Comprehensive Geriatric Assessment in the Emergency Department

Study Overview
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Brief Summary
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Comprehensive geriatric assessment (CGA) has been shown to improve outcomes in an inpatient setting; however, there is currently no compelling evidence of benefit for CGA interventions within the Emergency Department (ED). This study aims to explore the clinical and process outcomes of older adults who receive interdisciplinary ED-CGA over a period of six months after their initial ED attendance.

Detailed Description
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The significant growth in ED attendances is a growing public health issue, with attendances by older adults accelerating over the past decade, beyond that due to population ageing alone. The reasons underlying older adults higher rate of healthcare utilisation, specifically ED usage, are multifaceted. However, the most potent intrinsic factor is the clinical condition of frailty. The presence of diminished homeostatic reserves leaves older adults more susceptible to acute exacerbations of comorbid and long-term conditions, which result in a concomitant increased demand for emergency care. A presentation to an ED can be viewed as a sentinel event for an older adult. Conversely, it affords clinicians an opportunity to identify a high risk cohort followed by delivery of a holistic and bio-psychosocial intervention to mitigate against suboptimal outcomes. CGA is considered the gold standard approach to improving a range of outcomes for frail older adults in acute hospitals. Research has demonstrated that it is feasible to embed CGA within the ED and a model of care delivered by interdisciplinary teams incorporating geriatric competencies into their service has been recommended to meet the emergency and urgent care needs of this patient population within the ED. Despite this recommendation, there is no compelling evidence that ED-CGAs are clinically effective at improving clinical and process outcomes. An ED based interdisciplinary team aim to improve the quality of care and outcomes of older adults through delivery of a CGA. CGA is an intensive interdisciplinary intervention, which assesses an older adult in a holistic fashion incorporating medical, functional, physical and psychological process of care. The team compromises a senior registrar in Geriatric Medicine, specialist geriatric nurse, senior occupational therapist, senior physiotherapist, and senior medical social worker. The investigators propose to explore the clinical and process outcomes of older adults who receive an interdisciplinary ED-CGA over a period of six months after their initial ED attendance through the conduct of a prospective cohort study.

Official Title
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Comprehensive Geriatric Assessment in the Emergency Department: a Prospective Cohort Study of Clinical and Process Outcomes

Conditions
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Frailty

Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Aged ≥ 65 years; Identification of Seniors at Risk score of ≥ 2; Manchester Triage System category of 2 to 5; Presenting with a medical complaint. Exclusion Criteria: Older adults who are deemed not to have capacity to provide informed consent; Older adults who present to the ED outside of the operational working hours (Monday-Friday, 08:00-16:00) of the interdisciplinary ED-CGA team; Older adults presenting with acute cardiac and/or neurological pathology; Older adults presenting with injuries that require surgical intervention; Older adults presenting with high illness acuity, which necessitates treatment in the resuscitation room for the duration of their ED stay.

Ages Eligible for Study
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Minimum Age: 65 Years

Sexes Eligible for Study
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All

Study Plan
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How is the study designed?
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What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Incidence of hospital admission from the ED index attendance. | Number of participants who are admitted to hospital following their index ED attendance | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Incidence of functional decline (including functional decline at discharge from hospital among the cohort admitted from the ED). | Functional decline is defined as a net decrease in the number of activities of daily living performed independently as measured by the self-reported Barthel Index. The sum score of all subscales may range from 0-20 points, where 0 indicates the maximum level of dependency and 20 indicates maximum independence. | 30 days and 6 months | 
| Patient satisfaction with the ED index attendance | Participants will rate their satisfaction across a number of domains using the 18-item Patient Satisfaction Questionnaire. The sum score of all subscales may range from 18 to 90 points, where 18 points is the poorest possible evaluation and 90 points the best. | 30-day follow-up | 
| Number of unscheduled ED re-attendances | Number of participants who experienced an unscheduled ED re-attendance following their index attendance | 30 days and 6 months | 
| Number of unscheduled hospital admissions | Number of participants who experienced an unscheduled hospital (re)admission following their ED index attendance | 30 days and 6 months | 
| Nursing home admission | Number of participants who were admitted to a nursing home or residential care facility following their ED index attendance | 30 days and 6 months | 
| Mortality | Number of participants who died following their ED index attendance | 30 days and 6 months | 
| Healthcare utilisation | Number and duration of services that participants were in receipt of following ED index attendance e.g. specialist geriatric ambulatory care hub attendances, GP visits, public health nurse visits, home care support, outpatient clinic attendance, health and social care professionals input etc. | 30 days and 6 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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frailty, older adults, emergency department, comprehensive geriatric assessment