Targeting complexity of geriatric emergency department visitors: Comprehensiveness in a high-paced and efficiency-focused medical setting

Rarek, Marcel Pascal (2022). Targeting complexity of geriatric emergency department visitors: Comprehensiveness in a high-paced and efficiency-focused medical setting. PhD thesis, Universität zu Köln. Open Access

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Abstract

The emergency department (ED) is one of the most important access points to medical care worldwide and a central link between out- and inpatient care. The demographic development is predicted to change the age distribution of patients in the German health system over the next few decades which could strongly affect the ED as a multidisciplinary centre of the health system. Many EDs in Germany have already observed an increase in the number of older and clinically complex patients that bind more resources and personnel capacities. Geriatric patients in the ED are a particularly vulnerable group with an increased risk of clinical complications compared to younger age groups. The higher prevalence of frailty, atypical symptoms, multimorbidity, polypharmacy, neuropsychiatric and cognitive impairments impede fast diagnosis and therapy. The integration of an elaborate and time-consuming assessment of older patients in an otherwise fast-paced and efficiency-driven environment is a major challenge of present-day and future EDs. Therefore, an effective screening for older patients who would benefit from further evaluation will be paramount. Common standardized triage systems of EDs or existing screening instruments like the Identification of Seniors at Risk (ISAR) score show major difficulties in effectively identifying vulnerable older patients. The Multidimensional Prognostic Index (MPI), which is based on a comprehensive geriatric assessment (CGA), has already been tested in numerous settings and might be an alternative to grasp the complexity of older ED patients. An important but rarely evaluated clinical outcome parameter is health-related quality of life (HRQOL). It is a central component of patient-related treatment concepts and plays a crucial role in the care for geriatric patients. Existing literature shows a strong influence of the health status on HRQOL of older people. The results of the study by Rarek et al., on which this thesis is based upon, were able to show that the HRQOL of geriatric ED patients is significantly associated with clinical prognosis at ED admission and up to 6 months after. Attention to the association between patient-related outcome factors such as HRQOL and objective clinical prognosis can improve a holistic approach for allocation decisions in future concepts of geriatric ED care. Various innovative concepts for the improvement of detection and management of geriatric and patients in the ED have been tested and evaluated in the USA in recent years. The initial experience about advantages and disadvantages of approaches that were tested can help to create adapted concepts for the German health care system. First responses to the increasing number of geriatric patients already exist in Germany and range from new screening tools to specialized ED units and an improved linking of different health care providers. Adapting EDs to the complexities and needs of geriatric patients will be a major challenge in an aging society. The global outbreak of the Coronavirus Disease 2019 (COVID-19) pandemic has threatened the health systems of numerous nations and at the time of this publication, the end is still unforeseeable. Many aspects and challenges of the complexity in geriatric patients in clinical practice have been illustrated by the impact of the pandemic on geriatric care. Older, multimorbid and frail patients are particularly affected by this disease due to an increased risk of a severe course of disease and higher mortality. The need to effectively identify vulnerable patients in the ED with a poor clinical prognosis has become more important due to the pandemic-related scarcity of resources. In addition, it has been observed that the COVID-19 pandemic had a negative impact on HRQOL of older people and the treatment of chronic illnesses. Given that geriatric patients have a higher risk for the development of chronic remnants of COVID-19, the pandemic could have unforeseeable influence on future health of the aging society. In the face of demographic changes, present and future challenges for health systems, effective identification and management of frail and vulnerable patients in the ED and structural changes to obtain geriatric-friendly EDs are important steps to guarantee adequate geriatric care and improve the clinical outcome as well as HRQOL.

Item Type:

Thesis (PhD thesis)

Creators:

Creators	Email	ORCID	ORCID Put Code
Rarek, Marcel Pascal	UNSPECIFIED	UNSPECIFIED	UNSPECIFIED

Contributors:

Contribution	Name	Email
Thesis advisor	Polidori Nelles, Maria Cristina, Universitätsprofessorin Dr. med.	UNSPECIFIED
Surveyor	Pförtner, Timo-Kolja, Privatdozent Dr. rer. pol.	UNSPECIFIED

Corporate Creators:

Zentrum für Innere Medizin der Universität zu Köln Klinik und Poliklinik für Innere Medizin II der Universität zu Köln, Klinik und Poliklinik für Innere Medizin II der Universität zu Köln

URN:

urn:nbn:de:hbz:38-645450

Date:

2022

Language:

English

Faculty:

Faculty of Medicine

Divisions:

Faculty of Medicine > Innere Medizin > Klinik II für Innere Medizin - Nephrologie, Rheumatologie, Diabetologie und Allgemeine Innere Medizin

Subjects:

Medical sciences Medicine