A Randomized Controlled Trial of Geriatric Emergency Department Innovations

项目摘要 老年患者比任何其他年龄段的患者更多地使用急诊科(ED)。一旦进了急诊室， 老年患者住院时间更长，接受诊断性检查的次数更多，更有可能 住院的人比年轻人多。老年患者的急诊室就诊是前哨健康事件。如果老年患者 出院后，他们往往会返回急症室或住院，健康相关质量下降 生活质量(HRQL)和残疾。如果他们住院，他们将承担更高的费用和穷人更大的风险 结果包括感染、精神错乱和跌倒。老年患者的急诊护理不够理想是个问题 在全国范围内，导致制定了国家老年急诊科指南，并由 重要的利益相关者群体。为改善老年患者的急诊护理，西北纪念医院 实施老年急诊科创新(GEDI)计划。Gedi是一个综合的， 老年患者急诊护理的跨学科方法；它应用循证方案来改善急诊 关心和改善从教育部门到社区的过渡。该方案以老年护士联络为中心。 (GNL)谁是接受过老年病学额外培训的急诊护士，他们的时间用于GEDI而不是 而不是传统的床边护理。当ED团队咨询时，GNL执行有效的评估和 协调急诊室、医院或门诊环境中的病人护理。通过这一评估和协调 GEDI提供以患者为中心的护理，旨在防止不必要的住院治疗。虽然GEDI 是建立在最佳可用证据的基础上的，并反映了老年急诊部指南 在多个国家利益相关者团体的支持下，美国还没有关于ED-D的前瞻性疗效研究 为像GEDI这样的老年患者提供的基础计划。因此，GEDI的效果还没有得到测试 未雨绸缪。我们提出了一项随机对照试验(RCT)来确定GEDI的疗效。 体量，城市医院。此外，确定最有可能从GEDI中受益的患者是困难的。可用 工具对住院、返回急诊室和功能衰退的预测效度较差。然而， “老年急诊审查和评价工具”(ERRET)是由AHRQ资助开发的， 这是一个很有希望的筛查工具，可以识别可能受益于GEDI的老年人。将加强GEDI的区域协调机制 通过使用白鹭来筛查有不良预后风险的老年患者。这项研究涉及几个AHRQ 优先人群：妇女、少数民族、市中心、临终关怀、低收入和老年人。

Project Summary Geriatric patients use the emergency department (ED) more than any other age group. Once in the ED, geriatric patients have longer stays, receive a greater number of diagnostic tests, and are more likely to be hospitalized than younger adults. ED visits for geriatric patients are sentinel health events. If geriatric patients are discharged, they often return to the ED or are hospitalized and experience declines in health-related quality of life (HRQoL) and disability. If they are hospitalized, they incur increased costs and greater risk for poor outcomes including infections, delirium, and falls. Suboptimal acute care for geriatric patients is a problem nationally, resulting in development of national geriatric emergency department guidelines and endorsement by prominent stakeholder groups. To improve acute care for geriatric patients, Northwestern Memorial Hospital implemented the Geriatric Emergency Department Innovations (GEDI) program. GEDI is an integrated, interdisciplinary approach to ED care for geriatric patients; it applies evidence-based protocols to improve ED care and improve transitions from the ED to the community. The program centers on geriatric nurse liaisons (GNLs) who are ED nurses with additional training in geriatrics and whose time is dedicated to GEDI rather than traditional bedside nursing. When consulted by the ED team, GNLs perform validated assessments and coordinate patient care in the ED, hospital, or outpatient setting. Through this assessment and coordination model, GEDI provides patient-centered care and aims to prevent unnecessary hospitalizations. Though GEDI was built on the best available evidence, and reflects the Geriatric Emergency Department guidelines supported by multiple national stakeholder groups, there are no prospective efficacy studies in the U.S. of ED- based programs for geriatric patients like GEDI. Therefore, GEDI's efficacy has not been tested prospectively. We propose a randomized controlled trial (RCT) to determine the efficacy of GEDI at a high- volume, urban hospital. Additionally, identifying patients most likely to benefit from GEDI is difficult. Available instruments have poor predictive validity for hospitalization, return to the ED, and functional decline. However, the “Emergency Geriatric Review and Evaluation Tool” (EGRET), which was developed with AHRQ funding, is a promising screener to identify older adults who may benefit from GEDI. A RCT of GEDI will be strengthened by using EGRET to screen geriatric patients at risk of poor outcomes. This study addresses several AHRQ priority populations: women, minorities, inner-city, End-of-Life, low income and the elderly.