Clinical utility of a functional status assessment in emergency

Clinical utility of a
functional status
assessment of seniors
in emergency
department
Nathalie Veillette, Ph.D., OT.
Associate professor, Departments of Rehabilitation; University of Montreal
Researcher, Research Center of the Institut universitaire de gériatrie de Montréal
Marie-Claude Beaudoin, OT.
CISSS Montérégie EST – RLS Pierre-De-Saurel
Background
• The Emergency Department (ED) is one of the
primary means of accessing health services
(Gruneir, Silver & Rochon, 2011; Agence de la santé et des services sociaux de Montréal,
2008; Ministère de la Santé et des Services sociaux, 1998,2004, 2010, 2011; Canadian Institute
for Health Information, 2010)
• For each ED visit, the treatment team must
make decisions as soon as possible about
• Whether admission is appropriate
• What post-discharge follow-up is required
(Wilber, Blanda, Gerson et al., 2010; Sirois, Émond, Ouellet et al., 2013; Salter, Khan,
Donaldson et al., 2006)
Background
• ED practitioners consult occupational
therapists (OTs) to assess the functional
status of elderly patients
(Veillette et al., 2007, 2009; Carlill et al., 2002; Johnson et al., 2009; Smith & Rees, 2002; Bruun
& Norgaard, 2014; Spang & Holmqvist, 2015 )
• Studies have found that functional status assessment
in ED and follow-up interventions generate positive
outcomes for older patients
(Hendriksen & Harrison, 2001; Smith & Rees, 2004; Carlill, Gash & Hawkins, 2002; Lee, Ross &
Tracy, 2001; Moss et al., 2002)
Background
• Published articles also show that the
assessment tools used lack specificity
for the ED setting and have limited
clinical applicability
(Bissett et al., 2013; Lee et al., 2001; Rudman et al., 1998)
To fill this gap, a specific tool
1- was developed in collaboration with:
Louise Demers (Director PhD)
Élisabeth Dutil (Co-director PhD)
and Dr Jane McCusker (Member of the advisory committee)
2- and then translated/adapted to English
in collaboration with:
Leanne Leclair,
Marlene Stern,
Ashley Struther
and Marie-Josée Sirois
(all co-applicants on the team project "Knowledge Translation for
assessment of the functional status of older adults in Emergency Department",
funded by the Canadian Institutes of Health Research (CIHR)
Clinical utility of
a functional status assessment
of seniors in emergency department
(in 2 steps…)
Step 1:
A pilot project implementing
Occupational Therapy in the ED of a
semi-urban hospital
Context:
• No OT services were provided in the ED prior to the project
• No additional professional resources were available from the
hospital to support the project
Objectives:
• To implement OT services in the ED
• Convenience sample of 24 patients:
19 (79%)
5 (21%)
Age:
•
•
•
Average = 84.3 years
Median = 86 years
Range = 72 - 93 years
• Consulted ED between March and December 2010
Reasons for ED consultation
•
Oncological problem
Neurological problem
2
5
Fall
Musculoskeletal problem
Patients evaluated were:
•
medically stable,
•
screened by ED staff as to having limitations in ADL.
Patients not evaluated were:
•
those who clearly required admission,
•
those who required significant physical assistance.
8
9
Of the 24 users assessed…
= 19 Returned home (RH)
= 2 Transferred for rehabilitation at the
Community Geriatric Unit
= 2 Required longer hospitalization and follow-up
with the geriatric consultation team
= 1 Discharged before the assessment was
completed (but subsequently readmitted for a fracture!).
Recommendations:
3
3
23
14
Equipment (combination of 1 to 3 devices for 12 users)
Education with the person
Education with the caregiver
Additional (or expanded) home care services
Referrals were addressed to :
1
1
1 1 1
10
Occupational therapy
Social Service
Physiotherapy
3
Day Centre
Speech-Language Therapy
Meals-on-Wheels
Day hospital
7
Clinical Nutrition
9
Respiratory Therapy
For 15 users, the recommendations helped
prevent…
Progressive
deconditioning
Deterioration
of general
condition
and falls
Poor nutrition,
risk of food
poisoning
Related to
Poor
medication
management
Incontinence
problems
For 8 users, the recommendations helped
prevent…
4 for cognitive
deficit
Unnecessary or
prolonged
hospitalization
2 for
anxiety
2 quickly directed
to Community
Geriatric Unit
For 3 users, the recommendations helped
prevent…
A serious
risk to the
safety of
others
3 cases related
to motor vehicle
operation
1 case of a fire risk
in a housing
complex
Here is an example of how…
Mr. Smith, a 68 y.o. man, who consulted in ED for a
problem with knee pain…
•
•
•
•
•
Lives at home alone
Diabetic (type1)
Nil acute on X-ray
Diagnosis: onset of arthritis
Medical plan: discharge home with
anti-inflammatory medication
• Chart mentioned him as “odd”
because he spoke little when
providing his personal info
While Mr. Smith was in the ED…
• he was seen by the OT, for a joint protection
education program
 Spending time with Mr. Smith, OT identified concerns
that only revealed themselves within the course of the
program
 OT decided to further her evaluation using the FSAS-ED
• Results showed significant signs
of cognitive impairment
But more importantly…
• His main occupation was
driving a school bus !
Impact of the Assessment
• The users and families were interested in, open to and
appreciative of the recommendations provided.
• OT in ED facilitated access to home care services or day
hospital by documenting the need for prioritization.
• Real-time training of ED staff (related to restraints, pressure
ulcers, patient mobility with a focus on maximum user participation).
