Effectiveness of interventions to alleviate emergency department crowding by older adults: a systematic review

Abstract Background The growing demand for elderly care often exceeds the ability of emergency department (ED) services to provide quality of care within reasonable time. The purpose of this systematic review is to assess the effectiveness of interventions on reducing ED crowding by older patients, and to identify core characteristics shared by successful interventions. Methods Six major biomedical databases were searched for (quasi)experimental studies published between January 1990 and March 2017 and assessing the effect of interventions for older patients on ED crowding related outcomes. Two independent reviewers screened and selected studies, assessed risk of bias and extracted data into a standardized form. Data were synthesized around the study setting, design, quality, intervention content, type of outcome and observed effects. Results Of the 16 included studies, eight (50%) were randomized controlled trials (RCTs), two (13%) were non-RCTs and six (34%) were controlled before-after (CBA) studies. Thirteen studies (81%) evaluated effects on ED revisits and four studies (25%) evaluated effects on ED throughput time. Thirteen studies (81%) described multicomponent interventions. The rapid assessment and streaming of care for older adults based on time-efficiency goals by dedicated staff in a specific ED unit lead to a statistically significant decrease of ED length of stay (LOS). An ED-based consultant geriatrician showed significant time reduction between patient admission and geriatric review compared to an in-reaching geriatrician. Conclusion Inter-study heterogeneity and poor methodological quality hinder drawing firm conclusions on the intervention’s effectiveness in reducing ED crowding by older adults. More evidence-based research is needed using uniform and valid effect measures. Trial registration The protocol is registered with the PROSPERO International register of systematic reviews: ID = CRD42017075575).

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Clinical features and outcomes of COVID-19 in older adults: a systematic review and meta-analysis

BMC Geriatrics ◽

10.1186/s12877-021-02261-3 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Sunny Singhal ◽

Pramod Kumar ◽

Sumitabh Singh ◽

Srishti Saha ◽

Aparajit Ballav Dey

Keyword(s):

Systematic Review ◽

Older Adults ◽

Critically Ill ◽

Clinical Features ◽

Older Patients ◽

Clinical Characteristics ◽

Meta Analysis ◽

Severe Infection ◽

Factors Affecting ◽

Pooled Prevalence

Abstract Background Few studies have focused on exploring the clinical characteristics and outcomes of COVID-19 in older patients. We conducted this systematic review and meta-analysis to have a better understanding of the clinical characteristics of older COVID-19 patients. Methods A systematic search of PubMed and Scopus was performed from December 2019 to May 3rd, 2020. Observational studies including older adults (age ≥ 60 years) with COVID-19 infection and reporting clinical characteristics or outcome were included. Primary outcome was assessing weighted pooled prevalence (WPP) of severity and outcomes. Secondary outcomes were clinical features including comorbidities and need of respiratory support. Result Forty-six studies with 13,624 older patients were included. Severe infection was seen in 51% (95% CI– 36-65%, I2–95%) patients while 22% (95% CI– 16-28%, I2–88%) were critically ill. Overall, 11% (95% CI– 5-21%, I2–98%) patients died. The common comorbidities were hypertension (48, 95% CI– 36-60% I2–92%), diabetes mellitus (22, 95% CI– 13-32%, I2–86%) and cardiovascular disease (19, 95% CI – 11-28%, I2–85%). Common symptoms were fever (83, 95% CI– 66-97%, I2–91%), cough (60, 95% CI– 50-70%, I2–71%) and dyspnoea (42, 95% CI– 19-67%, I2–94%). Overall, 84% (95% CI– 60-100%, I2–81%) required oxygen support and 21% (95% CI– 0-49%, I2–91%) required mechanical ventilation. Majority of studies had medium to high risk of bias and overall quality of evidence was low for all outcomes. Conclusion Approximately half of older patients with COVID-19 have severe infection, one in five are critically ill and one in ten die. More high-quality evidence is needed to study outcomes in this vulnerable patient population and factors affecting these outcomes.

