Care of the Older Adult in the Emergency Department   38  

Marie Boltz and Amala Sooklal

OVERVIEW

Older adults aged 65 years and older use more ED services than any other age group, comprising approximately 21% to 40% of all consumers who use the ED (Niska, Bhuiya, & Xu, 2010). One in five patients aged 65 to 74 years and one in four patients aged 75 years and older visit the ED each year; the percentage of ED visits made by nursing home (NH) residents, patients arriving by ambulance, and patients admitted to the hospital increases with age (Albert, McCaig, Jill, & Ashman, 2013). Approximately 42% of ED visits of patients 65 years and older result in hospitalization.

The ED plays a critical role in the health care system for older adults. Most common, it is the point of entry for hospitalization. The higher prevalence of chronic disease and exacerbations of these conditions is one reason for high utilization (Salvi et al., 2007; Samaras, Chevalley, Samaras, & Gold, 2010). In other cases, older adults transition from the ED to other settings such as long-term care or mental health facilities. Finally, others receive care for crises such as mistreatment or displacement. The ED may be used for the performance of complex diagnostic workups, overflow, and off-hours medical care; for some older adults, the ED is the only source of health care evaluation and treatment (Gonzalez Morganti et al., 2013; Samaras et al., 2010). This chapter describes evidence-based approaches to assessing the older adult presenting to the ED, as well as interventions to prevent and manage common geriatric syndromes that occur before or during the ED admission. Transitions from the ED and organizational approaches to senior-friendly ED care are also discussed.

BACKGROUND AND STATEMENT OF PROBLEM

Older adults present to the ED with serious complaints, such as injury, dyspnea, chest pain, and abdominal pain, as well as nonspecific complaints, including weakness, fatigue, and dizziness, which may indicate serious disease (Wilber & Gerson, 2009). As compared to younger people, older adults have more diagnostic tests, longer stays in the ED, and are more likely to be admitted to the hospital (Banerjee, Dehnadi, & Mbamalu, 2011). Those older adults who are discharged from the ED are more likely to be readmitted; they also risk functional loss and higher rates of mortality (McCusker et al., 2007; Niska et al., 2010; Sklar et al., 2007).

Although they represent a cohort of frequent ED users, it has been argued that older adults typically do not receive specialized care. As compared to younger persons, older adults are more likely to experience missed or incorrect diagnoses (Salvi et al., 2007), inadequate pain management (Hwang, Richardson, Harris, & Morrison, 2010; Iyer, 2011), and less information (Baillie, 2005; George, Jell, & Todd, 2006). There is international consensus that care of older adults in the ED warrants close attention and systemic approaches that support uptake of evidence-based care (Gruneir, Silver, & Rochon, 2011; Parke & McCusker, 2008).

ASSESSMENT OF THE OLDER ADULT IN THE ED

The complex presentation of disease and illness in older adults, along with complicated polypharmacy, functional impairments (Schnitker, Martin-Khan, Beattie, & Gray, 2011; Wilber, Blanda, & Gerson, 2006), communication problems, and cognitive impairment (Press et al., 2009; Salvi et al., 2007), presents a challenge to the ED nurse. Therefore, assessment of older adults encompasses a comprehensive evaluation to detect critical health issues hidden within a complex clinical and social presentation. Whenever possible, and with the permission of the older adult, the emergency nurse should include the patient’s significant other, family, and support person in the assessment process (Boltz, Parke, Shuluk, Capezuti, & Galvin, 2013). The three major components of assessment include triage, risk assessment to prevent adverse outcomes, and general assessment.

Triage/Primary Assessment

Accurate triage of elder patients is a key component of providing effective emergency care for this vulnerable population. The large number of ED visits by elders, the growing problem of ED crowding, and the longer time it takes to evaluate older adults often result in delays at the point of triage (Platts-Mills et al., 2010; Salvi et al., 2007). Delays in triage are associated with increased waiting time, anxiety, and discomfort for older adults (Miró et al., 1999). Moreover, the resulting delay in treatment increases the risk of mortality, especially in older trauma patients (Perdue, Watts, Kaufmann, & Trask, 1998). Thus, there is a need for triage that promotes timely treatment.

