In-reach nursing services improve older patient outcomes and access to emergency care : Improving emergency care for older people

We sought to synthesize the literature on patterns of use of emergency services among older adults, risk factors associated with adverse health outcomes, and effectiveness of intervention strategies targeting this population. Relevant articles were identified by means of an English-language search of MEDLINE, HealthSTAR, CINAHL, Current Contents, and Cochrane Library databases from January 1985 to January 2001. This search was supplemented with literature from reference sections of the retrieved publications. A qualitative approach was used to synthesize the literature. Compared with younger persons, older adults use emergency services at a higher rate, their visits have a greater level of urgency, they have longer stays in the emergency department, they are more likely to be admitted or to have repeat ED visits, and they experience higher rates of adverse health outcomes after discharge. The risk factors commonly associated with the negative outcomes are age, functional impairment, recent hospitalization or ED use, living alone, and lack of social support. Comprehensive geriatric screening and coordinated discharge planning initiatives designed to improve clinical outcomes in older emergency patients have provided inconclusive results. Older ED patients have distinct patterns of service use and care needs. The current disease-oriented and episodic models of emergency care do not adequately respond to the complex care needs of frail older patients. More research is needed to determine the effectiveness of screening and intervention strategies targeting at-risk older ED patients.

Objective To evaluate the effectiveness of comprehensive geriatric assessment in hospital for older adults admitted as an emergency. Search strategy We searched the EPOC Register, Cochrane’s Controlled Trials Register, the Database of Abstracts of Reviews of Effects (DARE), Medline, Embase, CINAHL, AARP Ageline, and handsearched high yield journals. Selection criteria Randomised controlled trials of comprehensive geriatric assessment (whether by mobile teams or in designated wards) compared with usual care. Comprehensive geriatric assessment is a multidimensional interdisciplinary diagnostic process used to determine the medical, psychological, and functional capabilities of a frail elderly person to develop a coordinated and integrated plan for treatment and long term follow-up. Data collection and analysis Three independent reviewers assessed eligibility and trial quality and extracted published data. Two additional reviewers moderated. Results Twenty two trials evaluating 10 315 participants in six countries were identified. For the primary outcome “living at home,” patients who underwent comprehensive geriatric assessment were more likely to be alive and in their own homes at the end of scheduled follow-up (odds ratio 1.16 (95% confidence interval 1.05 to 1.28; P=0.003; number needed to treat 33) at a median follow-up of 12 months versus 1.25 (1.11 to 1.42; P<0.001; number needed to treat 17) at a median follow-up of six months) compared with patients who received general medical care. In addition, patients were less likely to be living in residential care (0.78, 0.69 to 0.88; P<0.001). Subgroup interaction suggested differences between the subgroups “wards” and “teams” in favour of wards. Patients were also less likely to die or experience deterioration (0.76, 0.64 to 0.90; P=0.001) and were more likely to experience improved cognition (standardised mean difference 0.08, 0.01 to 0.15; P=0.02) in the comprehensive geriatric assessment group. Conclusions Comprehensive geriatric assessment increases patients’ likelihood of being alive and in their own homes after an emergency admission to hospital. This seems to be especially true for trials of wards designated for comprehensive geriatric assessment and is associated with a potential cost reduction compared with general medical care.

Objective To assess the effectiveness of acute geriatric units compared with conventional care units in adults aged 65 or more admitted to hospital for acute medical disorders. Design Systematic review and meta-analysis. Data sources Medline, Embase, and the Cochrane Library up to 31 August 2008, and references from published literature. Review methods Randomised trials, non-randomised trials, and case-control studies were included. Exclusions were studies based on administrative databases, those that assessed care for a single disorder, those that evaluated acute and subacute care units, and those in which patients were admitted to the acute geriatric unit after three or more days of being admitted to hospital. Two investigators independently selected the studies and extracted the data. Results 11 studies were included of which five were randomised trials, four non-randomised trials, and two case-control studies. The randomised trials showed that compared with older people admitted to conventional care units those admitted to acute geriatric units had a lower risk of functional decline at discharge (combined odds ratio 0.82, 95% confidence interval 0.68 to 0.99) and were more likely to live at home after discharge (1.30, 1.11 to 1.52), with no differences in case fatality (0.83, 0.60 to 1.14). The global analysis of all studies, including non-randomised trials, showed similar results. Conclusions Care of people aged 65 or more with acute medical disorders in acute geriatric units produces a functional benefit compared with conventional hospital care, and increases the likelihood of living at home after discharge.