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The Impact of Gamified Instruction on Students’ Learning Outcomes: Systematic Review of Experimental Studies

International Journal of Education ◽

10.5296/ije.v13i4.19193 ◽

2021 ◽

Vol 13 (4) ◽

pp. 55

Author(s):

Nevena Jaftha ◽

Marouska Zahra-Micallef ◽

Tatjana Chircop

Keyword(s):

Systematic Review ◽

Learning Outcomes ◽

Digital Libraries ◽

Experimental Studies ◽

Intervention Design ◽

Assessment Instruments ◽

Learning Technology ◽

Content Type ◽

Replication Studies ◽

The Impact

This systematic review critically explores the intervention design and findings of the experimental studies that were published between January 2012-December 2020 in a number of digital libraries and databases and had the effect of a gamified instruction on students’ learning outcomes in their focus, with the aim of identifying what constitutes success or the lack thereof in the given context. The found effect(s) of gamified instruction on students’ learning engagement and achievement are discussed in relation to the a) intervention design, its flaws and their potential impact on reported outcomes and b) prevalent practice in gamification research. The discussion is structured around data collection sources, sample size, and intervention duration, but also the characteristics of learning technology, learning approach, course content, type of games and game elements. This study proposes a list of categories to be included in the description of a study context so that it is possible to a) systematically organise research findings, b) filter the variety of findings via means of replication studies. c) recognise the variant effect on different sub-populations, and d) suggest the way forward when designing and implementing gamified instruction within specific conditions. Furthermore, the study highlights the necessity of approaching the topic through a mixed-method approach involving a more intensive tracking schedule with new assessment instruments and a larger number of participants that are longitudinal or at least of a longer duration in order to obtain more comprehensive findings.

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Should the family or the state provide support for the elderly people? Findings from a two-generational Finnish study

International Journal of Sociology and Social Policy ◽

10.1108/ijssp-06-2018-0102 ◽

2019 ◽

Vol 39 (1/2) ◽

pp. 138-155 ◽

Cited By ~ 1

Author(s):

Antti O. Tanskanen ◽

Johanna Kallio ◽

Mirkka Danielsbacka

Keyword(s):

Older Adults ◽

Elderly People ◽

Elderly Care ◽

The Elderly ◽

The State ◽

Younger Adults ◽

Content Type ◽

Public Opinions ◽

The Family ◽

Nationally Representative

Purpose The purpose of this paper is to investigate public opinions towards elderly care. The authors analysed respondents’ opinions towards financial support, practical help and care for elderly people. Design/methodology/approach The authors used nationally representative data collected in Finland in 2012. Respondents represent an older generation (born between 1945 and 1950, n=1,959) and their adult children (born between 1962 and 1993, n=1,652). Findings First, the authors compared the opinions of older and younger Finns but did not find that older adults were more likely than younger adults support the state responsibility, or vice versa. It was also when only actual parent-child dyads (n=779) from same families were included. Next, the authors found that several socioeconomic and family-related variables were associated with public opinions of elderly care in both generations. For instance, in both generations lower-income individuals supported the state’s responsibility more compared to their better-off counterparts. Originality/value The study provides important knowledge on attitudes towards elderly care using unique two-generational data of younger and older adults.

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Can in-hospital or post discharge caregiver involvement increase functional performance of older patients? A systematic review

BMC Geriatrics ◽

10.1186/s12877-020-01769-4 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Margaretha van Dijk ◽

Jasmien Vreven ◽

Mieke Deschodt ◽

Geert Verheyden ◽

Jos Tournoy ◽

...

Keyword(s):

