Comprehensive Geriatric Assessment in the Emergency Department

Frailty Clinical Trial

Official title:

Comprehensive Geriatric Assessment in the Emergency Department: a Prospective Cohort Study of Clinical and Process Outcomes

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT05252182
• Other study ID #: ED-CGA
• Status: Completed
• Start date: February 1, 2022
• Est. completion date: February 10, 2023

Study information

• Verified date: June 2023
• Source: University of Limerick
• Contact: n/a
• Is FDA regulated: No
• Study type: Observational

Clinical Trial 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.

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.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 133
• Est. completion date: February 10, 2023
• Est. primary completion date: August 5, 2022
• Gender: All
• Age group: 65 Years and older

Eligibility

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.

Related Conditions & MeSH terms

• Emergencies
• Frailty

Locations

Country	Name	City	State
Ireland	University of Limerick	Limerick	Munster

Sponsors (2)

Lead Sponsor	Collaborator
University of Limerick	University Hospital of Limerick

Country where clinical trial is conducted

Ireland, 

References & Publications (14)

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. Erratum In: Lancet. 2013 Oct 19;382(9901):1328. — View 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. — View 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. — View 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. — View 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. — View Citation

Harding S. Comprehensive geriatric assessment in the emergency department. Age Ageing. 2020 Oct 23;49(6):936-938. doi: 10.1093/ageing/afaa059. — View 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. — View Citation

Mackway-Jones K ed: Emergency triage. London: BMJ Publishing Group. 1997.

MAHONEY FI, BARTHEL DW. FUNCTIONAL EVALUATION: THE BARTHEL INDEX. Md State Med J. 1965 Feb;14:61-5. No abstract available. — View Citation

Marshall GN, Hays RD: The Patient Satisfaction Questionnaire Short Form (PSQ-18). Santa Monica, CA: Rand; 1994.

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. — View 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. — View 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.

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. — View Citation

* Note: There are 14 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Incidence of hospital admission from the ED index attendance.	Number of participants who are admitted to hospital following their index ED attendance	6 months
Secondary	Incidence of functional decline (including functional decline at discharge from hospital among the cohort admitted from the ED).	Functional decline is defined as a net decrease in the number of activities of daily living performed independently as measured by the self-reported Barthel Index. The sum score of all subscales may range from 0-20 points, where 0 indicates the maximum level of dependency and 20 indicates maximum independence.	30 days and 6 months
Secondary	Patient satisfaction with the ED index attendance	Participants will rate their satisfaction across a number of domains using the 18-item Patient Satisfaction Questionnaire. The sum score of all subscales may range from 18 to 90 points, where 18 points is the poorest possible evaluation and 90 points the best.	30-day follow-up
Secondary	Number of unscheduled ED re-attendances	Number of participants who experienced an unscheduled ED re-attendance following their index attendance	30 days and 6 months
Secondary	Number of unscheduled hospital admissions	Number of participants who experienced an unscheduled hospital (re)admission following their ED index attendance	30 days and 6 months
Secondary	Nursing home admission	Number of participants who were admitted to a nursing home or residential care facility following their ED index attendance	30 days and 6 months
Secondary	Mortality	Number of participants who died following their ED index attendance	30 days and 6 months
Secondary	Healthcare utilisation	Number and duration of services that participants were in receipt of following ED index attendance e.g. specialist geriatric ambulatory care hub attendances, GP visits, public health nurse visits, home care support, outpatient clinic attendance, health and social care professionals input etc.	30 days and 6 months