Clinical trial NCT05252182: Comprehensive Geriatric Assessment in the Emergency Department
Official title: Comprehensive Geriatric Assessment in the Emergency Department: a Prospective Cohort Study of Clinical and Process Outcomes
Study type: OBSERVATIONAL
Overall status: COMPLETED
Conditions: Frailty
Keywords: older adults
frailty
emergency department
comprehensive geriatric assessment
Lead sponsor: University of Limerick
Sponsor class: OTHER
Collaborators: name: University Hospital of Limerick
First posted: 2022-02-23
Enrollment: 133
Sex: ALL
Minimum age (years): 65
Standard ages: OLDER_ADULT
Observational model: COHORT
Time perspective: PROSPECTIVE
Sampling method: NON_PROBABILITY_SAMPLE
Study population: Older adults aged ≥ 65 years who screen positive for risk of adverse outcomes following ED attendance.

Brief summary: 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: 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.

Eligibility criteria: 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.

Primary outcomes:
measure: Incidence of hospital admission from the ED index attendance.
timeFrame: 6 months
Secondary outcomes:
measure: Incidence of functional decline (including functional decline at discharge from hospital among the cohort admitted from the ED).
timeFrame: 30 days and 6 months
measure: Patient satisfaction with the ED index attendance
timeFrame: 30-day follow-up
measure: Number of unscheduled ED re-attendances
timeFrame: 30 days and 6 months
measure: Number of unscheduled hospital admissions
timeFrame: 30 days and 6 months
measure: Nursing home admission
timeFrame: 30 days and 6 months
measure: Mortality
timeFrame: 30 days and 6 months
measure: Healthcare utilisation
timeFrame: 30 days and 6 months
Other outcomes:
Locations:
city: Limerick
country: Ireland
facility: University of Limerick
state: Munster
Study officials:
affiliation: University of Limerick
name: Íde O'Shaughnessy, MSc
role: PRINCIPAL_INVESTIGATOR
References:
citation: MAHONEY FI, BARTHEL DW. FUNCTIONAL EVALUATION: THE BARTHEL INDEX. Md State Med J. 1965 Feb;14:61-5. No abstract available.
citation: McCusker J, Bellavance F, Cardin S, Trepanier S, Verdon J, Ardman O. Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool. J Am Geriatr Soc. 1999 Oct;47(10):1229-37. doi: 10.1111/j.1532-5415.1999.tb05204.x.
citation: Mackway-Jones K ed: Emergency triage. London: BMJ Publishing Group. 1997.
citation: Marshall GN, Hays RD: The Patient Satisfaction Questionnaire Short Form (PSQ-18). Santa Monica, CA: Rand; 1994.
citation: Conroy SP, Turpin S. New horizons: urgent care for older people with frailty. Age Ageing. 2016 Sep;45(5):577-84. doi: 10.1093/ageing/afw135. Epub 2016 Aug 1.
citation: Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: A systematic review of causes, consequences and solutions. PLoS One. 2018 Aug 30;13(8):e0203316. doi: 10.1371/journal.pone.0203316. eCollection 2018.
citation: Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013 Mar 2;381(9868):752-62. doi: 10.1016/S0140-6736(12)62167-9. Epub 2013 Feb 8.
citation: Lowthian JA, McGinnes RA, Brand CA, Barker AL, Cameron PA. Discharging older patients from the emergency department effectively: a systematic review and meta-analysis. Age Ageing. 2015 Sep;44(5):761-70. doi: 10.1093/ageing/afv102. Epub 2015 Aug 10.
citation: Sanders AB, Witzke D, Jones JS, et al.: Principles of care and application of the geriatric emergency care model. In: Sanders AB, ed. Emergency Care of the Elder Person. St Louis: Beverly Cracom Publications, 1996; 59-93.
citation: Vermeiren S, Vella-Azzopardi R, Beckwee D, Habbig AK, Scafoglieri A, Jansen B, Bautmans I; Gerontopole Brussels Study group. Frailty and the Prediction of Negative Health Outcomes: A Meta-Analysis. J Am Med Dir Assoc. 2016 Dec 1;17(12):1163.e1-1163.e17. doi: 10.1016/j.jamda.2016.09.010.
citation: Ellis G, Gardner M, Tsiachristas A, Langhorne P, Burke O, Harwood RH, Conroy SP, Kircher T, Somme D, Saltvedt I, Wald H, O'Neill D, Robinson D, Shepperd S. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2017 Sep 12;9(9):CD006211. doi: 10.1002/14651858.CD006211.pub3.
citation: Conroy SP, Stevens T, Parker SG, Gladman JR. A systematic review of comprehensive geriatric assessment to improve outcomes for frail older people being rapidly discharged from acute hospital: 'interface geriatrics'. Age Ageing. 2011 Jul;40(4):436-43. doi: 10.1093/ageing/afr060. Epub 2011 May 26.
citation: Conroy SP, Ansari K, Williams M, Laithwaite E, Teasdale B, Dawson J, Mason S, Banerjee J. A controlled evaluation of comprehensive geriatric assessment in the emergency department: the 'Emergency Frailty Unit'. Age Ageing. 2014 Jan;43(1):109-14. doi: 10.1093/ageing/aft087. Epub 2013 Jul 23.
citation: Harding S. Comprehensive geriatric assessment in the emergency department. Age Ageing. 2020 Oct 23;49(6):936-938. doi: 10.1093/ageing/afaa059.
citation: O'Shaughnessy I, Robinson K, O'Connor M, Conneely M, Steed F, Ryan D, Carey L, Shchetkovsky D, Shanahan E, Leahy A, Quinn C, Sheikhi A, Galvin R. Comprehensive geriatric assessment in the emergency department: A protocol for a prospective cohort study. HRB Open Res. 2022 Sep 14;5:26. doi: 10.12688/hrbopenres.13504.2. eCollection 2022.