Advertisement

Home FIRsT: interdisciplinary geriatric assessment and disposition outcomes in the Emergency Department

Open AccessPublished:November 24, 2020DOI:https://doi.org/10.1016/j.ejim.2020.11.015

      Highlights

      • A new ‘interface geriatrics’ team was embedded in our Emergency Department (ED).
      • The team routinely collected data on baseline frailty, illness acuity and delirium.
      • High acuity of illness and delirium were strong predictors of admission.
      • Frailty (alone) was associated with onward referral to the Geriatric Day Hospital.
      • The concomitant assessment of frailty, acuity and cognition is needed in the ED.

      Abstract

      Background

      Older people in the Emergency Department (ED) are clinically heterogenous and some presentations may be better suited to alternative out-of-hospital pathways. A new interdisciplinary comprehensive geriatric assessment (CGA) team (Home FIRsT) was embedded in our acute hospital's ED in 2017.

      Aim

      To evaluate if routinely collected CGA metrics were associated with ED disposition outcomes.

      Design

      Retrospective observational study.

      Methods

      We included all first patients seen by Home FIRsT between 7th May and 19th October 2018. Collected measures were sociodemographic, baseline frailty (Clinical Frailty Scale), major diagnostic categories, illness acuity (Manchester Triage Score) and cognitive impairment/delirium (4AT). Multivariate binary logistic regression models were computed to predict ED disposition outcomes: hospital admission; discharge to GP and/or community services; discharge to specialist geriatric outpatients; discharge to the Geriatric Day Hospital.

      Results

      In the study period, there were 1,045 Home FIRsT assessments (mean age 80.1 years). For hospital admission, strong independent predictors were acute illness severity (OR 2.01, 95% CI 1.50-2.70, P<0.001) and 4AT (OR 1.26, 95% CI 1.13 – 1.42, P<0.001). Discharge to specialist outpatients (e.g. falls/bone health) was predicted by musculoskeletal/injuries/trauma presentations (OR 6.45, 95% CI 1.52 – 27.32, P=0.011). Discharge to the Geriatric Day Hospital was only predicted by frailty (OR 1.52, 95% CI 1.17 – 1.97, P=0.002). Age and sex were not predictive in any of the models.

      Conclusions

      Routinely collected CGA metrics are useful to predict ED disposition. The ability of baseline frailty to predict ED outcomes needs to be considered together with acute illness severity and delirium.

      Keywords

      1. Introduction

      With population ageing worldwide, the numbers of older people attending Emergency Departments (ED) continue to increase, which may lead to adverse operational and patient outcomes. [
      • Carter EJ
      • Pouch SM
      • Larson EL
      The relationship between emergency department crowding and patient outcomes: a systematic review.
      ] Older people in the ED are clinically very heterogenous and some presentations may be better suited to alternative out-of-hospital pathways. Where appropriate ambulatory services exist, specialist geriatric assessment in the ED ‘interface’ may improve outcomes by avoiding the adverse effects of potentially avoidable admissions. [
      • Conroy S
      • Ferguson C
      • Woodard J
      • Banerjee J
      Interface geriatrics: evidence-based care for frail older people with medical crises.
      ]
      Research has shown that it is possible to embed Comprehensive Geriatric Assessment (CGA) within EDs [
      • Conroy SP
      • Ansari K
      • Williams M
      • Laithwaite E
      • Teasdale B
      • Dawson J
      • et al.
      A controlled evaluation of comprehensive geriatric assessment in the emergency department: the 'Emergency Frailty Unit'.
      ] and a model of care delivered by interdisciplinary teams incorporating geriatric competencies into their service has been recommended. [
      • Conroy SP
      • Turpin S
      New horizons: urgent care for older people with frailty.
      ] Innovations in early assessment and ‘front-loaded’ geriatric ED interventions have become an important policy focus, [
      • Adams JG
      • Gerson LW.
      A new model for emergency care of geriatric patients.
      ], [

      Kenny RA, McGarrigle C. Health and Wellbeing: Active Ageing for Older Adults in Ireland: Evidence from The Irish Longitudinal Study on Ageing. Chapter 1: Introduction. Available online: https://tilda.tcd.ie/publications/reports/W3KeyFindings/index.php [accessed 28 June 2020]. TILDA Reports. 2016.

      ] and hence multiple ‘interface geriatrics’ teams have emerged in EDs; these have variable interdisciplinary composition and modes of operation, but they all assess and address common geriatric syndromes encountered in the ED, for which feasible measurement tools exist. [
      • McCabe JJ
      • Kennelly SP.
      Acute care of older patients in the emergency department: strategies to improve patient outcomes.
      ]
      In our context, the Home FIRsT (Frailty Intervention & Response Team) was embedded in our acute hospital's ED from May 2017 [
      • Cullen P.
      Plan to keep frail A&E patients out of hospital saves almost 4,000 bed nights: St James's Hospital initiative also ensures well patients are discharged promptly.
      ] with the aim to embed CGA in the ED and maximise the patient-centered use of alternative out-of-hospital care pathways where appropriate. Home FIRsT provide specialist nursing, functional, cognitive and social needs assessments to older people in the ED, and liaise with the Emergency Medicine (EM) team to identify the optimal disposition, i.e. admission or discharge; in the latter case, Home FIRsT arrange referrals to the most appropriate out-of-hospital services.
      Home FIRsT developed a common assessment form [
      • O'Shaughnessy I
      • Edge L
      • Dillon A
      • Flynn S
      • Cunningham C
      • Briggs R MR
      Home FIRsT - Outcomes of a Frailty Intervention and Response Team in the Emergency Department of a Large Acute Teaching Hospital.
      ] incorporating key CGA metrics in the socio-demographic, diagnostic category, illness acuity, frailty and delirium domains. As ED-based geriatric evaluation and management programmes expand in our country and others, there is currently a gap in understanding who would benefit most from this type of care assessment. We hypothesised that these routinely collected metrics may help predict ED disposition, and as part of a service evaluation, we explored their predictive usefulness.

