A Randomized Controlled Trial of Geriatric Emergency Department Innovations

Study Overview
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Brief Summary
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This study evaluates the Geriatric Emergency Department Innovations (GEDI) program at Northwestern Memorial Hospital to care for older adults in the emergency department. Half of the patients will be cared for by a standard ED team plus the GEDI team, while half of the patients will receive usual ED care.

Detailed Description
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Hospitalization is common for older adults in the Emergency Department (ED) but it carries significant risks including the development of delirium, falls, and nosocomial infections. The Geriatric Emergency Department Innovations (GEDI) program at Northwestern Memorial Hospital attempts to identify and address health related risks for older adults without exposing them to the risks of hospitalization,. GEDI is a unique program consisting of a multidisciplinary team of Transitional Care Nurses (TCN), social workers, pharmacists, occupational therapists and physical therapists who perform ED-based geriatric assessment and care coordination. To determine the impact of GEDI on health services use and Health Related Quality-of-Life (HRQoL) we will conduct a randomized controlled trial comparing GEDI compared to usual ED care(which often involves hospitalization).

Official Title
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A Randomized Controlled Trial of Geriatric Emergency Department Innovations

Conditions
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Frailty

Intervention / Treatment
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* Behavioral: Intervention


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Northwestern Emergency Department patients who are: 65 years or older living independently or with friends, family, or caregivers in the community Clinical Frailty Scale (CFS) score of 4 or greater Exclusion Criteria: Patients will be excluded if they: Tested positive for COVID-19 Are unable to complete the assessments in English Are unable to provide informed consent with no Legally Authorized Representative Present or are unable to complete follow-up participation Are held in the ED involuntarily as a prisoner or patient with a psychiatric complaint Are enrolled in another study to avoid patient fatigue and confounding Received a GEDI, Social Work, Pharmacy, or Physical Therapy consult outside of this trial during the current ED visit Leave the ED against medical advice or without being seen by a physician Are admitted to the ICU Are too medically unstable to participate in the assessment

