Quality indicators for a geriatric emergency care (GeriQ-ED) – an evidence-based delphi consensus approach to improve the care of geriatric patients in the emergency department
verfasst von:
Susanne Schuster, Katrin Singler, Stephen Lim, Mareen Machner, Klaus Döbler, Harald Dormann
Using a triangulation methodology, a) clinical experience-based quality aspects were identified and verified, b) research-based quality statements were formulated and assessed for relevance, and c) preliminary quality indicators were operationalized and evaluated in order to recommend a feasible set of final quality indicators.
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Introduction
Every third patient admitted to prehospital emergency medicine and clinical emergency medicine is older than 65 years old [1‐3]. Demographic changes have led to unique challenges faced by emergency care.
Functional decline, cognitive impairments, such as delirium or dementia, multiple comorbidities, frailty, falls and polypharmacy often result in negative health outcomes [4‐8] It is known that in geriatric emergency patients, the risk of adverse outcomes such as hospital (re) admission, institutionalisation and mortality are increased compared to younger patients [9, 10].
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The American College of Emergency Physicians (ACEP), the American Geriatrics Society (AGS), the Emergency Nurses Association (ENA) and the Society for Academic Emergency Medicine (SAEM) have developed guidelines for the care of older people in the emergency department (ED) [11]. However, in Australia and Europe, there are currently no consensus on which aspects of care to be included [7, 8, 12, 13]. To bring together both disciplines, geriatrics and emergency medicine, a European curriculum in geriatric emergency medicine was developed and approved by the European Union of Medical Specialists (UEMS) [14]. Additionally, a position paper by the German Society of Emergency Medicine (DGINA), the German Society of Geriatrics (DGG), the German Society of Gerontology and Geriatrics (DGGG), the Austrian Society of Geriatrics and Gerontology (ÖGGG) and the Swiss Society for Geriatrics (SFGG) have identified the need for further research and objective quality indicators (QIs) for geriatric emergency care [15]. A recent review highlighted that “a balanced, methodologically robust set of QIs for care of older persons in the ED” is needed [16]. Well-defined QIs will enable the assessment, benchmarking, and improvement of quality of care for geriatric emergency care patients [17].
During the development of the QIs, the following quality criteria were considered: scientific character, relevance and feasibility [18].
Triangulation methodology was applied for the development of the quality indicators, based on exploration of current evidence through a systematic literature search, and expert opinion from an interdisciplinary and interprofessional expert panel.
An exploratory literature review was conducted between 09/2014–10/2014 and an expert panel (n = 11) was established to contribute with its expertise on geriatric emergency care through a Delphi process [19]. The expert panel consisted of three emergency physicians and specially trained nurses, a geriatrician, a pharmacologist, a health economist and two participants who represented the views of older emergency patients.
At the first expert meeting (11/2014) a qualitative group discussion among the expert panel was conducted to identify relevant quality aspects of care for geriatric emergency patients. These quality aspects were evaluated using qualitative content analysis according to Mayring supported by MAXQDA [20]. A second systematic literature review (12/2014–03/2015) [search terms: `geriatric OR elderly OR senior` AND `emergency department´; databases: PubMed and CINAHL; inclusion criteria: published scientific papers, reviews, systematic reviews and meta-analyses between 2010 and 2015] was conducted to explore evidence for the potentially relevant quality aspects identified by the expert panel. Another aim of this systematic literature review was to verify the clinical experience-based quality aspects and to formulate evidence-based quality statements. During the second expert meeting (03/2015) an anonymized assessment of the relevance of all quality statements was conducted by the panel using a four-staged Likert-scale. The assessment took into consideration the importance, benefit and risk of each quality statement, based on the QUALIFY- instrument [19]. During the operationalisation process (third and fourth expert meeting - 05/2015 and 06/2015) preliminary quality indicators (structural, process or outcome indicators) including respective reference ranges were defined for every quality statement that was classified as relevant. To facilitate implementation of the preliminary quality indicators (QIs) into daily practice, QIs were assessed for their feasibility. To find a consensus during the fifth meeting (12/2015), experts used the anonymized two-step approach by RAND UCLA [21]. Finally, the panel was asked to define the QIs of five quality statements they regarded to be most important. These were prioritized as the “top five”.
Results
The explorative literature review identified defined topics of geriatric emergency care [7, 8] QIs for selected areas in the field [13] and guidelines for geriatric emergency departments (ED) [11]. The potentially relevant quality aspects that were discussed during the first expert meeting were summarized into twelve different categories: education, staff, equipment, communication/information transfer, nursing care, medical treatment, geriatric screening, and risk factors such as falls, pain, cognitive impairment, medication and care needs (incontinence and the development of pressure sores).
