Geriatrics/original researchProfiles of Older Patients in the Emergency Department: Findings From the interRAI Multinational Emergency Department Study
Introduction
Population aging in most nations is resulting in aging of hospital patient profiles. The proportion of older patients using emergency departments (EDs) is also increasing.1, 2, 3 Older patients are more likely to have multiple diseases or chronic illnesses, with associated impaired physical and cognitive function, and to have more limited social support. They have disproportionately high ED use, a finding that persists despite international disparities in ED models of care.4, 5 Older patients attending the ED are more likely to have severe illnesses, to arrive by ambulance, and be admitted to the hospital after their ED visit.6, 7, 8, 9 Older age is also associated with increased ED length of stay and higher resource use.1, 6, 10 In addition, older persons are at increased risk of adverse events, with higher rates of missed diagnoses, return ED visits after discharge, and medication errors, than younger severity-matched controls.11, 12, 13, 14
As the proportion of older persons increases, there have been cases made for redesign of ED protocols and physical layout.15, 16, 17, 18, 19 However, the development of robust protocols and services requires a thorough understanding of the clinical and psychosocial needs of older patients in the ED.
The patterns of presentation and presenting diagnoses of older ED patients are well documented, but very little research describes their functional, symptom, and psychosocial profiles. A limited number of studies suggest that approximately a quarter of elderly patients have mental status impairment, one sixth have potential depression, and two thirds have some functional impairment.20, 21, 22, 23, 24 Few of these studies used multisite samples, and none provides a multinational context, to our knowledge. Comprehensive multinational studies are needed to provide a clearer profile of elderly ED patients, especially to determine whether these profiles vary among nations.
The incidence of geriatric syndromes and functional impairment may influence the layout of a department (eg, type of furniture, lighting, sound management, access to facilities), the care delivery protocols (eg, need for assistance in personal care, need for caregivers to be present), risk minimization (eg, falls, delirium, pressure ulcer), and staff training (eg, identification and management of geriatric syndromes).
The study reported here was undertaken by members of the interRAI research collaborative, which comprises more than 60 clinicians and researchers from 30 nations, who develop and research assessment systems for aged care, disability, and mental health services.25 This group set out to explore the characteristics and outcomes of older people attending EDs at an international level to gather information to support refinement of assessment systems and their embedded risk assessment tools. Our objectives were primarily focused on the development of risk assessment tools to guide decision making around discharge home from the ED and whether further assessment will be required should the patient be either discharged home or admitted to the hospital.
In this first article, the recruitment and data collection methods and the clinical characteristics and outcomes of the subjects recruited are described.
Section snippets
Study Design and Setting
A multinational prospective observational cohort study of ED patients aged 75 years or older was conducted. Members of the interRAI research collaborative and their colleagues were invited to participate in this study. Each national research team participant was required to recruit at least 100 subjects from at least 1 ED site and to secure any resources necessary for assessment and data compilation. In total, 13 ED sites from Australia, Belgium, Canada, Germany, Iceland, India, and Sweden were
Characteristics of Study Subjects
Thirteen hospitals from 7 nations joined the study (Figure 1). The EDs were predominantly located in large or medium-size metropolitan hospitals. A total sample of 2,282 patients was recruited, ranging from 98 to 549 across nations. Each hospital used varying recruitment hours across the week, depending on the availability of resources, with the majority of recruitment occurring during standard weekday working hours. In the 5 nations where formal consent was required, consent rates were high
Limitations
The participating EDs and countries were involved in the study because they were in some way affiliated with, or encouraged to join the study by, an interRAI member. This resulted in a focus on metropolitan or large regional hospitals.
Because the project was conducted on only a modest budget, and in some nations without any direct funding, compromises were required in the process of securing representativeness of the samples in each ED. Few of the EDs were able to recruit patients outside
Discussion
To our knowledge, this is the most extensive international study of the characteristics and outcomes of older ED patients to be reported to date.
The findings illustrate that the majority of older patients attending EDs are frail and dependent on others. The level of premorbid morbidity is high, with cognitive impairment and limitations in activities of daily living being particularly common. Consistent with studies conducted in the hospital,35, 36, 37, 38 a decline in physical functional status
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Supervising editor: Knox H. Todd, MD, MPH
Author contributions: LCG and JH conceived the study and developed the design in consultation with all of the authors. APC, ABD, PVJ, PL, GL, FS, WS, and NIHW assisted with site recruitment and supervised data collection in their respective countries. LCG, NMP, and APC assembled the data set and conducted the analyses. LCG, NMP, APC, and EB drafted the article, and all authors critically reviewed it. LCG takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Financial support for this project was provided in some nations, including Australia (Princess Alexandra Hospital Research Foundation), Canada (Canadian Institutes of Health Research), and Germany (Bavarian Ministry of Environment and Health).
Please see page 468 for the Editor's Capsule Summary of this article.
Publication date: Available online June 25, 2013.