View
213
Download
0
Category
Preview:
Citation preview
Fabio SalviU.O.C. Geriatria – Accettazione Geriatrica d’Urgenza
INRCA – POR Ancona
NUOVI MODELLI ORGANIZZATIVI:
IL PRONTO SOCCORSO GERIATRICO
GERIATRIC EMERGENCY MEDICINE
Emergenze-Urgenze nel Paziente
AnzianoVerona 16-17 maggio 2014
GERIATRIC EMERGENCY MEDICINE
Emergenze-Urgenze nel Paziente
AnzianoVerona 16-17 maggio 2014
OUTLINE
GERIATRIC EMERGENCY DEPARTMENT• Why• How• What experiences• What evidence• What alternatives
Roberts DC et al. Ann Emerg Med 2008
The overall trend in the rate of ED visits for the 65- to 74-year-old group showed a 34% increase in visit rate per populationthroughout the study period
Albert M et al. Adv Data 2013
THE ITALIAN PICTURE
2000 2002 2003 2004 20052001 2006
17.7 18.1 18.2 18.7 19.2 19.7 19.6
0
10
20
30
40
500-14 15-44 45-64 65+
Salvi F et al. Intern Emerg Med 2007
2007/2008
2009
20.8 21.0
2012 = 22.1%
THE MARCHE REGION PICTURE
0
10
20
30
40
50
0-14 15-44 45-64 65+
23.9
Salvi F et al. Aging Clin Exp Res 2013
Aminzadeh F, Dalziel WB. Ann Emerg Med 2002
• More likely to arrive by ambulance (35-40% vs. 10-12%)
• Higher proportion of emergent/urgent visits
• Use more diagnostic and staff resources
• Longer ED stay
• Higher admission rate (30-50%; 2.5-4.6 fold more than younger people)
• More likely to require an ICU bed
<1 y 1-14 y 15-44 y 45-64 y 65-79 y ≥80 y
AGE & TRIAGE (ITALY)
0
10
20
30
40
50
60
70
80
90
100
Salvi F et al. Aging Clin Exp Res 2013
AGE & ADMISSION RATE(ITALY)
65-79 y45-64 y15-44 y1-14 y<1 y ≥80 y0
5
10
15
20
25
30
35
40
57.4%
Salvi F et al. Aging Clin Exp Res 2013
AGE & LOS IN THE ED(ITALY)
• Phase 1: Triage to ED admission
• Phase 2: ED admission to first
diagnostic procedure
• Phase 3: First to last diagnostic
procedure
• Phase 4: Last diagnostic procedure
to hospitalization or discharge
Rossi PD et al. JAGS 2010 [Letter]
Aminzadeh F, Dalziel WB. Ann Emerg Med 2002
• More likely to arrive by ambulance (35-40% vs. 10-12%)
• Higher proportion of emergent/urgent visits
• Use more diagnostic and staff resources
• Longer ED stay
• Higher admission rate (30-50%; 2.5-4.6 fold more than younger people)
• More likely to require an ICU bed
• More often present problems of medical nature
• Higher rate of adverse outcomes (i.e. ED return, functional decline,hospitalization, death) in the 3-6 months after an ED index visit
• Their ED diagnoses tend to be less accurate
TRAUMA
Elderly trauma patients were more often admitted (13% vs. 4.2%, p<0.0001)
Visits for trauma were 34.5% of all of the visits
Young adults Elderly
38.3% 22.7%
p<0.0001
Salvi F et al. Aging Clin Exp Res 2013
TOP TEN OF CHIEF COMPLAINTS
Trauma Enclosed Trauma Excluded
Young adults Elderly Young adults Elderly
Lower limbs trauma 589 (13.3) Dyspnea 134 (9.6) Abdominal pain 296 (6.7) Dyspnea 134 (9.6)
Upper limbs trauma 405 (9.1) Lower limbs trauma 127 (9.1) Fever 202 (4.6) Abdominal pain 125 (9)
Abdominal pain 296 (6.7) Abdominal pain 125 (9) Lower limbs pain 135 (3) Chest pain 64 (4.6)
Column trauma 261 (5.9) Chest pain 64 (4.6) Chest pain 135 (3) Palpitations 62 (4.5)
Fever 202 (4.6) Palpitations 62 (4.5) Skin problems 129 (2.9) Lower limbs pain 55 (4)
Lower limbs pain 135 (3) Upper limbs trauma 56 (4) Foreign body (eye) 127 (2.9) Weakness 50 (3.6)
Chest pain 135 (3) Lower limbs pain 55 (4) Headache 113 (2.5) Syncope 40 (2.9)
Skin problems 129 (2.9) Weakness 50 (3.6) Eye pain 96 (2.2) Fever 31 (2.2)
Foreign body (eye) 127 (2.9) Syncope 40 (2.9) Back pain 92 (2.1) Headache 31 (2.2)
Headache 113 (2.5) Column trauma 35 (2.5) Dyspnea 87 (2) Paresthesias 27 (1.9)
Salvi F et al. Aging Clin Exp Res 2013
McCusker J et al. Acad Emerg Med 2000
ED diagnosis
Final diagnosis
Samaras N et al.Ann Emerg Med 2010
adapted fromLewis LM et al.
