Health care providers recognize that the complex care needs of older adults are not optimally met in the busy emergency department (ED) environment (Australian and New Zealand Society for Geriatric Medicine, 2008). Compared to younger patients, older patients are at increased risk of negative health outcomes when in the ED (Aminzadeh & Dalziel, 2002; Schnitker, Martin-Khan, Beattie, & Gray, 2011). Of ED patients who are 65 and older, 10% to 19% experience an ED representation (i.e., unplanned return to the ED for care), 5% to 11% are hospitalized, and 1% to 2% die within 1 month following their discharge from the ED (Ferrera, Bartfield, & D’Andrea, 1999; Friedmann et al., 2001; Hastings, Purser, Johnson, Sloane, & Whitson, 2008; McCusker, Roberge, Vadeboncoeur, & Verdon, 2009).
Particular concerns have been raised about the quality of care of older patients with cognitive impairment (CI). CI is highly prevalent in the older ED population (Hustey, 2002). Older ED patients with CI have an increased risk of negative outcomes (Kakuma et al., 2003; McCusker et al., 1999). The rapid pace of ED processes and decision making, and the characteristics of the ED environment, such as crowding, noise, bright lights, no signs to orientate, and interactions with multiple caregivers, may constitute a challenging and confusing place for acutely sick older individuals with CI.
Clinicians and researchers can measure quality of care using quality indicators (QIs), established by using available scientific evidence supplemented with expert opinion (Mainz, 2003) and derived from clinically available data. In association with the Society for Academic Emergency Medicine Geriatric Task Force, Terrell et al. (2009) developed six geriatric emergency care quality indicators for cognitive assessment, using an expert panel, to identify gaps in emergency care (Table 1). These evidence-based QIs focus on the processes of care received by older individuals with CI in the ED. The QIs focus on: (a) cognitive assessment, (b) assessment of cognitively impaired ED patients, (c) patients with acute CI who are discharged home, (d) detecting whether CI was previously recognized, and (e) care of ED patients with acute CI and patients with baseline abnormal mental status who are discharged home (Terrell et al., 2009). The aim of this study was to examine the quality of care received by older patients with CI in EDs by utilizing these process quality indicators.
Table 1: Quality Indicators (QIs) for Geriatric Emergency Care: Cognitive Assessment
A descriptive exploratory study was conducted using a retrospective review of medical records. Process quality indicators for cognitive assessment (Terrell et al., 2009) were used to adjudicate the quality of care given to the older ED patients.
Sample and Setting
This study involved a convenience sample of older individuals who participated in The Brittle Discharges Study, which was a prospective study aiming to identify predictors of poor outcomes among older patients discharged from EDs (Gray, 2011). Originally, 279 older patients in the ED, representing 283 ED visits, were identified for inclusion in this study; however, 4 medical records were not accessible within the chart review period (November 2010 to February 2011) and 2 medical records were retrieved, but all documentation relating to the ED episode was missing from the chart. Therefore, these six medical episodes were excluded from the study. Hence, the study sample included 273 patients 75 and older who arrived at the ED of two metropolitan public hospitals in Brisbane, Australia between October 2009 and April 2010. The mean patient age was 81; 120 patients were men. Triage category was predominantly Level 3 and 4 (of which Level 1 is “immediate” and level 5 is “non-urgent” care), the majority lived in the community, and approximately two thirds were sent home after their ED visit. Four patients experienced an ED representation in The Brittle Discharges Study; representations were included in this sample, therefore, the documentation of 277 ED episodes were evaluated (Table 2).
Table 2: Characteristics of Study Participants and Emergency Department (ED) Visits
Data Collection and Analysis
Measures were incorporated into a paper-based version of a chart-abstraction tool designed by the lead author (L.M.S.), which the research team revised until consensus regarding scoring was reached. Consensus was determined by using two independent abstracters to score charts using the revised versions of the tool until ambiguity was reduced. Consensus was defined as agreement at kappa = 0.9. After training in the auditing process and calculation of the chart-abstraction tool’s reliability coefficient (kappa = 1.0), one author (L.M.S.) abstracted data from the medical documentation of all selected patients using the tool. The medical record was reviewed fully to ensure that all data, regardless of the section within which it was filed, were used for data collection. The data collection focused on aspects of assessment of cognition, evidence of CI, and processes of care relevant to patients with CI (e.g., discharge instructions). Scores of the Glasgow Coma Scale (GCS), which is a neurological scale designed to quantify the conscious state of ED trauma patients (Teasdale & Jennett, 1974), were also examined.
