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Original article

Vol. 151 No. 1718 (2021)

Implementation of a telemedicine geriatric co-evaluation in the emergency department: a prospective pilot study

DOI
https://doi.org/10.4414/smw.2021.20500
Cite this as:
Swiss Med Wkly. 2021;151:w20500
Published
05.05.2021

Summary

INTRODUCTION

Complex drug management is a common challenge in the treatment of geriatric patients. Pandemic scenarios, such as the current one (COVID-19), call for a reduction of face-to-face meetings, especially for elderly patients. Therefore, the aim of the present study was to compare the innovative concept of applying telemedical assessment to geriatric patients in the emergency department (ED) with ED standard treatment. The therapeutic recommendations regarding drug management from the two assessments were compared. A special focus was the use of potentially inadequate drugs (PIMs) for geriatric patients according to the “Fit for the Aged” (FORTA) classification.

METHODS

50 patients (40% female) aged ≥70 years and assessed with an Identification of Seniors at Risk Score (ISAR score) of ≥2 admitted to the ED were prospectively enrolled in this study between November 2017 and February 2018. In addition to the standard treatment in the ED, co-evaluation via video transmission was independently carried out by a board-certified geriatrician. Drug recommendations by ED physicians (A) and the geriatrician (B) were compared.

RESULTS

There was a significantly higher frequency of recommendations regarding changes to preexisting medication (p <0.001, n = 50) via geriatric telemedicine in comparison with standard ED treatment. The geriatrician intervened significantly more often than the ED physicians: discontinuation of a drug, p <0.001; start of a new drug, p = 0.004; dose change of a drug, p = 0.001; n = 50). Based on the additional therapy recommendations of the geriatrician, the amount of medication taken by the patient was significantly reduced compared with standard ED treatment (ED assessment t(49) = 0.622 vs geriatrician’s assessment t(49) = 4.165; p <0.001; n = 50). Additionally, the number of PIMs was significantly reduced compared with standard medical treatment (p <0.001). The geriatrician changed 53.9% of the drugs (35/65) whereas the ED physicians changed only 12.3% (8/65). Recommendations for immediate drug therapy, however, were made more frequently by ED physicians (p <0.039, n = 50).

DISCUSSION

An early assessment of elderly emergency patients by a geriatrician had a significant impact on the number of drug interventions in the ED. The number of PIMs could be significantly reduced. Whether this also has a positive effect on the further inpatient course needs to be investigated in further prospective studies.

The study was retrospectively registered at ClinicalTrials.gov (NCT04148027).

