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Feasibility of nurses measuring gait speed in older community-dwelling Emergency Department patients
Geriatric Nursing xx (2016) 1e5
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Feature Article
Feasibility of nurses measuring gait speed in older community-dwelling Emergency Department patients Paula W. Tucker, DNP, FNP-BC a, b, c, *, Dian Dowling Evans, PhD, FNP-BC, ENP-BC, FAANP b, c, Carolyn K. Clevenger, DNP, RN, GNP-BC, AGPCNP-BC, FAANP a, c, Michelle Ardisson, DNP, RN, ACNP-BC d, Ula Hwang, MD, MPH, FACEP e, f a
Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA 30033, USA Emory University Hospital, Emergency Department, 1364 Clifton Road, NE, Atlanta, GA 30322, USA Nell Hodgson Woodruff School of Nursing, 1520 Clifton Road, Atlanta, GA 30322, USA d Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240, USA e Department of Emergency Medicine, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, P.O. Box 1620, New York, NY 10029, USA f GRECC (Geriatric Research, Education and Clinical Center), James J. Peters VA Medical Center, 130 Kingsbridge Road, Bronx, NY 10468, USA b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 March 2016 Received in revised form 13 June 2016 Accepted 19 June 2016 Available online xxx
Gait speed assessment is a rapid, simple and objective measure for predicting risk of unfavorable outcomes which may provide better prognostic and reliable information than existing geriatric ED (Emergency Department) screening tools. This descriptive pilot project was designed to determine feasibility of implementing gait speed screening into routine nursing practice by objectively identifying patients with sub-optimal gait speeds. Participants included community-dwelling adults 65 years and older with plans for discharge following ED treatment. Patients with a gait speed <1.0 m/s were identified as “high-risk” for an adverse event, and referred to the ED social worker for individualized resources prior to discharge. Thirty-five patients were screened and nurse initiated gait speed screens were completed 60% of the time. This project demonstrates ED gait speed screening may be feasible. Implications for practice should consider incorporating gait speed screening into routine nursing assessment to improve provider ED decision-making and disposition planning. Published by Elsevier Inc.
Keywords: Gait speed Emergency Department Screening Routine assessment
Introduction Older adults, account for an increasing proportion of Emergency Department (ED) visits. Of the 19.6 million ED visits occurring in the United States from 2009 to 2010, 15% were visits by adults 65 years and older. In fact, average ED visit rates increase as age increases.1 Once seen in the ED, older adults often present with acute illnesses which require higher acuity care.2 Furthermore, older adults are at risk for health complications, a decline in functional status, and poorer health-related quality of life after being seen in the ED, often indicating a multifaceted need that exceeds emergent care.2 Due to the rising number of ED visits associated with poor clinical outcomes, improved and more comprehensive evaluations
* Corresponding author. 3425 Sims Road, Snellville, GA 30039, USA. E-mail address: [email protected] (P.W. Tucker). 0197-4572/$ e see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.gerinurse.2016.06.015
are needed for this population. Interestingly, a recent systematic review identifying 14 functional assessments identified only four self-reportable assessments specifically established for ED practice: Triage Risk Screening Tool (TRST), Identification of Seniors At Risk (ISAR), Runciman Questionnaire, and Functional Status Assessment of Seniors in Emergency Departments (FSAS-ED).3 Although several ED screening instruments have been developed to better identify community-dwelling older adults at risk for adverse events, these instruments are limited based on the requirement to self-report.3,4 Utilizing a rapid, simple, objective screening tool to predict increasing risk of unfavorable outcomes may prove to be more prognostic and reliable than existing self-reportable ED screening instruments.5 Another approach to assessing at risk older adults has been to measure gait speed. Gait speed, also known as walking speed, has been recognized as a potentially valuable clinical marker of health status among older adults, and has been shown to be a valid and reliable measure of health and functional status within individual
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epidemiologic cohort studies.6 The ability to walk increases physiological demands and requires the successful integration of multiple body systems.7 Declines in gait speed are predictive of significant, adverse health-related outcomes including death, reduced quality of life, physical and mental decline, falls, hospitalization and institutionalization.5 Consequently, a decrease in organ system function can result in gait speed changes, specifically a slower gait. In fact, the appearance of gait difficulties in older adults may be an early indicator of physiological decline serving as the “sixth vital sign”; a marker for well-being or frailty.7 Gait speed may be a valuable assessment tool in identifying geriatric patients with established or unrecognized medical problems prompting further assessment and treatment of underlying cardiopulmonary, neurological, or musculoskeletal conditions.7 As a rapid, simple, objective, observer-rated screening tool, gait speed may be particularly useful in quickly identifying geriatric patients at risk in busy ED settings. Despite increasing number of visits to EDs by older adults and the frail elderly, existing ED systems for care may not be adequate in identifying patients at risk. Unfortunately, current ED care practices and models do not address age-related risks nor assess for specific needs of older adults as most ED systems of care were not specifically designed for older people.8 Others question whether emergency care providers are able to make rapid and accurate evaluations of older adults with multiple comorbidities on multiple medications, particularly patients who present with vague problems requiring additional social and community resources.9 A recent study utilizing geriatric nurse liaisons to perform the Timed Up and Go Test into routine care of geriatric patients presenting to the ED was found to be effective and feasible.10 Another study, investigating physician and nurse perceptions regarding the use of a dedicated geriatric technician to screen for geriatric syndromes in the ED was also found beneficial to ED care without becoming a barrier to patient flow.11 Common limitations identified for both studies revealed tailored interventions for geriatric patients at risk for falls were needed.10,11 Incorporating gait speed screening as part of routine nursing practice could improve the care of older adults in the ED by better identifying those at risk of poor treatment outcomes, return ED visits or mortality because of functional decline. Therefore, it will be important to determine if incorporating a gait speed assessment in the ED setting is a viable option. If so, it may be a valuable screening tool in identifying older adults at risk which may also improve patient outcomes by providing ED providers with a more accurate assessment of a patient’s health status leading to better treatment decisions involving care needs and disposition planning. The purpose of this project was to determine the feasibility of implementing gait speed screening into routine nursing practice through a standardized approach. Our goal was to address the following questions: 1. Is it feasible for nurses to perform the observer-rated gait speed screening in community-dwelling adults ages 65 and older presenting to the ED? 2. Is it feasible for the social worker to coordinate outpatient resources for “high-risk” clients? This project will further discuss nurse perceptions regarding gait speed screening in the ED, describe the characteristics of participants who received the gait speed screening and social work coordinator resources provided for “high-risk” clients. Methods Design This was a descriptive pilot project to determine the feasibility of implementing gait speed screening among community-residing adults ages 65 and older being discharged back to home by ED
