Thesis

IMPROVING ACUTE GERIATRIC CARE IN THE EMERGENCY DEPARTMENT A FOCUS ON EDUCATIONAL NEEDS AND INTERVENTIONS Özcan Sir

Improving acute geriatric care in the emergency department A focus on educational needs and interventions Özcan Sir

ISBN 978-94-6421-715-5 Design/lay-out Promotie In Zicht, www.promotie-inzicht.nl Print Ipskamp Printing Financial support for printing and distribution of this thesis was provided by Schola Medica, Marjan van Heerde Makelaardij, DEUS, NVSHA en Kinran Consultancy. Their support is gratefully acknowledged. © Özcan Sir, 2022 All rights are reserved. No part of this book may be reproduced, distributed, stored in a retrieval system, or transmitted in any form or by any means, without prior written permission of the author.

Proefschrift ter verkrijging van de graad van doctor aan de Radboud Universiteit Nijmegen op gezag van de rector magnificus prof. dr. J.H.J.M. van Krieken, volgens besluit van het college voor promoties in het openbaar te verdedigen op dinsdag 7 juni 2022 om 12.30 uur precies door Özcan Sir geboren op 5 november 1972 te Akyaka, Turkije Improving acute geriatric care in the emergency department A focus on educational needs and interventions

Promotoren prof. dr. M.G.M. Olde Rikkert prof. dr. Y. Schoon Copromotor dr. G.J. Hesselink Manuscriptcommissie prof. dr. C.R.M.G. Fluit prof. dr. H.W.B. Schreuder prof. dr. P.W.B. Nanayakkara (Vrije Universiteit Amsterdam) Paranimfen mr. Faik Kinran Selin S.E. Sir

Dissertation to obtain the degree of doctor from Radboud University Nijmegen on the authority of the Rector Magnificus prof. dr. J.H.J.M. van Krieken, according to the decision of the Doctorate Board to be defended in public on Tuesday, June 7, 2022 at 12.30 pm by Özcan Sir born on November 5, 1972 in Akyaka, Turkey Improving acute geriatric care in the emergency department A focus on educational needs and interventions

Supervisors prof. dr. M.G.M. Olde Rikkert prof. dr. Y. Schoon Co-supervisor dr. G.J. Hesselink Manuscript Committee prof. dr. C.R.M.G. Fluit prof. dr. H.W.B. Schreuder prof. dr. P.W.B. Nanayakkara (Vrije Universiteit Amsterdam) Paranymphs mr. Faik Kinran Selin S.E. Sir

aan mijn ouders

Table of contents Chapter 1 General introduction and outline of the thesis 11 Chapter 2 Risk Factors for Prolonged Length of Stay of Older Patients in an Academic Emergency Department: A Retrospective Cohort Study Emergency Medicine International. 2019 May 2 25 Chapter 3 Effectiveness of interventions to alleviate emergency department crowding by older adults: a systematic review BMC Emergency Medicine. 2019 Nov 20 45 Chapter 4 Dutch emergency physicians insufficiently educated in geriatric emergency medicine: results of a nationwide survey Age and Ageing. 2021 October 20 75 Chapter 5 Effects of a geriatric education program for emergency physicians: a mixed-methods study Health Education Research. 2020 Jun 1 101 Chapter 6 Teach-back of discharge instructions in the emergency department: a pre-post pilot evaluation Emergency Medicine Journal. 2021 Jun 17 121 Chapter 7 General discussion and future perspectives 155 Chapter 8 Summary of performed studies 171 Chapter 9 Nederlandse samenvatting (Dutch summary) 177 Chapter 10 Research datamanagement Acknowledgment (dankwoord) Curriculum vitae List of publications PhD portfolio 185 187 193 195 199

General introduction and outline of the thesis Chapter 1

13 General introduction and outline of the thesis CHAPTER 1 Motivation for this thesis The specialty of emergency medicine has evolved substantially over the last decades, and it continues to be an increasingly popular choice among graduating medical students (1). As the initial healthcare provider for many of his or her patients, an emergency physician is charged with the rapid assessment and gathering of the information needed for the initial workup and management of a variety of complaints and injuries. Emergency medicine is a team-oriented, dynamic specialty that focuses on the rapid evaluation and treatment of a diverse patient population consisting of both paediatric and adult patients. There are many potential reasons for choosing for a career as an emergency physician (2). Although a definite choice is usually made based on individual considerations, the decision to become an emergency physician is based on a strong interest in the dynamic aspects of an emergency physician’s working domain. One of the top reasons for becoming an emergency physician is probably the fact that in the emergency department (ED), no day is like another (3, 4) – emergency medicine is a field of work where variety is a key component: all types of patients (e.g., ranging from paediatric to geriatric), illnesses (covering almost all fields of medicine), and urgencies (e.g., ranging from non-lifethreatening to life-threatening) are seen in the ED. Indeed, a working shift in the ED is characterized by many challenges, as knowledge required to practise emergency medicine must be combined with both skills and compassion. Other appealing reasons for choosing emergency medicine are flexible work schedules, the variety of cases, the ability to perform procedures (e.g., placing tubes, stitching wounds, repositioning fractures), etc. (2). Although caring for older adults may not be the main reason that the majority of emergency physicians choose their careers, geriatric emergency medicine constitutes a large and increasing proportion of their work in the ED. This seems obvious, but it was only after the appointment of a geriatrician – Dr. Y. Schoon – as the medical head of our ED that I realized how strange it was that I did not receive any specific geriatric education during residency training. The ED residency program did not provide specific medical attention to the population of older adults in the ED, even though this group is rapidly growing and seems to benefit from ED physicians who are well aware of their specific clinical needs. Through the geriatric education sessions that were organized for our ED staff, I realized that better educated emergency physicians are needed to provide better medical care for older adults in the ED. It became clear to me that actions had to be taken for better preparation of both future and currently practising emergency physicians to make EDs suitable for the growing population of older adults, which was the reason for and starting point of this thesis work.