      2. Methods

      2.1 Background

      St. James's Hospital (SJH) delivers services to the South Inner City of Dublin covering a population of almost 250,000. Parts of this area have significant socioeconomic disadvantage. In 2017, there were over 48,000 ED attendances [

      SJH. St James's Hospital Annual Report 2017. Available online: http://www.stjames.ie/media/SJH%20Annual%20Report%202017.pdf (accessed 11 November 2020). 2017.

      ] of which 25% were aged over 65 years.
      The Home FIRsT (Frailty Intervention & Response Team) was embedded in SJH's ED from May 20178 and is comprised of an advanced nurse practitioner, clinical specialist physiotherapist, clinical specialist occupational therapist and senior medical social worker, all with specialist training and competencies in the care of the older person.
      Patients’ presenting complaint is first established by an ED triage nurse. As per Home FIRsT operational policy, persons who present to SJH's ED during Monday to Friday core working hours (8:00 – 18:00), are aged 70 years and older and have a Manchester Triage Score (MTS) [
      • Cooke MW
      • Jinks S.
      Does the Manchester triage system detect the critically ill?.
      ] of urgent, standard or non-urgent are referred to Home FIRsT, who initiate CGA using validated tools. There are no other exclusions, including usual place of residence (e.g. nursing home patients in the ED are also considered). Where indicated, Home FIRsT begin the clinical/diagnostic and functional work-up before the EM doctor has been assigned to the patient. As part of their routine clinical work, Home FIRsT team members often liaise with families and/or caregivers; as in many cases, this is essential for the obtention of baseline (i.e. pre-attendance) patient information (e.g. socio-economic characteristics, frailty level prior to acute illness). Home FIRsT operate under the supervision of a Geriatrician (i.e. the Geriatrician on-call for the day), who provides advice and clinical review as required. After the geriatric assessment, Home FIRsT discuss their findings with the EM team, who take their recommendations into account in order to establish the disposition.
      When the ED disposition is discharge, Home FIRsT recommend the most appropriate out-of-hospital pathway and facilitate referrals to and communication with those services. The main out-of-hospital pathways are:
      • Discharge to GP and/or community services (e.g. community Occupational Therapy and/or Physiotherapy; Public Health Nurse; Integrated Case Manager; Community Intervention Team; primary care team Medical Social Work);
      • Discharge to specialist geriatric outpatient clinics (e.g. falls and syncope unit, bone health clinic, memory clinic, general geriatric outpatient clinic), with a typical waiting time of weeks to months; and
      • Discharge to the Geriatric Day Hospital. In Ireland and other countries [
        • Aliberti MJ
        • Suemoto CK
        • Fortes-Filho SQ
        • Melo JA
        • Trindade CB
        • Kasai JY
        • et al.
        The Geriatric Day Hospital: Preliminary Data on an Innovative Model of Care in Brazil for Older Adults at Risk of Hospitalization.
        ], this has evolved to an ‘Ambulatory Care Hub’ model with access to outpatient diagnostics/therapy staff enabling ‘rapid access’ CGA and ongoing therapy to support and facilitate ED admission avoidance and hospital Early Supported Discharge schemes. [
        • O'Caoimh R
        • Kennelly S
        • O'Shea D
        Can the Geriatric Day Hospital Act As a Hub for Services for Older People across the Spectrum of Ageing from Active Ageing to Advanced Frailty?.
        ], [

        NC&ICP. Making a start in Integrated Care for Older Persons guide. Available online: https://www.icpop.org/single-post/2018/11/14/Making-a-start-in-Integrated-Care-for-Older-Persons-guide. Accessed 2 July 2020. 2017.

        ] The typical wait for this is days to weeks.

      2.2 Design and sample

      This was an observational retrospective study. In this evaluation, we included all patients seen by Home FIRsT between 7th May and 19th October 2018. During this period, the Home FIRsT team underwent a systematic, structured collection of their routinely collected clinical data, as part of an overall service evaluation. A predetermined sample size calculation was not conducted. We only analysed first-time encounters (i.e. repeated encounters were excluded).