The following definitions were determined a priori as a “pass” for a record of cognitive assessment and CI. Cognitive assessment was defined as having occurred if documentation relating to cognitive status was available. The documentation was coded according to the fullness of assessment (Level 1 or 2):
- Level 1: Screened informally, referring to documented observations regarding level of alertness and orientation. At this level, minimal comments such as “disoriented in time” would be coded as a “pass.”
- Level 2: Screened formally, referring to the use of a cognitive assessment tool to systematically assess cognitive functioning.
CI was defined as any documentation indicating problems in cognitive functioning, such as disorientation to place, person, or time; confusion; memory problems; inattention; dementia; or delirium. It is acknowledged that a formal recognition of CI would require a more precise level of documentation, but an inclusive approach was considered suitable for the purposes of this study. CI was coded as passed by the abstractor if the chart contained any of the predefined items.
The set of six process indicators for geriatric emergency care regarding cognitive assessment (Table 1; Terrell et al., 2009) were scored using the data pertaining to cognition and associated processes of care in the medical records. The geriatric emergency care QIs were defined in relation to a denominator (number of patients for which the indicator is relevant or triggered) and a numerator (number of patients passing the indicator). Percentage agreement was used to identify the proportion of patients passing individual process QIs. Data were analyzed using SPSS version 18.
This study was approved by the relevant research ethics committee and by the two individual hospital ethics committees.
One hundred fifty (54%) cases triggered the initial QI, which states that ED providers should carry out and document a cognitive assessment in the older ED population (or reason why not) (Table 1). The approaches to determine cognitive functioning were mostly informal: Of these 150 cases, 142 (95%) cases comprised informal written notes regarding alertness and orientation (Level 1). The audit indicated that formal screening was not routine but an adjunct that followed an informal recognition of impaired cognitive function. Assessment of cognitive function was performed using a formal screener (Level 2) in 22 instances. The GCS was documented in 187 of 277 (67.5%) medical records. The QI was also passed if no cognitive assessment was carried out but an explanation was recorded. In 8 (5%) cases, an explanation was present. Comparison of QI 1 scores (attempt to carry out a cognitive assessment) at hospital level indicated variation in performance between the two emergency services: 90 (60%) versus 60 (40%) cases, respectively.
The remaining five process QIs are designed to specifically evaluate the quality of care of older ED patients with CI. Subsequently, QIs 2–6 are directed at a subset of the study population, as 142 of the 277 older patients had documented evidence of cognitive functioning. From the total sample, 54 (20%) patients had written evidence of CI, such as abnormal scores on formal screening tools, notes concerning disorientation, confusion, poor memory, or evidence of dementia within the medical history. Thirty-one of 54 patients with documented evidence of CI had a maximum score of 15 points on their GCS, indicating full consciousness, despite the presence of CI. In 11 (20%) of the patients with CI, the CI was recorded as previously recognized and a diagnosis was presented. Notes regarding statements from patients’ family or caregivers, such as “He is more confused than usual” or “This behavior is not normal for him,” indicated that the identified CI was an acute change from baseline (n = 6). Eighteen patients had evidence in their medical record that the identified CI was not an acute change from baseline. This was based on notes such as: “Patient appears to be at baseline cognition” or “According to patient’s daughter, this is normal behavior.” Of the 54 patients who had written evidence of CI, 30 (56%) patients had no documentation on premorbid cognitive functioning. The overall frequencies of QIs 2–6 are shown in Table 1.
This study, based on available documentation, suggests that older ED patients with CI do not receive optimal care according to the QIs for geriatric emergency care. However, cognitive assessment and its documentation in medical records occurred in too few patients to confidently assume that the quality of care relevant to all older patients with CI was appropriately measured. An attempt to screen for CI occurred in only 54% of patients. Given the previously documented high prevalence of CI in the older ED population (up to 40% of older individuals have cognitive issues when arriving at EDs [Naughton, Moran, Kadah, Heman-Ackah, & Longano, 1995]), it can be assumed that a proportion of those ED patients with no documentation regarding cognition had some form of (apparently unrecognized) CI, including delirium. The small sample of patients with documented evidence of CI in this study affects the interpretation of the results regarding quality of care. It can be assumed that only a subset of the relevant patients are included in the denominators of QIs 2–6 because of the absence of routine cognitive assessment. In this study sample, the GCS was a routine assessment tool used in more than half (67.5%) of the patients. It may be that staff in EDs assume that the GCS is an appropriate screen for cognition, as it contains a question related to confusion and disorientation (verbal response). Of the patients with documented CI (evidence of confusion or disorientation), 57.4% had a maximum score on the GCS (15–indicating full consciousness). This may indicate that the GCS is a measure of the conscious state only and not a suitable tool to identify CI in the older ED population, or it is routinely poorly completed. The study by Gill, Reiley, and Green (2004) found only moderate degrees of interrater agreement for the use of GCS in ED patients.