Systematic Review ◽

Older Adults ◽

Older Patients ◽

Functional Performance ◽

Care Pathway ◽

Intervention Group ◽

Post Discharge ◽

Home Setting ◽

Randomized Controlled ◽

Caregiver Involvement

Abstract Background Regaining pre-hospitalization activity levels is only achieved in 30–50% of older patients. Extra physiotherapy time has been proven to improve functional outcome and shorten length of stay, but is costly. Considering their key role in caring for older people, involving informal caregivers in rehabilitation might further improve functional performance. Aim To determine if in-hospital or post discharge caregiver involvement can increase functional performance in older adults. The secondary aim was to determine if caregiver involvement can influence, quality of life of patient and caregiver, medical costs, readmission rate, discharge location, and mortality. Design Systematic review with narrative synthesis. Methods The electronic bibliographic databases MEDLINE, Embase, CINAHL, Cochrane and Web of Science were searched for (quasi) experimental and observational studies, with the following inclusion criteria; caregiver involvement regarding functional performance, mean age over 65 years, admitted to a hospital unit and subsequently discharged to their home setting. Risk of bias was assessed with the Rob 2 (randomized trials) and the ROBINS-1 tool (non-randomized studies). Results Eight studies of an initial 4683 were included: four randomized controlled trials, one prospective cohort study, one non-randomized controlled trial, one subgroup analysis of an RCT and one prospective pre-post study. All but one study included patients with stroke. Three types of caregiver interventions could be distinguished: a care pathway (inclusion of caregivers in the process of care), education on stroke and teaching of bed-side handling-skills, and caregiver-mediated exercises. The one study evaluating the care pathway reported 24.9% more returns home in the intervention group. Studies evaluating the effect of education and bed-side handling-skills reported higher effect sizes for several outcomes with increasing session frequency. All studies with caregiver-mediated exercises showed beneficial effects on functional performance, immediately after the intervention and within 3 months follow-up. Conclusion The findings of this review suggest that involvement of caregivers in the rehabilitation of older adults leads to better functional performance up to 3 months after initiation. However, evidence is low and mainly focusing on stroke.

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Advance Directives for Older Adults in the Emergency Department: A Systematic Review

Journal of Palliative Medicine ◽

10.1089/jpm.2014.0368 ◽

2015 ◽

Vol 18 (6) ◽

pp. 500-505 ◽

Cited By ~ 28

Author(s):

Jeremy Oulton ◽

Suzanne Michelle Rhodes ◽

Carol Howe ◽

Mindy J. Fain ◽

Martha Jane Mohler

Keyword(s):

Systematic Review ◽

Older Adults ◽

Emergency Department ◽

Advance Directives

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Systematic review of patient-engagement interventions: potentials for enhancing person-centred care for older patients with multimorbidity

BMJ Open ◽

10.1136/bmjopen-2020-048558 ◽

2021 ◽

Vol 11 (12) ◽

pp. e048558

Author(s):

Mathilde Bendix Søgaard ◽

Katrine Andresen ◽

Maria Kristiansen

Keyword(s):

Systematic Review ◽

Older Adults ◽

Patient Engagement ◽

Older Patients ◽

Data Extraction ◽

Beneficial Effects ◽

Life Years ◽

Patient Reported ◽

Engagement Interventions

IntroductionPerson-centred care based on systematic and comprehensive patient-engagement is gaining momentum across healthcare systems. Providing care that is responsive to the needs, values and priorities of each patient is important for patients, relatives and providers alike, not least for the growing population of older patients living with multi-morbidity and associated complex care trajectories.ObjectivesThe aim of this systematic review is to investigate the effects of patient engagement interventions for older patients with multimorbidity.MethodsSystematic review conducted in August 2021. Two reviewers independently screened the international databases Embase and PubMed. Reviewers carried out duplicate and independent data extraction and assessment of study quality. Grading of Recommendations Assessment, Development and Evaluation was used to assess the quality of the evidence for each study.ResultsWe included twelve studies from primary care setting and hospitals. The included studies were heterogeneous in terms of characteristics of populations, types of interventions to enhance patient-engagement, outcome measures and length of follow-up. Nine of the 12 included studies found significant improvements in health and patient-reported outcomes such as higher quality-adjusted life-years, fewer hospital visits and disease specific symptoms. Quality of the included studies was of low to moderate.ConclusionThis review identifies potential beneficial effects of interventions to enhance patient-engagement in older adults with multimorbidity. Nevertheless, the limited and very diverse evidence-based calls for more robust studies into efficient approaches to engaging older adults with multimorbidity in care trajectories.

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Emergency Department Interventions for Older Adults: A Systematic Review

Journal of the American Geriatrics Society ◽

10.1111/jgs.15854 ◽

2019 ◽

Vol 67 (7) ◽

pp. 1516-1525 ◽

Cited By ~ 16

Author(s):

Jaime M. Hughes ◽

Caroline E. Freiermuth ◽

Megan Shepherd‐Banigan ◽

Luna Ragsdale ◽

Stephanie A. Eucker ◽

...