      2.3 Clinical characterisation variables

      As well as ED disposition, the following patient information was routinely collected by Home FIRsT:
      • Sociodemographic: age, sex, living alone (yes/no), previous formal care package at home (yes/no), referred to ED from a nursing home (yes/no).
      • Frailty: baseline (pre-admission) frailty was collected with the 9-point Clinical Frailty Scale (https://www.dal.ca/sites/gmr/our-tools/clinical-frailty-scale.html). [
        • Rockwood K
        • Song X
        • MacKnight C
        • Bergman H
        • Hogan DB
        • McDowell I
        • et al.
        A global clinical measure of fitness and frailty in elderly people.
        ,
        • Rockwood K
        • Theou O.
        Using the Clinical Frailty Scale in Allocating Scarce Health Care Resources.
        ] The CFS includes an overall estimation of patients’ usual (i.e. pre-attendance) functional status.
      • Major Diagnostic Categories (MDC: http://health.utah.gov/opha/IBIShelp/codes/MDC.htm) were generated by classifying all recorded principal ED presenting complaints into 25 mutually exclusive categories.
      • Acuity of illness as indicated by the MTS. [
        • Cooke MW
        • Jinks S.
        Does the Manchester triage system detect the critically ill?.
        ]
      • Delirium as assessed by the 4AT score, with a score of 4 or more being indicative of delirium. [
        • Bellelli G
        • Morandi A
        • Davis DH
        • Mazzola P
        • Turco R
        • Gentile S
        • et al.
        Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people.
        ]

      2.4 Statistical analyses

      Analyses were computed with IBM® SPSS® Statistics version 26. Descriptive statistics were given as mean with standard deviation (SD), median with interquartile range (IQR), or number with percentage (%). Missing data was reported without imputation.
      For the prediction of each of the four disposition outcomes (i.e. admission, GP/community services, specialist geriatric clinics, geriatric day hospital), we used a multivariate binary logistic regression model that fulfilled the following premises:
      • a)
        There were at least 10 observations per predictor to avoid underpower; this was the reason for combining some MDCs (i.e. musculoskeletal/injuries/major trauma; circulatory/respiratory). This rule of 10 subjects per independent predictor was applied retrospectively and did not determine the original sample size.
      • b)
        There was no multicollinearity among predictors. This was checked with a correlation matrix of 2-sided Spearman correlation coefficients, where none was found to be ≥ 0.6.
      The final set of predictors in each model was: age (continuous), sex, living alone, formal care package, CFS (continuous), musculoskeletal/injuries/major trauma, circulatory/respiratory; infections, MTS (continuous, inverse), 4AT (continuous). The overall probability level was saved to generate a regression Area Under the Curve (AUC) with 95% confidence intervals (CI). The multivariate regression Odds Ratios (OR) (per one-unit increase) and 95% CIs for age, CFS, MTS and 4AT were visualised with forest plots using Microsoft Excel. Models were repeated dichotomising the continuous predictors to increase ORs comparability. The P value to denote statistical significance was set at < 0.05 throughout.

      2.5 Ethics

      The study was approved by St James's Hospital/Tallaght University Hospital Research Ethics Committee (REC: 2018-12). The dataset was fully anonymised and data processing was in full compliance with Data Protection regulations.

