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Prof. Len Gray delivered the presentation at the 2014 Emergency Department Management Conference. The 2014 Emergency Department Management Conference explored areas such as how to improve access to care, clinical redesign, NEAT compliance, patient flow, point of care testing, geriatric care, and enhance the performance of Emergency Department. For more information about the event, please visit: http://bit.ly/edmanagement14
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Centre for Research in Geriatric Medicine
Centre for Online Health
Centre for Research in Geriatric Medicine
Centre for Online Health
OLDER PEOPLE IN THE
EMERGENCY DEPARTMENT:
THE INTERRAI “SOLUTION”
Professor Len Gray
July 2014
Centre for Research in Geriatric Medicine
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Acknowledgements
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– Melinda Martin-Khan (Research Fellow)
– Ellen Burkett (PhD Candidate)
– Linda Schnikter (PhD Candidate)
International contributors
– John Hirdes (University of Waterloo, Canada)
– Andrew Costa (McGill University, Canada)
Centre for Research in Geriatric Medicine
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Older people have complex needs
High admission rates to hospital from ED
High levels of morbidity
– Multiple medical problems
– Cognitive impairment common
– Frequently disabled prior to becoming unwell
Small but complex population arriving from
RACFs
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Geriatric syndromes are common
0
20
40
60
80
100
Australia Belgium Canada Germany Iceland India Sweden AllNations
Pre
vale
nce %
Premorbid
Admission
Source: Gray, L.C., Peel, N.M., Costa, A.P., Burkett, E., et al. Profiles of Older Patients in the emergency
Department: Findings from the interRAI Multinational Emergency Department Study. Annals of Emergency
Medicine 2013: 20 (10)
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Some attendances may be avoidable…
Patients with minor medical issues that can be
managed elsewhere
– RACFs
– Re-attendances of patients discharged from ED
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Some presentations aren’t a good ED “fit”
Older patients without major medical issues
requiring urgent treatment
– Subacute presentations with major functional or
psychosocial issues
– Patients requiring essential, but minor, diagnostic review
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Transfers from RACFs can be reduced?
Incidence > 30 transfers / 100 residents / year – Arendts G, Howard K. Age And Ageing 2010;39:306-12.
36% of ED transfers are inappropriate – Saliba D, Kington R, Buchanan J, et al. JAGS 2000;48:154-63.
31% of ED arrivals from RACFs could be avoided – Codde J, Arendts G, Frankel J, et al. Australasian Journal On Ageing
2010;29:150-4
There is some evidence that the rate can be reduced – Arendts G, Reibel T, Codde J, Frankel J. Australasian Journal On Ageing
2010;29:61-5
Methods might include advance care planning, better treatment of acute illnesses & improved primary care – Arendts G, Howard K. Age And Ageing 2010;39:306-12.
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How can the process be improved?
Older people with complex functional and psychosocial needs should be identified promptly
If home discharge is contemplated, detailed assessment may be required in the ED
Frail patients may have special treatment requirements within the ED and affiliated treatment areas
Discharged patients can be supported in their usual environment
Preventive strategies can be implemented in RACFs
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Structured assessment may assist…
Early screening to identify patients with complex
needs
Support tools for assessment and discharge
preparation within the ED
www.interrai.org
Structured Assessment for Acute Care:
The interRAI Acute Care Mini-Suite
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Comprehensive Geriatric Assessment
Identification of geriatric syndromes
Assessment of functional performance and
capacity
Evaluation of recent changes
Elucidation of diagnoses influencing function
Understanding the social and physical
environment
Monitoring performance over time
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The Hospital Journey
ED Acute Care Post - Acute Care Post - Acute Community
Care
CAM AMT
CAM MMSE Waterlow FRAT MNA
FIM MMSE GDS
Barthel MMSE
Result: Inconsistent data format; high documentation burden; poor compliance; no data sharing
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Why use a Clinical Decision Support
System?