Keyword(s):

Systematic Review ◽

Older Adults ◽

Emergency Department

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Risk factors for delirium among older adults in the emergency department: a systematic review protocol

BMJ Open ◽

10.1136/bmjopen-2020-039175 ◽

2020 ◽

Vol 10 (7) ◽

pp. e039175

Author(s):

Lucas Oliveira J e Silva ◽

Michelle J Berning ◽

Jessica A Stanich ◽

Danielle J Gerberi ◽

Jin Han ◽

...

Keyword(s):

Risk Factors ◽

Systematic Review ◽

Older Adults ◽

Emergency Department ◽

Risk Factor ◽

Random Effect ◽

Quantitative Relationship ◽

Original Research ◽

Eligibility Criteria ◽

Screening Process

IntroductionDelirium is commonly missed in older adults presenting to the emergency department (ED). Although current recommendations for active screening of delirium in the ED, this might not be feasible or practical. Identifying patients at high risk for prevalent and incident delirium in the ED will help to improve the screening process and to build interventions. There is currently scattered synthesis of evidence on risk factors associated with delirium in the ED. To address this gap, we are conducting a systematic review to describe the risk factors (patient vulnerability factors and precipitating factors) for delirium in the ED.Methods and analysisA literature search was performed from inception to March 2020 in Ovid EBM Reviews, Ovid EMBASE, Ovid MEDLINE, Scopus and Web of Science. We will include original research studies that report a quantitative relationship between at least one risk factor and delirium in the ED setting. Two investigators will use eligibility criteria from this protocol to independently screen titles and abstracts, and select studies based on full-text review of potentially eligible studies. After arriving at a final set of included studies, two investigators will extract data using a standardised data collection form. If appropriate, data regarding each risk factor will be pooled through a random-effect meta-analysis. The Grading of Recommendations Assessment, Development and Evaluation approach will be used to evaluate the overall quality of evidence.Ethics and disseminationTo our knowledge, this will be the first systematic review evaluating risk factors for prevalent and incident delirium specifically related to the ED setting. Results of this study will aid in the identification of older adults at risk for delirium in the ED. We aim to publish the results of this systematic review in a peer-reviewed journal with good visibility for the fields of emergency medicine and geriatrics.PROSPERO registration numberCDR42020175261

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152 Implementation of Older Persons Rapid Assessment Hub (OPRAH) in the Emergency Department (ED)

Age and Ageing ◽

10.1093/ageing/afz103.89 ◽

2019 ◽

Vol 48 (Supplement_3) ◽

pp. iii17-iii65

Author(s):

Comfort Adedokun ◽

Rosa McNamara ◽

Nessa O’Herlihy

Keyword(s):

Older Adults ◽

Emergency Department ◽

Older People ◽

Rapid Assessment ◽

Admission Rate ◽

Clinical Decision ◽

Admission Rates ◽

Clinical Decision Unit ◽

Medical Referral ◽

The Impact

Abstract Background The Emergency Department (ED) is where most people, including older adults in crises, seek care. OPRAH was introduced in order to meet the needs of our changing population. The unit was developed out of existing resources within the ED and cohorts both older patients and staff to an area more suitable to carry out assessments. Methods We used a quality improvement framework to develop our service. OPRAH is led by an ED GEM (Geriatric Emergency Medicine) consultant, staffed using the existing ED team, housed within footprint of the ED as part of the Clinical Decision Unit (CDU) with the addition of an HCA (healthcare assistant) as required. To determine the impact of the service on admissions of older adults, we collated patient records prospectively. These were reviewed and coded by senior ED professionals blinded to outcomes, to determine medical-referral rate for admission in these cohort. Results In the first 3 weeks of implementation, 76 patients were assessed. Four were admitted and 2 transferred to other hospitals. Mean age was 83 years ranging 66-103 years with an average of 262 minutes in the ED prior to OPRAH admission. Blinded coders review determined 53 (76%) of these patients would have been referred for admission. The majority of the remainder would have completed their care in the ED, as they were not eligible for admission to CDU. Conclusion Introduction of OPRAH to the ED has improved access for older people to short-stay ED led care and reduced admission rates. We have identified a trend towards fewer episodes where care by in-house teams is completed within the ED. We are in an early phase of this project. Nonetheless, it is evident that by redesigning how we assess older people in the ED and using available outpatient resources, we could impact on admission rate and length of stay in the ED without compromising patient care. Implementation has increased the use of the integrated care team, hospital and community MDT (multidisciplinary team).

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