The association of geriatric syndromes with hospital outcomes

Sample

We analyzed all first nonelective inpatient episodes (ie, from ED admission to discharge) of people 75 years and older (all specialties) between the October 26, 2014 and the October 26, 2015. Data were obtained via the hospital’s information systems following the implementation of a new electronic patient record on October 26, 2014.

Patients’ Characteristics

The following anonymized variables were extracted:

• Age and gender
• AIS information is routinely collected in our ED using a Modified Early Warning Score (ED-MEWS). The components and scoring of ED-MEWS are shown in Table 1. Where more than 1 ED-MEWS was collected, the highest was used in the analyses.
• Charlson Comorbidity Index (CCI, without age adjustment).¹³ The CCI is based on the discharge diagnoses, as coded according to WHO International Classification of Diseases, v 10 (ICD-10). The CCI was calculated retrospectively and would have not been available to clinicians early during the patients’ admission.
• Clinical Frailty Scale (CFS). The scoring of CFS is based on a global assessment of patients’ comorbidity symptoms, and their level of physical activity and dependency on activities of daily living, estimated to reflect the status immediately before the onset of the acute illness leading to hospitalization. The possible scores are: 1 (very fit), 2 (well), 3 (managing well), 4 (vulnerable), 5 (mildly frail), 6 (moderately frail), 7 (severely frail), 8 (very severely frail), and 9 (terminally ill) ().¹⁴ The use of the CFS in admissions of people 75 years and older was introduced in our center in 2013 under a local Commissioning for Quality and Innovation (CQUIN) scheme.⁸ The CQUIN required that all patients 75 years and older admitted to the hospital, via the ED, be screened for frailty using the CFS within 72 hours of admission. The admitting doctor usually scores the CFS on the electronic admission record, but it can also be completed by ED nurses or by nursing or therapy staff from the trust-wide Specialist Advice for the Frail Elderly team. Training on CFS scoring is provided to staff at a hiring orientation and at regular educational meetings. Permission to use CFS for clinical purposes was obtained from the principal investigator at Geriatric Medicine Research, Dalhousie University, Halifax, Canada.
• Cognitive variables were collected early during the admission in patients 75 years and older, thanks to a parallel local CQUIN scheme. The cognitive CQUIN variables are screening variables, not gold standard. The admission clerking is designed to clinically classify patients within 72 hours of admission into the following 3 mutually exclusive categories:

○ Known HoD (in the database: no = 0; yes = 1)

○ ACS, without HoD (in the database: no = 0; yes = 1)

○ Neither HoD nor ACS

• The cognitive CQUIN assessment does not intend to diagnose dementia in those who are not known to have it, but tries to separate the dementias that general practitioners (GPs) know from hospital-identified acute cognitive concerns that GPs may need to assess or investigate after discharge. The latter may include delirium and/or undiagnosed dementia.
• In our routine hospital practice, the initial cognitive assessment is performed by a clinician in the following fashion: if the patient is known to have dementia (ie, based on clinical history and/or chart review), the clinician selects the “known history of dementia” option in the admission navigator, and no further cognitive screening is conducted. If the patient has no known dementia, the clinician administers the 4-item Abbreviated Mental Test (AMT4): (1) age, (2) date of birth, (3) place, and (4) year, with impaired cognition indicated by an AMT4 of less than 4 and triggering the selection of “ACS without known HoD” option. If the AMT4 is normal, the clinician selects the “neither HoD nor ACS” option.
• Due to the service evaluation nature of our work, these measures could not be assessed for reliability within the electronic medical records system (eg, regarding sensitivity and specificity against a gold standard or inter-rater reliability).
• Discharged from geriatric medicine (no = 0; yes = 1). Every year, our hospital admits over 12,000 patients 75 years and older, of which 25% are managed by the Department of Medicine for the Elderly (DME). The DME specialist bed base consists of 5 core wards, which specialize in ward-based comprehensive geriatric assessment (CGA) and are supported by dedicated nursing, physiotherapy, occupational therapy, and social work teams, as well as by readily available input from speech and language therapy, clinical nutrition, psychogeriatric, pharmacy and palliative care teams. Formal multidisciplinary team meetings occur at least twice weekly. A sixth specialist DME ward with a more acute perspective has been operational for 7 years; this ward was renamed the Frailty and Acute Medicine for the Elderly (FAME) ward in 2014 and has daily multidisciplinary team meetings. Although admission to FAME is through the ED, admission to core DME wards can occur from FAME (ie, within-DME transfer), via the ED, or from other inpatient specialty areas if older patients are perceived to be in high need of CGA after screening by the Specialist Advice for the Frail Elderly team. An audit in our center showed that up to 20% of patients discharged by DME were not initially admitted by DME, underscoring the significant role of core specialist DME wards in absorbing complex cases, especially from the general medical wards.⁸
• Discharged from general medicine (no = 0; yes = 1). In our setting, virtually all patients discharged by general medicine were first admitted by general medicine.⁸
• Discharged by a surgical specialty (no = 0; yes = 1)