The Canadian Triage and Acuity Scale (CTAS) is widely used as an emergency patient triage tool. The CTAS has demonstrated high validity for older adults and it is an especially useful tool for categorizing severity and for recognizing older adults who require immediate life-saving intervention (Bullard, Unger, Spence, & Grafstein, 2008; Lee et al., 2011). See Table 38.1 for the CTAS levels and associated descriptions, examples of conditions, and recommended time to be seen by a physician in an ED. Another tool, the Emergency Severity Index (ESI), includes a comprehensive algorithm that describes symptoms, and physiological indicators as well as the resources anticipated to be used (Gilboy, Tanabe, Travers, & Rosenau, 2012). However, there has been reported under-triage in older adults when the ESI guidelines are not precisely followed (Platts-Mills et al., 2010).

Airway–Breathing–Circulation

The goal of the primary assessment is to identify and immediately treat the patient for all life-threatening conditions, incorporating prearrival information from emergency medical services. During the assessment of airway patency, the emergency clinician considers the physiological changes with age that may alter patency of the airway. Dentures can occlude the airway if dislodged; additionally, dentures can cause difficulty with bag-valve mask ventilation of the airway. Kyphosis and other spinal alignment changes may cause changes in positioning of a cervical collar or spinal backboard, which may inhibit appropriate airway patency. Cervical rigidity may present challenges to establishing of a definitive airway (Aresco & Stein, 2010). The quality of breathing and ventilation is evaluated. While assessing the volume of lung expansion and effectiveness of breathing, it is important to consider that pulmonary vascular tissue and parenchyma tissue may become stiff and cause decreased compliance as well as an increase in pulmonary vascular resistance. Lung capacity is diminished by alveolar changes in depth and width. Older adults are at risk to have decreased respiratory reserve and arterial blood oxygenation, which can lead to decompensation sooner than their younger counterparts (Blumenthal, Plummer, & Gambert, 2010). Assessment of circulation may also be affected by physiological changes with increased age. Patients with cardiac history may be consuming antihypertensive medications or rate-control medications that may inhibit or alter the physiological responses. Additionally, hypertension in the patient may mask the signs of a lowered blood pressure caused by hypovolemic shock (Criddle, 2013).

Patients older than age 65 years are more likely to present with dysrhythmias. During the assessment phase, other causes of abnormal cardiac function should be evaluated, such as electrolyte imbalances, hypoxia, cardiac injury, or hypovolemia (McQuillan, Makic, & Whalen, 2009). Vague and, in some cases, nondramatic presentations indicate serious, life-threatening problems in older adults. Table 38.2 shows the common atypical presentation of geriatric emergencies. Additionally, “red flags” during triage that should be evaluated closely include acute change in mental status and/or physical function, dyspnea, fatigue, self-neglect, apathy, and falls (Fletcher, 2004).

TABLE 38.1

Canadian Triage and Acuity Scale (CTAS) Used in an ED

Screening for Risk of Adverse Outcomes

Two commonly used tools, the Identification of Seniors at Risk (ISAR) and the Triage Risk Screening Tool (TRST), evaluate the presence/absence of risk factors for adverse outcomes. These tools are useful in guiding a plan to preventing avoidable complications during the ED stay, if admitted during hospitalization, and after an ED visit, when transitioning to home or another setting. The TRST (Table 38.3) is considered positive when an older adult has cognitive impairment or has two or more of the remaining risk factors and the screening has been found to be predictive of subsequent ED use, hospitalization, and NH admission (Meldon et al., 2003). The ISAR tool (Table 38.4) is positive when the score is greater than or equal to 2 and is a predictor of increased risk of death, institutionalization, functional decline, and both repeat ED visit and hospital admission in the following 6 months after an ED visit (McCusker et al., 1999). ISAR or TRST is administered by a nurse just after triage, to identify high-risk patients more likely to benefit from a comprehensive geriatric evaluation and follow-up, a longer observation time (or access to observation units), and appropriate referrals (primary physician, geriatric evaluation and management unit, and social service). Furthermore, all patients noted to be at risk who are admitted to the hospital are referred to case management; those who are discharged from the hospital can be followed up the following day, either through a home visit or telephone consultation (Salvi et al., 2012).

