Controlled Trial of a Geriatric Case-Finding and Liaison Service in an Emergency Department

OBJECTIVE: To evaluate the effects of a program of case-finding and liaison service for older patients visiting the emergency department. DESIGN: Nonrandomized controlled trial with systematically assembled intervention cohort and matched control group. SETTING: An urban teaching hospital. PARTICIPANTS: There were 385 intervention subjects aged 65 years and older and 385 control subjects matched by day of visit, gender, and age within 5 years. INTERVENTIONS: Geriatric medical, dental and social problems were identified in intervention subjects by a geriatric nurse clinician using well validated assessment instruments during a 30-minute evaluation. Recommendations were made to the patient, family, and attending emergency department physician, and attempts were made to arrange appropriate follow-up services. MEASUREMENTS: Frequency with which geriatric problems were identified in intervention subjects; physician, patient, and family compliance with recommendations; and mortality, institutionalization, health status, use of medical and social services, presence of an advanced directive, and quality of life at 3-month follow-up. RESULTS: Sixty-seven percent of patients were dependent in at least one activity of daily living, 82% had at least one geriatric problem identified, and 77% reported at least one unmet dental or social support need. The cost of identifying geriatric and dental/social issues was $5 and $1, respectively, for each problem. Physicians complied with 61.6% of suggestions, and patients and families complied with 36.6% of recommendations. Mortality and nursing home residence proportions at 3 months were not significantly different (9.3% vs 9.7% and 5.0% vs 2.5% in intervention and control groups, respectively). Intervention subjects reported more difficulty communicating (21% fair or poor ability vs 13%, P = .02) than did control subjects. There were strong trends for fewer subsequent visits to emergency departments (0.26 intervention vs 0.39 control, P = .06) and more advance directives in the intervention group (6.7% intervention vs 2.9% control, P = .07). There was no statistically or clinically significant difference in any other health outcome. The number of new dental or social services initiated per patient over the 3-month follow-up was nearly identical (1.7 in the intervention group vs 1.5 in the control). Results in subjects aged 75 years and older and those discharged home from the emergency department were essentially identical to those in the main group. CONCLUSIONS: Numerous previously unrecognized geriatric medical and social problems can be detected in older persons visiting the emergency department. Despite this, an emergency department-based geriatric assessment and management program failed to produce improved outcomes. This suggests that either disease acuity is an overwhelming factor in subsequent outcome or, alternatively, more control over medical and social service delivery during and after the emergency department visit than was demonstrated in this program will be required before successful outcomes can be assured.