      3. Results

      Between 7th May and 19th October 2018, there were 1,045 Home FIRsT assessments, all corresponding to unique patients seen by the service for the first time. Their characteristics are shown in Table 1. Patients’ mean age was 80.1 (SD 6.6), with a range of 63-101 (14 under 70), and 59.5% were female. The mean CFS was 4 (very mild frailty). [
      • Rockwood K
      • Theou O.
      Using the Clinical Frailty Scale in Allocating Scarce Health Care Resources.
      ]
      Table 1Sociodemographic, clinical characteristics and outcomes of 1,045 Home FIRsT assessments, including missing data. SD: standard deviation; n: number; %: percentage; CFS: Clinical Frailty Scale; MTS: Manchester Triage Scale; IQR: interquartile range; GP: general practitioner.
      DescriptiveMissing, n (%)
      Sociodemographic
      Mean age, years (SD)80.1 (6.6)0
      Females, n (%)622 (59.5)0
      Lives alone, n (%)451 (43.2)2 (0.2)
      Has formal care package at home, n (%)230 (22.0)9 (0.9)
      Lives in a nursing home, n (%)24 (2.3)2 (0.2)
      Baseline frailty (Clinical Frailty Scale)
      Mean CFS score (SD)4.0 (1.5)10 (1.0)
      Very fit, n (%)16 (1.5)
      Fit, n (%)162 (15.7)
      Managing well, n (%)269 (26.0)
      Very mildly frail, n (%)190 (18.4)
      Mildly frail, n (%)233 (22.5)
      Moderately frail, n (%)120 (11.6)
      Severely frail, n (%)42 (4.1)
      Very severely frail, n (%)3 (0.3)
      Terminally ill, n (%)0 (0.0)
      Major diagnostic categories0
      Musculoskeletal, n (%)295 (28.2)
      Injuries, n (%)246 (23.5)
      Circulatory, n (%)110 (10.5)
      Respiratory, n (%)105 (10.0)
      Infectious, n (%)91 (8.7)
      Digestive, n (%)56 (5.4)
      Kidney and urinary, n (%)48 (4.6)
      Skin, n (%)47 (4.5)
      Ear, nose and throat, n (%)15 (1.4)
      Nervous system, n (%)12 (1.1)
      Alcohol/drug use or induced mental disorders, n (%)8 (0.8)
      Eye, n (%)5 (0.5)
      Acuity of illness (Manchester Triage Category)
      Median MTS score (IQR)3 (0.0)1 (0.1)
      Immediate, n (%)0 (0.0)
      Very urgent, n (%)55 (5.3)
      Urgent, n (%)736 (70.5)
      Standard, n (%)244 (23.4)
      Non-urgent (%)9 (0.9)
      Cognition
      Median 4-AT score (IQR)0 (1.0)36 (3.4)
      Delirium or severe cognitive impairment unlikely, n (%)693 (68.7)
      1-3 Possible cognitive impairment, n (%)256 (25.4)
      4+ Delirium, n (%)60 (5.9)
      Emergency Department Disposition outcomes
      Hospital admission, n (%)347 (33.2)0
      Discharge to GP and/or community services, n (%)589 (56.4)
      Discharge to Geriatric Day Hospital, n (%)62 (5.9)
      Discharge to specialist Geriatric outpatient clinics, n (%)47 (4.5)
      In terms of MDCs, the most common within musculoskeletal system were non fall-related injuries and musculoskeletal pain; falls were the leading presentation under injuries; chest pain, palpitations, cardiac arrhythmia (atrial fibrillation), congestive heart failure, deep vein thrombosis, syncope and pre-syncope were the most common circulatory presentations; shortness of breath was the most common respiratory presentation; under infections we classified patients who presented generally unwell; digestive presentations were often related to nausea/vomiting/diarrhoea or rectal bleeding; non-complicated urinary tract infections were classified under kidney and urinary tract; skin ulcers and rashes were most common under skin; nose bleeds under ENT; and seizures and possible TIA symptoms under nervous system.
      The median MTS was 3 (urgent) and 6% had a 4AT of 4 or higher (Table 1). The 4AT had the most missing data (3%). The ED disposition was GP/community supports in most cases (56%), followed by hospital admission (33%), referral to rapid access Geriatric Day Hospital (6%), and specialist geriatric clinics: bone health (22 patients), general (18), and Falls and Syncope Unit (7).
      In the correlation matrix between predictors, the largest bivariate association was between CFS and 4AT (2-sided Spearman's rho correlation coefficient = 0.514, P<0.001). The results of the multivariate binary logistic regression models are shown in Table 2. In terms of admission, independent predictors (by descending OR) were MTS (OR 2.01, 95% CI 1.50-2.70, P<0.001), systemic infections (OR 1.92, 95% CI 1.10 – 3.37, P=0.022), 4AT (OR 1.26, 95% CI 1.13 – 1.42, P<0.001), and CFS (OR 1.16, 95% CI 1.01 – 1.32, P=0.033). Discharge to GP/community services was less likely in the presence of systemic infection (OR 0.37, 95% CI 0.21 – 0.67, P=0.001), higher acuity (OR 0.57, 95% CI 0.43 – 0.75, P<0.001), cardio-respiratory condition (OR 0.59, 95% CI 0.38 – 0.92, P=0.019), higher 4AT (OR 0.76, 95% CI 0.67 – 0.87, P<0.001) and higher CFS (OR 0.79, 95% CI 0.69 – 0.89, P<0.001). Discharge to the Geriatric Day Hospital was only significantly predicted by CFS (OR 1.52, 95% CI 1.17 – 1.97, P=0.002); and referral to the above-mentioned specialist clinics was predicted by musculoskeletal/injuries/trauma (OR 6.45, 95% CI 1.52 – 27.32, P=0.011). Age or sex were not significant independent predictors of any of the ED disposition outcomes. Except for discharge to specialist geriatric clinics were the number of events was smallest, regression AUCs for the other outcomes were at least 0.7 suggesting reasonably good prediction.
      Table 2Results of the multivariate binary logistic regression analyses to predict Emergency Department disposition outcomes. For the continuous predictors (i.e. age, CFS, MTS inverse, and 4-AT) ORs reflect a one-point increase in the respective scale. AUC: area under the curve; OR: odds ratio; CI: confidence interval; CFS: Clinical Frailty Scale; MSK: musculoskeletal; MTS: Manchester Triage Scale.
      Hospital admission (n=1002, model AUC=0.71, 95% CI: 0.67-0.74, P<0.001)
      OR95% CI for OR (lower)95% CI for OR (upper)P
      Age1.010.991.030.450
      Female sex0.880.661.180.398
      Living alone1.210.901.620.211
      Formal care package1.020.701.480.914
      CFS1.161.011.320.033
      MSK/injuries/trauma0.800.541.170.244
      Cardio-respiratory1.300.832.020.248
      Infectious1.921.103.370.022
      MTS inverse2.011.502.70<0.001
      4-AT1.261.131.42<0.001
      Discharge to GP and/or community services (n=1002, model AUC=0.72, 95% CI: 0.69-0.75, P<0.001)
      Age0.980.961.010.199
      Female sex1.040.791.380.776
      Living alone0.840.631.120.230
      Formal care package1.150.801.670.451
      CFS0.790.690.89<0.001
      MSK/injuries/trauma0.850.581.230.378
      Cardio-respiratory0.590.380.920.019
      Infectious0.370.210.670.001
      MTS inverse0.570.430.75<0.001
      4-AT0.760.670.87<0.001
      Discharge to Geriatric Day Hospital (n=1002, model AUC=0.70, 95% CI: 0.64-0.76, P<0.001)
      Age1.010.961.050.733
      Female sex1.270.712.260.426
      Living alone1.270.722.220.408
      Formal care package0.860.451.640.639
      CFS1.521.171.970.002
      MSK/injuries/trauma1.790.724.430.207
      Cardio-respiratory2.360.886.350.088
      Infectious2.150.696.690.184
      MTS inverse0.970.571.630.896
      4-AT0.990.821.190.894
      Discharge to specialist Geriatric outpatient clinics (n=1002, model AUC=0.66, 95% CI: 0.58-0.73, P<0.001)
      Age1.020.971.070.492
      Female sex1.000.531.880.996
      Living alone0.810.431.530.517
      Formal care package0.550.221.360.195
      CFS1.100.831.480.499
      MSK/injuries/trauma6.451.5227.320.011
      Cardio-respiratory2.870.5714.550.202
      Infectious3.340.5320.960.198
      MTS inverse0.810.461.410.453
      4-AT0.960.731.250.737
      Fig. 1 shows as forest plot the multivariate ORs with 95% CIs per one-unit increase in age, CFS, MTS (inverse) and 4AT to predict ED dispositions. The results and forest plot for the repeated binary-only models are shown in the Supplementary material.
      Fig. 1
      Fig. 1Forest plot of multivariate Odds Ratios (OR) with 95% Confidence Intervals (CIs) (from ) for one-point increase in age, Clinical Frailty Scale (CFS), Manchester Triage Score (MTS, inverse) and 4AT in the prediction of Emergency Department disposition outcomes.