Ages Eligible for Study
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Minimum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Control<br>Standard emergency department care | |
| Other: Intervention<br>Standard emergency department are plus GEDI consult | Behavioral: Intervention<br>* Geriatric assessment and care coordination provided by a multidisciplinary team in the emergency department including transitional care nurses, social workers, pharmacists, occupational therapists, and physical therapists.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of patients with hospital admission or death | A composite measure of any hospitalizations or death during the index ED visit or within the follow up time frame | 30 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| PROMIS-Preference | The Patient-Reported Outcomes Measurement Information System (PROMIS)-Preference (PROPr) score summarizes multiple domains into a single score anchored at 0 (as bad as dead) and 1 (perfect or ideal health). This score quantifies the value that individuals place on different states of health. Preference-based scores can be used in cost-utility analyses and to estimate quality-adjusted life years (QALYs). PROPr is calculated from the scores for the 7 PROMIS domains: Cognition, Depression, Fatigue, Pain Interference, Physical Function, Sleep Disturbance, and Ability to Participate in Social Roles and Activities. Preference-based scores PROMIS domain scores can be calculated using the HealthMeasures Scoring Service. The HealthMeasures Scoring Service export includes PROMIS theta values used to calculate PROPr using Multi-Attribute Utility Theory (MAUT) which is available at https://github.com/janelhanmer/PROPr | 9 days | 
| PROMIS-Preference | The Patient-Reported Outcomes Measurement Information System (PROMIS)-Preference (PROPr) score summarizes multiple domains into a single score anchored at 0 (as bad as dead) and 1 (perfect or ideal health). This score quantifies the value that individuals place on different states of health. Preference-based scores can be used in cost-utility analyses and to estimate quality-adjusted life years (QALYs). PROPr is calculated from the scores for the 7 PROMIS domains: Cognition, Depression, Fatigue, Pain Interference, Physical Function, Sleep Disturbance, and Ability to Participate in Social Roles and Activities. Preference-based scores PROMIS domain scores can be calculated using the HealthMeasures Scoring Service. The HealthMeasures Scoring Service export includes PROMIS theta values used to calculate PROPr using Multi-Attribute Utility Theory (MAUT) which is available at https://github.com/janelhanmer/PROPr | 30 days | 
| Return Emergency Department Visits | Any Emergency Department Visits which occurs after the ED encounter in which the patient was enrolled in the study. | 9 days | 
| Return Emergency Department Visits | Any Emergency Department Visits which occurs after the ED encounter in which the patient was enrolled in the study. | 30 days | 
| Death | All cause death | 9 days | 
| Death | All cause death | 30 days | 
| PROMIS Item Bank v2.0 - Physical Function (Adaptive) | The Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Item Bank uses Computer Adaptive Testing (CAT) in which participant responses guide the system's choice of subsequent items from the full item bank (165 items in total in adult bank). Although items differ across respondents taking CAT, scores are comparable across participants. Measure Description: PROMIS subscale for physical function assesses the extent to which patients' perceived capability rather than actual performance of physical activities using a 5-point Likert scale. PROMIS uses a T-score metric in which 50 is the mean of a relevant reference population and 10 is the standard deviation (SD) of that population. T-scores range from 20 to 80. A higher PROMIS T-score represents more of the concept being measured. | 9 days | 
| PROMIS Item Bank v2.0 - Physical Function (Adaptive) | The Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Item Bank uses Computer Adaptive Testing (CAT) in which participant responses guide the system's choice of subsequent items from the full item bank (165 items in total in adult bank). Although items differ across respondents taking CAT, scores are comparable across participants. Measure Description: PROMIS subscale for physical function assesses the extent to which patients' perceived capability rather than actual performance of physical activities using a 5-point Likert scale. PROMIS uses a T-score metric in which 50 is the mean of a relevant reference population and 10 is the standard deviation (SD) of that population. T-scores range from 20 to 80. A higher PROMIS T-score represents more of the concept being measured. | 30 days | 
| PROMIS Item Bank v2.0 - Ability to Participate Social Roles and Activities (Adaptive) | The Patient-Reported Outcomes Measurement Information System (PROMIS) Ability to Participate in Social Roles and Activities Item Bank uses Computer Adaptive Testing (CAT) in which participant responses guide the system's choice of subsequent items from the full item bank (35 items in total). Although items differ across respondents taking CAT, scores are comparable across participants. Measure Description: PROMIS item bank for ability to participate in social roles and activities assesses the extent to which patients' perceived ability to perform one's usual social roles and activities using a 5-point Likert scale. PROMIS uses a T-score metric in which 50 is the mean of a relevant reference population and 10 is the standard deviation (SD) of that population. T-scores range from 20 to 80. A higher PROMIS T-score represents more of the concept being measured. | 9 days | 
| PROMIS Item Bank v2.0 - Ability to Participate Social (Adaptive) | The Patient-Reported Outcomes Measurement Information System (PROMIS) Ability to Participate in Social Roles and Activities Item Bank uses Computer Adaptive Testing (CAT) in which participant responses guide the system's choice of subsequent items from the full item bank (35 items in total). Although items differ across respondents taking CAT, scores are comparable across participants. Measure Description: PROMIS item bank for ability to participate in social roles and activities assesses the extent to which patients' perceived ability to perform one's usual social roles and activities using a 5-point Likert scale. PROMIS uses a T-score metric in which 50 is the mean of a relevant reference population and 10 is the standard deviation (SD) of that population. T-scores range from 20 to 80. A higher PROMIS T-score represents more of the concept being measured. | 30 days | 
| PROMIS Item Bank v. 1.0 - Emotional Distress - Anxiety (Adaptive) | The Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety Item Bank uses Computer Adaptive Testing (CAT) in which participant responses guide the system's choice of subsequent items from the full item bank (29 items in total). Although items differ across respondents taking CAT, scores are comparable across participants. Measure Description: PROMIS item bank for anxiety assesses the extent to which patients experience anxiety symptoms over the past 7 days using a 5-point Likert scale. PROMIS uses a T-score metric in which 50 is the mean of a relevant reference population and 10 is the standard deviation (SD) of that population. T-scores range from 20 to 80. A higher PROMIS T-score represents more of the concept being measured. | 9 days | 
| PROMIS Item Bank v. 1.0 - Emotional Distress - Anxiety (Adaptive) | The Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety Item Bank uses Computer Adaptive Testing (CAT) in which participant responses guide the system's choice of subsequent items from the full item bank (29 items in total). Although items differ across respondents taking CAT, scores are comparable across participants. Measure Description: PROMIS item bank for anxiety assesses the extent to which patients experience anxiety symptoms over the past 7 days using a 5-point Likert scale. PROMIS uses a T-score metric in which 50 is the mean of a relevant reference population and 10 is the standard deviation (SD) of that population. T-scores range from 20 to 80. A higher PROMIS T-score represents more of the concept being measured. | 30 days | 
| PROMIS Item Bank v. 1.0 - Emotional Distress - Depression (Adaptive) | The Patient-Reported Outcomes Measurement Information System (PROMIS) Depression Item Bank uses Computer Adaptive Testing (CAT) in which participant responses guide the system's choice of subsequent items from the full item bank (28 items in total). Although items differ across respondents taking CAT, scores are comparable across participants. Measure Description: PROMIS item bank for depression assesses the extent to which patients experience depressive symptoms over the past 7 days using a 5-point Likert scale. PROMIS uses a T-score metric in which 50 is the mean of a relevant reference population and 10 is the standard deviation (SD) of that population. T-scores range from 20 to 80. A higher PROMIS T-score represents more of the concept being measured. | 9 days | 
| PROMIS Item Bank v. 1.0 - Emotional Distress - Depression (Adaptive) | The Patient-Reported Outcomes Measurement Information System (PROMIS) Depression Item Bank uses Computer Adaptive Testing (CAT) in which participant responses guide the system's choice of subsequent items from the full item bank (28 items in total). Although items differ across respondents taking CAT, scores are comparable across participants. Measure Description: PROMIS item bank for depression assesses the extent to which patients experience depressive symptoms over the past 7 days using a 5-point Likert scale. PROMIS uses a T-score metric in which 50 is the mean of a relevant reference population and 10 is the standard deviation (SD) of that population. T-scores range from 20 to 80. A higher PROMIS T-score represents more of the concept being measured. | 30 days | 
| Number of patients admitted | A patient who is admitted to inpatient status during the emergency department visit in which they are enrolled in the study | 24 hours | 
| Number of patients admitted | A patient who is admitted to inpatient status during the emergency department visit in which they are enrolled in the study or within the follow up time frame | 9 days | 
| Number of patients admitted | A patient who is admitted to inpatient status during the emergency department visit in which they are enrolled in the study or within the follow up time frame | 30 days | 
| Number of patients with hospital admission or death | A composite measure of any hospitalizations or death during the index ED visit or within the follow up time frame | 9 days |