to arrive by ambulance (35-40% vs. 10-12%)

• Higher proportion of emergent/urgent visits

• Use more diagnostic and staff resources

• Longer ED stay

• Higher admission rate (30-50%; 2.5-4.6 fold more than younger people)

• More likely to require an ICU bed

Downing A et al. Publ Health 2004

McCaig LF et al. Adv Data 2001-2006 Albert M et al. Adv Data 2013

<1 y 1-14 y 15-44 y 45-64 y 65-79 y ≥80 y

AGE & TRIAGE (ITALY)

0

10

20

30

40

50

60

70

80

90

100


AGE & ADMISSION RATE(ITALY)

65-79 y45-64 y15-44 y1-14 y<1 y ≥80 y0

5

10

15

20

25

30

35

40

57.4%


AGE & LOS IN THE ED(ITALY)

• Phase 1: Triage to ED admission

• Phase 2: ED admission to first

diagnostic procedure

• Phase 3: First to last diagnostic

procedure

• Phase 4: Last diagnostic procedure

to hospitalization or discharge

Rossi PD et al. JAGS 2010 [Letter]

Aminzadeh F, Dalziel WB. Ann Emerg Med 2002

• More likely to arrive by ambulance (35-40% vs. 10-12%)

• Higher proportion of emergent/urgent visits

• Use more diagnostic and staff resources

• Longer ED stay

• Higher admission rate (30-50%; 2.5-4.6 fold more than younger people)

• More likely to require an ICU bed

• More often present problems of medical nature

• Higher rate of adverse outcomes (i.e. ED return, functional decline,hospitalization, death) in the 3-6 months after an ED index visit

• Their ED diagnoses tend to be less accurate

TRAUMA

Elderly trauma patients were more often admitted (13% vs. 4.2%, p<0.0001)

Visits for trauma were 34.5% of all of the visits

Young adults Elderly

38.3% 22.7%

p<0.0001


TOP TEN OF CHIEF COMPLAINTS

Trauma Enclosed Trauma Excluded

Young adults Elderly Young adults Elderly

Lower limbs trauma 589 (13.3) Dyspnea 134 (9.6) Abdominal pain 296 (6.7) Dyspnea 134 (9.6)

Upper limbs trauma 405 (9.1) Lower limbs trauma 127 (9.1) Fever 202 (4.6) Abdominal pain 125 (9)

Abdominal pain 296 (6.7) Abdominal pain 125 (9) Lower limbs pain 135 (3) Chest pain 64 (4.6)

Column trauma 261 (5.9) Chest pain 64 (4.6) Chest pain 135 (3) Palpitations 62 (4.5)

Fever 202 (4.6) Palpitations 62 (4.5) Skin problems 129 (2.9) Lower limbs pain 55 (4)

Lower limbs pain 135 (3) Upper limbs trauma 56 (4) Foreign body (eye) 127 (2.9) Weakness 50 (3.6)

Chest pain 135 (3) Lower limbs pain 55 (4) Headache 113 (2.5) Syncope 40 (2.9)

Skin problems 129 (2.9) Weakness 50 (3.6) Eye pain 96 (2.2) Fever 31 (2.2)

Foreign body (eye) 127 (2.9) Syncope 40 (2.9) Back pain 92 (2.1) Headache 31 (2.2)

Headache 113 (2.5) Column trauma 35 (2.5) Dyspnea 87 (2) Paresthesias 27 (1.9)


McCusker J et al. Acad Emerg Med 2000

ED diagnosis

Final diagnosis

Samaras N et al.Ann Emerg Med 2010

adapted fromLewis LM et al.

