Post-emergency department evidence-based interventions for the prevention of frailty and functional decline in injured community-dwellers
We are now able to summarize all evidence-based post-ED community services that help restore functional ability and prevent frailty from the international literature and generate a toolbox of recommended post-emergency department (ED) community services that could be implemented in the Canadian context in undetected pre-frail/frail community-dwellers.
Research Results
Findings: There is limited high-quality evidence on optimal and effective transition services following ED discharge, but there is a trend in favour of holistic geriatric assessment and targeted referral to community services tailored to individual needs of injured seniors (e.g., multifactorial fall-prevention programs). Interventions to restore or maintain functional status of injured older patients following ED visit should be further investigated and improved coordination of services along the continuum of care for community-dwelling seniors, with emphasis on primary and secondary preventive interventions requires additional attention.
Impact of findings: Our team called the Canadian Emergency Team Initiative (CETI) previously created and validated a simple Clinical Decision Rule tool (CETI-CDR) that empowers ED professionals to screen, and direct post-ED care of frail. However, broad adoption of the tool has proven difficult. The completed scoping review is intended to describe evidence about successful interventions for the discharged elderly at risk of functional decline which will support implementation of CETI-CDR. This knowledge synthesis study will help ED physicians and allied health care professionals optimize care of community-dwelling seniors in order to aid the recovery of patient’s autonomy following injury by presenting a broad range of potential post-ED interventions.
About the Project
In a recent nation-wide meeting with clinicians, stakeholders and researchers; our group identified a gap in knowledge for evidence-based post-acute care interventions for semi-independent and independent elders. Comprehensive knowledge is needed about how to orient this population once the frailest injured independent elders are identified.
Our main objective is to complete a knowledge synthesis in order to help clinicians, patients, decision makers, stakeholders and researchers to know where to orient those patients. Specifically, we will 1) identify community services aiming to help restore the patient’s previous state of independence; 2) create a tool-box of potential post-ED/community services to help pre-frail independent elders with minor injuries; 3) identify which services are most efficient in recovery of the patient’s independence.
We will do a scoping review that will include a stakeholder/key informant focus group. The purpose of a scoping study is to review the literature without evaluating or interpreting the findings. It is a pragmatic approach that is useful in grasping the broader issues. The proposed study involves five steps: (1) identification of the research question, (2) identification of relevant studies, (3) selection of studies, (4) charting the data and (5) collating, summarizing and reporting results. English and French documentation from Canada, USA, France, England and Australia will be included.
For more details on the project rationale, hypothesis, objectives and research plan, click here.
Project Team
Principal Investigators:
Marcel Émond, MD, MSc — Université Laval
Marie-Josée Sirois, OT, PhD — Université Laval/CHU de Québec
Co-Investigators:
Katherine Berg, PhD, PT — University of Toronto
Debra Eagles, MD, FRCPC — The Ottawa Hospital
Jacques Lee, MD, FRCPC, MSc — Sunnybrook Health Centre
Jeffrey Perry, MD, MSc, CCFP-EM — Ottawa Hospital Research Institute
Nancy Salbach, BSc, BScPT, MSc, PhD — University of Toronto
Laura Wilding, RN, BScN, MHS — The Ottawa Hospital
Knowledge Users and Partners:
Centre d’excellence du vieillissement de Québec (CEVQ)
Project Contact: Marcel Émond — marcelemond1@me.com
FRA 2015-A-06
Key Findings for Families
- We have found many strategies that could be implemented in the emergency room (ER) to save older adults’ independence after a harm or a fall
- However, given the available scientific proofs, we still do not know what is best for all seniors that visit the ER
- Appraisal of senior’s real needs should be done in the ER to choose the right intervention for each patient
Our research is the first step in identifying and implementing successful care of injured older patients who visit the ER; and in promoting their optimal mobility.
- We hope to improve the services now available for seniors along their way from their visit in the ER to their return home to avoid losses of mobility after an injury or a fall
Why This Matters
Around 16% of 65 years and older who come to the ER for a minor injury will lose mobility, even if they were fully independent before the event. At this time, we don’t know the best ER intervention to stop this, and help these patients stay independent. Currently, they are discharged home with barely no intervention planned. We need to know what we can do to improve patient’s care.