14 Chapter 1 Olderadults insocietyandintheemergencydepartment Although there are commonly used definitions of old age, there is no agreement on the age at which a person becomes an older adult. Most developed countries worldwide accept the age of 65 years to define older adults (5), and the United Nations has defined older adults as those aged 60 or 65 years or over (6). The proportion of older adults in the Netherlands has steadily increased after the second world war (7). Moreover, the average age of the older population in the Netherlands has become increasingly high. In the twentieth century, the number of adults over 65 years increased more than tenfold: from 0.3 million in 1900 to 3.4 million in 2020 (8). This resulted in a rising share of adults over 65 years in the total population, from 6% (in 1900) to 19.5% (in 2020) (8). In addition, almost a quarter of adults over 65 years old are older than 80 years (8). The proportion of people aged 65 and older in the Netherlands (19.5%) is comparable to the European average (20%) but higher than that in Australia (16%) and the United States (16%) (9). Compared to young adults (18-60 years), older adults (65 years and older) present to EDs with a higher level of emergency and more serious medical illnesses (10). They often present with nonspecific complaints and have cognitive and functional impairment, multimorbidity and polypharmacy (11). Compared to younger patients, they require transport by ambulance more often, utilize more diagnostic resources and have a longer duration of stay at the ED (12). They are 2.5 to 4.6 times more likely to be hospitalized and have a fivefold higher admission rate to the intensive care unit (13), although hospitalization has been shown to carry significant risk for older adults (14). They are also more likely to be misdiagnosed and consequently are more frequently discharged with unrecognized and untreated health problems (12). Studies have shown that many of these patients have repeat ED visits in the following months (15, 16).

15 General introduction and outline of the thesis CHAPTER 1 Impact of ageing on emergency departments and quality of care The growing population of older adults with a rising life expectancy challenges health services (17). Care must be reorganized to meet the specific needs of older adults (18). This applies especially to EDs, where the utilization of medical resources has increased most among older adults compared to other demographic groups (19). Older adults currently constitute an average of 24% of ED visitors in the Netherlands (20). Additional challenges that have accompanied the increase in the population of older adults presenting at the ED is the prolonged length of stay at the ED and crowding at the ED (21). Published data show that prolonged length of stay is not only a result but also a cause of ED crowding, yielding a vicious cycle: a greater number of patients present at the ED at the same time leads to longer stays at the ED, while longer stays at the ED also lead to increasing crowdedness at the ED (22). There is a growing understanding of the relationship between crowding, ED length of stay, and poor patient outcomes (23, 24, 25). Studies investigating the relationship between crowding and ED length of stay have shown that length of stay increases with increased crowding. One of these studies reported a 10% increase in ED length of stay for patients who presented at times when the ED was crowded (24). An increase in ED length of stay during crowded periods was observed for both medical and surgical complaints (25). The consequences of ED crowding on patient outcomes have been extensively studied. Studies have shown that crowding results in poorer outcomes (26-29), including increased mortality (30-33). One study showed that ED crowding was associated with increased inpatient mortality among critically ill patients (31). The effect of ED crowding was highest in patients suffering from trauma, followed by patients with infection. Another study raised important concerns about the quality of care during periods of ED crowding by illustrating that increased bed occupancy was associated with an increase in the rates of 30-day adverse outcomes (32). This remained true even after adjustment for patient and ED characteristics. In the previous study, a 10% increase in ED bed occupancy was associated with a 3% increase in mortality. Comparable results were found by a third study: compared to patients who were admitted on days without high ED crowding, patients who were admitted on days with high ED crowding experienced 5% greater odds of inpatient death (33). These studies indicate that it is necessary to alleviate ED crowding and to avoid prolonged ED length of stay to improve the quality of care for older adults at the ED.

16 Chapter 1 Geriatric education of emergency physicians Better geriatric education of health care professionals is key for providing a high standard of care for older adults in the ED. Emergency physicians are expected to acquire the ability to care for older adults during undergraduate and postgraduate medical education. However, evidence shows that current education does not adequately prepare ED professionals to provide high-quality care for older adults (34-36). Medical students, residents working at the ED, and staff report feeling unprepared and uncomfortable caring for older adults (35, 36, 37). Shortcomings in training and education in geriatric emergency medicine could be an underlying cause of inadequate geriatric knowledge and skills. To overcome the problem of inadequate training, geriatric curriculum domains have been published (38), and specific geriatric curricula for emergency care residency training in Europe have been developed (39, 40). Nevertheless, in the Netherlands, no emergency medicine residency program has incorporated formalized geriatric education. The organization and implementation of nonformalized education in the care of older adults during emergency care residency training is also lacking, perhaps because many emergency staff members have had insufficient geriatric training themselves. Inadequacies in core curricula and residency training and a lack of continued medical education in geriatrics for emergency physicians are probably the main reasons why practising emergency physicians feel uncomfortable with the treatment of older adults in the ED. Despite the recognition of the need for geriatric education and training for emergency physicians, insight is lacking regarding the currently available geriatric education programs in the Netherlands and whether these programs meet the perceived educational needs of emergency physicians. Improvement of acute geriatric care in the emergency department Multiple studies have shown that older adults admitted to the ED are at high risk for adverse health outcomes (functional decline, hospitalization, ED return visits, death) after the ED visit (10, 41, 42). These outcomes show the urgent need to improve the care of older adults visiting the ED. A number of interventions have been performed to improve the quality of care for older adults in the ED (43). Many of these interventions focused on the use of screening tools, the use of specialized beds for older adults, follow-up care, and the education of ED professionals.