Poor screening for cognitive issues in the older ED population has been identified previously (Hustey, 2002; Press et al., 2009). Press et al. (2009), who studied ED patients 65 and older, found that a high proportion (87.5%) of older ED patients did not receive a cognitive assessment. Although the ED is not an ideal environment to make a reliable diagnosis of dementia, recognition of CI—whether it be in the form of dementia, delirium, or other syndromes—is important for the provision of quality care. Identification of CI is particularly relevant if the individual is discharged home because the presence of CI may interfere with safety issues (Han et al., 2011), particularly if the individual lives alone. Additionally, existing CI places the sick older individual at high risk of developing delirium, which in some cases may be prevented with an appropriate intervention (Inouye et al., 1999).
The study findings implicate that an opportunity exists to enhance the recognition of CI in the older ED population. A significant first step toward improvement in the quality of care for older patients would be applying cognitive screening in all older patients in the ED. The level of cognitive functioning may affect the correctness and completeness of the patient history and the understanding of subsequent care. Emergency nurses should recognize the importance of evaluating the cognitive status as an essential element of the nursing diagnostic process to obtain a full and accurate picture of a patient’s condition and situation. Cognitive screening allows early treatment of any reversible causes and effective planning of care when CI is identified.
However, for nurses seeking to improve cognitive screening in the ED, there is a lack of clarity to support the choice of a suitable tool (Sanders, 2002). An ED-validated, short, and sensitive screening tool, suiting the demanding ED care environment, is required. Various tools have been proposed for suitable screening options for the detection of CI in the older ED population, but strong reliability and validity have not been shown (Allison, Kontoyannis, Durai, Turner, & Fone, 2004; Carpenter, Bassett, et al., 2011; Carpenter, DesPain, Keeling, Shah, & Rothenberger, 2011; Wilber, Carpenter, & Hustey, 2008; Wilber, Lofgren, Mager, Blanda, & Gerson, 2005). Poor methodology in these studies limits the generalizability of the results. For example, previous work in validating tools has focused on comparing the outcomes to Mini-Mental State Examination (MMSE) outcomes. However, the MMSE has not been validated in the ED setting, and it is recognized that the MMSE is not the most practical tool in busy EDs (Zun & Gold, 1986). A well-designed study using an accepted gold standard as a reference of CI would add greatly to this discussion.
Five of the process QIs (QIs 2–6) are designed to evaluate the quality of care of older ED patients with CI. Identifying the QIs’ denominator (trigger) depends on first establishing that CI is present, identified, and documented by the ED provider. In this study, lack of cognitive assessment documentation eliminated half of the patient sample from further evaluation of quality of care. Studies considering QIs related to patients with CI would benefit from an additional prospective identification of CI by a blinded assessor, separate from the medical chart, to ensure that the care of the true sample of CI patients is being reviewed. As well, the multilayered “if” statement in QIs 2–6 creates subgroups within the total sample, resulting in a significantly smaller denominator. The outcome is either an unscorable QI or a requirement for a specifically targeted study population. For example, to trigger the QI “ED care of patients with acute CI who are discharged home,” the older patients must have documented evidence of CI (in our sample n = 54), written evidence that the CI was an acute change (n = 6), and that the patient was discharged home (n = 0), which renders the QI unworkable in this small sample. Further research should include a larger sample to capture relevant patients for QIs 2–6. Quality measures are based on comparison between either multiple time points or different sites at the same time point. This study considered two sites at one time point, which limits generalizability, but allows opportunities for power analysis for future research. A larger sample across multiple sites at one time point would enable the identification of health services where care processes and outcomes show high levels of quality. This is important to establish a quality-of-care “gold standard” against which other health services’ levels of care may be compared so that they can work toward achieving the optimal standard.
This study identified that the majority of patients did not receive appropriate screening for CI, and those with documented evidence of cognitive issues did not receive optimal care in the ED, according to the QIs for cognitive assessment. A lack of both formal screening and documentation on cognitive issues means the quality of care cannot be reliably measured for all patients with these issues. A significant first step toward improvement in the quality of care for older patients in EDs would be the adoption of a systematic approach to screening for cognitive issues in all older patients with the use of an ED-validated tool.
- Allison, M.C., Kontoyannis, A., Durai, D., Turner, G.I. & Fone, D.L. (2004). GOAL: A simplified mental test for emergency medical admissions. QJM, 97, 663–669 doi:10.1093/qjmed/hch109 [CrossRef] .
