Introduction

Older adults with multi-morbidities have the highest rate of ED usage. These patients are typically on numerous medications, may have underlying dementia, and often present with falls and delirium. Identifying these high-risk older adults for possible intervention is challenging in the ED setting since available screening methods are manual and resource-intensive. The objective is to study the feasibility of using the Electronic Medical Record (EMR) for identifying high-risk older adults in Emergency Department (ED).

Study Setting

Academic ED with 67,000 total and 24% geriatric (age ≥ 65 years) annual visits, American College of Emergency Physician (ACEP) accredited Level 1 Geriatric Emergency Department with ED-based geriatric consultation program.

Materials and Methods

This is a feasibility study incorporating criteria from existing manual geriatric screening instruments and the 4M framework into an automated EMR screen to identify high-risk geriatric patients. ED providers were then alerted by an EMR Best Practice Alert (BPA) if high-risk status was identified. Initial development and impact on geriatric ED consults are reported.

Results

During the study period, 7,450 patient encounters occurred; 1,836 (24.6%) encounters involved patients who were 65 years or older. 1398 (76.1%) high-risk ED encounters resulted in BPA alerts using the EMR automated screen. BPA alerts resulted in 82 (5.9%) geriatric evaluations.

Conclusion

Using the EMR to automate screening for older adults for high-risk geriatric conditions in the ED is feasible. An automated EMR screen with a BPA to ED providers identified a well-defined cohort of older patients appropriate for further ED geriatric evaluation.

This was a descriptive feasibility study of the use of EMR screening for high-risk older patients in the setting of a busy urban academic American College of Emergency Physician (ACEP)-accredited Level 1 Geriatric Emergency Department with an ED-based geriatric consult program, and 67 000 total annual visits, with 24% geriatric (age ≥ 65) years visits conducted from March 31, 2020, to May 31, 2020.

Subject matter experts from Emergency Medicine, Geriatric Medicine, Nursing, Pharmacy, Case Management, and Social Work used a modified Delphi method, based on review of the literature and professional judgment, to develop criteria to define high-risk geriatric characteristics which can be captured by the EMR.

Prior to EMR screening implementation, ED providers were educated on 8 geriatric domains using case series and CME modules and patients aged 65 years and older were screened for delirium at the time of triage using the 4AT delirium screen. The 4AT is a brief delirium screening tool with high sensitivity and specificity compared to established delirium tools such as the Confusion Assessment Method (CAM).

An EMR best-practice alert (BPA) was developed to notify ED providers for high-risk geriatric characteristics defined as: age ≥80 years, fall complaint (Mobility), documented dementia history (Mentation), polypharmacy (≥10 Medications recorded), high ED utilization (>5 visits in 1 year), or a (+) 4AT delirium screen (Table 1). This BPA alerted the ED provider if one or more high-risk criteria were present. In addition, the BPA had an embedded link allowing ED providers to place an order for a geriatric evaluation in the ED. ED providers could also request a geriatric evaluation, independent of BPA, based on professional judgment.

Charlson Comorbidity Index (CCI) was not used as a component for the BPA but was calculated as a surrogate marker for Multi-morbidity.

Frequency of BPA notification and ED geriatric consultations (Comprehensive Geriatric Assessment, CGA) are reported. Data were abstracted from the EMR.

RESULTS

During the study period, 7450 patient encounters occurred; 1836 (24.6%) encounters were in patients 65 years or older. Additional population characteristics and high-risk criteria (excluding age over 80 years) are shown in Table 2. The mean age was 74.6 years and 49.5% were female. Delirium detection by 4AT was approximately 6% in this population. Preexisting dementia was documented in 6.6%. The average number of medications per patient was 8.4. Notably, 18% had more than 5 ED encounters in last the 12 months and the average number of ED encounters per patient during the same time period was 3.66. The average CCI was 3.82, reflective of Multi-Morbid older adults with poor prognoses.

A total of 1398 (76.1%) geriatric ED encounters resulted in BPA alerts using the EMR automated screen. Four hundred thirty-eight (33.9%) patients did not meet high-risk criteria. BPA alerts resulted in 82 (5.9%) comprehensive geriatric assessments. Fourteen (3.2%) BPA-negative patients were also referred for CGA due to clinical judgment by ED providers. Overall, 96 (5.2%) patients had a CGA. We also examined the proportion of geriatric assessments performed in BPA-positive patients compared to the overall number of CGA obtained. In this group, 82/96 (85.4%) patients who underwent a CGA, were BPA positive.

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