TABLE 38.2

Atypical Presentation of Common Geriatric Emergencies

Adapted from Fletcher, (2004).

TABLE 38.3

Triage Risk Screening Tool (TRST)

^aEmergency department (ED) nurse (RN) concern for elder abuse/neglect, substance abuse, medication noncompliance, problems meeting instrumental activities of daily living, or other.

Adapted from Meldon et al. (2003).

TABLE 38.4

Identification of Seniors At Risk Tool

Adapted from McCusker et al. (1999).

General Assessment

At a minimum, the social history should address the person’s living situation, marital status, work status, and advance directives. A social assessment also focuses on supports within the family and in the community. A way to assess this is to ask, “If something bad happened, who would you call?” Stressors related to loss, grief, relationship changes, and environmental factors are often antecedents to acute onset or exacerbation of illness, and should be ascertained (Graf, Zekry, Giannelli, Michel, & Chevalley, 2011). In addition to the past medical/surgical history, medication use, and allergies, weight loss/changes in oral intake, and details of recent changes in diagnosis or medication regimes are standard data. When evaluating the reason for coming to the ED, the nurse should elicit a comparison between the older adult’s condition before the acute illness and new or exacerbated symptoms. Information about baseline cognition, mood, and physical function is essential as changes within these dimensions can be early and sensitive indicators of physiological dysfunction (Ellis, Marshall, & Ritchie, 2014; Hare, Wynaden, McGowan, & Speed, 2008).

Cognition and Mood

It is estimated that one fourth of all older adults who present to the ED show impaired mental status associated with delirium, dementia, or both (Hustey & Meldon, 2002; Hustey, Meldon, Smith, & Lex, 2003). Although common in older ED patients, cognitive impairment is often undetected (Hustey & Meldon, 2002; Lewis et al., 1995). The Geriatric Emergency Medicine Task Force recommends a mental status evaluation for all older adults presenting to the ED (Wilber, Lofgren, et al., 2005). The Six-Item Screener (immediate recall of three words; orientation to year, month, day of the week; recall of three words) is short and easy to use and detects cognitive impairment with a sensitivity of 94% and a specificity of 86% in the ED setting (Callahan, Unverzagt, Hui, Perkins, & Hendrie, 2006). If cognitive impairment is detected, the family or formal caregiver should be questioned as to the baseline cognition; abrupt onset suggests delirium.

The Geriatric Emergency Department Guidelines Task Force (2014), developed by the Emergency Nurses Association, American College of Emergency Physicians, American Geriatrics Society, and Society for Academic Emergency Medicine, includes a two-step process to assess for delirium. Step 1 (Figure 38.1) is the highly sensitive delirium triage screen (DTS). Step 2 is the highly specific Brief Confusion Assessment Method (bCAM; Han et al., 2013).

The DTS is comprised of two parts: (a) level of consciousness as measured by the Richmond Agitation Sedation Scale (RASS); and (b) inattention by spelling the word “LUNCH” backwards. If the patient has an RASS other than 0 (0 = alert and calm; Ely et al., 2003) or makes more than one error on the “LUNCH” backward spelling test, then the DTS is considered positive. The bCAM is then used to rule in delirium.

A variety of ED-appropriate dementia and mild cognitive impairment screening instruments have been validated; they are useful to reduce the probability of nondelirium cognitive impairment (dementia or mild cognitive impairment) rather than to rule-in the diagnosis (Geriatric Emergency Department Guidelines Task Force, 2014). On the diagnosis of delirium, attention is paid to identifying the underlying cause, which can be infection, medications, dehydration, electrolyte imbalance, alcohol/drug use or withdrawal, depression, stroke or other neurological problems (Elie, Cole, Primeau, & Bellavance, 1998) Additionally, the following should be evaluated as risk factors for the development of delirium: decreased vision or hearing, decreased cognitive ability, severe illness, or dehydration/prerenal azotemia (Geriatric Emergency Department Guidelines Task Force, 2014).

