Ellen Burkett

The objective of this paper is to describe the profile of older people with cognitive impairment (CI) presenting to emergency departments (EDs). This was a multi-centre (n=8) observational study of a convenience sample of older (≥70y) ED patients (n=579). Participants were prospectively assessed for CI and surveyed for the duration of their ED stay (n=191). A picture of patients' health status and ED responses to care needs was obtained through application of standardised assessment tools. Additionally, observations of care processes in ED were undertaken. Demographic data were collected through both ED's information system and survey. Outcome data were collected 28 days post-ED visit using follow-up telephone interviews. Of 579 older persons, 191 (33%) persons met criteria for CI. The majority of older ED patients with CI in ED lived in the community (157/177, 88.7%), arrived by ambulance (116/172, 67%), were accompanied by a support person (94/149, 63%), were triaged as urgent to semi-urgent (157/191, 82%), and were hospitalised (108/172, 57%). The median ED length of stay was 6h. In ED, 53% of the sample experienced pain (92/173). Older ED patients with CI pose the following characteristics: prior hospital admissions (43/129, 33%), incontinence (61/178, 34%), dependence in activities in daily living (81/190, 43%), issues in nutrition (73/182, 40%), vision and hearing impairment (93% (160/172) and 26% (44/171) respectively). Increased understanding of these presenting characteristics and their impacts on patient risk facilitates tailoring the quality of emergency care to better suit the needs and improve outcomes of this increasing ED population.

Ageing population trends create a strong imperative for healthcare systems to develop models of care that reduce dependence on hospital services. People living in residential aged care facilities (RACFs) currently have high rates of presentation to emer-gency departments. The care provided in these environments may not optimally satisfy the needs of frail older persons from RACFs. To describe the Comprehensive Aged Residents Emergency and Partners in Assessment, Care and Treatment 
(CARE-PACT) program: a hospital substitutive care and demand management project that aims to improve, in a fiscally efficient manner, the quality of care received by residents of aged care facilities when their acute healthcare needs exceed the scope of the aged care facility staff and general practitioners to manage independently of the hospital system. The project delivers high-quality gerontic nursing and emergency specialist assessment, collaborative care planning, skills sharing across the care conti...

The purpose of this study was to identify the structural quality of care domains and to establish a set of structural quality indicators (SQIs) for the assessment of care of older people with cognitive impairment in emergency departments (EDs). A structured approach to SQI development was undertaken including: 1) a comprehensive search of peer-reviewed and gray literature focusing on identification of evidence-based interventions targeting structure of care of older patients with cognitive impairment and existing SQIs; 2) a consultative process engaging experts in the care of older people and epidemiologic methods (i.e., advisory panel) leading to development of a draft set of SQIs; 3) field testing of drafted SQIs in eight EDs, leading to refinement of the SQI set; and 4) an independent voting process among the panelists for SQI inclusion in a final set, using preestablished inclusion and exclusion criteria. At the conclusion of the process, five SQIs targeting the management of ol...

The objective of this study was to develop process quality indicators (PQIs) to support the improvement of care services for older people with cognitive impairment in emergency departments (ED). A structured research approach was taken for the development of PQIs for the care of older people with cognitive impairment in EDs, including combining available evidence with expert opinion (phase 1), a field study (phase 2), and formal voting (phase 3). A systematic review of the literature identified ED processes targeting the specific care needs of older people with cognitive impairment. Existing relevant PQIs were also included. By integrating the scientific evidence and clinical expertise, new PQIs were drafted and, along with the existing PQIs, extensively discussed by an advisory panel. These indicators were field tested in eight hospitals using a cohort of older persons aged 70 years and older. After analysis of the field study data (indicator prevalence, variability across sites), ...

The medical records of 273 patients 75 years and older were reviewed to evaluate quality of emergency department (ED) care through the use of quality indicators. One hundred fifty records contained evidence of an attempt to carry out a cognitive assessment. Documented evidence of cognitive impairment (CI) was reported in 54 cases. Of these patients, 30 had no documented evidence of an acute change in cognitive function from baseline; of 26 patients discharged home with preexisting CI (i.e., no acute change from baseline), 15 had no documented evidence of previous consideration of this issue by a health care provider; and 12 of 21 discharged patients who screened positive for cognitive issues for the first time were not referred for outpatient evaluation. These findings suggest that the majority of older adults in the ED are not receiving a formal cognitive assessment, and more than half with CI do not receive quality of care according to the quality indicators for geriatric emergency care. Recommendations for improvement are discussed.