Background and importance Although aging societies in Western Europe use presenting complaints (PCs) in emergency departments (EDs) triage systems to determine the urgency and severity of the care... Show moreBackground and importance Although aging societies in Western Europe use presenting complaints (PCs) in emergency departments (EDs) triage systems to determine the urgency and severity of the care demand, it is unclear whether their prognostic value is age-dependent.Objective To assess the frequency and association of PCs with hospitalization and mortality across age categories.Methods An observational multicenter study using all consecutive visits of three EDs in the Netherlands Emergency department Evaluation Database. Patients were stratified by age category (0-18; 19-50; 51-65; 66-80; >80 years), in which the association between PCs and case-mix adjusted hospitalization and mortality was studied using multivariable logistic regression analysis (adjusting for demographics, hospital, disease severity, comorbidity and other PCs)Results We included 172 104 ED-visits. The most frequent PCs were 'extremity problems' [range across age categories (13.5-40.8%)], 'feeling unwell' (9.5-23.4%), 'abdominal pain' (6.0-13.9%), 'dyspnea' (4.5-13.3%) and 'chest pain' (0.6-10.7%). For most PCs, the observed and the case-mix-adjusted odds for hospitalization and mortality increased the higher the age category. The most common PCs with the highest adjusted odds ratios (AORs, 95% CI) for hospitalization were 'diarrhea and vomiting' [2.30 (2.02-2.62)] and 'feeling unwell' [1.60 (1.48-1.73)]. Low hospitalization risk was found for 'chest pain' [0.58 (0.53-0.63)] and `palpitations' [0.64 (0.58-0.71)].Conclusions Frequency of PCs in ED patients varies with age, but the same PCs occur in all age categories. For most PCs, (case-mix adjusted) hospitalization and mortality vary across age categories. 'Chest pain' and 'palpitations,' usually triaged 'very urgent', carry a low risk for hospitalization and mortality. European Journal of Emergency Medicine 29: 33-41 Copyright (c) 2021 Wolters Kluwer Health, Inc. All rights reserved. Show less
Candel, B.G.J.; Duijzer, R.; Gaakeer, M.I.; Avest, E. ter; Sir, O.; Lameijer, H.; ... ; Groot, B. de 2022
Background Appropriate interpretation of vital signs is essential for risk stratification in the emergency department (ED) but may change with advancing age. In several guidelines, risk scores such... Show moreBackground Appropriate interpretation of vital signs is essential for risk stratification in the emergency department (ED) but may change with advancing age. In several guidelines, risk scores such as the Systemic Inflammatory Response Syndrome (SIRS) and Quick Sequential Organ Failure Assessment (qSOFA) scores, commonly used in emergency medicine practice (as well as critical care) specify a single cut-off or threshold for each of the commonly measured vital signs. Although a single cut-off may be convenient, it is unknown whether a single cut-off for vital signs truly exists and if the association between vital signs and in-hospital mortality differs per age-category. Aims To assess the association between initial vital signs and case-mix adjusted in-hospital mortality in different age categories. Methods Observational multicentre cohort study using the Netherlands Emergency Department Evaluation Database (NEED) in which consecutive ED patients >= 18 years were included between 1 January 2017 and 12 January 2020. The association between vital signs and case-mix adjusted mortality were assessed in three age categories (18-65; 66-80; >80 years) using multivariable logistic regression. Vital signs were each divided into five to six categories, for example, systolic blood pressure (SBP) categories (<= 80, 81-100, 101-120, 121-140, >140 mm Hg). Results We included 101 416 patients of whom 2374 (2.3%) died. Adjusted ORs for mortality increased gradually with decreasing SBP and decreasing peripheral oxygen saturation (SpO(2)). Diastolic blood pressure (DBP), mean arterial pressure (MAP) and heart rate (HR) had quasi-U-shaped associations with mortality. Mortality did not increase for temperatures anywhere in the range between 35.5 degrees C and 42.0 degrees C, with a single cut-off around 35.5 degrees C below which mortality increased. Single cut-offs were also found for MAP 22/min. For all vital signs, older patients had larger increases in absolute mortality compared with younger patients. Conclusion For SBP, DBP, SpO(2) and HR, no single cut-off existed. The impact of changing vital sign categories on prognosis was larger in older patients. Our results have implications for the interpretation of vital signs in existing risk stratification tools and acute care guidelines. Show less