17 General introduction and outline of the thesis CHAPTER 1 Literature shows that an ED visit may predict functional decline, frailty and increased dependency for an older patient (44). Screening of older adults in the ED may be a first opportunity to intervene and improve outcomes. The implementation of simple-to-use screening tools has proven to help identify patients at risk and to prevent poor outcomes by resulting in the referral of patients to appropriate health care resources, both in- and outpatient (45, 46). A second intervention becoming more common is the use of geriatric consultation services in the ED (47, 48). Although studies on such interventions have demonstrated improved quality of care (49, 50), randomized controlled trials are lacking to prove a reduction in ED length of stay and readmission. A third intervention employed to improve geriatric care is the better implementation of follow-up care, as hospitalization of older adults is associated with high rates of delirium, iatrogenic complications, and functional decline (51). Although a decrease in inappropriate hospital admissions is one of the main goals in geriatric care, discharge from the ED is a significant challenge, as care cannot be provided appropriately at home. Effective transition of care is required to facilitate outpatient care (52, 53). Given the lack of time and heavy workload in the ED, this transition process presents difficulties, as effective, reliable discharge instructions are time-consuming (54). A few strategies have been developed to improve the comprehension of discharge instructions (55, 56). The teach-back method is one of these improvement methods to confirm full comprehension of instructions provided to patients (57). Although teach-back is considered an effective intervention to improve ED discharge (58), limited knowledge is available on the effect of teach-back in the ED, particularly for older adults. We believe that implementation of the teach-back method could help prevent re-admissions to the ED and contribute to alleviating crowding of the ED. A fourth intervention to improve care for older adults in the ED may be the implementation of geriatric emergency medicine education for ED professionals (59). With emergency care professionals who are better trained in geriatric care, EDs can optimize ED visits, effectively deliver care, and coordinate resources. The need for education for ED professionals has been recognized, as they often lack sufficient geriatric care skills (59, 60). Although studies have shown that emergency care residents and staff benefit from geriatric emergency training (6163), clinical evaluation of these programs is needed to confirm the improvement of patient care.

18 Chapter 1 Aims of the thesis The aims of the thesis are as follows: 1. To identify risk factors for a prolonged length of stay in the ED for older adults. 2. To assess the effectiveness of interventions in reducing ED crowding with older adults (systematic review). 3. To assess emergency physicians’ self-perceived needs and their facilities regarding geriatric emergency care education (nationwide survey). 4. To evaluate the effect of a geriatric education program on emergency physicians’ geriatric knowledge, attitudes and medical practice when treating older adults (pre-post study). 5. To determine whether the teach-back method can reduce ED revisits and increase patient knowledge retention of discharge instructions, self-management at home and satisfaction with the provision of discharge instructions (prepost study). Outline of the thesis To achieve the abovementioned research goals, we conducted 5 studies, which we briefly describe below. In chapter 2, we describe our retrospective cohort study. We determined the length of stay of older adults in our ED and identified risk factors for prolonged length of stay of older adults in the ED. We analysed the medical records of 2000 patients ≥70 years old presenting at our ED and identified the associations between length of stay and patient characteristics, as well as organizational and clinical factors. In chapter 3, we present a systematic review to assess the effectiveness of interventions on reducing ED crowding by older adults and to identify core characteristics shared by successful interventions. Six major biomedical databases were searched for (quasi)experimental studies published between January 1990 and March 2017. In chapter 4, we assess emergencyphysicians’ self-perceivedneeds regarding geriatric emergency medicine education by an online survey. The survey was administered by e-mail to all 503 emergency physicians in the Netherlands. Another survey was e-mailed to all 83 emergency department managers in the Netherlands to assess their role in providing support for geriatric emergency medicine education for emergency physicians. In chapter 5, we evaluate the effect of a self-developed and implemented geriatric education program on emergency physicians’ geriatric knowledge,

19 General introduction and outline of the thesis CHAPTER 1 attitudes and medical practice when treating older adults. A mixed methods studywas performed on emergency physicians from two Dutch hospitals. Effects were measured by pre–post tests of emergency physicians’ (n=21) knowledge of geriatric syndromes and attitudes towards older adults. We also performed a retrospective pre–post analysis of 100 records of patients aged 70 years or more. In chapter 6, we evaluate the effects of using the teach-back method at ED discharge on ED revisits and retention of discharge instructions. A single-centre pilot study involved a pre-post evaluation of patients discharged from the ED receiving standard discharge care (pre) or discharge after teach-back (post). In chapter 7, a general discussion, critical reflections on this thesis, reflections on the challenges of performing educational program research in the emergency department, and suggestions for future perspectives are provided.

20 Chapter 1 References 1. Haas MRC, Hopson LR, Zink BJ. Too Big Too Fast? Potential Implications of the Rapid Increase in Emergency Medicine Residency Positions. AEM Educ Train. 2019 Nov 22;4(Suppl 1):S13-S21. doi: 10.1002/aet2.10400. PMID: 32072104; PMCID: PMC7011403. 2. RosenB, RosenP, Schofer J, Asher S,WaldD, CheaitoMA, EpterM, Kazzi A. Is EmergencyMedicine the Right Choice for Me? J Emerg Med. 2019 Mar;56(3):e35-e38. doi: 10.1016/j.jemermed.2018.11.001. PMID: 30910064. 3. Kazzi AA, Langdorf MI, Ghadishah D, HandlyN. Motivations for a career in emergencymedicine: a profile of the 1996 US applicant pool. CJEM. 2001 Apr;3(2):99-104. doi: 10.1017/s1481803500005327. PMID: 17610798. 4. Hillier M, McLeod S, Mendelsohn D, Moffat B, Smallfield A, Arab A, Brown A, Sedran R. Emergency medicine training in Canada: a survey of medical students’ knowledge, attitudes, and preferences. CJEM. 2011 Jul;13(4):251-8, E18-27. doi: 10.2310/8000.2011.110333. PMID: 21722554. 5. Gruneir A, Silver MJ, Rochon PA. Emergency department use by older adults: a literature review on trends, appropriateness, and consequences of unmet health care needs. Med Care Res Rev. 2011 Apr;68(2):131-55. doi: 10.1177/1077558710379422. Epub 2010 Sep 9. PMID: 20829235 6. https://www.un.org/en/development/desa/population/publications/pdf/ageing/WorldPopulationAgeing2019-Highlights.pdf 7. Smits CH, van den Beld HK, Aartsen MJ, Schroots JJ. Aging in the Netherlands: state of the art and science. Gerontologist. 2014 Jun;54(3):335-43. doi: 10.1093/geront/gnt096. Epub 2013 Sep 2. PMID: 24000267. 8. Bevolking, cijfers, context, vergrijzing. https://www.volksgezondheidenzorg.info/onderwerp/ bevolking/cijfers-context/vergrijzing#node-totaal-aantal-ouderen 9. https://data.worldbank.org/indicator/SP.POP.65UP.TO.ZS 10. Aminzadeh F, Dalziel WB. Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med. 2002 Mar;39(3):238-47. doi: 10.1067/mem.2002.121523. PMID: 11867975. 11. Samaras N, Chevalley T, Samaras D, Gold G. Older patients in the emergency department: a review. Ann Emerg Med. 2010 Sep;56(3):261-9. doi: 10.1016/j.annemergmed.2010.04.015. PMID: 20619500. 12. Gruneir A, Silver MJ, Rochon PA. Emergency department use by older adults: a literature review on trends, appropriateness, and consequences of unmet health care needs. Med Care Res Rev. 2011 Apr;68(2):131-55. doi: 10.1177/1077558710379422. Epub 2010 Sep 9. PMID: 20829235. 13. Strange GR, Chen EH, Sanders AB. Use of emergency departments by elderly patients: projections from a multicenter data base. Ann Emerg Med. 1992 Jul;21(7):819-24. doi: 10.1016/s0196-0644(05)81028-5. PMID: 1610039. 14. Horwitz LI, Meredith T, Schuur JD, Shah NR, Kulkarni RG, Jenq GY. Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Ann Emerg Med. 2009 Jun;53(6):701-10.e4. doi: 10.1016/j.annemergmed.2008.05.007. Epub 2008 Jun 16. PMID: 18555560. 15. Friedmann PD, Jin L, Karrison TG, Hayley DC, Mulliken R, Walter J, Chin MH. Early revisit, hospitalization, or death among older persons discharged from the ED. Am J Emerg Med. 2001 Mar;19(2):125-9. doi: 10.1053/ajem.2001.21321. PMID: 11239256. 16. Lowthian J, Straney LD, Brand CA, Barker AL, Smit Pde V, Newnham H, Hunter P, Smith C, Cameron PA. Unplanned early return to the emergency department by older patients: the Safe Elderly Emergency Department Discharge (SEED) project. Age Ageing. 2016 Mar;45(2):255-61. doi: 10.1093/ageing/afv198. Epub 2016 Jan 12. PMID: 26764254. 17. Arai H, Ouchi Y, Yokode M, Ito H, Uematsu H, Eto F, Oshima S, Ota K, Saito Y, Sasaki H, Tsubota K, Fukuyama H, Honda Y, Iguchi A, Toba K, Hosoi T, Kita T; Members of Subcommittee for Aging. Toward the realization of a better aged society: messages from gerontology and geriatrics. Geriatr Gerontol Int. 2012 Jan;12(1):16-22. doi: 10.1111/j.1447-0594.2011.00776.x. PMID: 22188494.