nurses using a 4-m, timed, walking assessment. After informal discussions with key ED stakeholders, buy-in was obtained from the Chief of Service/Medical Director, Nurse Manager, Shift Charge Nurses, Clinical Nurse Specialist and Social Worker by implementing this quality improvement initiative/pilot project to assess the feasibility of having ED nurses perform a standardized gait speed screening as part of a routine assessment in older adults presenting to the ED. The project team consisted of the Project Leader, ED Nurses and ED Social Worker. Setting/participants This project was conducted at an academic ED facility. Participants for this project were community-dwelling older adults and ED nurses. Patients presenting to the ED during identified data collection times meeting inclusion criteria underwent gait speed screening. Inclusion criteria included ED patients aged 65 and older with stable vital signs, who were able to ambulate without assistance, and who were discharged home following evaluation and ED treatment. Twenty-one ED nurses received education and training to perform the gait speed screening. An expedited review of the protocol and a waiver of informed consent were granted for this project from the Institutional Review Board and determined this project was quality improvement, therefore deemed exempt. There were no identified or potential conflicts of interest involving this project as discussed by the stakeholders with the project leader prior to the implementation of the study. Intervention This project was implemented in two phases. Phase I, the staff education phase, was provided by the project leader and conducted at a one-time mandatory monthly staff meeting. The project leader gave a brief power point presentation which included a YouTube video link on how to perform the gait speed screening (http:// youtu.be/MRDV6ndIoME).12 After the didactic session and demonstration, each nurse performed gait speed screening and competency was validated through required check-offs to ensure reliability of gait speed screening. The project leader was on-site throughout the entire data collection period providing spot checks, verbal reminders and personalized feedback to reinforce and encourage gait speed screening accuracy. A flyer was placed in the break room of the ED as a friendly reminder to initiate gait speed screening when appropriate. Weekly treats and snacks were provided as an incentive. Phase II, the intervention phase, was conducted from 10 am to 4 pm Monday through Thursday over a four-week period from September to October 2014. Materials required for this project included a tape measure, two stopwatches, two clipboards, and the Gait Speed Screening Form (Appendix A). A patient registration label was placed at the top of each form after the completion of gait screening to later track for further analysis. The ED nurses implemented and documented gait speed screening using the gait speed screening protocol and gait speed screening form during the duration of the study. Gait speed was measured using a stopwatch and a 4-m walking distance. Tape was placed on the wall and floor designating a 4-m walking distance located in an area of the ED away from heavy traffic areas. Gait speed screening was initiated on any patient ready for discharge who met inclusion criteria. Patients who met gait speed screening inclusion were instructed to begin walking (from a standing still position) at their usual pace for a distance of 4-m after being instructed to begin walking at the command of “ready-set-go.”6 Gait speeds were timed from the onset of the start command and ended as soon as the patient’s front foot crossed the four-meter marker.13 During the gait speed
P.W. Tucker et al. / Geriatric Nursing xx (2016) 1e5
screening, nurses were instructed to remain at the patient’s side during ambulation to decrease the risk of falling. Nurses were instructed to inform the project leader to initiate a social work referral for any patient whose measured gait speed was less than 1.0 m/s. Once notified, the project leader then collaborated with the ED social worker to determine any additional outpatient resources that might be needed, based on the patients’ medical and social needs, to reduce their risk of readmission. The ED social worker then coordinated all recommended outpatient resources. Additional outpatient resources included the following: referrals for physical/occupational therapy, home health, palliative care, private duty assistance and for supplies such as durable medical equipment. Informal debriefing with ED nurses was conducted daily by the project leader to review processes and concerns to evaluate factors that either enabled or prevented gait speed screening. The gait speed screening forms were placed face down in a clearly marked collection bin at the nurse’s station to increase visibility and were collected daily during the implementation phase by the project leader. The project leader was responsible for the secured storage of all data forms not part of the electronic medical record for the duration of the project in compliance with HIPPA regulations. The gait speed screening forms were destroyed once the data were analyzed and the project was complete. Throughout the duration of this project, the project leader served as the on-site resource during data collection times. In cases when nurses did not identify or were unable to perform the gait speed screening due to conflicting patient demands, the project leader performed the gait speed screenings. The percentage of nurse performed gait speed screenings was also evaluated when the project leader was not on site to determine the actual feasibility of nurse initiated gait speed screenings regardless of the time or day. Feedback was obtained from the nurses by means of a three-question survey and through one-on-one discussions that occurred during the implementation phase of the project. Barriers and facilitators of the screening identified through nursing feedback were described as part of the qualitative analysis. Measures Data collection measures included gait speed screening form and nursing feedback regarding gait speed screening in the ED in the form of a survey. The gait speed screening form included: age, gender, chief complaint, gait speed, whether an individualized inhome or outpatient resource was arranged by the ED social worker and five-year mortality risk as discussed by previous investigators.6 Proposed gait speed cut points were established for average life expectancy based on previous literature.6 For example, gait speeds <0.80 m/s were considered lower than average life expectancy, gait speeds 0.8 m/se<1.0 m/s were considered average life expectancy, and gait speeds 1.0 m/s were considered better than average life expectancy. Five-year survival estimates for men and women by age and gait speed groups were generalized among the participants in this study utilizing a formulated table. These estimates were originated from individual KaplaneMeier survival estimates pooled across studies by means of randomeffects models with opposite variance weighting.6 A three-question survey using a four-point Likert format to assess nurses opinions regarding the gait speed screening was provided during project week four. Survey questions included: Implementing the gait speed screening is feasible for nurses to complete; The gait speed screen should be implemented in the ED as standard of care for patients 65 years and older; The gait speed screen is a risk assessment that improves quality of care for older adults presenting to the ED.