About This Study
- We looked at all the scientific and non-scientific publications on care for seniors from their visit to the ER to their return home in order to construct a knowledge synthesis
- We chose every document that described services to help older adults living home keep their independence after a visit to ER for a fall or a minor injury
- We compared every study to find a wide range of care that can be carried out in emergency rooms and see what is currently missing to help older adults when they leave ER
Key Findings for Policy
- A broad range of interventions that can help seniors maintain or restore their independence following an ED visit for a minor injury or a fall were identified
- There is limited high-quality evidence on optimal transition services following ED discharge of elders
- Comprehensive geriatric assessment, discharge planning and care coordination, as well as targeted multifactorial fall-prevention interventions are the most frequently cited modalities in selected papers for transition of seniors from ED to community
Interventions that can help seniors maintain or restore their independence following an emergency room visit for a minor injury or a fall were identified and provide the basis of improved care.
- Rigorous assessment of intervention to restore or maintain functional status of injured independent seniors and fallers should be promoted
- Improved coordination of services along the continuum of care for community-dwelling seniors with emphasis on primary and secondary preventive interventions requires further attention
- Emergency care professional should be formally taught of which community transition services are available for seniors
Why This Study was Needed
16% of previously independent seniors who visited ED for minor injuries will suffer a downward spiral of mobility decline. Specific efficient interventions to prevent functional decline in this population when discharged home are currently not known. Favourable outcomes for patient and organization depend not only on the care received in the ED, but also on the successful transitions of care from the ED to the patients’ home. Currently, these transitions often result in discontinuity of services for patients and in an increase in health services utilization following discharge.
Study Summary
- A knowledge synthesis was conducted in order to create an inventory of potential interventions that can be planned in the ED to suit the needs of independent frail or pre-frail seniors while they return to community
- Databases and grey literature were screened to find relevant studies and 22 papers that met our inclusion criteria were selected for this scoping review
- Documents were included if they described community-dwelling independent seniors of 60 years and older who have a history of minor injury or fall and visited ED or primary care settings, and described care transition strategies or interventions that take place in or from the ED to improve outcomes of patients discharged home
- Documents were excluded if they described patients admitted to hospital or institutionalized, described health related problems, or reported no intervention
- Data extracted was compiled into category-specific tables describing type on interventions and brief author’s conclusions on effectiveness
- Two key concepts of interventions arose from this review; one based on ED and post-ED care transitions strategies during or following older patients discharge(n=10), and the other focused on fall-prevention strategies when the patient has returned home (n=12)
Key Findings for Researchers
- Limited high-quality evidence on optimal transition services following ED discharge
- Comprehensive geriatric assessment, discharge planning and care coordination, as well as targeted multifactorial fall-prevention interventions are the most frequently cited modalities in selected papers for transition of seniors from ED to community after a minor injury or a fall
- Improved coordination of services along the continuum of care for community-dwelling seniors with emphasis on primary and secondary preventive interventions requires further attention
Why This Study was Needed
Independent seniors who visit ED for minor injuries suffer a downward spiral of mobility decline in 16% of cases. Specific interventions to prevent functional decline in this population when discharged home are currently not done. Favourable patient outcomes depend not only on the care received in the ED, but also on the successful transition of care from the ED to the patient’s home.
About This Study
- A scoping review was conducted to identify the efficient ED/post-ED community transition services for community-dwelling seniors who suffered an injury or a fall in order to maintain their long-term independence
- Databases and grey literature were screened to find relevant studies, and 22 papers that met our inclusion criteria were selected for our review
- Two key concepts of interventions arose from this review; one based on ED and post-ED care transitions strategies during or following older patients discharge (n=10), and the other focused on fall-prevention strategies (n=12)
Future Research
- No specific research on effectiveness of interventions to fight against frailty of injured independent elders and no comprehensive knowledge to orient elders presenting to ED in relation with their frailty state and risk factors
- Lack of clear and coordinated care continuum for frail seniors discharged from ED following an injury or fall
CFN Webinar (July 6, 2016): Discharging Elders from ED to Community: What You Need to Know?
Rationale: We previously showed that minor injuries can trigger a functional decline in 15% of previously independent seniors three months post-trauma and persists to six months later. Therefore, specific interventions to prevent frailty and functional decline must be tailored to moderate and high-risk community-dwelling seniors discharged from EDs.
Hypothesis: Comprehensive knowledge is needed about how to orient the pre-frail elderly person once discharged from the ED so as to prevent functional decline.
Objectives: The objective of this scoping review is to describe and estimate the effectiveness of post-ED and community services to help pre-frail independent seniors to maintain or restore their autonomy following a minor injury and secondly develop a toolbox to guide clinicians in emergency care settings.
Research plan: Literature published from inception to October 2015 in PubMed, EMBASE and grey literature was searched. We selected studies that described care transition strategies and interventions that take place or that are organized from the ED to restore functional status of patients discharged home. A total of 22 documents were included in this review.