• Collaboration with liaison nurses helped ensure effective
service implementation and referral to the various
professionals.
Conclusion of the pilot study
• OT in ED using the FSAS-ED may reduce
some adverse outcomes following ED
discharge.
• Further studies were needed to
• validate the results obtained in this pilot study,
• confirm the positive impact of the assessment of
functional status in ED with larger sample sizes,
using a longitudinal case control method.
Therefore…
Step 2 :
A longitudinal case-control study
•
An group of patients evaluated by an OT
was compared to a control group
• Based on medical chart review
•
Controls are randomly selected and matched to
subjects on specific criteria:
• Age, gender, residence, chief complaint/reasons for
ED consultation, Dx in ED, number of comorbidities,
community/home services already in place.
A longitudinal case-control study
Comparisons between the groups
were made in 3 instances:
At ED
discharge
3 months
post-ED
•Destination post-ED
•Lengh of stay in ED
• Return to ED
• Hospitalization
• Transfer to Long
Term Care
• Death
6 months
post-ED
• Return to ED
• Hospitalization
• Transfer to Long
Term Care
• Death
Baseline characteristics of the participants
OT group
(n=196)
Control group
(n= 236)
83,0
82
81,9
82
Gender (female)
68,5 %
68,6 %
Domicile
House
Residence (all types)
63,6 %
32,9 %
66,1 %
31,4 %
31,4 %
67,2 %
1,0 %
38,1 %
52,6 %
0,9 %
Age
Mean
Median
Comorbidities
0-2
3-5
6 and +
Both groups were similar in many characteristics, including level of
autonomy prior to ED visit and reason for ED consultation and
categories of diagnoses at discharge by ED physician.
Community/home services already in place
60
50
40
30
20
10
0
OT group (N=196)
Control Group (N=236)
OT group
(n=196)
Control group
(n= 236)
Circulatory system
33,6 %
30,3 %
Symptoms, signs not elsewhere classified
(myasthenia, dizziness, etc.)
13,0 %
13,5 %
Respiratory system
11,9 %
16,3 %
Traumas, injury, and consequences of external
causes (falls, etc.)
11,9 %
10,9 %
Musculoskeletal system/connective tissue
7,6 %
6,3 %
Digestive system
6,5 %
8,1 %
Endocrine, nutritional and metabolic
5,4 %
3,6 %
Skin and subcutaneous tissue
4,3 %
4,5 %
Mental and behavioural
3,2 %
4,5 %
Genitourinary system
2,1%
0,9 %
Main complaint/
reasons for ED consultation
Medical diagnoses at discharge (based on ICD-10)
40
35
30
25
20
15
10
5
0
OT group (N=196)
Control Group (N=236)
Destination after the ED visit
OT group
(n=196)
Non-OT control
group (n= 236)
Admission 
39 %
51 %
Return home 
59 %
48 %
Transfer to other hospital
1%
1%
 X2 de Pearson (IC: 95%)
After 3 and 6 months following initial ED visit
OT group (n=196)
3 months
6 months
Non-OT control group (n= 236)
3 months
6 months
37%
30% 
35%
41% 
1 time
28%
17%
23%
23%
2 times
6%
8% 
9%
16% 
3 times
1%
4%
2%
5%
4 times and +
2%
2%
1%
4%
Hospitalized
20%
18%
19%
24%
18%
13%
10%
15%
Returned to ED
1 time
2 times
2% 
2%
8% 
1%
3 times
3%
2%
1%
4 times and +
Placed in care
4%
2%
2%
1%
Deceased
2%
4%
5%
6%
 X2 de Pearson (IC: 95%)
Conclusion
Results suggest that OT in ED using the FSAS-ED may
be beneficial in ED settings by
• reducing hospital admissions and increasing return home
rates without increasing return to ED or hospitalization rates
after 6 months post ED visit,
• identifying patient’s unmet needs and undiagnosed
functional impairments,
• participating in discharge planning to prevent unsafe
discharges and to improve safety upon discharge.
Further studies with larger sample sizes are needed to
• confirm the positive impact (organizational and financial) of
the assessment of functional status in ED.
for your attention!
Many thanks to
And to:
• Myriam Lachance, OT
• Christelle Pelbois, Head Medical Records at CSSS Pierre-de-Saurel
• Mélanie Ricard, OT student
• And finally, thanks to all members of
the project team at CSSS Pierre-de-Saurel
31
Contact: [email protected]
Overview of the FSAS-ED
• +/- 45 minutes interview administered by OTs in ED
• Scored according to the evaluator's clinical judgement
based on:
•
•
•
•
The subject’s responses
Observations of the evaluator
Medical record
Information available from a caregiver present in ED
• To be used with a population
• Aged 65 and older
• Living in the community
• Present initially in ED for a physical health problem and/or
functional decline
Veillette, N., et al., Development of a functional status assessment of seniors visiting emergency department. Archives of Gerontology and
Geriatrics, 2009. 48(2): p. 205-12.
Veillette, N., et al., Item analysis of the functional status assessment of seniors in the emergency department. Disability and Rehabilitation,
2009. 31(7): p. 565-72.
Excerpt
of the
FSAS-ED
(IADL subscale)








• Describes what the person does in his/her usual environment
• Represents the subject’s level of difficulty as well as the help needed
to carry out the activity (if any)
Functional status “Before”
 Prior to visiting the ED
Functional status “Current”…  Since the event* bringing
the person to the ED
Excerpt
of the
FSAS-ED



Her medication was not effective
anymore; was adjusted in ED
Her new wheelchair is perfectly
adapted; now goes out more often
Nothing special…
(Environmental
Factors subscale)





Lives with her son who’s an IV
drug addict (maybe $ abusive)
Get the occasional help she needs
from her neighbour
Lives in a housing complex with
no major obstacles
Adapted transportation services
overall OK.
• Describe the facilitators or barriers (if any) present in the environment
which have an impact on the person’s functioning