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Data analysis All project data were stored and managed using REDCapÔ (Research Electronic Data Capture) electronic data capture tools hosted at Vanderbilt University. REDCapÔ is a secure, web-based application designed to support data capture for research studies [and quality improvement projects], providing a) an intuitive interface for validated data entry; b) audit trails for tracking data manipulation and export procedures; c) automated export procedures for seamless data downloads to common statistical packages; and d) procedures for importing data from external sources.14 Data was imported into Statistical Package for the Social Sciences (SPSS) version 23.0 for further analysis. Descriptive statistics were applied to determine frequencies for categorical variables (gender, number of patients screened by nurses or project leader, high or usual risk status based on gait speed, and the number of patients who received social work resources). Central tendency measures (mean, standard deviation, median, interquartile range) were determined for interval variables (age and gait speed). Based on the percentage of eligible patients who received the gait speed screening, more than 50% of screenings performed by ED nurses and the “high-risk” patients (gait speeds slower than 1.0 m/s) who received SW referrals were required in order for feasibility to be established for this project. The percentage of gait speed screenings were collected weekly, and nurse feasibility rate was determined by the number of nurse-performed gait speed screens by the total number of patients screened in the ED who met inclusion criteria throughout the data collection period. Feasibility rate among the social worker was determined by the number of “high-risk” patients who actually received in-home or outpatient resources arranged by the social work coordinator by the total number patients with sub-optimal gait speeds, considered as “high-risk.” Results Feasibility A total of 35 participants were screened during the course of this project and seven (20%) of those screened were admitted to the hospital; leaving 28 participants who met inclusion criteria, screened and discharged home. Of the 35 patients screened 21 (60%) were screened by an ED nurse and 14 (40%) were screened by the project leader. Feasibility was also established among the social worker in providing individualized in-home or outpatient resources for 52% (n ¼ 11) of the “high-risk” patients (Table B1). Social work assessments were completed and specific care coordinator interventions included the following: resources provided for assisted living facilities, walking assistive devices and alternative levels of care, home health arrangements, reinforcement of home safety matters addressed, community resources provided such as Meals on Wheels, transportation resources and primary care physician notification regarding patient ED visit. Nurse perceptions regarding gait speed screening Twenty-one nurses (N ¼ 21) completed the three-question survey during project week four. Most of the nurses agreed that implementing the gait speed screening was feasible for nurses to complete in the ED (57.1%), and 33.3% strongly agreed. The majority of the nurses also agreed that the gait speed screen should be implemented in the ED as standard of care for patients 65 years and older (52.4%) and 42.9% strongly agreed. A large percentage of the nurses strongly agreed that gait speed screen is a risk assessment that improves quality of care for older adults presenting to the ED
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(66.7%) and the remaining 28.6% agreed. Interestingly, only one nurse either disagreed or strongly disagreed to each question in the survey. See Figure C1. Patient characteristics Of the 35 participants screened, 18 (51.4%) were males and 17 (48.6%) were females. The mean age and standard deviation (SD) was (M ¼ 75.37, SD ¼ 7.96) and the median age (interquartile range) was 75 (68e82). Gait speed mean and SD was (M ¼ 0.86, SD ¼ 0.28) and median gait speed (interquartile range) was 0.92 (0.63e1.10). Twenty-one (60%) of the patients screened were considered “highrisk” (gait speed less than 1.0 m/s), 14 (40%) were considered usual risk. Among those “high-risk” patients (n ¼ 21), 11 (52%) received social work intervention (Table B1). Discussion Incorporating gait speed screening into routine ED nursing practice among patients 65 years and older may provide clinical value in highlighting patients at risk for adverse events following an ED visit. This study highlights the clinical value and the importance of care coordinator intervention for older adults with functional decline or sub-optimal gait speeds. Although feasibility was established among the nurses, acceptance by the nurses could have been higher. Factors that affected feasibility involved being pulled away to manage emergency situations and lack of staffing. Following informal debriefings with the nurses, a suggestion was provided to utilize nursing assistants in the event feasibility was not established for the nurses to perform the gait speed screen. Strengths of this project highlight the feasibility of ED nurses completing the gait speed screening and the importance of identifying older, community-dwelling patients considered high-risk for adverse events. Accurate and consistent identification of patients with increased risk is the first step in being able to provide individualized interventions to address those risks. Gait speed screening took approximately 3e5 min of nurse time per client, and did not require a significant amount of additional time to complete. This screening could easily be incorporated among face-to face interaction with the patient, and should not take an additional fulltime employee. This project centered around incorporating a new step within a process by engaging stakeholder buy-in. Therefore, the majority of nurses displayed favorable perceptions regarding gait speed screening in the ED, and were positive about incorporating this into their assessment. From that stand point it was feasible among the nursing staff. While other feasibility studies utilized nurse liaisons to perform geriatric assessments in the ED,10,11 this particular project focuses on the ability to utilize multiple nurses within a busy ED setting to ultimately demonstrate feasibility and sustainability if this project was adopted as standardized screening for older ED adults. The feasibility of assessing frailty among older adults presenting to the ED has been investigated. In light of the association between frailty in the setting of falls, acute illness and injuries, an improved assessment of frailty as measured by walking speed rather than by self-report of slowness could support the identification of older adults at risk for adverse events following an ED visit.15 Interestingly, suggestions were made that the gait speed assessment might not be feasible or realistic among all older ED patients in the setting of frailty. However, additional research is needed to establish if frailty and performance measures such as gait speed are linked to adverse events following an ED visit.15 Therefore, this quality improvement project focused on stable community-dwelling older ED patients without mobility issues or requiring mobility assistance.
