Background.This study aims to (i) describe frailty in the subgroup of independent community-dwelling seniors consulting emergency departments (EDs) for minor injuries, (ii) examine the association between frailty and functional decline 3 months postinjury, (iii) ascertain the predictive accuracy of frailty measures and emergency physicians' for functional decline.
Frailty predicts adverse health outcomes, and the Clinical Frailty Scale (CFS) has been validated internationally to predict adverse outcomes and mortality. Emergency Departments (ED) are challenged to assess frailty due to a lack of training and limited time. We studied the agreement between ED physicians and patient self-assessments using a tablet-based CFS that includes graphics and short descriptors for each of 9 frailty categories. We conducted a prospective observational cohort study of people >65 years seen in the ED of 3 Canadian academic centers. We excluded patients who were critically ill, visually impaired, or unable to communicate in English or French. We compared agreement on the tablet-based CFS between 4 categories of assessors: Patients, ED physicians, trained research assistants and caregivers using the kappa statistic. We enrolled 274/380 eligible patients who provided complete data (72.1%). Their average age was 75.8 years, and 48.9% were female. Their median MOCA score was 23/30 (IQR = 17 – 26) and their median OARS was 26/28 (IQR 22–28). Agreement between physicians and research assistants was good (κ=0.60, 95% CI 0.50 – 0.70), as was physician-caregiver agreement and patient-caregiver agreement (κ=0.66, 95% CI 0.40 – 0.93). Agreement between ED physicians and patients was only moderate (κ =0.47, 95% CI 0.36 – 0.58).ED physicians more often rated patients as frail (40% vs 29%, p<0.001). There was less agreement between ED physicians and patient self-assessments for the CFS compared to physicians-research assistant agreement and care-giver patient assessments. Future research should validate whether patient or physician assessments have higher predictive validity of frailty.
Objectives To compare functional decline in activities of daily living ( ADL s) of older adults visiting emergency departments ( ED s) for minor injuries according to frailty and cognitive status. Design Prospective cohort study. Setting Seven Canadian EDs. Participants Individuals aged 65 and older who were independent in ADL s at baseline were recruited between March 2011 and March 2013 (N = 1,114). Measurements The Older American Resources and Services ( OARS ) questionnaire was completed during the ED visit or within 7 days and 3 and 6 months after a minor injury to ascertain functional decline (≥1‐point drop in ADL score). Participants were considered frail based on the Canadian Study of Health and Aging Clinical Frailty Scale (≥Level 4, vulnerable). Cognitive impairment was defined as performing below cutoffs on the Montreal Cognitive Assessment (<23/30) or Telephone Interview for Cognitive Status (≤31/50). Four subgroups were created: frail with cognitive impairment, frail without cognitive impairment, nonfrail with cognitive impairment, nonfrail without cognitive impairment. Sociodemographic and health data were also collected. Results Information on OARS , frailty, and cognitive impairment were available for 850 at 3 months and 728 at 6 months; 19.9% of participants showed declining function at 3 months and 25.3% at 6 months. After adjusting for age, number of comorbidities, and instrumental activity of daily living disability at baseline, frail participants with cognitive impairment were at significantly greater risk of functional decline at 3 (adjusted risk ratio ( aRR ) = 1.89; 95% confidence interval ( CI ) = 1.38–2.59) and 6 ( aRR = 2.09; 95% CI = 1.45–3.00) months than nonfrail participants without cognitive impairment. Conclusion Easy‐to‐administer frailty and cognitive screening tools should be included in ED assessments to identify independent older adults at high risk of functional decline after minor injury so that appropriate services may be provided to prevent deterioration in ADL s.
This study compared effects of exercise-based interventions with usual care on functional decline, physical performance, and health-related quality of life (12-item Short-Form health survey) at 3 and 6 months after minor injuries, in older adults discharged from emergency departments. Participants were randomized either to the intervention or control groups. The interventions consisted of 12-week exercise programs available in their communities. Groups were compared on cumulative incidences of functional decline, physical performances, and 12-item Short-Form health survey scores at all time points. Functional decline incidences were: intervention, 4.8% versus control, 15.4% (p = .11) at 3 months, and 5.3% versus 17.0% (p = .06) at 6 months. While the control group remained stable, the intervention group improved in Five Times Sit-To-Stand Test (3.0 ± 4.5 s, p < .01). The 12-item Short-Form health survey role physical score improvement was twice as high following intervention compared with control. Early exercises improved leg strength and reduced self-perceived limitations following a minor injury.
BACKGROUND The International Classification of Diseases (ICD) is the main classification system used for population-based injury surveillance activities but does not contain information on injury severity. ICD-based injury severity measures can be empirically derived or mapped, but no single approach has been formally recommended. This study aimed to compare the performance of ICD-based injury severity measures to predict in-hospital mortality among injury-related admissions. METHODS A systematic review and a meta-analysis were conducted. MEDLINE, EMBASE, and Global Health databases were searched from their inception through September 2014. Observational studies that assessed the performance of ICD-based injury severity measures to predict in-hospital mortality and reported discriminative ability using the area under a receiver operating characteristic curve (AUC) were included. Metrics of model performance were extracted. Pooled AUC were estimated under random-effects models. RESULTS Twenty-two eligible studies reported 72 assessments of discrimination on ICD-based injury severity measures. Reported AUC ranged from 0.681 to 0.958. Of the 72 assessments, 46 showed excellent (0.80 ≤ AUC < 0.90) and 6 outstanding (AUC ≥ 0.90) discriminative ability. Pooled AUC for ICD-based Injury Severity Score (ICISS) based on the product of traditional survival proportions was significantly higher than measures based on ICD mapped to Abbreviated Injury Scale (AIS) scores (0.863 vs. 0.825 for ICDMAP-ISS [p = 0.005] and ICDMAP-NISS [p = 0.016]). Similar results were observed when studies were stratified by the type of data used (trauma registry or hospital discharge) or the provenance of survival proportions (internally or externally derived). However, among studies published after 2003 the Trauma Mortality Prediction Model based on ICD-9 codes (TMPM-9) demonstrated superior discriminative ability than ICISS using the product of traditional survival proportions (0.850 vs. 0.802, p = 0.002). Models generally showed poor calibration. CONCLUSION ICISS using the product of traditional survival proportions and TMPM-9 predict mortality more accurately than those mapped to AIS codes and should be preferred for describing injury severity when ICD is used to record injury diagnoses. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.