J Gerontol A 2005

• The elderly in the ED is a diagnostic challenge

Disease presentations in the elderly:• Classic• Silent• Pseudosilent• Atypical

– Weakness/fatigue– Functional decline– Falls/immobilization– Incontinence– Delirium– “Social crisis”

ATYPICAL PRESENTATIONS• Solo il 40% degli anziani segue la regola “1 sintomo = 1 malattia”

– IMA senza dolore toracico

– FA come sintomo di crisi tireotossica; iposodiemia/ipotiroidismo

– Astenia (deficit funzionale acuto) quale sintomo principale discompenso cardiaco, infezione (polmonite; sepsi)

– Sincope quale presentazione di embolia polmonare

Grossmaitre P et al. Arch Cardiovasc Dis 2013

Nemec M et al. Acad Emerg Med 2010

DELIRIUM

Inouye S et al. Lancet 2014 Han JH et al. Ann Emerg Med 2010

DELIRIUM: ETIOLOGY

Drugs

Environment

Low oxygen

Infections

Ritention

Ischemia

Undernutrition

Metabolic

Subdural haematoma

Vascular

Infections

Nutrition

Drugs

Injury (trauma)

Cardiac

Autoimmune

Tumors

Endocrine

Iatrogenic (drugs)

Infections

Injury (trauma)

Illness exacerbation

Inconsistent environment

Inconsistent caregiver

Is patient depressed?

• The elderly in the ED is a diagnostic challenge– Atypical presentations– Delirium

• Polypharmacy– Adverse Drug Reactions (ADR)– Inappropriate prescriptions

AGE & ADR

Budnitz DS et al. JAMA 2006

ADR & INAPPROPRIATE PRESCRIPTIONS

• ADR represent 10-16% of the ED visits of elderly patients, but thediagnosis is correctly done only in 50% of the cases!

Hohl CM et al. Acad Emerg Med 2005

MORE FREQUENTLY IMPLIED DRUGS

Budnitz DS et al. Ann Intern Med 2007

Drugs classes more frequently involved are:- NSAIDs / Anticoagulants - Antibiotics- Hypoglycemics (oral or insulin) - Diuretics- β-blockers & CCB - BDZ, -H1

ADR & POTENTIALLY INAPPROPRIATE MEDICATIONS

• ADR represent 10-16% of the ED visits of elderly patients, but thediagnosis is correctly done only in 50% of the cases

• 31% of the elderly ED patients have at least one potentially inappropriatemedication (PIM) following the Beers’ criteria; 50% of those with an ADRhave also a second, not-related PIM

• 13% of the elderly ED patients receive one PIM; among them, 20% hasmore than one; the risk of receiving a PIM correlates with the number ofadministered/prescribed medications in the ED

Caterino JM et al. JAGS 2004

• The elderly in the ED is a diagnostic challenge– Atypical presentations– Delirium

• Polypharmacy– ADR– Inappropriate prescriptions

• Cognitive assessment• Functional assessment• Quality of care (ageism)

STATO COGNITIVOUn certo grado di deterioramento cognitivo è presente nel 15-40%degli ultra65enni in PS (specie se >80 aa e/o istituzionalizzati), maviene riconosciuto solo nel 27-50% dei casi, con gravi implicazioninella precisione dell’anamnesi (undertriage, ritardo indiagnosi/terapia) e nella comprensione delle indicazioni date alladimissione (ADRs, compliance, presenza/affidabilità del caregiver)

Hustey FM et al. Ann Emerg Med 2002Chiovenda P et al. Am J emerg Med 2002

Han JH et al. Ann Emerg Med 2011

STATO FUNZIONALELo stato funzionale viene pressoché ignorato (75% casi), eppure:

– i ⅔ sono disabili in almeno una IADL o BADL

– soltanto il 22% è completamente indipendente in tutte le ADL

– il 74% afferma che il declino funzionale dall’inizio dei sintomi èstato determinante nella decisione di ricorrere al PS

– il 28% non sarebbe in grado di badare a sé stesso a domicilio:il 20% viene dimesso ugualmente

Spesso vi è discordanza tra lo stato funzionale autopercepito dalpaziente e quello percepito dal familiare/caregiver, principalmenteper il mancato utilizzo di strumenti standardizzati per la suavalutazione (ADL, IADL, Barthel Index etc.)