The ED has been described as the “front porch” to improving care for vulnerable older patients by identifying opportunities for transforming the ED’s traditional role.16 Specifically, prior to discharge, older adults in the ED could receive a risk assessment, comprehensive discharge planning, and receive transitions of care providing a medical home, primary care providers or appropriate specialty consultations such as physical therapy or home care services.16 This model may prove to be cost-effective and improve overall health outcomes through the avoidance of hospital admission and return ED visits.16 Providing personalized social work resources for older adults with gait speeds less than 1.0 m/s may be helpful in reducing the risk for 30-day readmissions to the ED. Patients who participated in gait speed screening and experienced 30-day readmissions to the ED were categorized by the percentage of patients with gait speeds slower than 1.0 m/s (highrisk) versus the percentage of patients with gait speeds equal to or faster than 1.0 m/s (usual risk). The percentage of “high-risk” patients who received care coordinator intervention by the social worker was also assessed at the end of each project week. Among those high-risk patients (n ¼ 21), 11 (52%) received social work intervention, and 4 (19%) of the patients who received a social work intervention experienced 30-day readmission to the ED. Gait speed is a highly predictable measure in assessing functional status regardless of age or gender. Therefore, an expanded version of this project may be meaningful in demonstrating a statistically significant correlation between personalized outpatient intervention and reduction of 30-day readmissions. A recent systematic review of gait speed screening among community-dwelling adults found that the tool demonstrated testretest reliability and construct and predictive validity when compared to disability measures.17 Furthermore, the predictive validity of gait speed for early mortality has been demonstrated across race, gender, and age and normative data is available for inpatient as well as for healthy community-dwelling populations.6,18 Despite limitations, findings show promise for translating gait speed into the clinical setting as a possible indicator of health and function to improve plans of care for older adults.6 Among community-dwelling older adults, gait speeds of 0.8 m/s predicted median life expectancy for age and sex. Hence, gait speeds greater than 1.0 m/s consistently proved longer survival compared to age and sex alone.6 The proposed gait speed cut points that were established for this project could be used as additional information in further evaluating a patient’s medical needs. The benefits of an observer rated, standardized screening tool such as gait speed and providing an objective measure of functional status as a key indicator of frailty may ultimately help to improve the care and management of older community-dwelling adults. This could promote positive clinical health outcomes, resulting in decreases in overall health care costs and increases in patient safety and satisfaction in the ED. Limitations A major limitation of this study was the inability to capture patients 65 years and older within the electronic medical record, as a patient reminder for the nurses to complete the screening prior to ED discharge. The ED nurses performed no gait speed screens after assigned data collection times. Another limitation of this project was the short time frame for data collection, which yielded a small sample size. During project week one, the social worker was not available. The lack of control over treatment reliability or validity relating to the individualized outpatient interventions provided by the social worker was also a limitation. No follow up was completed to evaluate for intervention adherence.
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Conclusions The integration of gait speed to an assessment can assist in the evaluation of patients with mobility limitations and improve discharge planning for patients who may need supportive outpatient intervention.18 For this project, gait speed screen was completed during the medical screening exam instead of triage to allow for provider evaluation and appropriate ED disposition. However, gait speed screening could be completed as part of the triage process in order to avoid negligible time to the discharge process. Future implications for practice should consider adults 65 years and older receive the gait speed screen in the ED prior to discharge with continuous care coordination for older adults. Establishing gait speed trajectories may provide ED clinicians with baseline gait speed data to further evaluate for improvement or decline in functional status. Trajectory gait speed data may also assist clinicians in developing better plans of care fostering interprofessional collaboration and managed care approach. Future projects should include collaborating with informatics in developing a questionnaire form within the electronic health record that will flag patients 65 years and older. This questionnaire would transmit a prompt in identifying a patient’s ambulatory status; i.e. use of a walker, cane, wheelchair or ambulatory without assistance. This would provide a better way of capturing patients who could receive gait speed screening prior to ED discharge. The Institute of Medicine urges the importance of improving data collection in renovating the clinical practice environment; therefore, the use of EHRs can be utilized as a resource in capturing patient data for future studies.19 Gait speeds 0.6 m/s or slower have been described as “dismobility,” and considered a valuable diagnosis as a means for improving patient care, research and regulatory approval of interventions, which could ultimately improve mobility.20 Re-defining more specific gait speed cut points would be helpful in targeting patients with an increasing risk of 30-day readmissions to the ED as would expansion of the definition of high-risk and/or randomization of patients who receive gait speed evaluation. Additionally, an investigation of the association between gait speed and comorbidities may be useful in highlighting the significance of health status and gait speeds, and to establish relationships in assessing mortality risk and gait speed cut points. Acknowledgments This review is the result of work supported with resources and use of facilities by fellows in the VA Quality Scholars Fellowship Program located at the Atlanta VA Medical Center, Decatur, GA, funded by the Department of Veterans Affairs. The conclusions in this publication are those of the authors and they do not necessarily represent the views of the Department of Veterans Affairs or the United States government.
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Appendix. Supplementary data Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.gerinurse.2016.06.015.
References 1. Albert M, McCaig LF, Ashman JJ. Emergency department visits by persons aged 65 and over: United States, 2009-2010. NCHS Data Brief. 2013;130:1e8. 2. Gruneir A, Silver MJ, Rochon PA. Emergency department use by older adults: a literature review on trends, appropriateness, and consequences of unmet health care needs. Med Care Res Rev. 2011;68(2):131e155. 3. Bissett M, Cusick A, Lannin NA. Functional assessments utilised in emergency departments: a systematic review. Age Ageing. 2013;42(2):163e172. 4. Di Bari M, Salvi F, Roberts AT, et al. Prognostic stratification of elderly patients in the emergency department: a comparison between the “identification of seniors at risk” and the “silver code”. J Gerontol A Biol Sci Med Sci. 2012;67(5): 544e550. 5. Van Kan GA, Rolland Y, Andrieu S, et al. Gait speed at usual pace as a predictor of adverse outcomes in community-dwelling older people an international academy on nutrition and aging (IANA) task force. J Nutr Health Aging. 2009;13(10):881e890. 6. Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA. 2011;305(1):50e58. 7. Studenski S. Bradypedia: is gait speed ready for clinical use? J Nutr Health Aging. 2009;13(10):878e880. 8. Hwang U, Morrison RS. The geriatric emergency department. J Am Geriatr Soc. 2007;55(11):1873e1876. 9. Conroy S. Emergency room geriatric assessmenteurgent, important or both? Age Ageing. 2008;37(6):612e613. 10. Huded JM, Dresden SM, Gravenor SJ, Rowe T, Lindquist LA. Screening for fall risks in the emergency department: a novel nursing-driven program. West J Emerg Med. 2015;16(7):1043e1046. 11. Carpenter CR, Griffey RT, Stark S, Coopersmith CM, Gage BF. Physician and nurse acceptance of technicians to screen for geriatric syndromes in the emergency department. West J Emerg Med. 2011;12(4):489e495. 12. University of Pittsburgh Medical Center. Using gait speed to measure patient’s health. Available at: http://youtu.be/MRDV6ndIoME; Accessed 13.09.13. 13. Fritz S, Lusardi M. White paper: “walking speed: the sixth vital sign”. J Geriatr Phys Ther. 2009;32(2):46e49. 14. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)ea metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377e381. 15. Stiffler KA, Finley A, Midha S, Wilber ST. Frailty assessment in the emergency department. J Emerg Med. 2013;45(2):291e298. 16. Hwang U, Shah MN, Han JH, Carpenter CR, Siu AL, Adams JG. Transforming emergency care for older adults. Health Aff (Millwood). 2013;32(12):2116e 2121. 17. Munoz-Mendoza C, Cabrero-Garcia J, Reig-Ferrer A, Cabanero-Martinez M. Evaluation of walking speed tests as a measurement of functional limitations in elderly people: a structured review. Int J Clin Health Psychol. 2010;10(2):359e 378. 18. Peel NM, Kuys SS, Klein K. Gait speed as a measure in geriatric assessment in clinical settings: a systematic review. J Gerontol A Biol Sci Med Sci. 2013;68(1): 39e46. 19. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington (DC): National Academies Press; 2011. 20. Cummings SR, Studenski S, Ferrucci L. A diagnosis of dismobilityegiving mobility clinical visibility: a mobility working group recommendation. JAMA. 2014;311(20):2061e2062.