FIGURE 38.1

(A) Step 1: Delirium triage screen. (B) Brief Confusion Assessment Method.

bCAM, Brief Confusion Assessment Method; DTS, delirium triage screen; RASS, Richmond Agitation Sedation Scale.

Depression may interfere with the clinical presentation of acute medical disorders and results in a larger number of ED visits (Fabacher, Raccio-Robak, McErlean, Milano, & Verdile, 2002). Approximately one third of older ED patients present with depression (Meldon et al., 2003; Sanders, 2001). The Emergency Department Depression Screening Instrument (ED-DSI) is appropriate for the detection of depression in the ED; it is brief, consisting of three questions (Do you often feel (a) sad and depressed? (b) helpless? (c) downhearted and blue?). The ED-DSI has a sensitivity of 79% and a specificity of 66% as compared with the longer Geriatric Depression Scale (Fabacher et al., 2002).

Physical Function

Physical function is an important metric of health in older adults, as described in Chapter 7, “Assessment of Physical Function.” A recent loss of function often precedes a visit to the ED and can signify underlying illness (Wilber, Blanda, & Gerson, 2006). Additional, information on function is used to benchmark response to treatment as the patient transitions among various settings. Finally, the degree of services, including rehabilitation therapy, is largely guided by an assessment of functional status. Basic activities of daily living (ADL) and instrumental ADL (IADL) function should be assessed for each patient, including capacity for dressing, eating, transferring, toileting, hygiene, ambulation, and medication adherence. Measurement needs to capture baseline function (before the acute admitting problem, typically 2 weeks before admission) as well as current functional performance. Physical function is appraised using a valid measure of basic function such as the Katz ADL Index (Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963) or Barthel Index (Mahoney & Barthel, 1965) and instrumental activities of daily living (IADL) using the Lawton IADL Scale (Lawton & Brody, 1969).

Medication Evaluation

A national surveillance study of adverse drug events (ADE) and a national outpatient survey estimated that Americans aged 65 years or older have more than 175,000 ED visits for ADE yearly. One third of ADE-related visits were attributed to three commonly prescribed drugs: warfarin, insulin, and digoxin (Budnitz, Shehab, Kegler, & Richards, 2007). Furthermore, older adults who are more frequent ED users have a greater number of potentially inappropriate medications (PIMs); they also tend to experience significant delay between hospital discharge and primary care follow-up (Wong, Marr, Kwan, Meiyappan, & Adcock, 2014). In addition to following established medication reconciliation processes, the emergency nurse has a pivotal role in facilitating systematic screening for polypharmacy and use of PIMs as well as detecting ADE in the ED (Samaras et al., 2010). For those patients who demonstrate polypharmacy, PIMs, and/or ADEs, and are admitted, a referral to the pharmacist and interdisciplinary team will enable collaborating with the attending physician to correct the medication problem (Geriatric Emergency Department Guidelines Task Force, 2014).

Fall Assessment

According to the Centers for Disease Control and Prevention (CDC, 2015a), falls are the number one cause of nonfatal injuries treated in hospital emergencies in people older than age 65 years. Furthermore, almost one third of adults aged 65 years and older who fell in a bathroom were diagnosed with a fracture and among adults aged 85 years and older, 38% were hospitalized as a result of their injuries (CDC, 2015).

