A Randomized Controlled Trial of Geriatric Emergency Department Innovations

项目概要 老年患者比任何其他年龄段的患者更多地使用急诊科 (ED)。一旦进入急诊室， 老年患者住院时间更长，接受更多的诊断测试，并且更有可能 比年轻人住院。老年患者的急诊就诊是哨兵健康事件。如果是老年患者 出院后，他们经常返回急诊室或住院并经历健康相关质量下降 生活质量 (HRQoL) 和残疾。如果他们住院，他们的费用就会增加，穷人面临的风险也会更大 结果包括感染、谵妄和跌倒。老年患者的急性护理欠佳是一个问题 在全国范围内，制定了国家老年急诊科指南并得到了批准 突出的利益相关者群体。为了改善老年患者的急症护理，西北纪念医院 实施了老年急诊科创新 (GEDI) 计划。 GEDI 是一个综合性的、 老年患者急诊科护理的跨学科方法；它应用基于证据的协议来改善 ED 护理并改善从急诊室到社区的过渡。该计划以老年护士联络人为中心 (GNL) 是急诊科护士，接受过老年病学方面的额外培训，他们的时间专门用于 GEDI，而不是 与传统的床旁护理相比。当 ED 团队咨询时，GNL 会进行经过验证的评估并 协调急诊室、医院或门诊的患者护理。通过这次评估和协调 GEDI 模式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 建立在现有最佳证据的基础上，并反映了老年急诊科指南 在多个国家利益相关者团体的支持下，美国尚无 ED- 的前瞻性疗效研究 GEDI 等针对老年患者的项目。因此，GEDI的功效尚未经过测试 前瞻性地。我们提出了一项随机对照试验（RCT）来确定 GEDI 在高 卷，城市医院。此外，确定最有可能从 GEDI 中受益的患者也很困难。可用 仪器对住院、返回急诊室和功能下降的预测有效性较差。然而， 由 AHRQ 资助开发的“紧急老年病审查和评估工具”(EGRET) 一种很有前途的筛查方法，可以识别可能从 GEDI 中受益的老年人。 GEDI 的 RCT 将得到加强 使用 EGRET 筛查有不良结果风险的老年患者。本研究涉及几个 AHRQ 优先人群：妇女、少数族裔、市中心、临终者、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.