- Aminzadeh, F. & Dalziel, W.B. (2002). Older adults in the emergency department: A systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Annals of Emergency Medicine, 39, 238–247. doi:10.1067/mem.2002.121523 [CrossRef]
- Australasian College for Emergency Medicine. (2002). The Australasian Triage Scale. Emergency Medicine, 14, 335–336.
- Australian and New Zealand Society for Geriatric Medicine. (2008). Guidelines for the management of older patients presenting to emergency department (Position Statement No. 14). Retrieved from http://www.anzsgm.org/posstate.asp
- Carpenter, C.R., Bassett, E.R., Fischer, G.M., Shirshekan, J., Galvin, J.E. & Morris, J.C. (2011). Four sensitive screening tools to detect cognitive dysfunction in geriatric emergency department patients: Brief Alzheimer’s Screen, Short Blessed Test, Ottawa 3DY, and the caregiver-completed AD8. Academic Emergency Medicine, 18, 374–384. doi:10.1111/j.1553-2712.2011.01040.x [CrossRef]
- Carpenter, C.R., DesPain, B., Keeling, T.N., Shah, M. & Rothenberger, M. (2011). The Six-Item Screener and AD8 for the detection of cognitive impairment in geriatric emergency department patients. Annals of Emergency Medicine, 57, 653–661. doi:10.1016/j.annemergmed.2010.06.560 [CrossRef]
- Ferrera, P.C., Bartfield, J.M. & D’Andrea, C.C. (1999). Geriatric trauma: Outcomes of elderly patients discharged from the ED. American Journal of Emergency Medicine, 17, 629–632 doi:10.1016/S0735-6757(99)90146-8 [CrossRef] .
- Friedmann, P.D., Jin, L., Karrison, T.G., Hayley, D.C., Mulliken, R., Walter, J. & Chin, M.H. (2001). Early revisit, hospitalization, or death among older persons discharged from the ED. American Journal of Emergency Medicine, 19, 125–129 doi:10.1053/ajem.2001.21321 [CrossRef] .
- Gill, M.R., Reiley, D.G. & Green, S.M. (2004). Interrater reliability of Glasgow Coma Scale scores in the emergency department. Annals of Emergency Medicine, 43, 215–223. doi:10.1016/S0196-0644(03)00814-X [CrossRef]
- Gray, L.C. (2011). [Brittle Discharges Study]. Unpublished raw data.
- Han, J.H., Bryce, S.N., Ely, E.W., Kripalani, S., Morandi, A., Shintani, A. & Schnelle, J. (2011). The effect of cognitive impairment on the accuracy of the presenting complaint and discharge instruction comprehension in older emergency department patients. Annals of Emergency Medicine, 57, 662.e2–671.e2. doi:10.1016/j.annemergmed.2010.12.002 [CrossRef]
- Hastings, S.N., Purser, J.L., Johnson, K.S., Sloane, R.J. & Whitson, H.E. (2008). Frailty predicts some but not all adverse outcomes in older adults discharged from the emergency department. Journal of the American Geriatrics Society, 56, 1651–1657. doi:10.1111/j.1532-5415.2008.01840.x [CrossRef]
- Hustey, F. (2002). The prevalence and documentation of impaired mental status in elderly emergency department patients. Annals of Emergency Medicine, 39, 248–253 doi:10.1067/mem.2002.122057 [CrossRef] .
- Inouye, S.K., Bogardus, S.T. Jr.. , Charpentier, P.A., Leo-Summers, L., Acampora, D., Holford, T.R. & Cooney, L.M. Jr.. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine, 340, 669–676. doi:10.1056/NEJM199903043400901 [CrossRef]
- Kakuma, R., du Fort, G.G., Arsenault, L., Perrault, A., Platt, R.W., Monette, J. & Wolfson, C. (2003). Delirium in older emergency department patients discharged home: Effect on survival. Journal of the American Geriatrics Society, 51, 443–450 doi:10.1046/j.1532-5415.2003.51151.x [CrossRef] .
- Mainz, J. (2003). Developing evidence-based clinical indicators: A state of the art methods primer. International Journal for Quality in Health Care, 15(Suppl. 1), i5–i11 doi:10.1093/intqhc/mzg084 [CrossRef] .
- McCusker, J., Bellavance, F., Cardin, S., Trépanier, S., Verdon, J. & Ardman, O. (1999). Detection of older people at increased risk of adverse health outcomes after an emergency visit: The ISAR screening tool. Journal of the American Geriatrics Society, 47, 1229–1237.
- McCusker, J., Roberge, D., Vadeboncoeur, A. & Verdon, J. (2009). Safety of discharge of seniors from the emergency department to the community. Healthcare Quarterly, 12(Special), 24–32.