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Feature Article
Feasibility of nurses measuring gait speed in older community-dwelling Emergency Department patients Paula W. Tucker, DNP, FNP-BC a, b, c, *, Dian Dowling Evans, PhD, FNP-BC, ENP-BC, FAANP b, c, Carolyn K. Clevenger, DNP, RN, GNP-BC, AGPCNP-BC, FAANP a, c, Michelle Ardisson, DNP, RN, ACNP-BC d, Ula Hwang, MD, MPH, FACEP e, f a
Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA 30033, USA Emory University Hospital, Emergency Department, 1364 Clifton Road, NE, Atlanta, GA 30322, USA Nell Hodgson Woodruff School of Nursing, 1520 Clifton Road, Atlanta, GA 30322, USA d Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240, USA e Department of Emergency Medicine, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, P.O. Box 1620, New York, NY 10029, USA f GRECC (Geriatric Research, Education and Clinical Center), James J. Peters VA Medical Center, 130 Kingsbridge Road, Bronx, NY 10468, USA b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 March 2016 Received in revised form 13 June 2016 Accepted 19 June 2016 Available online xxx
Gait speed assessment is a rapid, simple and objective measure for predicting risk of unfavorable outcomes which may provide better prognostic and reliable information than existing geriatric ED (Emergency Department) screening tools. This descriptive pilot project was designed to determine feasibility of implementing gait speed screening into routine nursing practice by objectively identifying patients with sub-optimal gait speeds. Participants included community-dwelling adults 65 years and older with plans for discharge following ED treatment. Patients with a gait speed <1.0 m/s were identified as “high-risk” for an adverse event, and referred to the ED social worker for individualized resources prior to discharge. Thirty-five patients were screened and nurse initiated gait speed screens were completed 60% of the time. This project demonstrates ED gait speed screening may be feasible. Implications for practice should consider incorporating gait speed screening into routine nursing assessment to improve provider ED decision-making and disposition planning. Published by Elsevier Inc.
Keywords: Gait speed Emergency Department Screening Routine assessment
Introduction Older adults, account for an increasing proportion of Emergency Department (ED) visits. Of the 19.6 million ED visits occurring in the United States from 2009 to 2010, 15% were visits by adults 65 years and older. In fact, average ED visit rates increase as age increases.1 Once seen in the ED, older adults often present with acute illnesses which require higher acuity care.2 Furthermore, older adults are at risk for health complications, a decline in functional status, and poorer health-related quality of life after being seen in the ED, often indicating a multifaceted need that exceeds emergent care.2 Due to the rising number of ED visits associated with poor clinical outcomes, improved and more comprehensive evaluations
* Corresponding author. 3425 Sims Road, Snellville, GA 30039, USA. E-mail address: [email protected] (P.W. Tucker). 0197-4572/$ e see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.gerinurse.2016.06.015
are needed for this population. Interestingly, a recent systematic review identifying 14 functional assessments identified only four self-reportable assessments specifically established for ED practice: Triage Risk Screening Tool (TRST), Identification of Seniors At Risk (ISAR), Runciman Questionnaire, and Functional Status Assessment of Seniors in Emergency Departments (FSAS-ED).3 Although several ED screening instruments have been developed to better identify community-dwelling older adults at risk for adverse events, these instruments are limited based on the requirement to self-report.3,4 Utilizing a rapid, simple, objective screening tool to predict increasing risk of unfavorable outcomes may prove to be more prognostic and reliable than existing self-reportable ED screening instruments.5 Another approach to assessing at risk older adults has been to measure gait speed. Gait speed, also known as walking speed, has been recognized as a potentially valuable clinical marker of health status among older adults, and has been shown to be a valid and reliable measure of health and functional status within individual
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epidemiologic cohort studies.6 The ability to walk increases physiological demands and requires the successful integration of multiple body systems.7 Declines in gait speed are predictive of significant, adverse health-related outcomes including death, reduced quality of life, physical and mental decline, falls, hospitalization and institutionalization.5 Consequently, a decrease in organ system function can result in gait speed changes, specifically a slower gait. In fact, the appearance of gait difficulties in older adults may be an early indicator of physiological decline serving as the “sixth vital sign”; a marker for well-being or frailty.7 Gait speed may be a valuable assessment tool in identifying geriatric patients with established or unrecognized medical problems prompting further assessment and treatment of underlying cardiopulmonary, neurological, or musculoskeletal conditions.7 As a rapid, simple, objective, observer-rated screening tool, gait speed may be particularly useful in quickly identifying geriatric patients at risk in busy ED settings. Despite increasing number of visits to EDs by older adults and the frail elderly, existing ED systems for care may not be adequate in identifying patients at risk. Unfortunately, current ED care practices and models do not address age-related risks nor assess for specific needs of older adults as most ED systems of care were not specifically designed for older people.8 Others question whether emergency care providers are able to make rapid and accurate evaluations of older adults with multiple comorbidities on multiple medications, particularly patients who present with vague problems requiring additional social and community resources.9 A recent study utilizing geriatric nurse liaisons to perform the Timed Up and Go Test into routine care of geriatric patients presenting to the ED was found to be effective and feasible.10 Another study, investigating physician and nurse perceptions regarding the use of a dedicated geriatric technician to screen for geriatric syndromes in the ED was also found beneficial to ED care without becoming a barrier to patient flow.11 Common limitations identified for both studies revealed tailored interventions for geriatric patients at risk for falls were needed.10,11 Incorporating gait speed screening as part of routine nursing practice could improve the care of older adults in the ED by better identifying those at risk of poor treatment outcomes, return ED visits or mortality because of functional decline. Therefore, it will be important to determine if incorporating a gait speed assessment in the ED setting is a viable option. If so, it may be a valuable screening tool in identifying older adults at risk which may also improve patient outcomes by providing ED providers with a more accurate assessment of a patient’s health status leading to better treatment decisions involving care needs and disposition planning. The purpose of this project was to determine the feasibility of implementing gait speed screening into routine nursing practice through a standardized approach. Our goal was to address the following questions: 1. Is it feasible for nurses to perform the observer-rated gait speed screening in community-dwelling adults ages 65 and older presenting to the ED? 2. Is it feasible for the social worker to coordinate outpatient resources for “high-risk” clients? This project will further discuss nurse perceptions regarding gait speed screening in the ED, describe the characteristics of participants who received the gait speed screening and social work coordinator resources provided for “high-risk” clients. Methods Design This was a descriptive pilot project to determine the feasibility of implementing gait speed screening among community-residing adults ages 65 and older being discharged back to home by ED