The appropriate ED evaluation of an older adult who has fallen includes three components: (a) a thorough assessment for traumatic injuries, (b) an assessment of the cause of the fall, and (c) an estimation of future fall risk. Evaluation of the patient for injury should include a complete head-to-toe evaluation for all patients, including those presenting with seemingly isolated injuries. An EKG; complete blood count; standard electrolyte panel; evaluation of medications, including measurable levels; and appropriate imaging should be secured. For those older adults who present to the ED after a fall, traumatic injuries may be occult, presenting without classic signs or symptoms (Geriatric Emergency Department Guidelines Task Force, 2014). High-risk injuries, such as blunt head trauma, spinal fractures, and hip fractures, warrant a higher degree of suspicion and extensive workups (Sterling, O’Connor, & Bonadies, 2001). For example, hip fractures can present as isolated knee pain and can be underdetected on x-ray (Dominguez, Liu, Roberts, Mandell, & Richman, 2005; Guss, 1997). Older adults who have sustained head trauma, even when perceived by the patient to be slight, require neurological assessment and observation (Rathlev et al., 2006). Altered mental state, focal neurologic deficits, headache, and falls may indicate the presence of a chronic subdural hematoma (Adhiyaman, Asghar, Ganeshram, & Bhowmick, 2002).

A targeted interview with the patient and the family member should address previous falls as well as the location, activity, potential environmental factors, and symptoms proceeding the actual fall. This description helps identify a fall as a result of an underlying pathology or general frailty. Falls may be the chief symptom of orthostatic hypotension, cardiovascular syncope, or carotid sinus syndrome (Mitchell, Richardson, Davies, Bexton, & Kenny, 2002). Other responsible pathologies may include acute myocardial infarction, infection, medications (side effects, interactions, and toxicity), metabolic disturbances, neurological event or conditions (e.g., seizure and transient ischemic attack), acute abdominal pathology, or elder abuse (Sanders, 1999). Finally, environmental factors, including physical hazards and unfamiliar surroundings, are common culprits.

A recent systematic review revealed the paucity of evidence in the literature regarding ED-based screening for risk of future falls among older adults (Carpenter et al., 2014). Six fall predictors were identified in more than one study (past falls, living alone, use of walking aid, depression, cognitive deficit, and more than six medications), with a self-report of depression associated with the highest likelihood of falling. Additionally, the assessment of the etiology of a fall will help determine whether a patient will continue to be at risk for a fall at the time of discharge and the potential risk factors (Carpenter, Scheatzle, D’Antonio, Ricci, & Coben, 2009). This may include involving home health services (nursing, physical, or occupational therapies) to schedule a home safety evaluation. A home evaluation typically involves an assessment to determine whether home modifications/hazard removal is needed as well as whether use of assistive devices and proper footwear, medication management, and so forth, will decrease fall risk. Depending on hospital protocol, a physical therapy evaluation in the ED should be considered to ensure a safe discharge home, and is indicated for all patients admitted to the hospital after a fall (Aschkenasy & Rothenhaus, 2006). Communicating the details of the fall event and evaluation is critical during handoff to ensure mobilization of fall-prevention measures (see Chapter 19, “Preventing Falls in Acute Care”).

Substance Misuse

The ED may be the portal to treatment for older adults dealing with substance misuse. Alcohol is the drug that is most commonly misused by older adults, followed by tobacco and psychoactive prescription drugs, with trends indicating an increase in the numbers of older individuals using marijuana (Moore et al., 2009). Misuse is defined as the use of a drug for purposes other than that for which it was intended. Alcohol abuse is present in 6% to 11% of older persons admitted to the hospital and 14% of older adults presenting to the ED have diagnosable alcoholism (Ferreira & Weems, 2008). Validated screening instruments for older adults, including the Alcohol Use Screening and Assessment for Older Adults, have shown to have good to excellent sensitivity and specificity (Ong-Flaherty, 2012). Other simple questions can also uncover a substance abuse problem. For example, the CAGE questionnaire, originally developed for alcohol (Ewing, 1984), has been modified to ascertain drug use and has been tested in older adults with some success. CAGE is an acronym for the four basic questions:

A complete social evaluation is vital given that social risk factors play a role in substance misuse. It is important to evaluate the patient’s social network and identify which members are supportive of treatment and which are potentially hazardous to the patient. Harmful network members include active substance abusers; those who “enable” the patient’s misuse; and those who abuse the patient physically, sexually, or emotionally. In addition, the evaluation should make sure the patient has adequate housing and access to food, adequate transportation, and medical care. The patient’s mood, cognition, sleep patterns, and mental health history, including past treatment, should also be ascertained (Ross, 2005).

