Adverse outcomes in older adults attending emergency departments: a systematic review and meta-analysis of the Identification of Seniors At Risk (ISAR) screening tool

Galvin, Rose; Gilleit, Yannick; Wallace, Emma; Cousins, Gráinne; Bolmer, M.; Rainer, Timothy; Smith, Susan M; Fahey, Tom

doi:10.1093/ageing/afw233

Cited by 70 publications

(93 citation statements)

References 26 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…However, the overall analgesic time exceeded a clinically acceptable pain management response. In our study, the findings suggest that the implementation of an intervention, such as PAINAD, requires a coordinated transdisciplinary approach, interprofessional education and contextually relevant resources to support clinician behavioural change 28. In comparison to the large array of clinical trials comparing different types of drugs in the management of acute pain, there is a paucity of randomised trial evidence for system changes to improve analgesic provision and no trial evidence for system measures to improve analgesia in people with cognitive impairment 29…”

Section: Discussionmentioning

confidence: 87%

Can an observational pain assessment tool improve time to analgesia for cognitively impaired older persons? A cluster randomised controlled trial

2017

View full text Add to dashboard Cite

Objective The primary objective of the study was to measure the impact of an observational pain assessment dementia tool on time from ED arrival to first dose of analgesic medicine. Methods A multisite cluster randomised controlled trial was conducted to test the Pain Assessment in Advanced Dementia (PAINAD) tool. Patients aged 65 years or older suspected of a long bone fracture were screened for cognitive impairment using the Six-Item Screening (SIS) tool. Patients scoring 4 or less on SIS (intervention sites) were assessed for pain using PAINAD. Control sites, assessed pain using standard methods. The primary outcome was time to first dose of analgesia and was analysed on an intention-to-treat basis with a sensitivity analysis. results We enrolled 602 patients, of which 323 (54%) were at intervention sites (n=4). The median time to analgesia was 82 min (IQR 45-151 min). There was no statistically significant difference in median time to analgesia for intervention 83 (IQR 48-158 min) and nonintervention 82 min (IQR 41-147 min) sites (p=0.414). After adjusting for age, fracture type, arrival mode and triage category, there remained no significant difference in time to analgesia (HR 0.97, 95% CI 0.80 to 1.17, p=0.74). Of the 602 patients enrolled, 273 actually had cognitive impairment. A sensitivity analysis demonstrated patients at intervention sites received analgesia 13 min sooner (90 vs 103 min, p=0.91). conclusion Use of the PAINAD was not associated with a shorter time to analgesia, although there was a clinically important but non-significant improvement in the cognitively impaired patient group. Further research is needed to address this clinically important and complex issue.

show abstract

Section: Discussionmentioning

confidence: 87%

Can an observational pain assessment tool improve time to analgesia for cognitively impaired older persons? A cluster randomised controlled trial

2017

View full text Add to dashboard Cite

show abstract

“…This ideal tool does not exist. 14, [28][29][30] Each ED must carefully consider how such an instrument can help their team although acknowledging their limitations. 13,23,24 Constructs of frailty have also been trialled to predict adverse patient outcomes such as risk of nursing home placement or hospital readmission.…”

Section: Screening Instrumentsmentioning

confidence: 99%

“…These include observation for further multidisciplinary geriatric assessment prior to discharge or Hospital at Home programmes. 14, [28][29][30] Each ED must carefully consider how such an instrument can help their team although acknowledging their limitations. It may be that a tiered response is useful with early screening using one of these tools and then progressing to more complex evaluations, similarly to fall risk evaluations.…”

Section: Screening Instrumentsmentioning

confidence: 99%

Safe to send home? Discharge risk assessment in the emergency department

Southerland

Pearson

Hullick

et al. 2019

Emerg Medicine Australasia

View full text Add to dashboard Cite

“…Risk stratification and prediction is emerging as one such strategy to assist clinicians in discussing decisions such as observation or palliative care referral. However, some prediction tools are gaining widespread use with limited validation, and others are used for decision making despite their modest predictive accuracy . Baseline population risks alone are insufficient to give clinicians confidence in an individual prognosis as other demographic, disease‐specific, and personal factors may change the course of illness …”

Section: Primary Objectivementioning

confidence: 99%

Prospective Validation of a Checklist to Predict Short‐term Death in Older Patients After Emergency Department Admission in Australia and Ireland

Cardona

O’Sullivan

Lewis

et al. 2018

Academic Emergency Medicine

View full text Add to dashboard Cite

Background Emergency departments (EDs) are pressured environment where patients with supportive and palliative care needs may not be identified. We aimed to test the predictive ability of the CriSTAL (Criteria for Screening and Triaging to Appropriate aLternative care) checklist to flag patients at risk of death within 3 months who may benefit from timely end‐of‐life discussions. Methods Prospective cohorts of >65‐year‐old patients admitted for at least one night via EDs in five Australian hospitals and one Irish hospital. Purpose‐trained nurses and medical students screened for frailty using two instruments concurrently and completed the other risk factors on the CriSTAL tool at admission. Postdischarge telephone follow‐up was used to determine survival status. Logistic regression and bootstrapping techniques were used to test the predictive accuracy of CriSTAL for death within 90 days of admission as primary outcome. Predictability of in‐hospital death was the secondary outcome. Results A total of 1,182 patients, with median age 76 to 80 years (IRE‐AUS), were included. The deceased had significantly higher mean CriSTAL with Australian mean of 8.1 (95% confidence interval [CI] = 7.7–8.6) versus 5.7 (95% CI = 5.1–6.2) and Irish mean of 7.7 (95% CI = 6.9–8.5) versus 5.7 (95% CI = 5.1–6.2). The model with Fried frailty score was optimal for the derivation (Australian) cohort but prediction with the Clinical Frailty Scale (CFS) was also good (areas under the receiver‐operating characteristic [AUROC] = 0.825 and 0.81, respectively). Values for the validation (Irish) cohort were AUROC = 0.70 with Fried and 0.77 using CFS. A minimum of five of 29 variables were sufficient for accurate prediction, and a cut point of 7+ or 6+ depending on the cohort was strongly indicative of risk of death. The most significant independent predictor of short‐term death in both cohorts was frailty, carrying a twofold risk of death. CriSTAL's accuracy for in‐hospital death prediction was also good (AUROC = 0.795 and 0.81 in Australia and Ireland, respectively), with high specificity and negative predictive values. Conclusions The modified CriSTAL tool (with CFS instead of Fried's frailty instrument) had good discriminant power to improve certainty of short‐term mortality prediction in both health systems. The predictive ability of models is anticipated to help clinicians gain confidence in initiating earlier end‐of‐life discussions. The practicalities of embedding screening for risk of death in routine practice warrant further investigation.

show abstract

Adverse outcomes in older adults attending emergency departments: a systematic review and meta-analysis of the Identification of Seniors At Risk (ISAR) screening tool

Abstract: the ISAR has modest predictive accuracy and may serve as a decision-making adjunct when determining which older adults can be safely discharged.

Cited by 70 publications

References 26 publications

Can an observational pain assessment tool improve time to analgesia for cognitively impaired older persons? A cluster randomised controlled trial

Can an observational pain assessment tool improve time to analgesia for cognitively impaired older persons? A cluster randomised controlled trial

Safe to send home? Discharge risk assessment in the emergency department

Prospective Validation of a Checklist to Predict Short‐term Death in Older Patients After Emergency Department Admission in Australia and Ireland

Contact Info

Product

Resources

About