J Gerontol A 2005
• The elderly in the ED is a diagnostic challenge
Disease presentations in the elderly:• Classic• Silent• Pseudosilent• Atypical
– Weakness/fatigue– Functional decline– Falls/immobilization– Incontinence– Delirium– “Social crisis”
ATYPICAL PRESENTATIONS• Solo il 40% degli anziani segue la regola “1 sintomo = 1 malattia”
– IMA senza dolore toracico
– FA come sintomo di crisi tireotossica; iposodiemia/ipotiroidismo
– Astenia (deficit funzionale acuto) quale sintomo principale discompenso cardiaco, infezione (polmonite; sepsi)
– Sincope quale presentazione di embolia polmonare
Grossmaitre P et al. Arch Cardiovasc Dis 2013
DELIRIUM: ETIOLOGY
Drugs
Environment
Low oxygen
Infections
Ritention
Ischemia
Undernutrition
Metabolic
Subdural haematoma
Vascular
Infections
Nutrition
Drugs
Injury (trauma)
Cardiac
Autoimmune
Tumors
Endocrine
Iatrogenic (drugs)
Infections
Injury (trauma)
Illness exacerbation
Inconsistent environment
Inconsistent caregiver
Is patient depressed?
• The elderly in the ED is a diagnostic challenge– Atypical presentations– Delirium
• Polypharmacy– Adverse Drug Reactions (ADR)– Inappropriate prescriptions
ADR & INAPPROPRIATE PRESCRIPTIONS
• ADR represent 10-16% of the ED visits of elderly patients, but thediagnosis is correctly done only in 50% of the cases!
Hohl CM et al. Acad Emerg Med 2005
MORE FREQUENTLY IMPLIED DRUGS
Budnitz DS et al. Ann Intern Med 2007
Drugs classes more frequently involved are:- NSAIDs / Anticoagulants - Antibiotics- Hypoglycemics (oral or insulin) - Diuretics- β-blockers & CCB - BDZ, -H1
ADR & POTENTIALLY INAPPROPRIATE MEDICATIONS
• ADR represent 10-16% of the ED visits of elderly patients, but thediagnosis is correctly done only in 50% of the cases
• 31% of the elderly ED patients have at least one potentially inappropriatemedication (PIM) following the Beers’ criteria; 50% of those with an ADRhave also a second, not-related PIM
• 13% of the elderly ED patients receive one PIM; among them, 20% hasmore than one; the risk of receiving a PIM correlates with the number ofadministered/prescribed medications in the ED
Caterino JM et al. JAGS 2004
• The elderly in the ED is a diagnostic challenge– Atypical presentations– Delirium
• Polypharmacy– ADR– Inappropriate prescriptions
• Cognitive assessment• Functional assessment• Quality of care (ageism)
STATO COGNITIVOUn certo grado di deterioramento cognitivo è presente nel 15-40%degli ultra65enni in PS (specie se >80 aa e/o istituzionalizzati), maviene riconosciuto solo nel 27-50% dei casi, con gravi implicazioninella precisione dell’anamnesi (undertriage, ritardo indiagnosi/terapia) e nella comprensione delle indicazioni date alladimissione (ADRs, compliance, presenza/affidabilità del caregiver)
Hustey FM et al. Ann Emerg Med 2002Chiovenda P et al. Am J emerg Med 2002
STATO FUNZIONALELo stato funzionale viene pressoché ignorato (75% casi), eppure:
– i ⅔ sono disabili in almeno una IADL o BADL
– soltanto il 22% è completamente indipendente in tutte le ADL
– il 74% afferma che il declino funzionale dall’inizio dei sintomi èstato determinante nella decisione di ricorrere al PS
– il 28% non sarebbe in grado di badare a sé stesso a domicilio:il 20% viene dimesso ugualmente
Spesso vi è discordanza tra lo stato funzionale autopercepito dalpaziente e quello percepito dal familiare/caregiver, principalmenteper il mancato utilizzo di strumenti standardizzati per la suavalutazione (ADL, IADL, Barthel Index etc.)