21 General introduction and outline of the thesis CHAPTER 1 18. Briggs AM, Araujo de Carvalho I. Actions required to implement integrated care for older people in the community using the World Health Organization’s ICOPE approach: A global Delphi consensus study. PLoS One. 2018 Oct 11;13(10):e0205533. doi: 10.1371/journal.pone.0205533. PMID: 30308077; PMCID: PMC6181385. 19. Street M, Berry D, Considine J. Frequent use of emergency departments by older people: a comparative cohort study of characteristics and outcomes. Int J Qual Health Care. 2018 Oct 1;30(8):624-629. doi: 10.1093/intqhc/mzy062. PMID: 29659863. 20. SEH contacten gebaseerd op het DIS, 2012 [https://www.cbs.nl/nl-nl/maatwerk/2016/26/sehcontacten-gebaseerd-op-het-dis-2012-] 21. Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: a systematic review of causes, consequences and solutions. PLoS One. 2018;13:e0203316. 22. Kreindler SA, Cui Y, Metge CJ, Raynard M. Patient characteristics associated with longer emergency department stay: a rapid review. Emerg Med J. 2016 Mar;33(3):194-9. doi: 10.1136/ emermed-2015-204913. Epub 2015 Sep 4. PMID: 26341654. 23. McCarthy ML, Zeger SL, Ding R, Levin SR, Desmond JS, Lee J, Aronsky D. Crowding delays treatment and lengthens emergency department length of stay, even among high-acuity patients. Ann Emerg Med. 2009 Oct;54(4):492-503.e4. doi: 10.1016/j.annemergmed.2009.03.006. Epub 2009 May 6. PMID: 19423188. 24. White BA, Biddinger PD, Chang Y, Grabowski B, Carignan S, Brown DF. Boarding inpatients in the emergency department increases discharged patient length of stay. J Emerg Med. 2013 Jan;44(1):230-5. doi: 10.1016/j.jemermed.2012.05.007. Epub 2012 Jul 4. PMID: 22766404. 25. Wickman L, Svensson P, Djärv T. Effect of crowding on length of stay for common chief complaints in the emergency department: A STROBE cohort study. Medicine (Baltimore). 2017 Nov;96(44):e8457. doi: 10.1097/MD.0000000000008457. PMID: 29095294; PMCID: PMC5682813. 26. Bond K, Ospina MB, Blitz S, AfilaloM, Campbell SG, BullardM, Innes G, Holroyd B, Curry G, Schull M, Rowe BH. Frequency, determinants and impact of overcrowding in emergency departments in Canada: a national survey. Healthc Q. 2007;10(4):32-40. doi: 10.12927/hcq.2007.19312. PMID: 18019897. 27. Diercks DB, Roe MT, Chen AY, PeacockWF, Kirk JD, Pollack CV Jr, Gibler WB, Smith SC Jr, Ohman M, Peterson ED. Prolonged emergency department stays of non-ST-segment-elevation myocardial infarction patients are associated with worse adherence to the American College of Cardiology/ American Heart Association guidelines for management and increased adverse events. Ann Emerg Med. 2007 Nov;50(5):489-96. doi: 10.1016/j.annemergmed.2007.03.033. Epub 2007 Jun 20. PMID: 17583379. 28. Pines JM, Pollack CV Jr, Diercks DB, Chang AM, Shofer FS, Hollander JE. The association between emergency department crowding and adverse cardiovascular outcomes in patients with chest pain. Acad Emerg Med. 2009 Jul;16(7):617-25. doi: 10.1111/j.1553-2712.2009.00456.x. Epub 2009 Jun 22. PMID: 19549010. 29. Zhou JC, Pan KH, Zhou DY, Zheng SW, Zhu JQ, Xu QP, Wang CL. High hospital occupancy is associated with increased risk for patients boarding in the emergency department. Am J Med. 2012 Apr;125(4):416.e1-7. doi: 10.1016/j.amjmed.2011.07.030. Epub 2012 Feb 3. PMID: 22306273. 30. Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA. Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ. 2011 Jun 1;342:d2983. doi: 10.1136/bmj.d2983. PMID: 21632665; PMCID: PMC3106148. 31. Jo S, Jeong T, Jin YH, Lee JB, Yoon J, Park B. ED crowding is associated with inpatient mortality among critically ill patients admitted via the ED: post hoc analysis from a retrospective study. Am J Emerg Med. 2015 Dec;33(12):1725-31. doi: 10.1016/j.ajem.2015.08.004. Epub 2015 Aug 7. PMID: 26336833. 32. McCusker J, Vadeboncoeur A, Lévesque JF, Ciampi A, Belzile E. Increases in emergency department occupancy are associated with adverse 30-day outcomes. Acad Emerg Med. 2014 Oct;21(10):1092-100. doi: 10.1111/acem.12480. Erratum in: Acad Emerg Med. 2015 Apr;22(4):497. PMID: 25308131.