When there is evidence of substance misuse, nursing interventions focus on (a) monitoring for withdrawal; (b) providing an environment that is safe from potential harm to patient; and (c) collaborating with the patient, family, physician, and social worker to secure a mental health evaluation and program directed to the substance abuse needs and support. If the patient is admitted to the hospital, careful handoff should include the communication of the patient’s history and clinical findings as well as safety issues, including fall risk and the presence of delirium (Center for Substance Abuse Treatment, 1998).

Elder Mistreatment

EDs are often the first point of contact for elder mistreatment (EM) victims (Fulmer, Paveza, Abraham, & Fairchild, 2000). EM includes physical, verbal, sexual, and psychological abuse, as well as abandonment, exploitation, and neglect (Acierno et al., 2010). The ED nurse needs to be vigilant to recognize the clinical features of EM, and to know their organization’s policies for reporting suspected EM, as required by the Joint Commission on Accreditation and state mandatory reporting requirements (Dong, 2012; Falk, Baigis, & Kopac, 2012). The clinician should look for red flags of mistreatment—delays in seeking treatment, signs of withholding or giving too much medication, missed appointments, use of several hospitals, driving to a hospital farther away from home, description of an event that does not fit the injury sustained, and repetitive injuries (Heath & Phair, 2009). Signs of caregiver indifference, berating or threatening comments, hypervigilant/possessive behavior, or excessive concerns over finances warrant suspicion of EM (Bond & Butler, 2013; Stiegel, Klem, & Turner, 2007).

When EM is suspected, it is recommended to separate the older adult from the caregiver and obtain a detailed history and physical assessment; interviewing the patient about his or her feelings of safety is important (Bond & Butler, 2013). Care needs to be taken by clinicians to secure a careful medical history, including baseline conditions, and conduct a comprehensive physical examination. Physical examination cues may include poor hydration; poor hygiene; suspicious injuries in unusual locations and bruises in various stages of healing; unexplained abrasions and/or markings on skin, including human bite marks, skin tears, pressure ulcers, or genital complaints, including infections or injury (Stiegel et al., 2007).

NURSING INTERVENTIONS

Delirium and Dementia

In addition to collaborating with the physician to detect cognitive impairment, including delirium or delirium superimposed on dementia, the nurse provides key interventions to prevent delirium and promote comfort and safety. Strategies include controlling the environment: (a) supporting the family/familiar person (or volunteer) present with the patient; (b) providing sensory aides (glasses and hearing aids and offering hearing amplifiers and magnifiers as indicated); (c) controlling noise; (d) avoiding excessively bright lights when possible; and (e) providing comfort measures, including fluids and a warm blanket. Additional nursing interventions include promoting mobility and addressing need for pain management, toileting, rest/sleep, and fluid/hydration (Hshieh et al., 2015; Rivosecchi, Smithburger, Svec, Campbell, & Kane-Gill, 2015). Invasive procedures should be avoided as much as possible. Alternatives to physical restraints should be employed such as camouflaging dressings and securing intravenous and other lines to promote comfort. Adapting communication to cognitive loss through the use of verbal and physical cues, brief and clear instructions and inclusion of family in the sharing of information and decision making will promote a sense of security for the patient and promote effective collaboration with family (Boltz, Chippendale, Resnick, & Galvin, 2015; Boltz, Resnick, Chippendale, & Galvin, 2014).

When delirium is detected, interventions are aimed at reversing the cause (which may include the use of supplemental oxygen, hydration, etc.) while continuing to provide supportive preventive measures. The use of physical and chemical restraints should be avoided (American Association of Critical-Care Nurses, 2011). Education about the etiology of delirium and planned interventions will reassure anxious family members and help enlist their involvement in promoting safety and comfort for the patient (Boltz et al., 2014, 2015).