Wilber ST et al. Acad Emerg Med 2006Rodriguez-Molinero A et al. BMC Geriatrics 2006

QUALITY OF CARE

Magid DJ et al. Ann Emerg Med 2005

ASA -blockers

Reperfusion

ED ENVIRONMENT

• Uncomfortable for older persons

• High volume, high stress

• Anxious, worried patients

• Little privacy

• Limited ED provider time

• Beds, lighting, noise

• Modifications can make a difference

OUTLINE

GERIATRIC EMERGENCY DEPARTMENT• Why• How• What experiences• What evidence• What alternatives

THE IDEAL GERIATRIC ED1. Geriatric education and experience of the ED staff indealing with and management of elderly patients

2. Knowledge of the patient (primary physician contact,transfer form, electronic database) helps to save timeand have reliable information (e.g. diseases, prescriptionmedications, recent x-ray or lab examinations, allergies)

3. Team management following CGA protocols

4. Possibility to observe the patient (Observation Unit)

5. Adequate environment

A hybridized ED and observation unit might optimizecare for complex but stable older people in the midst ofprolonged diagnostic works

J Am Geriatr Soc 2007

Adams JG, Gerson LW

Hwang U, Morrison RS. J Am Geriatr Soc 2007

McCusker J et al. JAGS 2001Mion L et al. Ann Emerg Med 2003Meldon S et al. Acad Emerg Med 2003

- +ELDERLY IN THE ED

SCREENING

USUAL CARE second-level CGA

problem identification

INTERVENTION(discharge, admission, referral, liason, etc.)

DISCHARGE PLANNING

SCREENING TOOLS ISAR

(Identification of Seniors At Risk)Y N

1) Before the illness or injury that brought you to theED, did you need someone to help you on a regularbasis?

1 0

2) Since the illness or the injury that brought you tothe ED, have you needed more help than usual totake care of yourself?

1 0

3) Have you been hospitalized for one or morenights during the past six months (excluding a stayin the ED)?

1 0

4) In general, do you see well? 0 1

5) In general, do you have serious problems withyour memory? 1 0

6) Do you take more than three different medicationseveryday? 1 0

TOTAL

TRST(Triage Risk Screening Tool)

Y N

1) Presence of cognitive impairment (i.e. confusion,unable to follow directions, diagnosis of dementia ordelirium)

1 0

2) Lives alone or no caregiver available, willing or able 1 0

3) Difficulty with walking or transfers or history ofrecent falls 1 0

4) Patient/family states has used ED within past 30days or has been hospitalized within last 3 months 1 0

5) Five or more different medications 1 0

6) Professional recommendations: nurse believes thispatient requires further follow-up at home for any ofthe following:a) suspected abuse, neglect, self-neglect, exploitationb) noncompliant patient with <5 medications whokeeps coming back to the EDc) suspected substance abuse (alcohol or drug)d) problems with meeting IADLe) other (please specify)

1 0

TOTAL

McCusker J et al. Acad Emerg Med 2000 Mion LC et al. JAGS 2001

OR (95%CI) p

Early ED return (within 30 days)* 1.67 (0.76-3.64) 0.20

ED revisit (within 6 months) 2.07 (1.06-4.05) 0.034

Frequent ED return (≥3 in 6m) 4.69 (1.29-17.1) 0.019

Admission within 6 months 2.07 (1.02-4.20) 0.043

Functional decline (1 ADL) 2.98 (1.23-7.20) 0.016

Composite outcome [1] 4.85 (2.22-10.6) <0.0001

Composite outcome [2] 3.46 (1.68-7.15) 0.001

Salvi F et al. Aging Clin Exp Res 2009Covariate: età, condizioni familiari, e *reale durata del follow-up

HR 6.9 (95%CI 1.65-29; p=0.008)

ISAR 0-1

ISAR 2+

Di Bari M et al. J Gerontol A 2010

McCusker J et al. J Am Geriatr Soc 2012

Ann Emerg Med 2014; May

EDUCATION• Atypical presentations of disease• Trauma, including falls and hip fracture• Cognitive and behavioral disorders• Modifications for older patients of emergent interventions• Medication management• Transitions of care and referrals to services• Pain management and palliative care• Effect of comorbid conditions• Functional impairments and disorders• Management of the group pf diseases peculiar to the geriatric adult,

including conditions causing abdominal pain• Weakness and dizziness• Iatrogenic injuries• Elder abuse and neglect

PROTOCOLLI

(ISAR)

