Abstract
BackgroundURGENT is a comprehensive geriatric assessment (CGA) based nurse-led care model in the emergency department (ED) with geriatric follow-up after ED discharge aiming to prevent unplanned ED readmissions.MethodsA quasi-experimental study (sequential design with two cohorts) was conducted in the ED of University Hospitals Leuven (Belgium). Dutch-speaking, community-dwelling ED patients aged 70 years or older were eligible for enrolment. Patients in the control cohort received usual care. Patient in the intervention cohort received the URGENT care model.A geriatric emergency nurse conducted CGA and interdisciplinary care planning among older patients identified as at risk for adverse events (e.g. unplanned ED readmission, functional decline) with the interRAI ED Screener© and clinical judgement of ED staff. Case manager follow-up was offered to at risk patients without hospitalization after index ED visit. For inpatients, geriatric follow-up was guaranteed on an acute geriatric ward or by the inpatient geriatric consultation team on a non-geriatric ward if considered necessary.Primary outcome was unplanned 90-day ED readmission. Secondary outcomes were ED length of stay (LOS), hospitalization rate, in-hospital LOS, 90-day higher level of care, 90-day functional decline and 90-day post-hospitalization mortality.ResultsAlmost half of intervention patients (404/886 = 45.6%) were categorized at risk. These received on average seven advices. Adherence rate to advices on the ED, during hospitalization and in community care was 86.1, 74.6 and 34.1%, respectively. One out of four at risk patients without hospitalization after index ED visit accepted case manager follow-up. Unplanned ED readmission occurred in 170 of 768 (22.1%) control patients and in 205 of 857 (23.9%) intervention patients (p = .11). The intervention group had shorter ED LOS (12.7 h versus 19.1 h in the control group; p < .001), but higher rate of hospitalization (70.0% versus 67.0% in the control group; p = .003).ConclusionsThe URGENT care model shortened ED LOS and increased the hospitalization rate, but did not prevent unplanned ED readmissions. A geriatric emergency nurse could improve in-hospital patient management, but failed to introduce substantial out-hospital case-management.Trial registrationThe protocol of this study was registered retrospectively with ISRCTN (ISRCTN91449949; registered 20 June 2017).
Highlights
URGENT is a comprehensive geriatric assessment (CGA) based nurse-led care model in the emergency department (ED) with geriatric follow-up after ED discharge aiming to prevent unplanned ED readmissions
As mentioned in the protocol paper, the aim of this study is to evaluate the effectiveness of the URGENT care model compared to usual care on the unplanned ED readmission rate, as primary outcome, and secondary outcomes (i.e. ED length of stay (LOS), hospitalization rate, in-hospital LOS, higher level of care, functional decline and post-hospitalization mortality) of community-dwelling, older adults
The aim of this study was to evaluate the effectiveness of the URGENT care model that combined CGA-based, interdisciplinary care planning on the ED with geriatric follow-up after ED discharge
Summary
The growing group of older adults has become an important subset of emergency department (ED) patients with already 12–24% of ED admissions being persons aged 65 years or over [1]. This evolution results in increasing patient volumes in a system that is already burdened with crowding [2] and yields a qualitative challenge, as well, because older adults are characterized by vulnerability features, such as decreased physiological reserves, presence of geriatric syndromes (e.g. delirium), multimorbidity with polypharmacy and potential atypical disease presentation. It is obvious that managing these patients in a fast-paced environment is challenging [2, 3] This is reflected in poorer outcomes regarding functional decline, hospitalization and return rates and death in older adults, compared with younger patients [4]. Up to one out of four older adults return to the ED within 3 months [4, 5]
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