      4. Discussion

      This evaluation set out to examine if CGA metrics routinely collected by Home FIRsT were associated with ED disposition outcomes. Only 33% of patients seen by Home FIRsT required hospital admission, and as expected this was mostly driven by acute illness severity and delirium, with baseline frailty being an additional predictor. Discharge to GP/community services seemed to be predicted by the opposite of the above; referral to a rapid access Geriatric Day Hospital ‘hub’ was predicted by frailty, suggesting the need to unravel its determinants and modifiable factors through further CGA; and referral to specialist geriatric clinics seemed to be driven by specific clinical presentations. It is reassuring that high acuity and delirium, which are often associated to adverse outcomes in the short term (e.g. early ED reattendance [
      • Í O'Shaughnessy
      • R Briggs
      • Timmons S
      • Cunningham C
      286 Predictors and Outcomes of Older Persons Attending the Emergency Department of a Large Acute Dublin Teaching Hospital.
      ]), were not predictive of the use of out-of-hospital pathways, suggesting appropriate clinical decision making and highlighting the value of these routinely collected metrics for ongoing service monitoring and quality improvement. Also reassuring, is the fact that decisions on most appropriate service use were not based on age or sex, suggesting that decisions were based on clinical need.
      Our results emphasise that frailty is not the only CGA dimension that matters in the ED; [
      • Hastings SN
      • Purser JL
      • Johnson KS
      • Sloane RJ
      • Whitson HE
      Frailty predicts some but not all adverse outcomes in older adults discharged from the emergency department.
      ] as also highlighted in the acute inpatient geriatric setting, [
      • Romero-Ortuno R
      • Forsyth DR
      • Wilson KJ
      • Cameron E
      • Wallis S
      • Biram R
      • et al.
      The Association of Geriatric Syndromes with Hospital Outcomes.
      ] the measurement of other dimensions such as acuity and delirium can help better explain operational outcomes and support clinical decision making. [
      • Alabaf Sabbaghi S
      • De Souza D
      • Sarikonda P
      • Keevil VL
      • Wallis SJ
      • Romero-Ortuno R
      Allocating patients to geriatric medicine wards in a tertiary university hospital in England: A service evaluation of the Specialist Advice for the Frail Elderly (SAFE) team.
      ] The different prognostic implications of illness severity and baseline frailty in acute care settings are attracting increasing attention, [
      • Pulok MH
      • Theou O
      • van der Valk AM
      • Rockwood K
      The role of illness acuity on the association between frailty and mortality in emergency department patients referred to internal medicine.
      ], [
      • Romero-Ortuno R
      • Wallis S
      • Biram R
      • Keevil V
      Clinical frailty adds to acute illness severity in predicting mortality in hospitalized older adults: An observational study.
      ] and a strength of our study is that it illustrates their independent value to support decision-making in the interface setting.
      Overall, 70.5% and 5.3% of patients arrived at ED for urgent or very urgent conditions, respectively, but only 33.2% of patients were hospitalised. This may not only reflect the ability of the EM team to quickly stabilise and treat many acute medical presentations, but also the availability of rapid access, ambulatory care services where there can be a timely medical follow up. Yet, the fact that a minority of patients seen by Home FIRsT required hospital admission reflects specific patient selection. The data demonstrated some flexibility around the referral/acceptance criteria (i.e. 55 patients initially triaged as very urgent and 14 under 70 years of age), which reflects that Home FIRsT staff are senior professionals with discretion to be flexible in their work processes when it seems appropriate. However, patients triaged as MTS 2 (very urgent) are normally seen by an EM doctor before Home FIRsT see them, and in most of those cases the ED treatment focuses exclusively on medical care and CGA will take place later on the ward once patients have been admitted and stabilised. The latter patients are not recorded by Home FIRsT as part of their activity.
      In our evaluation, the very small proportions of missing data suggest that the measures chosen were feasible in our setting. A systematic review focusing on the feasibility of frailty identification in the ED showed that commonly used risk-stratification tools do not cover much more than 50% of the potential population eligible for screening in practice. [
      • Elliott A
      • Hull L
      • Conroy SP
      Frailty identification in the emergency department-a systematic review focussing on feasibility.
      ] The fact that in our series only 1% of CFSs were missing could be related to the conscientiousness of the Home FIRsT team, but also to patient selection criteria; indeed, a study in acute inpatients found that greater proportions of missing CFS were associated with high illness severity in patients who were admitted to critical care areas. [
      • Wallis SJ
      • Wall J
      • Biram RW
      • Romero-Ortuno R
      Association of the clinical frailty scale with hospital outcomes.
      ] Naturally, in life threatening situations professionals focus on medical care first, but even in these situations, the assessment of frailty may still be useful as a focus for discussion around goals and expectations of care. [
      • So R.K.L.
      • Bannard-Smith J.
      • Subbe C.P
      • et al.
      The association of clinical frailty with outcomes of patients reviewed by rapid response teams: an international prospective observational cohort study.
      ]
      The correct use of the CFS incorporates cognition in its scoring, and hence the bivariate correlation between CFS and 4AT in our sample was of moderate strength, but not incurring multicollinearity. A previous study in an ED setting found a weak-to-moderate association between frailty and delirium, [
      • Choutko-Joaquim S
      • Tacchini-Jacquier N
      • Pralong D'Alessio G
      • Verloo H
      Associations between Frailty and Delirium among Older Patients Admitted to an Emergency Department.
      ] and another one reported that cognitive impairment and physical frailty had synergistic effects on hospitalisations and ED visits. [