The systematic literature review of potentially relevant quality aspects identified nine reviews, seven systematic reviews and two meta-analyses. Based on these results 41 quality statements were formulated. At the second meeting of the expert panel all 41 quality statements were assessed as being relevant. The following quality statements were rated as most relevant (\( \overline{\mathrm{X}} \) = mean value):
screening for delirium (\( \overline{\mathrm{X}} \) 3,93)
professional training requirements for emergency care staff (\( \overline{\mathrm{X}} \) 3,90)
barrier-free access to toilets with the possibility of supported transfer (\( \overline{\mathrm{X}} \) 3,90)
repetitive pain assessment including appropriate use of analgesics (\( \overline{\mathrm{X}} \) 3,90)
During their third and fourth meeting the expert panel operationalized the 41 quality statements into 69 QIs. Apart from the statement ‘to implement a separate waiting area for geriatric patients’, the expert panel considered all other QIs as feasible at the fifth expert meeting.
taking a full medication history including an assessment of the indications
3.
education of geriatric knowledge and skills to emergency staff
4.
screening for patients with geriatric needs
5.
identification of patients with risk of falls/ recurrent falls
TOP 1: screening for delirium
Consequences of an undetected delirium include progressive deterioration of functional and cognitive impairment, and an increased risk of mortality [23, 24]. Studies show a strong association between the duration of delirium and mortality [25, 26]. Thus early detection of delirium in the emergency care setting is essential. Currently only a few screening-tools are validated and feasible in daily practice in the ED, such as the Confusion Assessment Method (CAM), the modified CAM-ED (mCAM-ED) [27, 28] and the 4-AT [29].
Polypharmacy is common among older adults and is associated with an increased risk of adverse outcomes such as adverse drug reactions or medication errors. Adverse drug events (ADR) are a major cause of ED visits among older people [8, 30‐32]. Nevertheless, most ADR are not detected. Studies have shown that up to 60% of all ADR are potentially avoidable [33]. Special attention should be given to the intake of anticoagulants, benzodiazepines, non-steroidal anti-inflammatory drugs, diuretics and antidepressants. These classes of drugs have in many cases been associated with complaints from older people who have been admitted to ED [32, 34‐37].
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Good clinical practice for the detection and prevention of ADRs in vulnerable patients include a detailed documentation and regular review of prescribed as well as over-the-counter medication by using a standardized medication reconciliation [38].
TOP 3: staff education on geriatric knowledge and skills
Staff education level affects clinical outcomes in the emergency management [39]. In 2015 the Geriatric Section of the European Society for Emergency Medicine (EUSEM) together with the European Geriatric Medicine Society (EUGMS) established a joint task force to developed a curriculum for the care of older emergency patients (European Taskforce on Geriatric Emergency Medicine, ETFGEM). The aim was to outline relevant competencies in the care of older people, especially those with frailty. The curriculum incorporates knowledge on the physiology of ageing, common and atypical complaints, and the identification of geriatric syndromes or psychiatric needs of geriatric patients [14].
TOP 4: screening for patients with geriatric needs
A recent meta-analysis showed that risk stratification of geriatric emergency patients is strongly limited by the lack of feasible and validated instruments. Existing instruments designed for risk stratification of older ED patients do not distinguish precisely between high- or low-risk groups [40]. However, as long as no better screening instruments are developed, it is recommended to use established and validated instruments [41].
TOP 5: identification of patients with risk of falls/ recurrent falls
Appropriate evaluation of a fallen patient not only implies a thorough assessment for traumatic injuries, but also an assessment of potential causes and a stratification of future risk of falling [43, 44]. A proper assessment often requires a multidisciplinary team-approach. Currently no specific tools are recommended for the identification of potential risk factors [11]. The German Expert’s Standard for Fall and Fracture Prevention recommends an evaluation of person-, medication- and environmental-related risk factors such as fall history, the use of walking aids, depression, cognitive impairment and the long-term use of more than six different drugs [45].
Susanne Schuster and Katrin Singler act as chair of geriatric emergency medicine section (ÄlPaNo) at the German Society of Emergency Medicine (DGINA). Katrin Singler act as chair of emergeny and intensiv medicine section at the German Society of Geriatrics (DGG). Harald Dormann act as chair of patient care and science section and advisory member of the board directors at the German Society of Emergency Medicine (DGINA).
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Quality indicators for a geriatric emergency care (GeriQ-ED) – an evidence-based delphi consensus approach to improve the care of geriatric patients in the emergency department
verfasst von
Susanne Schuster Katrin Singler Stephen Lim Mareen Machner Klaus Döbler Harald Dormann