TRANSITION OF CARE

DISCHARGE LETTER

TRANSFER FORM

SMS/EMAIL

NH/LTC

ED

PHONEPC

ED

OUTLINEGERIATRIC EMERGENCY DEPARTMENT• Why• How• What experiences

– Jerusalem (Israel)– Ancona (Italy)– Others

• What evidence• What alternatives

THE HADASSAH-HEBREW GED(Mt Scopus, Jerusalem, Israel)

• Aperto nel 1995 (Dipartimenti di Emergenza/Geriatria)• 24/7; all 70 years and older are admitted directly• Routine Assessment includes:

– Functional Assessment (ADL, IADL)– Cognitive Assessment (MMSE)– Fall-risk Assessment– Depression Assessment (GDS)– Nutritional Assessment (MNA)– Social Assessment

• Staff includes:– Resident in Geriatrics– Attending Geriatrician– Geriatric Nurse– Social Worker– Consultants (all specialties available in the hospital)– Physical therapists, Occupational therapists as needed

courtesy of Dr. J Stessman & Dr. Y Maaravi

GeriatricED

HomeHospitalization

SubacuteDept.

Acute-CareHospital

Dischargeto

Community

GeriatricRehabil.

PalliativeCare

SkilledNursing

GED ROLE


GERIATRIC EMERGENCY DEPARTMENT• Why• How• What experiences



OUTLINE

ANCONA.

CHRONOLOGYBeginning (May 1997): the Geriatric Medical Acceptation openedas the first/unique example in Italy of ED-like hospital warddedicated to elderly patients (≥65 years-old) with acute illness orchronic disease relapse and complication, excluding trauma

Implementation (October 1998): 24h medical coverage; the GEDbecame an important healthcare resource for elderly people anda valid support for the main local ED (Academic Hospital) andEmergency Medical System (118)

Further implementation (April 2002): the adjacent Acute Geriatricward was merged with the Geriatric ED to realize a clinicalpathway from acute to sub-acute care

1st September 2008: the Marche Region officially recognized theactivity of the Geriatric ED (now renamed as First-Aid Point)

THE INRCA GERIATRIC ED(ANCONA, ITALY)

Waiting Room(arriving patients)

Triage Box

Waiting Room(visited patients)

Surgery(semiurgent/nonurgent patients)

Emergency Room(emergent/urgent patients)

Observation Unit(six beds; max LOS 48h)

EMS (118)(direct access)

Nurses’Working Room

Physicians’Working Room

TRIAGE BOX & WAITING ROOM

WAITING ROOM(visited patients)

Reclining chairs

SURGERIES

OBSERVATION UNIT

natural light

curtains

THE INRCA GERIATRIC ED(ANCONA, ITALY)

Staff: 9 geriatricians (3 in the morning, 2-3 in the afternoon, and 1 onthe night shift); 20 nurses with geriatric education and experience; 6Oss; social worker as needed

Methodology: CGA-oriented through screening tools for frailty (ISAR)and geriatric syndromes (cognitive and functional assessment); specificprotocols for medical problems (dyspnea, chest pain, gastro-intestinalbleeding, pulmonary embolus, dehydration, etc.)

Equipment: blood gas analyzer, noninvasive/invasive ventilators, bedmonitoring, defibrillator, dedicated lab machine, priority access toradiology, reanimation support

Links: post-acute long-term care unit, ICU (cardiology), stroke unit;phone contact with primary physicians or local long-term facilities

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

ACTIVITY DATA(January 1st, 2009 – December 31st, 2012)

37434 ED visits

<50 50-65 65-70 71-80 81-90 91-100 >100

MEAN AGE = 76.5 years

Inappropriate GED use(16.3%)

Discharge = 57.6% 49.8%Discharge after Obs = 9.5% 11.5%Admission 28% (+2%) 34.3%Death = 0.8% 1.1%

~67%68.8%

20.3%8.6%

Triage

1.7%

2013: +3%

2013: 3.2%

2013: 12%

U.S. GERIATRIC EDs EPIDEMIC

Hogan TM et al. Acad Emerg Med 2014

THE HADASSAH-HEBREW GED(Mt Scopus, Jerusalem, Israel)

• 100 Geriatric ED admissions (Mt Scopus)

• 100 General ED admissions (Ein Kerem)

• 70 years and older

• Prospective follow-up (6 months) for:

– Satisfaction with ED care

– Independence

– Readmission0

1020

3040

50

6070

8090

Very Reasonable Moderate

Geriatric EDGeneral ED

p=0.03

1830

8270

0

1020

3040

5060

7080

90

ReAdmission No ReAdmission


p<0.05

0

1020

3040

5060

7080

90

Independent Dependent


p=0.72


J Am Geriatr Soc 2008; 56(11);2131-8

DESIGN OF THE STUDY• Observational prospective clinical study

• 200 elderly patients presenting to the two urban EDs in Ancona

(100000 inhabitants, 23.7% over65): 100 patients enrolled in a

conventional ED (CED) and 100 patients in the Geriatric ED

• The only inclusion criterion: age ≥ 65 years

• Exclusion criteria: critically ill, severe cognitive impairment and no

proxy, trauma as presenting complaint, previously enrolled

• Data collection: age, sex, marital and living status, arrival, triage,

diagnosis, disposition, length of ED stay

• Brief CGA: Charlson Index, SPMSQ, Katz’s ADL

• Phone follow-up at 30 days and 6 months

OUTCOMES• Early (within 30 days) and late (within 6 months)unscheduled ED revisit• Frequent ED return (≥3 over 6 months)• Hospital admission (within 6 months)• 6-month functional decline (defined as loss of ≥1 ADL)• 6-month mortality

Composite outcome (within 6 months)• Death, functional decline, any ED revisit or hospitaladmission

CLINICAL FEATURESCharacteristics Mean±SD

or n (%)CED

(n=100)GED

(n=100) p

Age (years)65-7475-8485+

80.3 ± 7.447 (23.5)96 (48)

57 (28.5)

78.1 ± 7344917

82.5 ± 7.2134740

<0.0001

Sex (F/M) 115/85 47/53 68/32 0.004

TriageEmergentUrgentSemi-urgentNon-urgent

1 (0.5)51 (25.5)136 (68)12 (6)

029683

122689

0.18

DispositionDischargeAdmission

84 (42)116 (58)

4753

3763

0.2

CLINICAL FEATURESCharacteristics Mean±SD

or n (%)CED

(n=100)GED

(n=100) p

Living situationAloneIndependent relativeDisabled relativePaid caregiverInstitution

26 (13)131 (65.5)

8 (4)26 (13)9 (4.5)

1274581

14573188

0.031

Charlson Index0-2≥3

3.4 ± 274 (37)126 (63)

3.3 ± 2.34060

3.4 ± 1.73466

0.73

0.46

SPMSQ0-4≥5

3.9 ± 4137 (68.5)63 (31.5)

2.5 ± 3.38317

5.2 ± 4.25446

<0.0001

ADL4-6≤3

3.8 ± 2.3123 (61.5)77 (38.5)

4.3 ± 27129

3.2 ± 2.55248

0.001

0.009

OUTCOMESOR (95%CI) p

Early ED return (within 30 days) 1.06 (0.5-2.3) 0.88

ED revisit (within 6 months) 0.66 (0.3-1.4) 0.25

Frequent ED return (≥3 in 6m) 1.11 (0.4-3.1) 0.84

Admission within 6 months 0.63 (0.3-1.3) 0.20

Functional decline (1 ADL) 0.65 (0.3-1.6) 0.34

Composite outcome 0.95 (0.4-2.1) 0.89

6-MONTH MORTALITY

GED

CED

HR 0.47 (95%IC 0.22-0.99)

Keyes DC et al. Ann Emerg Med 2014

Conroy SP et al. Age Ageing 2014

• ED conversion:– 75-84 61.154.1– 85+ 69.661.2

• Ricovero entro 7gg– 75-84 4.63.8– 85+ 4.73.3



• LoS– 75-84 7.99.1– 85+ 8.911.1

OUTLINE

GERIATRIC EMERGENCY DEPARTMENT• Why• How• What experiences



ED

GERIATRICHOSPITAL

GENERALHOSPITALS

SMALLHOSPITALS

GED

GED

GEDIsEducation

Structural modificationsCognitive assessment

Pain managementTransitional careFrailty screeningStratification tools

TriageObservation

Discharge planning

PED TraumaCenter

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