      • Wang J
      • Kong D
      • Yu F
      • Conwell Y
      • Dong X
      Cognitive deficit, physical frailty, hospitalization and emergency department visits in later life.
      ] Our results are in keeping with those studies in that CFS and 4AT seemed to have complementary value to predict ED disposition in our setting. As regards MTS as our acuity metric, even though its performance has been reported to be inferior in older patients, [
      • Brouns SHA
      • Mignot-Evers L
      • Derkx F
      • Lambooij SL
      • Dieleman JP
      • Haak HR
      Performance of the Manchester triage system in older emergency department patients: a retrospective cohort study.
      ] we found it to be the best predictor of admission, supporting its value in our setting.
      Our study has important limitations. The single centre, retrospective observational design makes findings not necessarily generalisable to other settings. For example, in our context, direct access to post-acute and intermediate care services, inpatient rehabilitation services, long-term care facilities and hospices is not readily available from our ED but may be more available in other countries. The direct allocation to some of these pathways (e.g. long-term facilities for patients with severe dementia or hospice for patients with terminal diseases) was not within the mission of Home FIRsT.
      Even though patients were consecutively evaluated, once one excludes most of those aged between 65-69, most of those with an MTC of very urgent or immediate, and those who presented out of core working hours (Monday to Friday, 08:00-18:00), the sample analysed was clearly not representative of the total older population presenting to ED (i.e. 1,045 out of potentially 5,500). Unfortunately, we did not have information on the characteristics and outcomes of those not seen by Home FIRsT during the same period. Even though the focus of our report was to establish predictors of ED disposition, in this same cohort we identified that 17.8% had an unscheduled ED revisit within 30 days, with the best predictor being delirium. [
      • Í O'Shaughnessy
      • R Briggs
      • Timmons S
      • Cunningham C
      286 Predictors and Outcomes of Older Persons Attending the Emergency Department of a Large Acute Dublin Teaching Hospital.
      ] Delirium in the ED may be a marker of acute illness and higher risk of short-term mortality; [
      • Kakuma R
      • du Fort GG
      • Arsenault L
      • Perrault A
      • Platt RW
      • Monette J
      • et al.
      Delirium in older emergency department patients discharged home: effect on survival.
      ] those with delirium who are discharged may have inadequate diagnostic workups and difficultly following discharge instructions, which may explain Home FIRsT/EM's tendency to consider higher 4ATs for admission.
      Another potential limitation of our study is that other than capturing the pre-attendance overall functional status via the CFS, objective functional measures (e.g. mobility or balance scales) were not routinely evaluated on ED presentation and/or at the time of ED discharge. Our study captured a low proportion of nursing home residents, but these patients are often referred at high levels of acuity [
      • Keevil VL
      • Martin GJ
      • Biram R
      • Wallis S
      • Romero-Ortuno R
      Care home residents admitted to hospital through the emergency pathway: characteristics and associations with inpatient mortality.
      ] during out of hours, [
      • Briggs R
      • Coughlan T
      • Collins R
      • O'Neill D
      • Kennelly SP
      Nursing home residents attending the emergency department: clinical characteristics and outcomes.
      ] so many may have been outside Home FIRsT's criteria; in addition, for those not needing admission, their discharge disposition tends to be clear to EM (i.e. return to care home after medical treatment). The fact that we saw relatively low numbers of people who were very severely frail or terminally ill may also be reflective as to how the MTS is used as part of the Home FIRsT referral criteria. Similarly, the proportion of delirium seemed low, which may also be due to only seeing MTS 3-5 patients. Having said that, another limitation may be the recognised importance of subclinical and atypical symptoms of disease at advanced age, and how they may influence the assessment of illness severity in ED triage, before clinical input by trained geriatric professionals. [
      • Rutschmann OT
      • Chevalley T
      • Zumwald C
      • Luthy C
      • Vermeulen B
      • Sarasin FP
      Pitfalls in the emergency department triage of frail elderly patients without specific complaints.
      ]
      Home FIRsT interventions aim to positively influence patient experience times in older ED attendees, but assessments can take a few hours at a time (especially when Medical Social Worker interventions are necessary) and a limitation is that we did not have data as to how long Home FIRsT's assessments took. However, it is likely that in settings where there is a rigid disposition time target (e.g. 4-hour NHS target) it would be very challenging to run a service such as Home FIRsT. Overall, our study contributes important observations but does not provide causal evidence as to whether and to what extent geriatric assessment within the ED may influence disposition. Indeed, our results are only applicable to our centre and cannot help systematically identify a priori who would benefit from an admission avoidance (e.g. delirium may be manageable at home with the appropriate supports). Rather, the benefits of a CGA-driven, individualised patient approach are suggested.
      In the future, there may be potential for a reduced number of ‘multi-skilled professionals’ (including a suitable trained physician) to be able to deliver Home FIRsT-like services 24 hours a day, seven days a week. However, a limitation of such development may be that rapid access to social supports (which often ‘save the day’ in terms of avoiding admissions) are not normally available out of hours; hence, for such service to be successful, the out-of-hospital system (including community services) should also be able to offer a continuous service.
      Geriatric giants are large and powerful; if they are to be confronted, they must be taken seriously; for this, recognition is an essential first step’. [