Wilber ST et al. Acad Emerg Med 2006Rodriguez-Molinero A et al. BMC Geriatrics 2006
ED ENVIRONMENT
• Uncomfortable for older persons
• High volume, high stress
• Anxious, worried patients
• Little privacy
• Limited ED provider time
• Beds, lighting, noise
• Modifications can make a difference
OUTLINE
GERIATRIC EMERGENCY DEPARTMENT• Why• How• What experiences• What evidence• What alternatives
THE IDEAL GERIATRIC ED1. Geriatric education and experience of the ED staff indealing with and management of elderly patients
2. Knowledge of the patient (primary physician contact,transfer form, electronic database) helps to save timeand have reliable information (e.g. diseases, prescriptionmedications, recent x-ray or lab examinations, allergies)
3. Team management following CGA protocols
4. Possibility to observe the patient (Observation Unit)
5. Adequate environment
A hybridized ED and observation unit might optimizecare for complex but stable older people in the midst ofprolonged diagnostic works
J Am Geriatr Soc 2007
Adams JG, Gerson LW
McCusker J et al. JAGS 2001Mion L et al. Ann Emerg Med 2003Meldon S et al. Acad Emerg Med 2003
- +ELDERLY IN THE ED
SCREENING
USUAL CARE second-level CGA
problem identification
INTERVENTION(discharge, admission, referral, liason, etc.)
DISCHARGE PLANNING
SCREENING TOOLS ISAR
(Identification of Seniors At Risk)Y N
1) Before the illness or injury that brought you to theED, did you need someone to help you on a regularbasis?
1 0
2) Since the illness or the injury that brought you tothe ED, have you needed more help than usual totake care of yourself?
1 0
3) Have you been hospitalized for one or morenights during the past six months (excluding a stayin the ED)?
1 0
4) In general, do you see well? 0 1
5) In general, do you have serious problems withyour memory? 1 0
6) Do you take more than three different medicationseveryday? 1 0
TOTAL
TRST(Triage Risk Screening Tool)
Y N
1) Presence of cognitive impairment (i.e. confusion,unable to follow directions, diagnosis of dementia ordelirium)
1 0
2) Lives alone or no caregiver available, willing or able 1 0
3) Difficulty with walking or transfers or history ofrecent falls 1 0
4) Patient/family states has used ED within past 30days or has been hospitalized within last 3 months 1 0
5) Five or more different medications 1 0
6) Professional recommendations: nurse believes thispatient requires further follow-up at home for any ofthe following:a) suspected abuse, neglect, self-neglect, exploitationb) noncompliant patient with <5 medications whokeeps coming back to the EDc) suspected substance abuse (alcohol or drug)d) problems with meeting IADLe) other (please specify)
1 0
TOTAL
McCusker J et al. Acad Emerg Med 2000 Mion LC et al. JAGS 2001
OR (95%CI) p
Early ED return (within 30 days)* 1.67 (0.76-3.64) 0.20
ED revisit (within 6 months) 2.07 (1.06-4.05) 0.034
Frequent ED return (≥3 in 6m) 4.69 (1.29-17.1) 0.019
Admission within 6 months 2.07 (1.02-4.20) 0.043
Functional decline (1 ADL) 2.98 (1.23-7.20) 0.016
Composite outcome [1] 4.85 (2.22-10.6) <0.0001
Composite outcome [2] 3.46 (1.68-7.15) 0.001
Salvi F et al. Aging Clin Exp Res 2009Covariate: età, condizioni familiari, e *reale durata del follow-up
HR 6.9 (95%CI 1.65-29; p=0.008)
ISAR 0-1
ISAR 2+
EDUCATION• Atypical presentations of disease• Trauma, including falls and hip fracture• Cognitive and behavioral disorders• Modifications for older patients of emergent interventions• Medication management• Transitions of care and referrals to services• Pain management and palliative care• Effect of comorbid conditions• Functional impairments and disorders• Management of the group pf diseases peculiar to the geriatric adult,
including conditions causing abdominal pain• Weakness and dizziness• Iatrogenic injuries• Elder abuse and neglect
OUTLINEGERIATRIC EMERGENCY DEPARTMENT• Why• How• What experiences
– Jerusalem (Israel)– Ancona (Italy)– Others
• What evidence• What alternatives
THE HADASSAH-HEBREW GED(Mt Scopus, Jerusalem, Israel)
• Aperto nel 1995 (Dipartimenti di Emergenza/Geriatria)• 24/7; all 70 years and older are admitted directly• Routine Assessment includes:
– Functional Assessment (ADL, IADL)– Cognitive Assessment (MMSE)– Fall-risk Assessment– Depression Assessment (GDS)– Nutritional Assessment (MNA)– Social Assessment
• Staff includes:– Resident in Geriatrics– Attending Geriatrician– Geriatric Nurse– Social Worker– Consultants (all specialties available in the hospital)– Physical therapists, Occupational therapists as needed
courtesy of Dr. J Stessman & Dr. Y Maaravi
GeriatricED
HomeHospitalization
SubacuteDept.