- Naughton, B.J., Moran, M.B., Kadah, H., Heman-Ackah, Y. & Longano, J. (1995). Delirium and other cognitive impairment in older adults in an emergency department. Annals of Emergency Medicine, 25, 751–755 doi:10.1016/S0196-0644(95)70202-4 [CrossRef] .
- Press, Y., Margulin, T., Grinshpun, Y., Kagan, E., Snir, Y., Berzak, A. & Clarfield, A.M. (2009). The diagnosis of delirium among elderly patients presenting to the emergency department of an acute hospital. Archives of Gerontology and Geriatrics, 48, 201–204. doi:10.1016/j.archger.2008.01.008 [CrossRef]
- Sanders, A.B. (2002). Missed delirium in older emergency department patients: A quality-of-care problem. Annals of Emergency Medicine, 39, 338–341 doi:10.1067/mem.2002.122273 [CrossRef] .
- Schnitker, L., Martin-Khan, M., Beattie, E. & Gray, L. (2011). Negative health outcomes and adverse events in older people attending emergency departments: A systematic review. Australasian Emergency Nursing Journal, 14, 141–162. doi:10.1016/j.aenj.2011.04.001 [CrossRef]
- Teasdale, G. & Jennett, B. (1974). Assessment of coma and impaired consciousness: A practical scale. Lancet, 304, 81–84. doi:10.1016/S0140-6736(74)91639-0 [CrossRef]
- Terrell, K.M., Hustey, F.M., Hwang, U., Gerson, L.W., Wenger, N.S. & Miller, D.K. (2009). Quality indicators for geriatric emergency care. Academic Emergency Medicine, 16, 441–449. doi:10.1111/j.1553-2712.2009.00382.x [CrossRef]
- Wilber, S.T., Carpenter, C.R. & Hustey, F.M. (2008). The Six-Item Screener to detect cognitive impairment in older emergency department patients. Academic Emergency Medicine, 15, 613–616. doi:10.1111/j.1553-2712.2008.00158.x [CrossRef]
- Wilber, S.T., Lofgren, S.D., Mager, T.G., Blanda, M. & Gerson, L.W. (2005). An evaluation of two screening tools for cognitive impairment in older emergency department patients. Academic Emergency Medicine, 12, 612–616. doi:10.1111/j.1553-2712.2005.tb00915.x [CrossRef]
- Zun, L. & Gold, I. (1986). A survey of the form of the mental status examination administered by emergency physicians. Annals of Emergency Medicine, 15, 916–922 doi:10.1016/S0196-0644(86)80675-8 [CrossRef] .
Quality Indicators (QIs) for Geriatric Emergency Care: Cognitive Assessment
|QI for Geriatric Emergency Carea
||QIs Triggered n
||QIs Passed n (%)
||1. IF an older adult comes to an ED, THEN the ED provider should carry out and document a cognitive assessment (such as an indication of level of alertness and orientation or an indication of abnormal or intact cognitive status) or document why a cognitive assessment did not occur.
|Assessment of patients with CI in the ED
||2. IF an older adult comes to an ED and is found to have CI, THEN an ED care provider should document whether there has been an acute change in mental status from baseline (or document an attempt to do so).
|ED care of patients with acute CI who are discharged home
||IF an older adult comes to an ED and is found to have CI that is a change from baseline and is discharged home, THEN the ED provider should document the following:
3. Support in the home environment to manage the patient’s care.
4. A plan for medical follow up.
|Detecting whether cognitive abnormalities were previously recognized
||5. IF an older adult comes to an ED and is (a) found to have an abnormal mental status, (b) has no change in mental status from baseline, and (c) is discharged home, THEN the ED provider should document whether there has been previous recognition or diagnosis of an abnormal mental status by another health care provider (or document an unsuccessful attempt to determine status).
|ED care of patients with baseline abnormal mental status who are discharged home.
||6. IF an older adult comes to an ED and (a) is found to have an abnormal mental status that had not been previously recognized or diagnosed by another health care provider, (b) has no change in mental status from baseline, and (c) is discharged home, THEN a referral for outpatient evaluation of the CI should be documented.
Characteristics of Study Participants and Emergency Department (ED) Visits
|ED Population Characteristics (N = 273)
||Mean (SD, Range)
|Mean age (years)
||81.46 (4.97, 75 to 99)
| Independent in retirement village
| Residential aged care service
|ED Visits (N = 277)
|Service urgency according to a five-level triage instrumenta
| Level 1
| Level 2
| Level 3
| Level 4
| Level 5
|Subsequent hospital admission