Prevention of Falls and Related Injuries

The aforementioned interventions will also mitigate the risk for falls and injuries. In addition to addressing modifiable fall risk factors, such as offending medications or dehydration, attention to the patient’s safety is paramount. Patients often fall when trying to get out of bed unsupervised or unassisted; bedrails do not reduce the amount of falls and may increase the severity of the fall (Capezuti, Maislin, Strumpf, & Evans, 2002). For the person who is at risk of injury as a result of cognitive impairment, weakness, and low mobility, and who is nonambulatory and at risk of leaving the bed unsafely, low beds should be considered with bedside mats. Close oversight is essential (Capezuti et al., 2002). Encouraging physical activity (e.g., range of motion) and helping the older adult to walk to the bathroom when possible or use of a commode is helpful to prevent early deconditioning and thereby to mitigate fall risk (Alexander, Kinsley, & Waszinski, 2013; Capezuti et al., 2002).

Prevention of Pressure Ulcers

The use of pressure-redistributing foam mattresses has shown to be a cost-effective approach to prevent ED-acquired pressure ulcers (Pham et al., 2011). The use of reclining chairs in the ED instead of ED gurney beds has been shown to reduce pain and improve patient satisfaction (Wilber, Burger, Gerson, & Blanda, 2005). Evidence-based guidelines to prevent and manage pressure ulcers (as described in Chapter 24, “Preventing Pressure Ulcers and Skin Tears”) should be followed, including skin assessment, pressure relief/off-loading, prevention/treatment of infection, pain control, and nutritional evaluation and management (Ayello, 2011; Reddy, Gill, & Rochon, 2006).

Prevention of Catheter-Associated Urinary Tract Infection

A catheter-associated urinary tract infection (CAUTI) is a urinary tract infection (UTI) that occurs while a patient has an intrauterine catheter (IUC) or within 48 hours of its removal. The use of preventive practices is associated with a lower incidence of CAUTIs. These practices include avoiding unnecessary urinary catheter use, removal prompts and nurse-initiated urinary catheter discontinuation protocols, alternatives to indwelling urinary catheterization, portable bladder ultrasound monitoring, and insertion care and maintenance (Oman et al., 2012; Saint et al., 2013).

In the ED, the identification of appropriate patients for urinary catheter insertion is an essential component of a protocol to prevent CAUTIs. According to the Infectious Disease Society of America and other expert opinion (Apisarnthanarak et al., 2007; Fink et al., 2012; Saint et al., 2013), these indications are as follows: (a) urinary retention/obstruction; (b) need for very close monitoring of urine output and patient unable to use urinal or bedpan; (c) open wound in sacral or perineal area with urinary incontinence; (d) patient too ill, fatigued, or incapacitated to use alternative urine collection method; (e) patient status postrecent surgery, hip fracture, emergency pelvic ultrasound, neurogenic bladder, and other urologic problems; and (f) hospice/palliative care. After receiving a physician order with the appropriate indications documented, the nurse should insert the indwelling catheter as per protocol, using the smallest size catheter and sterile technique (Fink et al., 2012; Hooton et al., 2010). There should be a plan for the earliest removal, which is communicated during the handoff to the nurse on the transferred unit. Daily catheter rounds guide decision making for continued use or removal of indwelling catheters (Wald & Kramer, 2011).

TRANSITIONS FROM THE ED

In a 12-state survey study of a combined 65.5 million ED visits from 2006 to 2007, carried out with patients older than 65 years, approximately 40% had medication errors after a hospital discharge, and 18% of Medicare patients discharged from a hospital were readmitted within 30 days (Steiner, Barrett, & Hunter, 2010). Older ED patients have identified misinformation, a factor associated with ED readmissions, as a primary source of dissatisfaction with ED care. Factors associated with misinformation include underrecognition of cognitive dysfunction, lower health literacy, and financial impediments for prescriptions and recommended outpatient follow-up (Baraff et al., 1992; Carpenter et al., 2009; Han et al., 2011).

ED-based interventions that emphasize patient education and care coordination have demonstrated mixed results on the rate of ED readmissions and the prevention of complications (Basic & Conforti, 2005; Corbett, Lim, Davis, & Elkins, 2005; Hegney et al., 2006). Experts agree, however, that the transition from the ED to other settings includes three systematic processes: discharge planning, patient/family education, handoff, and follow-up (Geriatric Emergency Department Guidelines Task Force, 2014).