Acute-CareHospital
Dischargeto
Community
GeriatricRehabil.
PalliativeCare
SkilledNursing
GED ROLE
courtesy of Dr. J Stessman & Dr. Y Maaravi
GERIATRIC EMERGENCY DEPARTMENT• Why• How• What experiences
– Jerusalem (Israel)– Ancona (Italy)– Others
• What evidence• What alternatives
OUTLINE
ANCONA.
CHRONOLOGYBeginning (May 1997): the Geriatric Medical Acceptation openedas the first/unique example in Italy of ED-like hospital warddedicated to elderly patients (≥65 years-old) with acute illness orchronic disease relapse and complication, excluding trauma
Implementation (October 1998): 24h medical coverage; the GEDbecame an important healthcare resource for elderly people anda valid support for the main local ED (Academic Hospital) andEmergency Medical System (118)
Further implementation (April 2002): the adjacent Acute Geriatricward was merged with the Geriatric ED to realize a clinicalpathway from acute to sub-acute care
1st September 2008: the Marche Region officially recognized theactivity of the Geriatric ED (now renamed as First-Aid Point)
THE INRCA GERIATRIC ED(ANCONA, ITALY)
Waiting Room(arriving patients)
Triage Box
Waiting Room(visited patients)
Surgery(semiurgent/nonurgent patients)
Emergency Room(emergent/urgent patients)
Observation Unit(six beds; max LOS 48h)
EMS (118)(direct access)
Nurses’Working Room
Physicians’Working Room
THE INRCA GERIATRIC ED(ANCONA, ITALY)
Staff: 9 geriatricians (3 in the morning, 2-3 in the afternoon, and 1 onthe night shift); 20 nurses with geriatric education and experience; 6Oss; social worker as needed
Methodology: CGA-oriented through screening tools for frailty (ISAR)and geriatric syndromes (cognitive and functional assessment); specificprotocols for medical problems (dyspnea, chest pain, gastro-intestinalbleeding, pulmonary embolus, dehydration, etc.)
Equipment: blood gas analyzer, noninvasive/invasive ventilators, bedmonitoring, defibrillator, dedicated lab machine, priority access toradiology, reanimation support
Links: post-acute long-term care unit, ICU (cardiology), stroke unit;phone contact with primary physicians or local long-term facilities
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
ACTIVITY DATA(January 1st, 2009 – December 31st, 2012)
37434 ED visits
<50 50-65 65-70 71-80 81-90 91-100 >100
MEAN AGE = 76.5 years
Inappropriate GED use(16.3%)
Discharge = 57.6% 49.8%Discharge after Obs = 9.5% 11.5%Admission 28% (+2%) 34.3%Death = 0.8% 1.1%
~67%68.8%
20.3%8.6%
Triage
1.7%
2013: +3%
2013: 3.2%
2013: 12%
OUTLINEGERIATRIC EMERGENCY DEPARTMENT• Why• How• What experiences
– Jerusalem (Israel)– Ancona (Italy)– Others
• What evidence• What alternatives
OUTLINEGERIATRIC EMERGENCY DEPARTMENT• Why• How• What experiences
– Jerusalem (Israel)– Ancona (Italy)– Others
• What evidence• What alternatives
THE HADASSAH-HEBREW GED(Mt Scopus, Jerusalem, Israel)
• 100 Geriatric ED admissions (Mt Scopus)
• 100 General ED admissions (Ein Kerem)
• 70 years and older
• Prospective follow-up (6 months) for:
– Satisfaction with ED care
– Independence
– Readmission0