      Rockwood K. Translating Isaacs. Available online: https://britishgeriatricssociety.wordpress.com/2016/07/28/translating-isaacs/ (accessed 2 July 2020). 2016.

      ] Our study illustrates the importance of the routine measurement of multiple geriatric dimensions in the ED. However, well-designed trials of interface geriatrics models are still needed to generate high quality evidence. [
      • Conroy SP
      • Stevens T
      • Parker SG
      • Gladman JR
      A systematic review of comprehensive geriatric assessment to improve outcomes for frail older people being rapidly discharged from acute hospital: 'interface geriatrics'.
      ] Indeed, identifying out-of-hospital pathways according to a CGA is a step towards better clinical practice within the ED. However, further to our retrospective observational study, a prospective observational design is necessary to assess longitudinal outcomes such as re-attendance, re-hospitalisation and/or mortality in the months (or years) following patients’ baseline visit. Formal research studies (randomised or at least with a case-control design) are needed in order to demonstrate 1) the extent to which this approach affects the ED admission and the out-of-hospital pathway; and 2) whether there is a clinical benefit for patients compared with ED usual care.

      Funding

      None.

      Declaration of Competing Interest

      The authors declare they have no conflict of interest.

      Appendix. Supplementary materials

      References

        • Carter EJ
        • Pouch SM
        • Larson EL
        The relationship between emergency department crowding and patient outcomes: a systematic review.
        J Nurs Scholarsh. 2014; 46: 106-115
        • 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; 71: 98-101
        • Conroy SP
        • Ansari K
        • Williams M
        • Laithwaite E
        • Teasdale B
        • Dawson J
        • et al.
        A controlled evaluation of comprehensive geriatric assessment in the emergency department: the 'Emergency Frailty Unit'.
        Age Ageing. 2014; 43: 109-114
        • Conroy SP
        • Turpin S
        New horizons: urgent care for older people with frailty.
        Age Ageing. 2016; 45: 577-584
        • Adams JG
        • Gerson LW.
        A new model for emergency care of geriatric patients.
        Acad Emerg Med. 2003; 10: 271-274
      1. Kenny RA, McGarrigle C. Health and Wellbeing: Active Ageing for Older Adults in Ireland: Evidence from The Irish Longitudinal Study on Ageing. Chapter 1: Introduction. Available online: https://tilda.tcd.ie/publications/reports/W3KeyFindings/index.php [accessed 28 June 2020]. TILDA Reports. 2016.

        • McCabe JJ
        • Kennelly SP.
        Acute care of older patients in the emergency department: strategies to improve patient outcomes.
        Open Access Emerg Med. 2015; 7: 45-54
        • Cullen P.
        Plan to keep frail A&E patients out of hospital saves almost 4,000 bed nights: St James's Hospital initiative also ensures well patients are discharged promptly.
        The Irish Times, 2018 ([published: 7 December 2018]Available online) (accessed 14 June 2020)
        • O'Shaughnessy I
        • Edge L
        • Dillon A
        • Flynn S
        • Cunningham C
        • Briggs R MR
        Home FIRsT - Outcomes of a Frailty Intervention and Response Team in the Emergency Department of a Large Acute Teaching Hospital.
        Age and Ageing. 2018; 47: v13-v60
      2. SJH. St James's Hospital Annual Report 2017. Available online: http://www.stjames.ie/media/SJH%20Annual%20Report%202017.pdf (accessed 11 November 2020). 2017.

        • Cooke MW
        • Jinks S.
        Does the Manchester triage system detect the critically ill?.
        J Accid Emerg Med. 1999; 16: 179-181
        • Aliberti MJ
        • Suemoto CK
        • Fortes-Filho SQ
        • Melo JA
        • Trindade CB
        • Kasai JY
        • et al.
        The Geriatric Day Hospital: Preliminary Data on an Innovative Model of Care in Brazil for Older Adults at Risk of Hospitalization.
        J Am Geriatr Soc. 2016; 64: 2149-2153
        • O'Caoimh R
        • Kennelly S
        • O'Shea D
        Can the Geriatric Day Hospital Act As a Hub for Services for Older People across the Spectrum of Ageing from Active Ageing to Advanced Frailty?.
        Front Med (Lausanne). 2018; 5: 23
      3. NC&ICP. Making a start in Integrated Care for Older Persons guide. Available online: https://www.icpop.org/single-post/2018/11/14/Making-a-start-in-Integrated-Care-for-Older-Persons-guide. Accessed 2 July 2020. 2017.

