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Glenn Arendts, How comprehensive is comprehensive enough? Emergency Department assessment of older people, Age and Ageing, Volume 46, Issue 3, May 2017, Pages 340–341, https://doi.org/10.1093/ageing/afw258
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Around a quarter of people attending an emergency department (ED) are aged 65 or more. Our EDs generally provide good quality care in the face of rapidly escalating demand. But it is increasingly apparent that the environment, staffing and operational rules of EDs in the era of time-based targets do not optimally meet the needs of frail older people presenting for hospital care. Comprehensive geriatric assessment (CGA) is the raison d’être of specialist geriatric care in our hospitals, with good evidence for it's effectiveness, efficiency and sustainability [1]. A logical question, therefore, is can we bring those benefits of CGA that hospitalised inpatients enjoy to the front door of the hospital?
Theoretically, geriatric team assessment in ED could mitigate two common problems. Firstly, inadequate care by ED clinicians of individual patients occurs when complex age-associated syndromes are misinterpreted or ignored. The workplace culture of an ED is appropriately directed towards acute resuscitative care; older people presenting with exacerbations of chronic illness on a background of physical and cognitive frailty are often seen as ‘someone else's problem’ and given low priority as a result [2]. Secondly, poorly organised hospital practices result in systematic biases that either promote the ED discharge of older patients that should be admitted or the admission of those that could be discharged. The former receives a great deal of negative attention as ‘the failed discharge’ [3]. Yet, the latter is arguably more important as we strive to avoid iatrogenic mishap and deconditioning, and maintain a responsive hospital system with constrained public funding.
As counterargument, some contend that the concept of CGA in ED is an oxymoron, citing the nature of interventions provided by the multidisciplinary teams that perform CGA and management. These assessments are time consuming and have many external constraints impacting on how rapidly they can be done. Family members may be difficult to find and home assessments delayed due to access issues. Complex assessments, such as task specific capacity assessments, may need to be repeated in different environments and contexts.
In this edition of the journal, Jay et al. [4] have set themselves the task of systematically reviewing whether geriatrician coordinated assessment in the ED influences hospitalisation. No randomised trials were uncovered, all included studies have methodological flaws, and regrettably the authors provide no pooled statistical analysis. The form of interventions found was variable but at best reflects a truncated version of true CGA. With these heavy qualifications, the review concludes that multidisciplinary care by a dedicated geriatric team performed in ED reduces hospital admission. Even more interestingly, the pre-intervention variation in admission rates between sites reduced substantially after intervention, suggesting that geriatric teams lead to more standardised clinical care in the ED.
Hospital admission rate is not an outcome that in itself typically matters much to patients. The complexities of evaluating multicomponent interventions for patient-centred outcomes in heterogeneous populations of frail people are enormous. Large knowledge gaps for those of us that work in ED remain—which factor/s impart most discharge risk; what components of an intervention work for our patients, and which are redundant; where is the tipping point at which hospital admission fails to be restorative, and contributes to harm? These are just some of the long-term challenges for timely geriatric assessment and management in support of ED discharge decisions. Jay et al. have found some evidence for us to be confident but not certain we are on track.
Maximising the safe discharge of people from emergency departments is an important goal.
As currently configured, emergency departments are ill equipped to assess all of the pressing needs of frail older people presenting for care.
Multidisciplinary geriatric teams increase discharge rates from emergency departments, but the evidence base for high-level recommendations is not strong.
Conflicts of interest
None declared.
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