1020
3040
50
6070
8090
Very Reasonable Moderate
Geriatric EDGeneral ED
p=0.03
1830
8270
0
1020
3040
5060
7080
90
ReAdmission No ReAdmission
Geriatric EDGeneral ED
p<0.05
0
1020
3040
5060
7080
90
Independent Dependent
Geriatric EDGeneral ED
p=0.72
courtesy of Dr. J Stessman & Dr. Y Maaravi
DESIGN OF THE STUDY• Observational prospective clinical study
• 200 elderly patients presenting to the two urban EDs in Ancona
(100000 inhabitants, 23.7% over65): 100 patients enrolled in a
conventional ED (CED) and 100 patients in the Geriatric ED
• The only inclusion criterion: age ≥ 65 years
• Exclusion criteria: critically ill, severe cognitive impairment and no
proxy, trauma as presenting complaint, previously enrolled
• Data collection: age, sex, marital and living status, arrival, triage,
diagnosis, disposition, length of ED stay
• Brief CGA: Charlson Index, SPMSQ, Katz’s ADL
• Phone follow-up at 30 days and 6 months
OUTCOMES• Early (within 30 days) and late (within 6 months)unscheduled ED revisit• Frequent ED return (≥3 over 6 months)• Hospital admission (within 6 months)• 6-month functional decline (defined as loss of ≥1 ADL)• 6-month mortality
Composite outcome (within 6 months)• Death, functional decline, any ED revisit or hospitaladmission
CLINICAL FEATURESCharacteristics Mean±SD
or n (%)CED
(n=100)GED
(n=100) p
Age (years)65-7475-8485+
80.3 ± 7.447 (23.5)96 (48)
57 (28.5)
78.1 ± 7344917
82.5 ± 7.2134740
<0.0001
Sex (F/M) 115/85 47/53 68/32 0.004
TriageEmergentUrgentSemi-urgentNon-urgent
1 (0.5)51 (25.5)136 (68)12 (6)
029683
122689
0.18
DispositionDischargeAdmission
84 (42)116 (58)
4753
3763
0.2
CLINICAL FEATURESCharacteristics Mean±SD
or n (%)CED
(n=100)GED
(n=100) p
Living situationAloneIndependent relativeDisabled relativePaid caregiverInstitution
26 (13)131 (65.5)
8 (4)26 (13)9 (4.5)
1274581
14573188
0.031
Charlson Index0-2≥3
3.4 ± 274 (37)126 (63)
3.3 ± 2.34060
3.4 ± 1.73466
0.73
0.46
SPMSQ0-4≥5
3.9 ± 4137 (68.5)63 (31.5)
2.5 ± 3.38317
5.2 ± 4.25446
<0.0001
ADL4-6≤3
3.8 ± 2.3123 (61.5)77 (38.5)
4.3 ± 27129
3.2 ± 2.55248
0.001
0.009
OUTCOMESOR (95%CI) p
Early ED return (within 30 days) 1.06 (0.5-2.3) 0.88
ED revisit (within 6 months) 0.66 (0.3-1.4) 0.25
Frequent ED return (≥3 in 6m) 1.11 (0.4-3.1) 0.84
Admission within 6 months 0.63 (0.3-1.3) 0.20
Functional decline (1 ADL) 0.65 (0.3-1.6) 0.34
Composite outcome 0.95 (0.4-2.1) 0.89
Conroy SP et al. Age Ageing 2014
• ED conversion:– 75-84 61.154.1– 85+ 69.661.2
• Ricovero entro 7gg– 75-84 4.63.8– 85+ 4.73.3
• Ricovero entro 30gg– 75-84 11.48.8– 85+ 12.49.2
• Ricovero entro 90gg– 75-84 21.818.3– 85+ 26.019.9
• LoS– 75-84 7.99.1– 85+ 8.911.1
OUTLINE
GERIATRIC EMERGENCY DEPARTMENT• Why• How• What experiences
– Jerusalem (Israel)– Ancona (Italy)– Others
• What evidence• What alternatives
ED
GERIATRICHOSPITAL
GENERALHOSPITALS
SMALLHOSPITALS
GED
GED
GEDIsEducation
Structural modificationsCognitive assessment
Pain managementTransitional careFrailty screeningStratification tools
TriageObservation
Discharge planning
PED TraumaCenter
Recommended