Mortality risk for different presenting complaints amongst older patients assessed with the Manchester triage system

Purpose: Older people often present to the Emergency Department with nonspecific complaints. We aimed (1) to examine characteristics of older patients presenting to the ED triaged with the presentational flowchart ‘unwell adult’ of the Manchester triage system (MTS) and (2) to assess the different mortality and admission rates among triage categories. Methods: Retrospective cohort study including all consecutive patients aged 70 years and older who visited the ED of a tertiary care hospital in the Netherlands during a 1-year period. The primary outcome was 30-day mortality. Secondary outcomes were 7-day mortality, hospital admission and ED length of stay. Results: 4255 patients were included in this study. Mean age was 78 years (IQR 73.9–83.4) and 2098 were male (49.3%). The MTS presentational flowchart ‘unwell adult’ was the most commonly used flowchart (n = 815, 19.3%). After the infrequent flowchart ‘major trauma’ (n = 9, 13.8%), ‘unwell adult’ had the highest 30-day mortality (n = 88, 10.8%). When compared to all other flowcharts, patients assigned as ‘unwell adult’ have significantly higher 30-day mortality rates (OR 1.89 (95%CI 1.46–2.46), p = < 0.001), also when adjusted for age, gender and triage priority (OR 1.75 (95%CI 1.32–2.31), p = < 0.001). Patients from the ‘unwell adult’ flowchart had the highest hospital admission rate (n = 540, 66.3%), and had among the longest ED length of stay. Conclusions: Older ED patients are most commonly assigned the presentational flowchart ‘unwell adult’ when using the MTS. Patients in this category have the highest non-trauma mortality and highest hospital admission rates when compared to other presenting complaints

Patient-reported outcome and experience measures in geriatric emergency medicine

This is the author accepted manuscript. The final version is available from Springer via the DOI in this recordOlder people with frailty and health crises have complex physical and social needs. Modern emergency care systems are fast-flowing, using protocols optimised for single-problem presentations. Systems must incorporate individualised care to best serve people with multiple problems. Healthcare quality is typically appraised with service metrics, such as department length of stay and mortality. Worldwide, patient-reported outcome measures (PROM) and patient-reported experience measures (PREM) are increasingly used in research, service development and performance evaluation, paving the ground for their use to support individual clinical decision-making. The PROMs and PREMs are person-centred metrics, which inform healthcare decisions at the individual level and which at the strategic level drive improvement through comparison of interprovider effectiveness. To date, there is no PROM or PREM specifically developed for older people with frailty and emergency care needs

Comparing associations between frailty and mortality in hospitalised older adults with or without COVID-19 infection: a retrospective observational study using electronic health records

BACKGROUND: The aim of this study was to describe outcomes in hospitalised older people with different levels of frailty and COVID-19 infection. METHODS: We undertook a single centre, retrospective cohort study examining COVID-19 related mortality using Electronic Health Records, for older people (65 and over) with frailty, hospitalised with or without COVID-19 infection. Baseline covariates included demographics, Early Warning Scores, Charlson Comorbidity Indices and frailty (Clinical Frailty Scale, CFS), linked to COVID-19 status. FINDINGS: We analysed outcomes on 1,071 patients with COVID-19 test results; 285 (27%) were positive for COVID-19.)The mean age at ED arrival was 79.7 and 49.4% were female. All-cause mortality (by 30 days) rose from 9% (not frail) through to 33% (severely frail) in the COVID negative cohort but was around 60% for all frailty categories in the COVID positive cohort. In adjusted analyses, the hazard ratio for death in those with COVID-19 compared to those without COVID-19 was 7.3, 95% CI: 3.00, 18.0) with age, comorbidities and illness severity making small additional contributions. INTERPRETATION: In this study frailty, measured using the Clinical Frailty Scale, appeared to make little incremental contribution to the hazard of dying in older people hospitalised with COVID-19 infection; illness severity and comorbidity had a modest association with the overall adjusted hazard of death, whereas confirmed COVID-19 infection dominated, with a seven-fold hazard for death

Current Pyuria Cutoffs Promote Inappropriate Urinary Tract Infection Diagnosis in Older Women