22 Chapter 1 33. Sun BC, Hsia RY, Weiss RE, Zingmond D, Liang LJ, Han W, McCreath H, Asch SM. Effect of emergency department crowding on outcomes of admitted patients. Ann Emerg Med. 2013 Jun;61(6):605-611.e6. doi: 10.1016/j.annemergmed.2012.10.026. Epub 2012 Dec 6. PMID: 23218508; PMCID: PMC3690784Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: a systematic review of causes, consequences and solutions. PLoS One. 2018;13:e0203316. 34. Hesselink G, Demirbas M, Rikkert MO, Schoon Y. Geriatric Education Programs for Emergency Department Professionals: A Systematic Review. J Am Geriatr Soc. 2019 Nov;67(11):2402-2409. doi: 10.1111/jgs.16067. Epub 2019 Jul 23. PMID: 31335964; PMCID: PMC6900059. 35. Drickamer MA, Levy B, Irwin KS, Rohrbaugh RM. Perceived needs for geriatric education by medical students, internal medicine residents and faculty. J Gen Intern Med. 2006 Dec;21(12):12304. doi: 10.1111/j.1525-1497.2006.00585.x. PMID: 17105521; PMCID: PMC1924752. 36. Dent AW, Weiland TJ, Paltridge D. Australasian emergency physicians: a learning and educational needs analysis. Part Four: CPD topics desired by emergency physicians. Emerg Med Australas. 2008 Jun;20(3):260-6. doi: 10.1111/j.1742-6723.2007.01041.x. Epub 2007 Dec 6. PMID: 18062783. 37. McNamara RM, Rousseau E, Sanders AB. Geriatric emergency medicine: a survey of practicing emergency physicians. Ann Emerg Med. 1992 Jul;21(7):796-801. doi: 10.1016/s0196-0644(05)81024-8. PMID: 1610035. 38. Hogan TM, Losman ED, Carpenter CR, Sauvigne K, Irmiter C, Emanuel L, Leipzig RM. Development of geriatric competencies for emergency medicine residents using an expert consensus process. Acad Emerg Med. 2010 Mar;17(3):316-24. doi: 10.1111/j.1553-2712.2010.00684.x. PMID: 20370765; PMCID: PMC3221481. 39. Conroy S, Nickel CH, Jonsdottir AB et al. The development of a European curriculum in geriatric emergency medicine. Eur Ger Med J 2016; 7: 315–21. 40. Bellou A, Conroy SP, Graham CA. The European curriculum for geriatric emergency medicine. Eur J Emerg Med. 2016 Aug;23(4):239. doi: 10.1097/MEJ.0000000000000414. PMID: 27706002. 41. Lowenstein SR, Crescenzi CA, Kern DC, Steel K. Care of the elderly in the emergency department. Ann Emerg Med. 1986 May;15(5):528-35. doi: 10.1016/s0196-0644(86)80987-8. PMID: 3963531. 42. Caplan GA, Brown A, Croker WD, Doolan J. Risk of admission within 4 weeks of discharge of elderly patients from the emergency department--the DEED study. Discharge of elderly from emergency department. Age Ageing. 1998 Nov;27(6):697-702. doi: 10.1093/ageing/27.6.697. PMID: 10408663. 43. Conroy S, Ferguson C, Woodard J, Banerjee J. Interface geriatrics: evidence-based care for frail older people with medical crises. Br J Hosp Med (Lond). 2010 Feb;71(2):98-101. doi: 10.12968/ hmed.2010.71.2.46488. PMID: 20220698. 44. Rosenberg M, Rosenberg L. The Geriatric Emergency Department. Emerg Med Clin North Am. 2016 Aug;34(3):629-48. doi: 10.1016/j.emc.2016.04.011. PMID: 27475018. 45. Blomaard LC, Mooijaart SP, Bolt S, Lucke JA, de Gelder J, Booijen AM, Gussekloo J, de Groot B. Feasibility and acceptability of the ‘Acutely Presenting Older Patient’ screener in routine emergency department care. Age Ageing. 2020 Oct 23;49(6):1034-1041. doi: 10.1093/ageing/afaa078. PMID: 32428199; PMCID: PMC7583525. 46. McCusker J, Bellavance F, Cardin S, Trépanier S, Verdon J, Ardman O. Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool. J Am Geriatr Soc. 1999 Oct;47(10):1229-37. doi: 10.1111/j.1532-5415.1999.tb05204.x. PMID: 10522957. 47. Conroy SP, Ansari K, Williams M, Laithwaite E, Teasdale B, Dawson J, Mason S, Banerjee J. A controlled evaluation of comprehensive geriatric assessment in the emergency department: the ‘Emergency Frailty Unit’. Age Ageing. 2014 Jan;43(1):109-14. doi: 10.1093/ageing/aft087. Epub 2013 Jul 23. PMID: 23880143; PMCID: PMC3861335. 48. Sinoff G, Clarfield AM, Bergman H, Beaudet M. A two-year follow-up of geriatric consults in the emergency department. J Am Geriatr Soc. 1998 Jun;46(6):716-20. doi: 10.1111/j.1532-5415.1998. tb03806.x. PMID: 9625187.