nurses using a 4-m, timed, walking assessment. After informal discussions with key ED stakeholders, buy-in was obtained from the Chief of Service/Medical Director, Nurse Manager, Shift Charge Nurses, Clinical Nurse Specialist and Social Worker by implementing this quality improvement initiative/pilot project to assess the feasibility of having ED nurses perform a standardized gait speed screening as part of a routine assessment in older adults presenting to the ED. The project team consisted of the Project Leader, ED Nurses and ED Social Worker. Setting/participants This project was conducted at an academic ED facility. Participants for this project were community-dwelling older adults and ED nurses. Patients presenting to the ED during identified data collection times meeting inclusion criteria underwent gait speed screening. Inclusion criteria included ED patients aged 65 and older with stable vital signs, who were able to ambulate without assistance, and who were discharged home following evaluation and ED treatment. Twenty-one ED nurses received education and training to perform the gait speed screening. An expedited review of the protocol and a waiver of informed consent were granted for this project from the Institutional Review Board and determined this project was quality improvement, therefore deemed exempt. There were no identified or potential conflicts of interest involving this project as discussed by the stakeholders with the project leader prior to the implementation of the study. Intervention This project was implemented in two phases. Phase I, the staff education phase, was provided by the project leader and conducted at a one-time mandatory monthly staff meeting. The project leader gave a brief power point presentation which included a YouTube video link on how to perform the gait speed screening (http:// youtu.be/MRDV6ndIoME).12 After the didactic session and demonstration, each nurse performed gait speed screening and competency was validated through required check-offs to ensure reliability of gait speed screening. The project leader was on-site throughout the entire data collection period providing spot checks, verbal reminders and personalized feedback to reinforce and encourage gait speed screening accuracy. A flyer was placed in the break room of the ED as a friendly reminder to initiate gait speed screening when appropriate. Weekly treats and snacks were provided as an incentive. Phase II, the intervention phase, was conducted from 10 am to 4 pm Monday through Thursday over a four-week period from September to October 2014. Materials required for this project included a tape measure, two stopwatches, two clipboards, and the Gait Speed Screening Form (Appendix A). A patient registration label was placed at the top of each form after the completion of gait screening to later track for further analysis. The ED nurses implemented and documented gait speed screening using the gait speed screening protocol and gait speed screening form during the duration of the study. Gait speed was measured using a stopwatch and a 4-m walking distance. Tape was placed on the wall and floor designating a 4-m walking distance located in an area of the ED away from heavy traffic areas. Gait speed screening was initiated on any patient ready for discharge who met inclusion criteria. Patients who met gait speed screening inclusion were instructed to begin walking (from a standing still position) at their usual pace for a distance of 4-m after being instructed to begin walking at the command of “ready-set-go.”6 Gait speeds were timed from the onset of the start command and ended as soon as the patient’s front foot crossed the four-meter marker.13 During the gait speed
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screening, nurses were instructed to remain at the patient’s side during ambulation to decrease the risk of falling. Nurses were instructed to inform the project leader to initiate a social work referral for any patient whose measured gait speed was less than 1.0 m/s. Once notified, the project leader then collaborated with the ED social worker to determine any additional outpatient resources that might be needed, based on the patients’ medical and social needs, to reduce their risk of readmission. The ED social worker then coordinated all recommended outpatient resources. Additional outpatient resources included the following: referrals for physical/occupational therapy, home health, palliative care, private duty assistance and for supplies such as durable medical equipment. Informal debriefing with ED nurses was conducted daily by the project leader to review processes and concerns to evaluate factors that either enabled or prevented gait speed screening. The gait speed screening forms were placed face down in a clearly marked collection bin at the nurse’s station to increase visibility and were collected daily during the implementation phase by the project leader. The project leader was responsible for the secured storage of all data forms not part of the electronic medical record for the duration of the project in compliance with HIPPA regulations. The gait speed screening forms were destroyed once the data were analyzed and the project was complete. Throughout the duration of this project, the project leader served as the on-site resource during data collection times. In cases when nurses did not identify or were unable to perform the gait speed screening due to conflicting patient demands, the project leader performed the gait speed screenings. The percentage of nurse performed gait speed screenings was also evaluated when the project leader was not on site to determine the actual feasibility of nurse initiated gait speed screenings regardless of the time or day. Feedback was obtained from the nurses by means of a three-question survey and through one-on-one discussions that occurred during the implementation phase of the project. Barriers and facilitators of the screening identified through nursing feedback were described as part of the qualitative analysis. Measures Data collection measures included gait speed screening form and nursing feedback regarding gait speed screening in the ED in the form of a survey. The gait speed screening form included: age, gender, chief complaint, gait speed, whether an individualized inhome or outpatient resource was arranged by the ED social worker and five-year mortality risk as discussed by previous investigators.6 Proposed gait speed cut points were established for average life expectancy based on previous literature.6 For example, gait speeds <0.80 m/s were considered lower than average life expectancy, gait speeds 0.8 m/se<1.0 m/s were considered average life expectancy, and gait speeds 1.0 m/s were considered better than average life expectancy. Five-year survival estimates for men and women by age and gait speed groups were generalized among the participants in this study utilizing a formulated table. These estimates were originated from individual KaplaneMeier survival estimates pooled across studies by means of randomeffects models with opposite variance weighting.6 A three-question survey using a four-point Likert format to assess nurses opinions regarding the gait speed screening was provided during project week four. Survey questions included: Implementing the gait speed screening is feasible for nurses to complete; The gait speed screen should be implemented in the ED as standard of care for patients 65 years and older; The gait speed screen is a risk assessment that improves quality of care for older adults presenting to the ED.