Background: Pre-existing lower urinary tract symptoms (LUTS), cognitive impairment, and the high prevalence of asymptomatic bacteriuria (ASB) complicate the diagnosis of urinary tract infection (UTI) in older women. The presence of pyuria remains the cornerstone of UTI diagnosis. However, >90% of ASB patients have pyuria, prompting unnecessary treatment. We quantified pyuria by automated microscopy and flowcytometry to determine the diagnostic accuracy for UTI and to derive pyuria thresholds for UTI in older women. Methods: Women ≥65 years with ≥2 new-onset LUTS and 1 uropathogen ≥104 colony-forming units (CFU)/mL were included in the UTI group. Controls were asymptomatic and classified as ASB (1 uropathogen ≥105 CFU/mL), negative culture, or mixed flora. Patients with an indwelling catheter or antimicrobial pretreatment were excluded. Leukocyte medians were compared and sensitivity–specificity pairs were derived from a receiver operating characteristic curve. Results: We included 164 participants. UTI patients had higher median urinary leukocytes compared with control patients (microscopy: 900 vs 26 leukocytes/µL; flowcytometry: 1575 vs 23 leukocytes/µL; P < .001). Area under the curve was 0.93 for both methods. At a cutoff of 264 leukocytes/µL, sensitivity and specificity of microscopy were 88% (positive and negative likelihood ratio: 7.2 and 0.1, respectively). The commonly used cutoff of 10 leukocytes/µL had a poor specificity (36%) and a sensitivity of 100%. Conclusions: The degree of pyuria can help to distinguish UTI in older women from ASB and asymptomatic controls with pyuria. Current pyuria cutoffs are too low and promote inappropriate UTI diagnosis in older women

Acute medical unit comprehensive geriatric assessment intervention study (AMIGOS)

<p>Abstract</p> <p>Background</p> <p>Many older people presenting to Acute Medical Units (AMU) are discharged after only a short stay (< 72 hours), yet many re-present to hospital or die within 1 year. Comprehensive Geriatric Assessment may improve patient outcomes for this group.</p> <p>Method</p> <p>Participants</p> <p>Patients aged > 70 years and scoring positive on a risk screening tool ('Identification of Seniors At Risk') who are discharged within 72 hours of attending an AMU with a medical crisis, recruited prior to discharge. Sample size is 400. Carers of participants will also be recruited.</p> <p>Intervention</p> <p>Assessment on the AMU and further out-patient management by a specialist physician in geriatric medicine. Assessment and further management will follow the principles of Comprehensive Geriatric Assessment, providing advice and support to primary care services.</p> <p>Design</p> <p>Multi-centre, individual patient randomised controlled trial comparing intervention with usual care.</p> <p>Outcome measurement</p> <p>Follow up is by postal questionnaire 90 days after randomisation, and data will be entered into the study database by a researcher blind to allocation. The primary outcome is the number of days spent at home (for those admitted from home), or days spent in the same care home (if admitted from a care home). Secondary outcomes include mortality, institutionalisation, health and social care resource use, and scaled outcome measures, including quality of life, disability, mental well-being. Carer strain and well being will also be measured at 90 days.</p> <p>Analyses</p> <p>Comparisons of outcomes and costs, and a cost utility analysis between the intervention and control groups will be carried out.</p> <p>Trial Registration</p> <p>ISRCTN: <a href="http://www.controlled-trials.com/ISRCTN21800480">ISRCTN21800480</a></p

A systematic review and recommendations for prom instruments for older people with frailty in emergency care

INTRODUCTION: The current service metrics used to evaluate quality in emergency care do not account for specific healthcare outcome goals for older people living with frailty. These have previously been classified under themes of 'Autonomy' and 'Functioning'. There is no person-reported outcome measure (PROM) for older people with frailty and emergency care needs. This study aimed to identify and co-produce recommendations for instruments potentially suitable for use in this population. METHODS: In this systematic review, we searched six databases for PROMs used between 2010 and 2021 by older people living with frailty receiving acute hospital care. Studies were reviewed against predefined eligibility criteria and appraised for quality using the COSMIN Risk of Bias checklist. Data were extracted to map instrument constructs against an existing framework of acute healthcare outcome goals. Instrument face and content validity were assessed by lay collaborators. Recommendations for instruments with potential emergency care suitability were formed through co-production. RESULTS: Of 9392 unique citations screened, we appraised the full texts of 158 studies. Nine studies were identified, evaluating nine PROMs. Quality of included studies ranged from 'doubtful' to 'very good'. Most instruments had strong evidence for measurement properties. PROMs mainly assessed 'Functioning' constructs, with limited coverage of 'Autonomy'. Five instruments were considered too burdensome for the emergency care setting or too specific for older people living with frailty. CONCLUSIONS: Four PROMs were recommended as potentially suitable for further validation with older people with frailty and emergency care needs: COOP/WONCA charts, EuroQol, McGill Quality of Life (Expanded), and Palliative care Outcome Scale

Factors associated with compliance among users of solar water disinfection in rural Bolivia