Optimizing emergency care for the aging population is an important future challenge, as the proportion of older patients at the emergency department (ED) rapidly increases. Older patients,... Show moreOptimizing emergency care for the aging population is an important future challenge, as the proportion of older patients at the emergency department (ED) rapidly increases. Older patients, particularly those who are frail, have a high risk of adverse outcomes after an ED visit, such as functional decline, institutionalization, and death. The ED can have a key position in identifying frail older patients who benefit most from comprehensive geriatric care [including delirium preventive measures, early evaluation of after-discharge care, and a comprehensive geriatric assessment (CGA)]. However, performing extensive frailty assessment is not suitable at the ED. Therefore, quick and easy-to-use instruments are needed to identify older patients at risk for adverse outcomes. This narrative review outlines the importance and complexity of frailty assessment at the ED. It aligns the available screening instruments, including clinical judgment as frailty assessment, and summarizes arguments for and against frailty assessment at the ED. Show less
Loon-van Gaalen, M. van; Linden, M.C. van der; Gussekloo, J.; Mast, R.C. van der 2021
Background/Objectives Telephone follow-up calls could optimize the transition from the emergency department (ED) to home for older patients. However, the effects on hospital return rates are not... Show moreBackground/Objectives Telephone follow-up calls could optimize the transition from the emergency department (ED) to home for older patients. However, the effects on hospital return rates are not clear. We investigated whether telephone follow-up reduces unplanned hospitalizations and/or unplanned ED return visits within 30 days of ED discharge. Design Pragmatic randomized controlled trial with allocation by month; odd months intervention group, even months control group. Setting Two ED locations of a non-academic teaching hospital in The Netherlands. Participants Community-dwelling adults aged >= 70 years, discharged home from the ED were randomized to the intervention group (N = 4732) or control group (N = 5104). Intervention Intervention group patients: semi-scripted telephone call from an ED nurse within 24 h after discharge to identify post-discharge problems and review discharge instructions. Control group patients: scripted satisfaction survey telephone call. Measurements Primary outcome: total number of unplanned hospitalizations and/or ED return visits within 30 days of ED discharge. Secondary outcomes: separate numbers of unplanned hospitalizations and ED return visits. Subgroup analysis by age, sex, living condition, and degree of crowding in the ED at discharge. Results Overall, 42% were males, and median age was 78 years. In the intervention group, 1516 of 4732 patients (32%) consented, and in the control group 1659 of 5104 (33%) patients. Unplanned 30-day hospitalization and/or ED return visit was found in 16% of intervention group patients and 14% of control group patients (odds ratio 1.16; 95% confidence interval: 0.96-1.42). Also, no statistically significant differences were found in secondary outcome measures. Within the subgroups, the intervention did not have beneficial effects for the intervention group. Conclusion Telephone follow-up after ED discharge in older patients did not result in reduction of unplanned hospital admissions and/or ED return visits within 30 days. These results raise the question of whether other outcomes could be improved by post-discharge ED telephone follow-up. Show less
Background: Length of stay (LOS) in the Emergency Department (ED) is correlated with an extended in-hospital LOS and may even increase 30-day mortality. Older patients represent a growing... Show moreBackground: Length of stay (LOS) in the Emergency Department (ED) is correlated with an extended in-hospital LOS and may even increase 30-day mortality. Older patients represent a growing population in the ED and they are especially at risk of adverse outcomes. Screening tools that adequately predict admission could help reduce waiting times in the ED and reduce time to treatment. We aimed to develop and validate a clinical prediction tool for admission, applicable to the aged patient population in the ED.Methods: Data from 7,606 ED visits of patients aged 70 years and older between 2012 and 2014 were used to develop the CLEARED tool. Model performance was assessed with discrimination using logistic regression and calibration. The model was internally validated by bootstrap resampling in Erasmus Medical Center and externally validated at two other hospitals, Medisch Spectrum Twente (MST) and Leiden University Medical Centre (LUMC).Results: CLEARED contains 10 predictors: body temperature, heart rate, diastolic blood pressure, systolic blood pressure, oxygen saturation, respiratory rate, referral status, the Manchester Triage System category, and the need for laboratory or radiology testing. The internally validated area under the curve (AUC) was 0.766 (95% CI [0759; 0.780. External validation in MST showed an AUC of o.797 and in LUMC, an AUC of 0.725.Conclusions: The developed CLEARED tool reliably predicts admission in elderly patients visiting the ED. It is a promising prompt, although further research is needed to implement the tool and to investigate the benefits in terms of reduction of crowding and LOS in the ED. Show less
Blomaard, L.C.; Mooijaart, S.P.; Bolt, S.; Lucke, J.A.; Gelder, J. de; Booijen, A.M.; ... ; Groot, B. de 2020