References

  1. Martin-Khan M Burkett E Schnitker L Jones RN Gray LC. Methodology for developing quality indicators for the care of older people in the Emergency Department. BMC Emerg Med. 2013;13(1):23. doi:.https://doi.org/10.1186/1471-227X-13-23
  2. Rowe JW Andres R Tobin JD Norris AH Shock NW. The effect of age on creatinine clearance in men: a cross-sectional and longitudinal study. J Gerontol. 1976;31(2):155–63. doi:.https://doi.org/10.1093/geronj/31.2.155
  3. Klotz U. Pharmacokinetics and drug metabolism in the elderly. Drug Metab Rev. 2009;41(2):67–76. doi:.https://doi.org/10.1080/03602530902722679
  4. Hübscher A Isenmann S. Delir: Konzepte, Ätiologie und klinisches Management [Delirium: Concepts, Etiology, and Clinical Management]. Fortschr Neurol Psychiatr. 2016;84(4):233–44. Article in German. doi:https://dio.org/10.1055/s-0042-104502.
  5. Burkhardt H Wehling M Gladisch R. Pharmakotherapie älterer Patienten [Pharmacotherapy of elderly patients]. Internist (Berl). 2007;48(11):1220–31, 1222–4, 1226–31. Article in German. doi:.https://doi.org/10.1007/s00108-007-1947-1
  6. Schnitker LM Martin-Khan M Burkett E Brand CA Beattie ER Jones RN Research Collaboration for Quality Care of Older Persons: Emergency Care Panel. Structural quality indicators to support quality of care for older people with cognitive impairment in emergency departments. Acad Emerg Med. 2015;22(3):273–84. doi:.https://doi.org/10.1111/acem.12617
  7. Long SJ Brown KF Ames D Vincent C. What is known about adverse events in older medical hospital inpatients? A systematic review of the literature. Int J Qual Health Care. 2013;25(5):542–54. doi:.https://doi.org/10.1093/intqhc/mzt056
  8. Beers MH Ouslander JG Rollingher I Reuben DB Brooks J Beck JC UCLA Division of Geriatric Medicine. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med. 1991;151(9):1825–32. doi:.https://doi.org/10.1001/archinte.1991.00400090107019
  9. Werner H. Arzneimitteltherapie im Alter: zu viel und zu wenig, was tun? – Ein neues Bewertungssystem: fit for the aged (FORTA) [Drug therapy in the aged: too much and too little, what to do? A new evaluation system: fit for the aged (FORTA)]. Dtsch Med Wochenschr. 2009;134(3):95–6, author reply 96. Article in German. doi:.https://doi.org/10.1055/s-0028-1105898
  10. Galli TB Reis WC Andrzejevski VM. Potentially inappropriate prescribing and the risk of adverse drug reactions in critically ill older adults. Pharm Pract (Granada). 2016;14(4):818. doi:.https://doi.org/10.18549/PharmPract.2016.04.818
  11. Masnoon N Shakib S Kalisch-Ellett L Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017;17(1):230. doi:.https://doi.org/10.1186/s12877-017-0621-2
  12. Marx G Beckers R Brokmann JC Deisz R Pape HC. Telekooperation für die innovative Versorgung am Beispiel des Universitätsklinikums Aachen : Telematik in der Intensivmedizin (TIM), Telenotarzt und Telemedizinische intersektorale Rehabilitationsplanung in der Alterstraumatologie (TIRA) [Tele-cooperation for innovative care using the example of the University Hospital Aachen. Telematics in intensive care medicine, emergency medicine, and telemedical intersectoral rehabilitation planning in geriatric trauma]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2015;58(10):1056–61. Article in German. doi:.https://doi.org/10.1007/s00103-015-2224-4
  13. Lecce C. Einsatz von Telemedizin bei geriatrischen Notfallpatienten [dissertation]. Aachen (Germany): RWTH Aachen University; 2021.
  14. Yao JL Fang J Lou QQ Anderson RM. A systematic review of the identification of seniors at risk (ISAR) tool for the prediction of adverse outcome in elderly patients seen in the emergency department. Int J Clin Exp Med. 2015;8(4):4778–86.
  15. Rote Liste. Rote Liste - Arzneimittelinformationen für Deutschland. https://www.rote-liste.de/, 2018.
  16. Milton JC Hill-Smith I Jackson SHD. Prescribing for older people. BMJ. 2008;336(7644):606–9. doi:.https://doi.org/10.1136/bmj.39503.424653.80
  17. Muhlack DC Hoppe LK Weberpals J Brenner H Schöttker B. The Association of Potentially Inappropriate Medication at Older Age With Cardiovascular Events and Overall Mortality: A Systematic Review and Meta-Analysis of Cohort Studies. J Am Med Dir Assoc. 2017;18(3):211–20. doi:.https://doi.org/10.1016/j.jamda.2016.11.025
  18. Kim M Mitchell SH Gatewood M Bennett KA Sutton PR Crawford CA Older adults and high-risk medication administration in the emergency department. Drug Healthc Patient Saf. 2017;9:105–12. doi:.https://doi.org/10.2147/DHPS.S143341
  19. Laatikainen O Sneck S Bloigu R Lahtinen M Lauri T Turpeinen M. Hospitalizations Due to Adverse Drug Events in the Elderly-A Retrospective Register Study. Front Pharmacol. 2016;7:358. doi:.https://doi.org/10.3389/fphar.2016.00358
  20. Alhawassi TM Krass I Bajorek BV Pont LG. A systematic review of the prevalence and risk factors for adverse drug reactions in the elderly in the acute care setting. Clin Interv Aging. 2014;9:2079–86.
  21. Sinha SK Bessman ES Flomenbaum N Leff B. A systematic review and qualitative analysis to inform the development of a new emergency department-based geriatric case management model. Ann Emerg Med. 2011;57(6):672–82. doi:.https://doi.org/10.1016/j.annemergmed.2011.01.021
  22. 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;39(3):238–47. doi:.https://doi.org/10.1067/mem.2002.121523
  23. Preston LR, Chambers D, Campbell F, Cantrell A, Turner J, Goyder E. What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review. National Institute for Health Research. Southampton, UK: Queen’s Printer and Controller of HMSO; 2018.
  24. 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(4):436–43. doi:.https://doi.org/10.1093/ageing/afr060
  25. Fealy G McCarron M O’Neill D McCallion P Clarke M Small V Effectiveness of gerontologically informed nursing assessment and referral interventions for older persons attending the emergency department: systematic review. J Adv Nurs. 2009;65(5):934–45. doi:.https://doi.org/10.1111/j.1365-2648.2009.04961.x
  26. Jay S Whittaker P Mcintosh J Hadden N. Can consultant geriatrician led comprehensive geriatric assessment in the emergency department reduce hospital admission rates? A systematic review. Age Ageing. 2017;46(3):366–72. doi:.https://doi.org/10.1093/ageing/afw231
  27. Lowthian JA McGinnes RA Brand CA Barker AL Cameron PA. Discharging older patients from the emergency department effectively: a systematic review and meta-analysis. Age Ageing. 2015;44(5):761–70. doi:.https://doi.org/10.1093/ageing/afv102
  28. American College of Emergency PhysiciansAmerican Geriatrics SocietyEmergency Nurses AssociationSociety for Academic Emergency MedicineGeriatric Emergency Department Guidelines Task Force. Geriatric emergency department guidelines. Ann Emerg Med. 2014;63(5):e7–25. doi:.https://doi.org/10.1016/j.annemergmed.2014.02.008
  29. Hughes JM Freiermuth CE Shepherd-Banigan M Ragsdale L Eucker SA Goldstein K Emergency Department Interventions for Older Adults: A Systematic Review. J Am Geriatr Soc. 2019;67(7):1516–25. doi:.https://doi.org/10.1111/jgs.15854
  30. Hilty DM Ferrer DC Parish MB Johnston B Callahan EJ Yellowlees PM. The effectiveness of telemental health: a 2013 review. Telemed J E Health. 2013;19(6):444–54. doi:.https://doi.org/10.1089/tmj.2013.0075
  31. Narasimha S Madathil KC Agnisarman S Rogers H Welch B Ashok A Designing Telemedicine Systems for Geriatric Patients: A Review of the Usability Studies. Telemed J E Health. 2017;23(6):459–72. doi:.https://doi.org/10.1089/tmj.2016.0178
  32. Brignell M Wootton R Gray L. The application of telemedicine to geriatric medicine. Age Ageing. 2007;36(4):369–74. doi:.https://doi.org/10.1093/ageing/afm045