ABSTRACT: BACKGROUND: Diarrhoea is the second leading cause of childhood mortality, with an estimated 1.3 million deaths per year. Promotion of Solar Water Disinfection (SODIS) has been suggested as a strategy for reducing the global burden of diarrhoea by improving the microbiological quality of drinking water. Despite increasing support for the large-scale dissemination of SODIS, there are few reports describing the effectiveness of its implementation. It is, therefore, important to identify and understand the mechanisms that lead to adoption and regular use of SODIS. METHODS: We investigated the behaviours associated with SODIS adoption among households assigned to receive SODIS promotion during a cluster-randomized trial in rural Bolivia. Distinct groups of SODIS-users were identified on the basis of six compliance indicators using principal components and cluster analysis. The probability of adopting SODIS as a function of campaign exposure and household characteristics was evaluated using ordinal logistic regression models. RESULTS: Standardised, community-level SODIS-implementation in a rural Bolivian setting was associated with a median SODIS use of 32% (IQR: 17-50). Households that were more likely to use SODIS were those that participated more frequently in SODIS promotional events (OR = 1.07, 95%CI: 1.01-1.13), included women (OR = 1.18, 95%CI: 1.07-1.30), owned latrines (OR = 3.38, 95%CI: 1.07-10.70), and had severely wasted children living in the home (OR = 2.17, 95%CI: 1.34-3.49). CONCLUSIONS: Most of the observed household characteristics showed limited potential to predict compliance with a comprehensive, year-long SODIS-promotion campaign; this finding reflects the complexity of behaviour change in the context of household water treatment. However, our findings also suggest that the motivation to adopt new water treatment habits and to acquire new knowledge about drinking water treatment is associated with prior engagements in sanitary hygien and with the experience of contemporary family health concerns.Household-level factors like the ownership of a latrine, a large proportion of females and the presence of a malnourished child living in a home are easily assessable indicators that SODIS-programme managers could use to identify early adopters in SODIS promotion campaigns. TRIAL REGISTRATION: ClinicalTrials.gov: NCT0073149

Multiple populations in globular clusters. Lessons learned from the Milky Way globular clusters

Recent progress in studies of globular clusters has shown that they are not simple stellar populations, being rather made of multiple generations. Evidence stems both from photometry and spectroscopy. A new paradigm is then arising for the formation of massive star clusters, which includes several episodes of star formation. While this provides an explanation for several features of globular clusters, including the second parameter problem, it also opens new perspectives about the relation between globular clusters and the halo of our Galaxy, and by extension of all populations with a high specific frequency of globular clusters, such as, e.g., giant elliptical galaxies. We review progress in this area, focusing on the most recent studies. Several points remain to be properly understood, in particular those concerning the nature of the polluters producing the abundance pattern in the clusters and the typical timescale, the range of cluster masses where this phenomenon is active, and the relation between globular clusters and other satellites of our Galaxy.Comment: In press (The Astronomy and Astrophysics Review

What is the evidence for the management of patients along the pathway from the emergency department to acute admission to reduce unplanned attendance and admission? An evidence synthesis

Background Globally, the rate of emergency hospital admissions is increasing. However, little evidence exists to inform the development of interventions to reduce unplanned Emergency Department (ED) attendances and hospital admissions. The objective of this evidence synthesis was to review the evidence for interventions, conducted during the patient’s journey through the ED or acute care setting, to manage people with an exacerbation of a medical condition to reduce unplanned emergency hospital attendance and admissions. Methods A rapid evidence synthesis, using a systematic literature search, was undertaken in the electronic data bases of MEDLINE, EMBASE, CINAHL, the Cochrane Library and Web of Science, for the years 2000–2014. Evidence included in this review was restricted to Randomised Controlled Trials (RCTs) and observational studies (with a control arm) reported in peer-reviewed journals. Studies evaluating interventions for patients with an acute exacerbation of a medical condition in the ED or acute care setting which reported at least one outcome related to ED attendance or unplanned admission were included. Results Thirty papers met our inclusion criteria: 19 intervention studies (14 RCTs) and 11 controlled observational studies. Sixteen studies were set in the ED and 14 were conducted in an acute setting. Two studies (one RCT), set in the ED were effective in reducing ED attendance and hospital admission. Both of these interventions were initiated in the ED and included a post-discharge community component. Paradoxically 3 ED initiated interventions showed an increase in ED re-attendance. Six studies (1 RCT) set in acute care settings were effective in reducing: hospital admission, ED re-attendance or re-admission (two in an observation ward, one in an ED assessment unit and three in which the intervention was conducted within 72 h of admission). Conclusions There is no clear evidence that specific interventions along the patient journey from ED arrival to 72 h after admission benefit ED re-attendance or readmission. Interventions targeted at high-risk patients, particularly the elderly, may reduce ED utilization and warrant future research. Some interventions showing effectiveness in reducing unplanned ED attendances and admissions are delivered by appropriately trained personnel in an environment that allows sufficient time to assess and manage patients