Zorgpad voor ouderen die zich presenteren met niet-specifieke klachten op de SEH

Rationale: Approximately, 10-20% of older adult patients present with non-specific complaints (NSCs) at the emergency department (ED). NSCs are known as poorly described symptoms, such as ‘weakness’ and ‘fatigue’, often leading to an extensive differential diagnosis. Almost half of patients presenting with NSCs suffer from a serious underlying illness. Currently, a management protocol for patients with NSCs does not exist. Patients with NSCs are often under triaged, stay longer at the ED (ED-LOS) or hospital (HOSP-LOS) and are at a higher risk for complications during hospitalisation. A special care pathway for patients with NSCs was designed to resolve some of these problems and improve the efficiency of care at the ED. Objective: To implement and evaluate a care pathway for older adults presenting with non-specific complaints at the emergency department. Study design: A longitudinal multi-centre cohort with a stepped-wedge cluster design. Study population: Older adults ≥70 years of age presenting with NSCs at the practice of the general practitioner (GP), the elderly care physician at a nursing home or the emergency department of the hospital will be evaluated for inclusion. Data from control patients will be collected retrospectively. Recruitment: Recruitment will take place during workdays between Monday – Friday from 11:00 am – 20:00 pm and comprise of a study period of 6 months, according to the study protocol. The primary health care provider (such as a GP or elderly care physician at a nursing home) will indicate whether a patient is eligible for access to the care pathway and inform the specialist at the ED. Every referring care professional will have a card, which provides information on how to refer a patient to the care pathway and to whom. Patients can also enter the care pathway after triage at the ED, if the main complaint is non-specific. If the ED specialist registers access to the care pathway and the patient gives consent, the patient will be included and baseline data collected . Intervention: If feasible, an ED-coach (passive or active form) will be appointed to each participant of the care pathway. The NSC will be evaluated in-depth, the patient will undergo APOP-screening during triage and if indicated, a comprehensive geriatric assessment will be performed after discharge from the ED at another department. The patient will be seen by a specialist or experienced resident in training at the ED, who will order a standard set of diagnostic tests and review the results. The APOP-risk score will guide further actions in the care pathway. A verification of the medication list will be performed <24 hours and a review of the medication will follow during admission. Control cohort: Recruitment of controls will occur before implementation of the care pathway and on workdays between Monday – Friday from 11:00 am – 20:00 pm. The study period is estimated at approximately 6 months, according to study protocol. Each participating hospital will inform participants regarding their policy on data collection prior to implementing the care pathway. Data for controls within hospitals with access to CTcue will be collected retrospectively. The other participating hospitals will include eligible patients prospectively for the same estimated study period. After 30 days, the research nurse will evaluate complications that occurred after the patient leaves the care pathway. Main study parameters/endpoints: Main endpoints are to evaluate the length of stay at the ED (ED-LOS) and exploring patient satisfaction on 4 established domains. Secondary objectives are evaluating the length of stay at the hospital (HOSP-LOS), discharge destination, medical diagnosis (at admission versus discharge), frequency of readmissions / revisits, 30-day mortality, loss of functional status and costs-effectiveness of the care pathway. Study parameters are age, gender, main non-specific complaint, main diagnosis at ED-arrival and discharge, way of arrival (per ambulance, public transportation, etc.), main domain of NSC (somatic, nutrition, psychosocial, functional, mobility, falls), living situation (independent, care at home), diagnostic tests, specialist seeing the patient and consulting specialists and ED-logistics (time of arrival at ED, duration of triage, triage colour). Nature and extent of the burden and risks associated with participation, benefit and group relatedness: Participation in the care pathway is non-invasive. It includes specialized care for older adult patients presenting with NSCs at the emergency department. The burden regarding participation in this care pathway can be considered minimal

We hypothesize that the care pathway will primarily improve patient satisfaction and reduce the ED-length of stay. Reduced hospital length of stay, decreased 30-day mortality, improved functional status (daily activities, mobility, cognition), a reduction of (re-)admission rates for older adults with NSCs and reduced costs of care for this patient population might follow as a result of implementing this care pathway.

Participating patients in the intervention group will fill in a questionnaire at baseline (time of inclusion at the ED). Control patients will not fill in a questionnaire due to the retrospective character of inclusion.

If feasible, an ED-coach (passive or active form) will be appointed to each participant of the care pathway. The NSC will be evaluated in-depth, the patient will undergo APOP-screening during triage and if indicated, a comprehensive geriatric assessment will be performed after discharge from the ED at another department. The patient will be seen by a specialist or experienced resident in training at the ED, who will order a standard set of diagnostic tests and review the results. The APOP-risk score will guide further actions in the care pathway. A verification of the medication list will be performed <24 hours and a review of the medication will follow during admission.