...investigators did not assess transferences between different levels of acute care and it is plausible that older patients admitted to ICU for unforeseen clinical deterioration may have influenced ...their findings 4. ...we sought to compare the characteristics and outcomes of acutely ill older patients admitted from the emergency department (ED) based on whether their admissions to ICU were planned at the ED or occurred later due to unexpected clinical deteriorations.2 Material and methods We conducted a prospective cohort of patients aged ≥65 years admitted from the ED to a tertiary hospital in Brazil between November 2021 and April 2022 5. Demographic (age) and clinical characteristics (baseline functional and frailty status, delirium rates, and acute clinical severity) of patients experiencing unplanned ICU admissions differed from those directly admitted to the ICU and those not using ICU (Table 1). ...unplanned ICU admissions were associated with prolonged LoS and hospital-acquired infections (Table 1). ...although in-hospital mortality was higher in patients admitted to the ICU directly from the ED, those who had unplanned ICU admission while in the hospital presented higher mortality within the following months after discharge.4 Discussion Our findings indicate that older patients with unplanned ICU admissions generally present with worse baseline physical frailty and disability, and elevated levels of delirium and illness acuity in the ED compared to those not requiring ICU during hospitalization.
We developed prediction models for hospital admission and prolonged length of stay in older adults admitted from the emergency department (ED).
This was a retrospective cohort study of patients aged ...70 years or older who visited a geriatric ED in Brazil (N=5,025 visits). We randomly allocated participants to derivation and validation samples in a 2:1 ratio. We then selected 21 variables based on their clinical relevance and generated models to predict the following outcomes: hospital admission and prolonged length of stay, defined as the upper tertile of hospital stay. We used backward stepwise logistic regressions to select our final predictors and developed risk scoring systems based on the relative values of their β coefficients.
Overall, 57% of the participants were women, 31% were hospitalized, and 1% died in the hospital. The upper tertile of hospital stay was greater than 7 days. Hospital admission was best predicted by a model including male sex, aged 90 years or older, hospitalization in the previous 6 months, weight loss greater than or equal to 5% in the previous year, acute mental alteration, and acute functional decline. The prediction of prolonged length of stay retained the same variables, except male sex, which was substituted for fatigue. The final scoring system reached areas under the receiver operating characteristic curve of 0.74 for hospital admission and 0.79 for prolonged length of stay, and their accuracies were confirmed in the validation models.
The PRO-AGE scoring system predicted hospital admission and prolonged length of stay in older adults with good accuracy, using a simple approach and only 7 easily obtained clinical variables.
This study sought to explore and externally validate the Carpenter instrument's efficacy in predicting postdischarge fall risk among older adults admitted to the emergency department (ED) for reasons ...other than falls or related injuries.
A prospective cohort study was conducted on 779 patients aged ≥ 65 years from a tertiary hospital in São Paulo, Brazil, who were monitored for up to 6 months post-ED hospitalization. The Carpenter instrument, which evaluates the four risk factors nonhealing foot sores, self-reported depression, inability to self-clip toenails, and prior falls, was utilized to assess fall risk. Follow-up by telephone occurred at 30, 90, and 180 days to identify falls and mortality. Fine-Gray models estimated the predictive power of Carpenter instrument for future falls, considering death as a competing event and sociodemographic factors, frail status, and clinical measures as confounders.
Among 779 patients, 68 (9%) experienced a fall within 180 days post-ED admission, and 88 (11%) died. The majority were male (54%), with a mean age of 79 years. Upon utilizing the Carpenter score, those with a higher fall risk (≥2 points) displayed more comorbidities, greater frailty, and increased clinical severity at baseline. Regression analyses showed that every additional point on the Carpenter score increased the hazard of falls by 73%. Two primary contributors to its predictive potential were identified: a history of falls in the preceding year and an inability to self-clip toenails. However, the instrument's discriminative accuracy was suboptimal, with an area under the curve of 0.62.
While the Carpenter instrument associated with a higher 6-month postadmission fall risk among older adults post-ED visit, its accuracy for individual patient decision making was limited. Given the significant impact of falls on health outcomes and health care costs, refining risk assessment tools remains essential. Future research should focus on enhancing these assessments and devising targeted proactive strategies.
Falls are the main cause of morbidity among older adults. In this context, assistive gait devices are used to improve function and safety. However, inadequate selection and use can result in poor ...gait and risk of injury. All patients admitted to our emergency department (ED) undergo a medical evaluation in which, based on their clinical condition, the protocol for indication and training in the use of walking aids can be triggered. Patients need to be clinically stable and have enough physical and cognitive function to benefit from it. Once the patient is deemed able, the next step is an assessment of needs and potential benefits. After the patient and his proxy agree to undergo specific evaluation and training, the physician or the ED nurse calls the physical therapy team to carry out a broader assessment that includes the Timed Up and Go (TUG) test. Following the functional evaluation, the physical therapist identifies the mobility needs of the patient and indicates the most appropriate walking device. The TUG test is performed again with the use of the mobility aid device and the results are compared to confirm the improvement in the patient’s performance regarding balance and mobility. Finally, the physical therapist refers the patient to the rehab center of our hospital for further rehabilitation, if applicable, and provides a written document with the type of the suggested device and possible purchase locations. Hospital Sírio-Libanês is a leading philanthropic tertiary hospital in São Paulo, Brazil. It has 474 beds, 33 specialized centers, and is certified by the Joint Commission International. Its Emergency Department (ED) receives more than 90,000 visits every year, and, since 2017, it has housed a geriatric ED program (Pronto Atendimento Geriátrico Especializado ProAGE). ProAGE is an initiative designed to provide high-quality, specialized care to older adults in the ED. In 2019, ProAGE received the Level III geriatric ED accreditation (GEDA) of the American College of Emergency Physicians (ACEP) and became the first of its kind in the southern hemisphere. In 2022, ProAGE joined the Geriatric Emergency Department Collaborative (GEDC) and to this day remains its only center in South America. This manuscript will discuss the institutional protocol for the indication of mobility aids and training older patients to use them safely which was devised to adhere to international guidelines and comply with GEDA.
The purpose of our study was to evaluate the desire of the patients on being informed about diagnosis of severe diseases, the desire to have their families informed about this situation and to ...participate in therapeutic decisions.
363 patients (outpatients and inpatients) of a General Internal Medicine division of a University Hospital were interviewed. The questionnaire contained specific questions on their desire to be informed of the diagnosis in case of cancer or AIDS and on their desire to have their families informed as well. Specific questions on whether they wanted to be informed of and participate of the therapeutic discussion process in case of abdominal tumors were also included.
96.1% of men and 92.6% of women showed the desire of being informed in case of cancer diagnosis and 87.7% of men and 84.2% of women wanted to have their families informed, 94.2% of men and 91% of women wanted to know the diagnosis of AIDS. While 86% of women and 76.6% of men wanted be informed in the case of a diagnosis of an abdominal tumor, only 58.5% of women and 39.6% of men wanted to give their opinion about in the case of different therapeutic alternatives. The desire to participate in therapeutic decisions was significantly lower (p<0.05) in men, people older than 60 years and inpatients.
Our results showed that the great majority of the population that seeks for medical support in a Brazilian university hospital wishes to be informed on this health condition, even in case of serious illness. In addition, there are intense familiar bonds that make patients want to have their families also informed.
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