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Data analysis All project data were stored and managed using REDCapÔ (Research Electronic Data Capture) electronic data capture tools hosted at Vanderbilt University. REDCapÔ is a secure, web-based application designed to support data capture for research studies [and quality improvement projects], providing a) an intuitive interface for validated data entry; b) audit trails for tracking data manipulation and export procedures; c) automated export procedures for seamless data downloads to common statistical packages; and d) procedures for importing data from external sources.14 Data was imported into Statistical Package for the Social Sciences (SPSS) version 23.0 for further analysis. Descriptive statistics were applied to determine frequencies for categorical variables (gender, number of patients screened by nurses or project leader, high or usual risk status based on gait speed, and the number of patients who received social work resources). Central tendency measures (mean, standard deviation, median, interquartile range) were determined for interval variables (age and gait speed). Based on the percentage of eligible patients who received the gait speed screening, more than 50% of screenings performed by ED nurses and the “high-risk” patients (gait speeds slower than 1.0 m/s) who received SW referrals were required in order for feasibility to be established for this project. The percentage of gait speed screenings were collected weekly, and nurse feasibility rate was determined by the number of nurse-performed gait speed screens by the total number of patients screened in the ED who met inclusion criteria throughout the data collection period. Feasibility rate among the social worker was determined by the number of “high-risk” patients who actually received in-home or outpatient resources arranged by the social work coordinator by the total number patients with sub-optimal gait speeds, considered as “high-risk.” Results Feasibility A total of 35 participants were screened during the course of this project and seven (20%) of those screened were admitted to the hospital; leaving 28 participants who met inclusion criteria, screened and discharged home. Of the 35 patients screened 21 (60%) were screened by an ED nurse and 14 (40%) were screened by the project leader. Feasibility was also established among the social worker in providing individualized in-home or outpatient resources for 52% (n ¼ 11) of the “high-risk” patients (Table B1). Social work assessments were completed and specific care coordinator interventions included the following: resources provided for assisted living facilities, walking assistive devices and alternative levels of care, home health arrangements, reinforcement of home safety matters addressed, community resources provided such as Meals on Wheels, transportation resources and primary care physician notification regarding patient ED visit. Nurse perceptions regarding gait speed screening Twenty-one nurses (N ¼ 21) completed the three-question survey during project week four. Most of the nurses agreed that implementing the gait speed screening was feasible for nurses to complete in the ED (57.1%), and 33.3% strongly agreed. The majority of the nurses also agreed that the gait speed screen should be implemented in the ED as standard of care for patients 65 years and older (52.4%) and 42.9% strongly agreed. A large percentage of the nurses strongly agreed that gait speed screen is a risk assessment that improves quality of care for older adults presenting to the ED
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(66.7%) and the remaining 28.6% agreed. Interestingly, only one nurse either disagreed or strongly disagreed to each question in the survey. See Figure C1. Patient characteristics Of the 35 participants screened, 18 (51.4%) were males and 17 (48.6%) were females. The mean age and standard deviation (SD) was (M ¼ 75.37, SD ¼ 7.96) and the median age (interquartile range) was 75 (68e82). Gait speed mean and SD was (M ¼ 0.86, SD ¼ 0.28) and median gait speed (interquartile range) was 0.92 (0.63e1.10). Twenty-one (60%) of the patients screened were considered “highrisk” (gait speed less than 1.0 m/s), 14 (40%) were considered usual risk. Among those “high-risk” patients (n ¼ 21), 11 (52%) received social work intervention (Table B1). Discussion Incorporating gait speed screening into routine ED nursing practice among patients 65 years and older may provide clinical value in highlighting patients at risk for adverse events following an ED visit. This study highlights the clinical value and the importance of care coordinator intervention for older adults with functional decline or sub-optimal gait speeds. Although feasibility was established among the nurses, acceptance by the nurses could have been higher. Factors that affected feasibility involved being pulled away to manage emergency situations and lack of staffing. Following informal debriefings with the nurses, a suggestion was provided to utilize nursing assistants in the event feasibility was not established for the nurses to perform the gait speed screen. Strengths of this project highlight the feasibility of ED nurses completing the gait speed screening and the importance of identifying older, community-dwelling patients considered high-risk for adverse events. Accurate and consistent identification of patients with increased risk is the first step in being able to provide individualized interventions to address those risks. Gait speed screening took approximately 3e5 min of nurse time per client, and did not require a significant amount of additional time to complete. This screening could easily be incorporated among face-to face interaction with the patient, and should not take an additional fulltime employee. This project centered around incorporating a new step within a process by engaging stakeholder buy-in. Therefore, the majority of nurses displayed favorable perceptions regarding gait speed screening in the ED, and were positive about incorporating this into their assessment. From that stand point it was feasible among the nursing staff. While other feasibility studies utilized nurse liaisons to perform geriatric assessments in the ED,10,11 this particular project focuses on the ability to utilize multiple nurses within a busy ED setting to ultimately demonstrate feasibility and sustainability if this project was adopted as standardized screening for older ED adults. The feasibility of assessing frailty among older adults presenting to the ED has been investigated. In light of the association between frailty in the setting of falls, acute illness and injuries, an improved assessment of frailty as measured by walking speed rather than by self-report of slowness could support the identification of older adults at risk for adverse events following an ED visit.15 Interestingly, suggestions were made that the gait speed assessment might not be feasible or realistic among all older ED patients in the setting of frailty. However, additional research is needed to establish if frailty and performance measures such as gait speed are linked to adverse events following an ED visit.15 Therefore, this quality improvement project focused on stable community-dwelling older ED patients without mobility issues or requiring mobility assistance.