Background: risk stratification tools for older patients in the emergency department (ED) have rarely been implemented successfully in routine care.Objective: to evaluate the feasibility and... Show moreBackground: risk stratification tools for older patients in the emergency department (ED) have rarely been implemented successfully in routine care.Objective: to evaluate the feasibility and acceptability of the 'Acutely Presenting Older Patient' (APOP) screener, which identifies older ED patients at the highest risk of adverse outcomes within 2 minutes at presentation.Design and setting: 2-month prospective cohort study, after the implementation of the APOP screener in ED routine care in the Leiden University Medical Center.Subjects: all consecutive ED patients aged >= 70 years.Methods: feasibility of screening was assessed by measuring the screening rate and by identifying patient- and organisation-related determinants of screening completion. Acceptability was assessed by collecting experienced barriers of screening completion from triage-nurses.Results: we included 953 patients with a median age of 77 (IQR 72-82) years, of which 560 (59%) patients were screened. Patients had a higher probability of being screened when they had a higher age (OR 1.03 (95%CI 1.01-1.06), P = 0.017). Patients had a lower probability of being screened when they were triaged very urgent (OR 0.55 (0.39-0.78), P = 0.001) or when the number of patients upon arrival was high (OR 0.63 (0.47-0.86), P = 0.003). Experienced barriers of screening completion were patient-related ('patient was too sick'), organisation-related ('ED was too busy') and personnel-related ('forgot to complete screening').Conclusion: with more than half of all older patients screened, feasibility and acceptability of screening in routine ED care is very promising. To further improve screening completion, solutions are needed for patients who present with high urgency and during ED rush hours. Show less
BACKGROUND Urgency triage in the emergency department (ED) is important for early identification of potentially lethal conditions and extensive resource utilization. However, in older patients,... Show moreBACKGROUND Urgency triage in the emergency department (ED) is important for early identification of potentially lethal conditions and extensive resource utilization. However, in older patients, urgency triage systems could be improved by taking geriatric vulnerability into account. We investigated the association of geriatric vulnerability screening in addition to triage urgency levels with 30-day mortality in older ED patients.DESIGN Secondary analysis of the observational multicenter Acutely Presenting Older Patient (APOP) study.SETTING EDs within four Dutch hospitals.PARTICIPANTS Consecutive patients, aged 70 years or older, who were prospectively included.MEASUREMENTS Patients were triaged using the Manchester Triage System (MTS). In addition, the APOP screener was used as a geriatric screening tool. The primary outcome was 30-day mortality. Comparison was made between mortality within the geriatric high- and low-risk screened patients in every urgency triage category. We calculated the difference in explained variance of mortality by adding the geriatric screener (APOP) to triage urgency (MTS) by calculating Nagelkerke R-2.RESULTS We included 2,608 patients with a median age of 79 (interquartile range = 74-84) years, of whom 521 (20.0%) patients were categorized as high risk according to geriatric screening. Patients were triaged on urgency as standard (27.2%), urgent (58.5%), and very urgent (14.3%). In total, 132 (5.1%) patients were deceased within a period of 30 days. Within every urgency triage category, 30-day mortality was threefold higher in geriatric high-risk compared to low-risk patients (overall = 11.7% vs 3.4%; P < .001). The explained variance of 30-day mortality with triage urgency was 1.0% and increased to 6.3% by adding the geriatric screener.CONCLUSION Combining triage urgency with geriatric screening has the potential to improve triage, which may help clinicians to deliver early appropriate care to older ED patients. Show less
Loon, M. van; Mast, R.C. van der; Linden, M.C. van der; Gaalen, F.A. van 2020
BackgroundRoutine screening programmes for hazardous alcohol use in the ED miss large numbers of patients. We investigated whether patient-related or staff-related factors cause screening failures... Show moreBackgroundRoutine screening programmes for hazardous alcohol use in the ED miss large numbers of patients. We investigated whether patient-related or staff-related factors cause screening failures and whether unscreened patients are at increased risk of hazardous alcohol use.MethodsThis is a secondary analysis of a prospective study. From November 2012 to November 2013, all adult patients visiting a Dutch inner city ED were screened for hazardous alcohol consumption using the Alcohol Use Disorders Identification Test-Consumption. Reasons for failure of screening were categorised as: (A) patient is unable to cooperate (due to illness or pain, decreased consciousness or incomprehension due to intoxication, psychiatric, cognitive or neurological disorder or language barrier), (B) healthcare professional forgot to ask, (C) patient refuses cooperation and (D) screening was recently performed (<6 months ago). Presence of risk