23 General introduction and outline of the thesis CHAPTER 1 49. Foo CL, Siu VW, Tan TL, Ding YY, Seow E. Geriatric assessment and intervention in an emergency department observation unit reduced re-attendance and hospitalisation rates. Australas J Ageing. 2012 Mar;31(1):40-6. doi: 10.1111/j.1741-6612.2010.00499.x. Epub 2011 Aug 24. PMID: 22417153. 50. Yuen TM, Lee LL, Or IL, Yeung KL, Chan JT, Chui CP, Kun EW. Geriatric consultation service in emergency department: how does it work? Emerg Med J. 2013 Mar;30(3):180-5. doi: 10.1136/ emermed-2012-201139. Epub 2012 Mar 23. PMID: 22447816. 51. Hughes JM, Freiermuth CE, Shepherd-Banigan M, Ragsdale L, Eucker SA, Goldstein K, Hastings SN, Rodriguez RL, Fulton J, Ramos K, Tabriz AA, Gordon AM, Gierisch JM, Kosinski A, Williams JW Jr. Emergency Department Interventions for Older Adults: A Systematic Review. J Am Geriatr Soc. 2019 Jul;67(7):1516-1525. doi: 10.1111/jgs.15854. Epub 2019 Mar 15. PMID: 30875098; PMCID: PMC6677239. 52. Corbett HM, Lim WK, Davis SJ, Elkins AM. Care coordination in the Emergency Department: improving outcomes for older patients. Aust Health Rev. 2005 Feb;29(1):43-50. doi: 10.1071/ ah050043. PMID: 15683355. 53. Hegney D, Buikstra E, Chamberlain C, March J, McKay M, Cope G, Fallon T. Nurse discharge planning in the emergency department: a Toowoomba, Australia, study. J Clin Nurs. 2006 Aug;15(8):1033-44. doi: 10.1111/j.1365-2702.2006.01405.x. PMID: 16879548 54. Engel KG, Heisler M, Smith DM, Robinson CH, Forman JH, Ubel PA. Patient comprehension of emergency department care and instructions: are patients aware of when they do not understand? Ann Emerg Med. 2009 Apr;53(4):454-461.e15. doi: 10.1016/j.annemergmed.2008.05.016. Epub 2008 Jul 10. PMID: 18619710. 55. Samuels-Kalow ME, Stack AM, Porter SC. Effective discharge communication in the emergency department. Ann Emerg Med. 2012 Aug;60(2):152-9. doi: 10.1016/j.annemergmed.2011.10.023. Epub 2012 Jan 4. PMID: 22221840. 56. Hoek AE, Anker SCP, van Beeck EF, Burdorf A, Rood PPM, Haagsma JA. Patient Discharge Instructions in the Emergency Department and Their Effects on Comprehension and Recall of Discharge Instructions: A Systematic Review and Meta-analysis. Ann Emerg Med. 2020 Mar;75(3):435-444. doi: 10.1016/j.annemergmed.2019.06.008. Epub 2019 Aug 19. PMID: 31439363. 57. Slater BA, Huang Y, Dalawari P. The Impact of Teach-Back Method on Retention of Key Domains of Emergency Department Discharge Instructions. J Emerg Med. 2017 Nov;53(5):e59-e65. doi: 10.1016/j.jemermed.2017.06.032. Epub 2017 Sep 20. PMID: 28939399. 58. Oh EG, Lee HJ, Yang YL, Kim YM. Effectiveness of Discharge Education With the Teach-Back Method on 30-Day Readmission: A Systematic Review. J Patient Saf. 2021 Jun 1;17(4):305-310. doi: 10.1097/PTS.0000000000000596. PMID: 30882616. 59. Hesselink G, Demirbas M, Rikkert MO, Schoon Y. Geriatric Education Programs for Emergency Department Professionals: A Systematic Review. J Am Geriatr Soc. 2019 Nov;67(11):2402-2409. doi: 10.1111/jgs.16067. Epub 2019 Jul 23. PMID: 31335964; PMCID: PMC6900059. 60. McNamara RM, Rousseau E, Sanders AB. Geriatric emergency medicine: a survey of practicing emergency physicians. Ann Emerg Med. 1992 Jul;21(7):796-801. doi: 10.1016/s0196-0644(05)81024-8. PMID: 1610035. 61. Prendergast HM, Jurivich D, Edison M, Bunney EB, Williams J, Schlichting A. Preparing the front line for the increase in the aging population: geriatric curriculum development for an emergency medicine residency program. J Emerg Med. 2010 Apr;38(3):386-92. doi: 10.1016/j. jemermed.2008.05.003. Epub 2008 Nov 22. PMID: 19028039. 62. Biese KJ, Roberts E, LaMantia M, Zamora Z, Shofer FS, Snyder G, Patel A, Hollar D, Kizer JS, Busby-Whitehead J. Effect of a geriatric curriculum on emergency medicine resident attitudes, knowledge, and decision-making. Acad Emerg Med. 2011 Oct;18 Suppl 2:S92-6. doi: 10.1111/j.15532712.2011.01170.x. PMID: 21999564. 63. Witzke DB, Sanders AB. The development and evaluation of a geriatric emergency medicine curriculum. The SAEM Geriatric Emergency Medicine Task Force. Acad Emerg Med. 1997 Mar;4(3):219-22. doi: 10.1111/j.1553-2712.1997.tb03745.x. PMID: 9063551.