Consistent recording of important clinical features
Readiness for electronic format
Ability to share information across care settings
Automated interpretation of clinical information
Ability to delegate clinical tasks away from
specialists
Background administrative reporting at low cost
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Second generation assessment systems
First generation
(compilation)
Assembly of best of breed syndrome specific instruments
Strengths
• Minimum preparation
• Instruments already tested
• Familiarity
Weaknesses
• Gaps
• Redundancy
• Inconsistent scoring
Second generation (built for purpose)
Items developed to support derivative products Strengths • Good match with desired
purpose • Consistent scoring • Minimum redundancy Weaknesses • Expensive to develop &
implement • Require computerisation
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Constructing a Patient Profile
Clinical Observations Scales to measure severity
Screeners
to identify problems & estimate risk
Quality Indicators
to assess performance
Clinical Action Points
to prioritise interventions
Casemix tools to understand cost
Patient Profile
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The interRAI AC
Diagnostic
screeners
Delirium
Dementia
Depression
Malnutrition
Risk assessment
Delirium
Pressure ulcer
Falls
Functional decline
Institutional care
Readmission
Severity measures
Delirium
Cognition
Communication
Mood
ADL
IADL
Pain
Nutrition Recommendations
(CAPs)
ADL
Cognition
Communication
Delirium
Depression
Pain
Pressure ulcer
Institutional risk
Readmission
Medications
Quality indicators
Self care, mobility,
IDC, falls, pressure
ulcer, institutional
placement
Clin
ical
observ
ations
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Patient profile
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Striving for high scientific quality
All elements are subjected to intensive
psychometric testing
Standard for integrated scales and screeners:
performance at least as good at existing
“standalone” equivalents
Research findings are published in the peer-
reviewed literature
Training manuals for all instruments
18
www.interrai.org 19
interRAI AC
interRAI HC
interRAI ED Screener
Ward Admission Assessment
[PURPLE BOX]
SPECIALIST GERIATRIC ASSESSMENT
GENERAL ASSESSMENT
interRAI AC-PAC
interRAI ED CA
General ward geriatric care
www.interrai.org 20
ED Acute Post Acute Community
A P A A D D D
Core observations
Setting specific observations
P = premorbid
A = admission
D - discharge
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Scaling across the Continuum
21
0
2
4
6
8
10
Short ADL Scale
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The Hospital Mini-Suite: Progress
ED screener – Available
ED assessment – Late 2014
Nurse administered screener – In development
Acute Care - Available
Post-acute care - Late 2014
Home care – Available
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THE INTERRAI ED TOOLKIT
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Targeting assessment: The ED Screener
To identify, soon after arrival at ED, patients
who…
– If to be discharged home, are at risk of re-
attendance AND
– If to be admitted to hospital, are at risk of
prolonged stay or discharge to institutional care
In other words…
Comprehensive Geriatric Assessment is
recommended
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Screener Structure
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Predictive validity compared
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The ED Screener
Comprises 11 items
Average to complete 45 seconds
Suitable for administration by general ED or
specialist ED nurses
Available as an iPhone or Android Application
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Centre for Research in Geriatric Medicine
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The interRAI ED Contact Assessment
30 item mini-CGA
Domains – Cognition, mood, ADL, pain…
Premorbid vs current functional status
Outputs – Diagnostic and risk screeners
– Suggestions for care planning
Requires 20-60 minutes to complete – Nurse administered
– Training required
– Software required
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The interRAI solution summarised
Purpose built case finding and assessment
system for older people in the ED
Grounded in an extensive, ongoing multi-national
research program
Linked to a “whole of system” assessment and
care planning system for hospital and community
care
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Further research…
Development of Quality Indicators for care of
older persons in the ED (CRGM) 2015
Multi-national validation study of the ED screener
(McGill, Waterloo, CRGM) 2015
Proof of concept testing of the ED Assessment
system for the Australian context (CRGM) 2015
Telehealth intervention for RACFs – a cluster
RCT (CRGM – COH) 2016
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Learn more about us...
COH
http://www.uq.edu.au/coh
CRGM www.som.uq.edu.au/research/crgm
interRAI Australia
www.interrai-au.org
RAIplus
www.raiplus.com
CeGA Online
www.cegaonline.com