DOI: 10.5061/dryad.m63xsj470
title: Use of the Electronic Medical Record to screen for high-risk geriatric patients in the Emergency Department

description: Introduction Older adults with multi-morbidities have the highest rate of
 ED usage. These patients are typically on numerous medications, may have
 underlying dementia, and often present with falls and delirium.
 Identifying these high-risk older adults for possible intervention is
 challenging in the ED setting since available screening methods are manual
 and resource-intensive. The objective is to study the feasibility of using
 the Electronic Medical Record (EMR) for identifying high-risk older adults
 in Emergency Department (ED). Study Setting Academic ED with 67,000 total
 and 24% geriatric (age ≥ 65 years) annual visits, American College of
 Emergency Physician (ACEP) accredited Level 1 Geriatric Emergency
 Department with ED-based geriatric consultation program. Materials and
 Methods This is a feasibility study incorporating criteria from existing
 manual geriatric screening instruments and the 4M framework into an
 automated EMR screen to identify high-risk geriatric patients. ED
 providers were then alerted by an EMR Best Practice Alert (BPA) if
 high-risk status was identified. Initial development and impact on
 geriatric ED consults are reported. Results During the study period, 7,450
 patient encounters occurred; 1,836 (24.6%) encounters involved patients
 who were 65 years or older. 1398 (76.1%) high-risk ED encounters resulted
 in BPA alerts using the EMR automated screen. BPA alerts resulted in 82
 (5.9%) geriatric evaluations. Conclusion Using the EMR to automate
 screening for older adults for high-risk geriatric conditions in the ED is
 feasible. An automated EMR screen with a BPA to ED providers identified a
 well-defined cohort of older patients appropriate for further ED geriatric
 evaluation.
description: This was a
 descriptive feasibility study of the use of EMR screening for high-risk older patients in the setting of a
 busy urban academic American College of Emergency Physician
 (ACEP)-accredited Level 1 Geriatric Emergency Department with an ED-based geriatric
 consult program, and 67 000 total annual visits, with 24% geriatric (age ≥
 65) years visits conducted from March 31, 2020, to May 31, 2020.
 Subject matter
 experts from Emergency Medicine, Geriatric Medicine, Nursing, Pharmacy,
 Case Management, and Social Work used a modified Delphi method, based on
 review of the literature and professional judgment, to develop criteria to
 define high-risk geriatric characteristics which
 can be captured by the EMR. Prior to EMR
 screening implementation, ED providers were educated on 8 geriatric
 domains using case series and CME modules and patients aged 65 years and
 older were screened for delirium at the time of triage using the 4AT
 delirium screen. The 4AT is a brief delirium screening tool with high
 sensitivity and specificity compared to established delirium tools such as
 the Confusion Assessment Method (CAM). An EMR
 best-practice alert (BPA) was developed to
 notify ED providers for high-risk geriatric characteristics defined
 as: age ≥80 years, fall complaint (<em id="258" data-edummy="italic">M</em>obility), documented
 dementia history (<em id="259" data-edummy="italic">M</em>entation), polypharmacy (≥10
 <em id="260" data-edummy="italic">M</em>edications recorded), high
 ED utilization (&gt;5 visits in 1 year), or a (+) 4AT delirium screen
 (Table 1). This BPA alerted the ED provider if one or more high-risk criteria were present. In
 addition, the BPA had an embedded link allowing ED providers to place an
 order for a geriatric evaluation in the ED. ED providers could also
 request a geriatric evaluation, independent of BPA, based on professional
 judgment.
 Charlson Comorbidity
 Index (CCI) was not used as a component for the BPA but was calculated as
 a surrogate marker for <em id="301" data-edummy="italic">M</em>ulti-morbidity.
 Frequency of BPA
 notification and ED geriatric consultations (Comprehensive Geriatric
 Assessment, CGA) are reported. Data were abstracted from the EMR. RESULTS During the study period,
 7450 patient encounters occurred; 1836 (24.6%) encounters were in patients
 65 years or older. Additional population characteristics and high-risk criteria (excluding age over 80
 years) are shown in Table 2. The mean age was 74.6
 years and 49.5% were female. Delirium detection by 4AT was approximately
 6% in this population. Preexisting dementia was documented in 6.6%. The
 average number of medications per patient was 8.4. Notably, 18% had more
 than 5 ED encounters in last the 12 months and the average number of ED
 encounters per patient during the same time period was 3.66. The average
 CCI was 3.82, reflective of Multi-Morbid older adults with poor
 prognoses. <strong id="313"></strong> A total of 1398 (76.1%)
 geriatric ED encounters resulted in BPA alerts using the EMR automated
 screen. Four hundred thirty-eight (33.9%) patients did not meet
 high-risk criteria. BPA alerts resulted in
 82 (5.9%) comprehensive geriatric assessments. Fourteen (3.2%) BPA-negative patients were also referred for
 CGA due to clinical judgment by ED providers. Overall, 96 (5.2%) patients
 had a CGA. We also examined the proportion of geriatric assessments
 performed in BPA-positive patients compared to the overall
 number of CGA obtained. In this group, 82/96 (85.4%) patients who
 underwent a CGA, were BPA positive.
description: Please see README document and accompanying published
 article.