Risk factors for prolonged length of stay of older patients in an academic emergency department: a retrospective cohort study. Published in Emergency Medicine International. 2019 May 2. Özcan Sir Gijs Hesselink Mara van den Bogaert Reinier P. Akkermans Yvonne Schoon Chapter 2

26 Chapter 2 Abstract Background Emergency departments (EDs) are challenged with a growing population of older patients. These patients are at risk for a prolonged length of stay (LOS) at the ED and face more complications and poorer clinical outcomes. Objective We aimed to identify risk factors for a prolonged LOS of older patients at the ED. Methods For this retrospective clinical database study, we analyzed medical records of 2000 patients ≥70 years old presenting at the ED of a large level I trauma center in the Netherlands. LOS above the 75th percentile of LOS at our ED, 293 minutes, was considered prolonged. After bivariate analysis, we identified associations between LOS and patient, organizational, and clinical factors. Associations with a p < 0.05 were inserted in multivariable logistic regression models. Results We analyzed 1048 men (52%) and 952 women (48%) with a mean age of 78 ± 6.2 years. Risk factors for prolonged LOS of older patients at the ED were: higher number (more than one) of consultations (OR [Odds Ratio] 2.4, CI [Confidence Interval] 2.0-2.91) or diagnostic interventions (OR 1.5, CI 1.4-1.7); presenting complaints of a neurological (OR 2.2, CI 1.0-4.5) or internal medicine focus (OR 2.6, CI 1.4-4.6); patients with an altered consciousness (OR 3.3, CI 1.6-6.6); treatment by physicians of the departments of surgery (OR 3.4, CI 2.2-5.2), internal medicine (OR 2.6, CI 1.9-3.7) or pulmonology (OR 2.2, CI 1.4-3.6); urgency category of ≥ U1. Conclusion Awareness of factors associated with prolonged LOS of older patients presenting at the ED is essential. Physicians should recognize and take these factors into account, in order to improve clinical outcomes of the – strongly increasing – population of older patients at the ED.

27 Prolonged length of stay of older patients in the ED CHAPTER 2 Introduction The number of older patients attending the emergency department (ED) is increasing due to a growing population with a rising life expectancy [1-3]. Coping with the large number of older patients attending the ED is an international concern for emergency care staff [3]. Older patients often require more tailored care due to an atypical presentation of symptoms, multimorbidity and concomitant polypharmacy [4,5]. They also have more complex problems and need more diagnostics and consulting specialists [6]. All these factors potentially contribute to prolonged length of stay (LOS) at the ED. Prolonged LOS of older patients at the ED has been shown to be associated with a higher risk of hospitalization and adverse outcomes [5]. Identifying risk factors for a prolonged ED LOS of older patients may provide insight into possible strategies to decrease LOS of older patients at the ED. Despite the increase of older patients presenting at the ED and thereby contributing to crowding in the ED, relatively few studies have studied risk factors for a prolonged ED LOS of older patients presenting at the ED [7, 8]. Both studies being well-conducted, had an important limitation: the type of medical specialty – as an explanatory factor for prolonged LOS among older patients presenting at the ED – was not included in the analysis. This is in contrast with our experience at a level I trauma center in an urban area in the Netherlands, where we notice marked differences in ED LOS between patients treated by different specialties. The aim of this study is to identify all patient-, organizational- and clinical characteristics that may be associated with LOS of older patients at the ED. Insight into all factors contributing to prolonged LOS of older patients at the ED, could provide vital input for developing or choosing strategies to prevent prolonged LOS at the ED, thereby achieving better quality of care for older patients attending the ED. Methods and materials Study design, -setting and –participants Study design and setting This retrospective cohort study was performed at the ED of the Radboud University Medical Center (Radboudumc), an academic level I trauma center in the Netherlands, with a 650 bed capacity and an annual census of approximately 22,000 patients. The study was carried out in accordance with the regulations as governed by the Institutional Review Board of the Radboudumc and exempted from review.

28 Chapter 2 Study population We queried our institutional database for all patients who presented at the ED in 2014 (January – December). Patients admitted to the cardiac care unit were excluded, because these patients were all treated by a separate medical team under supervision of a cardiologist. Data collection The values of the variables of interest were digitally extracted out of the hospital’s electronic patient record database. Data that required clinical interpretation were collected manually. Variables Our variables of interest were the patient characteristics (i.e., age, sex, presence of cognitive impairment, polypharmacy, Charlson Age-Comorbidity Index), organizational factors (i.e., day of presentation, time of presentation, number of consultations, diagnostic interventions, therapeutic interventions, mode of presentation, method of transport, seniority of physician, assigned urgency, destination after ED visit, revisit of the ED (after index visit), and clinical factors (i.e., presenting complaint, diagnosis at ED visit, treating specialty). Definitions ED LOS was defined as time in minutes between arrival and ED discharge or hospital admission. Prolonged ED LOS was ascertained in accordance with the definition by Brouns et al [7]: i.e., LOS at the ED larger or equal to the 75th percentile of LOS at the ED. In our total study population prolonged ED LOS was calculated as >293 minutes. Time of presentation was classified as morning (7.00–11.59 h), afternoon (12.00–16.59 h), evening (17.00–23.59 h) and night (0.00– 6.59 h). Type of referral was categorized into referral by a general practitioner, practitioner of another hospital, emergency call, physician within the hospital and self-referral. Method of transport was classified as self-transport, ambulance, HEMS (Helicopter Emergency Medical Service) and other method of transport. Treating specialty at the ED was categorized into six specialties with most patients allocated (emergency physician, surgery, internal medicine, geriatrics, pulmonology, neurology). All other specialties were classified as “other specialties”. Each type of complaint was categorized into a subgroup of presenting complaints (table 1). Emergency physicians in our hospital treated all patients, referred to the ED by emergency calls, general practitioner or selfreferral, regardless of what type of presenting complaint. Our ED is 24/7 staffed with emergency physicians. Specialists of other specialties generally attend the ED on request of the emergency physician or the resident. All medical

29 Prolonged length of stay of older patients in the ED CHAPTER 2 specialties do have a trainee resident or non-trainee resident available to treat patients primarily or as a consultant. Triage levels were determined by using the Netherlands Triage System (NTS, with U0 being the highest urgency and U5 being the lowest urgency). The Charlson Age-Comorbidity Index was calculated to assess the co-morbidity levels (ranged from 0 to 40; higher score means more comorbidity [9]). Polypharmacy was defined as the use of five or more different medications prescribed by a physician. The seniority of the first physician was classified as ED resident, resident of specified other specialism, or emergency physician. Cognitive impairment was assessed by reviewingmedical history and ED notes of the day of visit. A pre-existent diagnosis of dementia was classified Table 1 Categories for presenting complaints. Category Type of complaints Traumatic injuries Pain after trauma, wounds, burns, complaints after falling, osteoporotic vertebral fractures. Small interventions Placing a urinary catheter for a newly diagnosed urinary retention, nose bleeds, abscesses. Neurological complaints Dizziness, epileptic insult, headache, radiating pain back/leg, neurological paralysis, slurred speech. Respiratory complaints Dyspnoea, haemoptysis, cough, suspected pneumonia / pulmonary embolism, pneumosepsis. Internal medicine Allergic reaction, anaemia, rash, hypertension, hyper/ hypoglycaemia, complaints while on chemotherapy, fever, painful joints without trauma, fatigue, skin infections, pain in eyes or ears, intoxication, septic arthritis. Abdominal complaints Vomiting, abdominal ache, diarrhoea, hematemesis, haematuria, icterus, melena, nausea, constipation, rectal blood loss, vaginal blood loss, pain in testes or vulva, suspected kidney stones, pain in groin or side. Painful or swollen leg Painful leg or ankle without trauma, suspected deep venous thromboembolism, painful hip without trauma, diabetic foot. Altered consciousness Collapse, confused, lowered level of consciousness. Chest complaints Chest pain. Complaints due to medical treatment All problems following surgery (bleeding, fever, pain, infection), catheter related problems, problems with plaster, casts and bandages, problems with drains and other medical devices. Resuscitation In need of resuscitation when arriving at the ED. ED= Emergency department