Discharge Planning

Discharge planning from the ED is a multidisciplinary process that includes the family or significant others. The process is tailored to the individual needs of the older adult patient according to his or her discharge diagnosis and the destination setting. Components of discharge planning include (a) evaluation of the clinical status related to the admitting problem, (b) assessment of physical and psychosocial functional status (including fall/safety risk), (c) risk assessment for subsequent functional decline (e.g., ISAR or TRST), (d) assessment of caregiver availability and ability, (e) an appraisal of the patient/family readiness and ability to learn, (f) medication review, (g) review of advance directives, and (h) referrals with follow-up arrangements (Agency for Healthcare Research and Quality [AHRQ], 2009; Centers for Medicare & Medicaid Services [CMS], 2014). If the assessment by the nurse, physician, and other relevant disciplines determines that post-ED care is indicated, active engagement of patients and families and offering a range of options will support the patient’s preferences and goals (Popejoy, 2011). The CMS (2014) recommends that the EDs maintain a complete and accurate file of appropriate community-based services, supports, and facilities to which the patient can be referred.

Patient/Family Education

ED patients frequently do not understand their discharge instructions (Crane, 1997; Jolly, Scott, Feied, & Sanford, 1993; Zavala & Shaffer, 2011). In a recent study of patient and caregiver understanding of discharge instructions, the investigators assessed patient and caregiver understanding of discharge instruction in four domains: (a) diagnosis and cause, (b) ED care, (c) post-ED care, and (d) return instructions. Seventy-eight percent of participants demonstrated deficient comprehension in at least one domain. Greater than one third of the deficiencies involved understanding of post-ED care (Engel et al., 2009). Within the emergency medicine literature, commonly cited challenges to patient/caregiver understanding are limited literacy and numeracy (Ginde, Clark, Goldstein, & Camargo, 2008; Ginde, Weiner, Pallin, & Camargo, 2008). Adding to the problem, print discharge instructions are not written at appropriate reading levels (Jolly et al., 1993; Williams, Counselman, & Caggiano, 1996).

To address these challenges, written instructions should be at the sixth-grade level (established using a literacy calculator). Nurses use plain language, focusing on “need to know” information, limiting the documents to essential content in order to avoid information overload (McCarthy et al., 2012). Also, information and educational material should be provided in large font suitable for older adults. The use of the teach-back method has demonstrated a positive impact on recall of discharge instructions in the ED regardless of age and education (Slater, Dalawari, & Huang, 2013). This teaching method assesses the effectiveness of teaching by having the person explain and/or demonstrate back to the nurse what he or she has just been taught, ensuring that the patient is actively involved in the teaching process (Schillinger et al., 2003).

The nurse may use a standardized tool that assesses older adults’ ability to self-administer their medication such as the Drug Regimen Unassisted Grading Scale (DRUGS), which takes approximately 5 minutes to complete. This tool requires subjects to perform the following four tasks with each of their medications: (a) identify the appropriate medication, (b) open the container, (c) select the correct dose, and (d) report the appropriate timing of doses (Edelberg, Shallenberger, Hausdorff, & Wei, 2000; Kripalani et al., 2006).

Handoff

Communication with primary care providers regarding an ED visit is considered to be a necessary process, particularly for vulnerable elders (ACOVE-3 Investigators, 2007). In an effort to improve continuity of care between the ED and other settings, the Geriatric Emergency Department Guidelines Task Force (2014) recommends standardized information be provided to the patient/family and outpatient care providers, including NHs and primary care providers (Table 38.5). Structured focus group interviews with NH staff, ED staff, and a county-wide emergency medical service (EMS) system identified the following additional approaches to support handoffs between EDs and NHs: (a) a verbal report from ED nurses provided to the NH as well as written documentation, (b) an emergency form in NH residents’ charts that contains predocumented information with an area to write in the reason for transfer, and (c) brief NH-to-ED and ED-to-NH transfer forms that are accepted and used by local NHs and EDs (Terrell & Miller, 2006).

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