factors for hazardous alcohol use was compared between screened and unscreened patients.ResultsOf the 28 019 ED patients, 18 310 (65%) were screened and 9709 (35%) were not. In 7150 patients staff forgot to screen, whereas 2559 patients were not screened due to patient factors (2340 being unable and 219 unwilling). Patients with any of these risk factors were less likely to be screened: male sex, alcohol-related visit, any intoxication, head injury, any kind of wound and major trauma. In multivariate analysis, all these risk factors were independently associated with not being screened. Patients with at least one risk factor for hazardous alcohol use were less likely to be screened. Highest prevalence of risk factors was found in patients unable or unwilling to cooperate.ConclusionPatients who do not undergo routine screening for alcohol use at triage in the ED have an increased risk for hazardous alcohol use. These data highlight the importance of screening patients, especially those initially unwilling or unable to cooperate, at a later stage. Show less
Verhoef, M.J.; Nijs, E.J.M. de; Fiocco, M.; Heringhaus, C.; Horeweg, N.; Linden, Y.M. van der 2019
Purpose: Patients with hematological malignancies (HM) have more unpredictable disease trajectories compared to patients with advanced solid tumors (STs) and miss opportunities for a palliative... Show morePurpose: Patients with hematological malignancies (HM) have more unpredictable disease trajectories compared to patients with advanced solid tumors (STs) and miss opportunities for a palliative care approach. They often undergo intensive disease-directed treatments until the end of life with frequent emergency department (ED) visits and in-hospital deaths. Insight into end-of-life trajectories and quality of end-of-life care can support arranging appropriate care according to patients' wishes. Method: Mortality follow-back study to compare of end-of-life trajectories of HM and ST patients who died <3 months after their ED visit. Five indicators based on Earle et al. for quality of end-of-life care were assessed: intensive anticancer treatment <3 months, ED visits <6 months, in-hospital death, death in the intensive care unit (ICU), and in-hospice death. Results: We included 78 HM patients and 420 ST patients, with a median age of 63 years; 35% had Eastern Cooperative Oncology Group performance status 3-4. At the ED, common symptoms were dyspnea (22%), pain (18%), and fever (11%). After ED visit, 91% of HM patients versus 76% of ST patients were hospitalized (P = .001). Median survival was 17 days (95% confidence interval [CI]: 15-19): 15 days in HM patients (95% CI: 10-20) versus 18 days in ST patients (95% CI: 15-21), P = .028. Compared to ST patients, HM patients more often died in hospital (68% vs 30%, P < .0001) and in the ICU or ED (30% vs 3%, P < .0001). Conclusion: Because end-of-life care is more aggressive in HM patients compared to ST patients, a proactive integrated care approach with early start of palliative care alongside curative care is warranted. Timely discussions with patients and family about advance care planning and end-of-life choices can avoid inappropriate care at the end of life. Show less
Objectives Delirium is a frequent problem among older patients in the emergency department (ED) and early detection is important to prevent its associated adverse outcomes. Several screening tools... Show moreObjectives Delirium is a frequent problem among older patients in the emergency department (ED) and early detection is important to prevent its associated adverse outcomes. Several screening tools for delirium have been proposed for the ED, such as the 6-Item Cognitive Impairment Test (6-CIT) and the Confusion Assessment Method-ICU (CAM-ICU). Previous validation of the CAM-ICU for use in the ED showed varying results, possibly because it was administered at different or unknown time points. The aim was to study the prevalence of delirium in older (>= 70 years) ED patients using the CAM-ICU and 6-CIT.Participants and methods A prospective cohort study was carried out in one tertiary care and one secondary care hospital in the Netherlands. Patients aged 70 years and older attending the ED were included. Delirium screening was performed within 1 h after ED registration using the CAM-ICU. The 6-CIT was determined for comparison using a cut-off point of at least 14 points indicating possible delirium.Results A total of 997 patients were included in the study, with a median age of 78 years (interquartile range 74-84). Delirium as assessed with CAM-ICU was positive in only 13 (1.3%, 95% confidence interval: 0.8-2.2) patients. Ninety-five (9.5% 95% confidence interval: 7.9-11.5) patients had 6-CIT more than or equal to 14.Conclusion We found a delirium prevalence of 1.3% using the CAM-ICU, which was much lower than the expected prevalence of around 10% as being frequently reported in the literature and what we found when using the 6-CIT. On the basis of these results, caution is warranted to use the CAM-ICU for early screening in the ED. (C) 2018 Wolters Kluwer Health, Inc. All rights reserved. Show less
Groenland, C.N.; Termorshuizen, F.; Rietdijk, W.J.R.; Brule, J. van den; Dongelmans, D.A.; Jonge, E. de; ... ; Uil, C.A. den 2019