Abstract Background Retrospective studies estimate Emergency Department (ED) delirium recognition at <20%; few prospective studies have assessed delirium recognition and outcomes for patients with unrecognized delirium. Objectives To prospectively measure delirium recognition by ED nurses and physicians, document their confidence in diagnosis and disposition, actual dispositions, and patient outcomes. Methods Prospective observational study of people ≥65 years. We assessed delirium using the Confusion Assessment Method, then asked ED staff if the patient had delirium, confidence in their assessment, if the patient could be discharged, and contacted patients 1 week postdischarge. We report proportions and 95% confidence intervals (Cls). Results We enrolled 1,493 participants; mean age was 77.9 years; 49.2% were female, 79 (5.3%, 95% CI 4.2–6.5%) had delirium. ED nurses missed delirium in 43/78 cases (55.1%, 95% CI 43.4–66.4%). Nurses considered 12/43 (27.9%) patients with unrecognized delirium safe to discharge. Median confidence in their delirium diagnosis for patients with unrecognized delirium was 7.0/10. Physicians missed delirium in 10/20 (50.0%, 95% CI 27.2–72.8) cases and considered 2/10 (20.0%) safe to discharge. Median confidence in their delirium diagnosis for patients with unrecognized delirium was 8.0/10. Fifteen patients with unrecognized delirium were sent home: 6.7% died at 1 week follow-up vs. none in those with recognized delirium and 1.1% in the rest of the cohort. Conclusion Delirium recognition by nurses and physicians was sub-optimal at ~50% and may be associated with increased mortality. Research should explore root causes of unrecognized delirium, and novel strategies to systematically improve delirium recognition and patient outcomes.
Abstract Background Older adults hospitalized following a fall often encounter preventable adverse events when transitioning from hospital to home. Discharge planning interventions developed to prevent these events do not all produce the expected effects to the same extent. This realist synthesis aimed to better understand when, where, for whom, why and how the components of these interventions produce positive outcomes. Methods Nine indexed databases were searched to identify scientific papers and grey literature on discharge planning interventions for older adults (65+) hospitalized following a fall. Manual searches were also conducted. Documents were selected based on relevance and rigor. Two reviewers extracted and compiled data regarding intervention components, contextual factors, underlying mechanisms and positive outcomes. Preliminary theories were then formulated based on an iterative synthesis process. Results Twenty-one documents were included in the synthesis. Four Intervention-Context-Mechanism-Outcome configurations were developed as preliminary theories, based on the following intervention components: 1) Increase two-way communication between healthcare providers and patients/caregivers using a family-centered approach; 2) Foster interprofessional communication within and across healthcare settings through both standardized and unofficial information exchange; 3) Provide patients/caregivers with individually tailored fall prevention education; and 4) Designate a coordinator to manage discharge planning. These components should be implemented from patient admission to return home and be supported at the organizational level (contexts) to trigger knowledge, understanding and trust of patients/caregivers, adjusted expectations, reduced family stress, and sustained engagement of families and professionals (mechanisms). These optimal conditions improve patient satisfaction, recovery, functional status and continuity of care, and reduce hospital readmissions and fall risk (outcomes). Conclusions Since transitions are critical points with potential communication gaps, coordinated interventions are vital to support a safe return home for older adults hospitalized following a fall. Considering the organizational challenges, simple tools such as pictograms and drawings, combined with computer-based communication channels, may optimize discharge interventions based on frail patients’ needs, habits and values. Empirically testing our preliminary theories will help to develop effective interventions throughout the continuum of transitional care to enhance patients’ health and reduce the economic burden of avoidable care.
The evaluation of acute trauma care is essential to the effort of alleviating the societal burden of injury. Trauma centre performance evaluations generally include adjustment for anatomic injury severity, physiological reaction to injury, physiological reserve and transfer status. However, socioeconomic status (SES) has been shown to be related to health outcomes and disparities across trauma centre source populations may bias performance evaluations. We aimed to evaluate whether SES influences risk-adjusted mortality following trauma in an inclusive trauma system with free access to medical care. The study was based on patients treated for major trauma in the inclusive trauma system of the province of Quebec, Canada (1999–2006). SES was quantified using an ecological index of material and social deprivation via patients residential postal code. Hierarchical logistic regression was used to evaluate the independent influence of SES on hospital mortality. The study sample comprised a total of 88 235 patients from 59 trauma centres, including 4731 deaths (5.4%). The proportion of patients in the highest quintile of material and social deprivation varied from 11% to 90% and from 3% to 43% across hospitals, respectively. After adjusting for anatomic injury severity, physiological reaction to injury, physiological reserve and transfer status, neither material (OR 0.97, 95% CI 0.94 to 1.01) nor social deprivation (OR 1.02, 95% CI 0.99 to 1.06) were associated with hospital mortality. This study suggests that in an inclusive trauma system with free access to healthcare, disparities in SES across source populations should not lead to biased trauma centre mortality evaluations, providing an adequate risk adjustment strategy is used.