30 Chapter 2 as ‘cognitive impairment’. Notes of emergency physicians and geriatricians were evaluated on terms as ‘unreliable anamnesis’, ‘confusion’ and ‘possible delirium’ and when found, were scored ‘probable cognitive impairment’. In the absence of a pre-existing diagnosis of dementia and no notes of suspected cognitive impairment, ‘no cognitive impairment’ was noted. The number of (how many) other specialisms that were consulted within one presentation at the ED were counted. Diagnostic interventions consisted of blood examinations, electrocardiogram, ultrasound, X-rays, CT-scan, MRI-scan, lumbar puncture, puncture of a swollen joint, thoracocentesis, ankle brachial pressure index, and flexible endoscopy by an ENT-physician. Radiological imaging with the same type of diagnostics, but on multiple body parts, was counted as one (e.g. X-rays of neck, pelvis and hip made at one ED visit). Therapeutic interventions comprised: (re)placing a urinary catheter, suprapubic catheter or nasogastric tube, reposition of a fracture or dislocation, sedation (including intubation), thrombolysis, placing a chest tube, or placing a halo-frame. Statistical analyses We used frequencies and percentages to describe discrete variables and the mean and standard deviation (SD) to describe continuous variables. We used a dataset consisting of patients with complete medical charts without any missing values of our study variables. We performed bivariate analysis to identify factors to be included in our multivariable analysis. The two-sample t-test was used to identify associations between continuous variables and prolonged ED LOS. The association between discrete variables and ED LOS was assessed by using the Pearson’s Chi-square test. We decided to use a p-value of < 0.05 in bivariate analysis as an entry criterion for the multivariable model. We checked the correlation of the factors and when factors were mutually strongly related, a variable was selected for exclusion from the multivariable logistic regression analysis model. Multivariable logistic regression analysis was used to calculate the odds ratio (OR) with 95% confidence intervals (CI) to identify independent risk factors for a prolonged ED LOS. p-values < 0.05 were considered statistically significant, based on two sided tests. The Nagelkerke‘s R2 is calculated for testing the performance of the model.

31 Prolonged length of stay of older patients in the ED CHAPTER 2 Results Study population A total of 22,285 patients visited the ED in 2014. After exclusion of patients younger than 70 years old, 4,781 patients were eligible for the study. We sorted the patients on ascending patient identification number and selected the first 2,000 patients for inclusion in our study. While preparing the database, 92 patients were excluded for a variety of reasons (table 2). They were substituted by 92 other patients, who were again selected on ascending patient number. Our final study cohort consisted of 2,000 patients. Demographical-, organizational- and clinical characteristics of patients The mean age of patients was 78 years (SD 6.2 years). Half of the patients were male (n=1,048; 52%). Most patients had no diagnosis or signs of cognitive impairment (n=1,654; 83%). Polypharmacy existed in two-thirds of the patients (n=1,310; 66%) (table 3). Table 2 Exclusions. Number of patients Reason for exclusion 2 Missing LOS No LOS could be calculated, neither automatically nor manually. 2 Administrative mistake Patient was registered twice. 21 No or incomplete notes Missing notes. 26 Observation Patients kept for observation due to a medical reason or a delay in transfer or logistics. 26 Outpatient department (OPD) Patients primarily admitted to OPD for ophthalmology, oral and maxillofacial surgery or ENT. For administrative reasons these patients were registered at the ED, however consultation took place at OPD. 15 Proceeding in the ED Patients coming in for a small procedure not involving a physicians’ consult, e.g. changing or flushing a urinary catheter or cutting a ring. Total of 92 ED= Emergency department; LOS= Length of stay; OPD= Outpatient department; ENT= Ear nose throat

32 Chapter 2 Table 3 Demographical-, organizational- and clinical characteristics of patients. Variable All patients (n=2000) Patient characteristics Age at ED visit, mean ± SD 78 ± 6.2 Sex, n (%) Men 1048 (52) Women 952 (48) Presence of (signs of) cognitive impairment, n (%) 346 (17) Polypharmacy, n (%) 1310 (66) CACI, mean ± SD 5.6 ± 2.1 Organizational factors Day of presentation, n (%) Monday through Friday 1536 (77) Saturday and Sunday 464 (23) Time of presentation, n (%) Night (00.00 - 6.59) 138 (6.9) Morning (7.00 - 11.59) 406 (20) Afternoon (12.00 - 17.59) 980 (49) Evening (18.00 - 23.59) 476 (24) Number of consultations per patient, mean ± SD 0.47 ± 0.74 Number of diagnostic interventions per patient, mean ± SD 2.2 ± 1.4 Number of therapeutic interventions per patient, mean ± SD 0.96 ± 0.33 Mode of presentation, n (%) General practitioner 760 (38) Specialist of our institution 561 (28) Emergency call 447 (22) Self-referral 157 (7.9) Other hospital 75 (3.8) Method of transport, n (%) Self-transport 1171 (59) Ambulance 782 (39) HEMS 33 (1.7) Other 14 (0.70) Seniority of physician, n (%) Resident 1678 (84) Attending specialist 322 (16) Assigned urgency, n (%) U0 101 (5.1) U1 - U2 876 (44)

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