        • Rockwood K
        • Song X
        • MacKnight C
        • Bergman H
        • Hogan DB
        • McDowell I
        • et al.
        A global clinical measure of fitness and frailty in elderly people.
        CMAJ. 2005; 173: 489-495
        • Rockwood K
        • Theou O.
        Using the Clinical Frailty Scale in Allocating Scarce Health Care Resources.
        Can Geriatr J. 2020 Sep 1; 23: 210-215
        • Bellelli G
        • Morandi A
        • Davis DH
        • Mazzola P
        • Turco R
        • Gentile S
        • et al.
        Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people.
        Age Ageing. 2014; 43: 496-502
        • Í O'Shaughnessy
        • R Briggs
        • Timmons S
        • Cunningham C
        286 Predictors and Outcomes of Older Persons Attending the Emergency Department of a Large Acute Dublin Teaching Hospital.
        Age and Ageing. 2019; 48: iii17-iii65
        • Hastings SN
        • Purser JL
        • Johnson KS
        • Sloane RJ
        • Whitson HE
        Frailty predicts some but not all adverse outcomes in older adults discharged from the emergency department.
        J Am Geriatr Soc. 2008; 56: 1651-1657
        • Romero-Ortuno R
        • Forsyth DR
        • Wilson KJ
        • Cameron E
        • Wallis S
        • Biram R
        • et al.
        The Association of Geriatric Syndromes with Hospital Outcomes.
        J Hosp Med. 2017; 12: 83-89
        • Alabaf Sabbaghi S
        • De Souza D
        • Sarikonda P
        • Keevil VL
        • Wallis SJ
        • Romero-Ortuno R
        Allocating patients to geriatric medicine wards in a tertiary university hospital in England: A service evaluation of the Specialist Advice for the Frail Elderly (SAFE) team.
        Aging Med (Milton). 2018; 1: 120-124
        • Pulok MH
        • Theou O
        • van der Valk AM
        • Rockwood K
        The role of illness acuity on the association between frailty and mortality in emergency department patients referred to internal medicine.
        Age Ageing. 2020;
        • Romero-Ortuno R
        • Wallis S
        • Biram R
        • Keevil V
        Clinical frailty adds to acute illness severity in predicting mortality in hospitalized older adults: An observational study.
        Eur J Intern Med. 2016; 35: 24-34
        • Elliott A
        • Hull L
        • Conroy SP
        Frailty identification in the emergency department-a systematic review focussing on feasibility.
        Age Ageing. 2017; 46: 509-513
        • Wallis SJ
        • Wall J
        • Biram RW
        • Romero-Ortuno R
        Association of the clinical frailty scale with hospital outcomes.
        QJM. 2015; 108: 943-949
        • So R.K.L.
        • Bannard-Smith J.
        • Subbe C.P
        • et al.
        The association of clinical frailty with outcomes of patients reviewed by rapid response teams: an international prospective observational cohort study.
        Crit Care. 2018; 22: 227
        • Choutko-Joaquim S
        • Tacchini-Jacquier N
        • Pralong D'Alessio G
        • Verloo H
        Associations between Frailty and Delirium among Older Patients Admitted to an Emergency Department.
        Dement Geriatr Cogn Dis Extra. 2019; 9: 236-249
        • Wang J
        • Kong D
        • Yu F
        • Conwell Y
        • Dong X
        Cognitive deficit, physical frailty, hospitalization and emergency department visits in later life.
        Aging Ment Health. 2019; : 1-7
        • Brouns SHA
        • Mignot-Evers L
        • Derkx F
        • Lambooij SL
        • Dieleman JP
        • Haak HR
        Performance of the Manchester triage system in older emergency department patients: a retrospective cohort study.
        BMC Emerg Med. 2019; 19: 3
        • Kakuma R
        • du Fort GG
        • Arsenault L
        • Perrault A
        • Platt RW
        • Monette J
        • et al.
        Delirium in older emergency department patients discharged home: effect on survival.
        J Am Geriatr Soc. 2003; 51: 443-450
        • Keevil VL
        • Martin GJ
        • Biram R
        • Wallis S
        • Romero-Ortuno R
        Care home residents admitted to hospital through the emergency pathway: characteristics and associations with inpatient mortality.
        J R Coll Physicians Edinb. 2018; 48: 202-209
        • Briggs R
        • Coughlan T
        • Collins R
        • O'Neill D
        • Kennelly SP
        Nursing home residents attending the emergency department: clinical characteristics and outcomes.
        QJM. 2013; 106: 803-808
        • Rutschmann OT
        • Chevalley T
        • Zumwald C
        • Luthy C
        • Vermeulen B
        • Sarasin FP
        Pitfalls in the emergency department triage of frail elderly patients without specific complaints.
        Swiss Med Wkly. 2005 Mar 5; 135: 145-150
      4. Rockwood K. Translating Isaacs. Available online: https://britishgeriatricssociety.wordpress.com/2016/07/28/translating-isaacs/ (accessed 2 July 2020). 2016.

        • Conroy SP
        • Stevens T
        • Parker SG
        • Gladman JR
        A systematic review of comprehensive geriatric assessment to improve outcomes for frail older people being rapidly discharged from acute hospital: 'interface geriatrics'.
        Age Ageing. 2011; 40: 436-443