The ED has been described as the “front porch” to improving care for vulnerable older patients by identifying opportunities for transforming the ED’s traditional role.16 Specifically, prior to discharge, older adults in the ED could receive a risk assessment, comprehensive discharge planning, and receive transitions of care providing a medical home, primary care providers or appropriate specialty consultations such as physical therapy or home care services.16 This model may prove to be cost-effective and improve overall health outcomes through the avoidance of hospital admission and return ED visits.16 Providing personalized social work resources for older adults with gait speeds less than 1.0 m/s may be helpful in reducing the risk for 30-day readmissions to the ED. Patients who participated in gait speed screening and experienced 30-day readmissions to the ED were categorized by the percentage of patients with gait speeds slower than 1.0 m/s (highrisk) versus the percentage of patients with gait speeds equal to or faster than 1.0 m/s (usual risk). The percentage of “high-risk” patients who received care coordinator intervention by the social worker was also assessed at the end of each project week. Among those high-risk patients (n ¼ 21), 11 (52%) received social work intervention, and 4 (19%) of the patients who received a social work intervention experienced 30-day readmission to the ED. Gait speed is a highly predictable measure in assessing functional status regardless of age or gender. Therefore, an expanded version of this project may be meaningful in demonstrating a statistically significant correlation between personalized outpatient intervention and reduction of 30-day readmissions. A recent systematic review of gait speed screening among community-dwelling adults found that the tool demonstrated testretest reliability and construct and predictive validity when compared to disability measures.17 Furthermore, the predictive validity of gait speed for early mortality has been demonstrated across race, gender, and age and normative data is available for inpatient as well as for healthy community-dwelling populations.6,18 Despite limitations, findings show promise for translating gait speed into the clinical setting as a possible indicator of health and function to improve plans of care for older adults.6 Among community-dwelling older adults, gait speeds of 0.8 m/s predicted median life expectancy for age and sex. Hence, gait speeds greater than 1.0 m/s consistently proved longer survival compared to age and sex alone.6 The proposed gait speed cut points that were established for this project could be used as additional information in further evaluating a patient’s medical needs. The benefits of an observer rated, standardized screening tool such as gait speed and providing an objective measure of functional status as a key indicator of frailty may ultimately help to improve the care and management of older community-dwelling adults. This could promote positive clinical health outcomes, resulting in decreases in overall health care costs and increases in patient safety and satisfaction in the ED. Limitations A major limitation of this study was the inability to capture patients 65 years and older within the electronic medical record, as a patient reminder for the nurses to complete the screening prior to ED discharge. The ED nurses performed no gait speed screens after assigned data collection times. Another limitation of this project was the short time frame for data collection, which yielded a small sample size. During project week one, the social worker was not available. The lack of control over treatment reliability or validity relating to the individualized outpatient interventions provided by the social worker was also a limitation. No follow up was completed to evaluate for intervention adherence.
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Conclusions The integration of gait speed to an assessment can assist in the evaluation of patients with mobility limitations and improve discharge planning for patients who may need supportive outpatient intervention.18 For this project, gait speed screen was completed during the medical screening exam instead of triage to allow for provider evaluation and appropriate ED disposition. However, gait speed screening could be completed as part of the triage process in order to avoid negligible time to the discharge process. Future implications for practice should consider adults 65 years and older receive the gait speed screen in the ED prior to discharge with continuous care coordination for older adults. Establishing gait speed trajectories may provide ED clinicians with baseline gait speed data to further evaluate for improvement or decline in functional status. Trajectory gait speed data may also assist clinicians in developing better plans of care fostering interprofessional collaboration and managed care approach. Future projects should include collaborating with informatics in developing a questionnaire form within the electronic health record that will flag patients 65 years and older. This questionnaire would transmit a prompt in identifying a patient’s ambulatory status; i.e. use of a walker, cane, wheelchair or ambulatory without assistance. This would provide a better way of capturing patients who could receive gait speed screening prior to ED discharge. The Institute of Medicine urges the importance of improving data collection in renovating the clinical practice environment; therefore, the use of EHRs can be utilized as a resource in capturing patient data for future studies.19 Gait speeds 0.6 m/s or slower have been described as “dismobility,” and considered a valuable diagnosis as a means for improving patient care, research and regulatory approval of interventions, which could ultimately improve mobility.20 Re-defining more specific gait speed cut points would be helpful in targeting patients with an increasing risk of 30-day readmissions to the ED as would expansion of the definition of high-risk and/or randomization of patients who receive gait speed evaluation. Additionally, an investigation of the association between gait speed and comorbidities may be useful in highlighting the significance of health status and gait speeds, and to establish relationships in assessing mortality risk and gait speed cut points. Acknowledgments This review is the result of work supported with resources and use of facilities by fellows in the VA Quality Scholars Fellowship Program located at the Atlanta VA Medical Center, Decatur, GA, funded by the Department of Veterans Affairs. The conclusions in this publication are those of the authors and they do not necessarily represent the views of the Department of Veterans Affairs or the United States government.
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Appendix. Supplementary data Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.gerinurse.2016.06.015.
References 1. Albert M, McCaig LF, Ashman JJ. Emergency department visits by persons aged 65 and over: United States, 2009-2010. NCHS Data Brief. 2013;130:1e8. 2. Gruneir A, Silver MJ, Rochon PA. Emergency department use by older adults: a literature review on trends, appropriateness, and consequences of unmet health care needs. Med Care Res Rev. 2011;68(2):131e155. 3. Bissett M, Cusick A, Lannin NA. Functional assessments utilised in emergency departments: a systematic review. Age Ageing. 2013;42(2):163e172. 4. Di Bari M, Salvi F, Roberts AT, et al. Prognostic stratification of elderly patients in the emergency department: a comparison between the “identification of seniors at risk” and the “silver code”. J Gerontol A Biol Sci Med Sci. 2012;67(5): 544e550. 5. Van Kan GA, Rolland Y, Andrieu S, et al. Gait speed at usual pace as a predictor of adverse outcomes in community-dwelling older people an international academy on nutrition and aging (IANA) task force. J Nutr Health Aging. 2009;13(10):881e890. 6. Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA. 2011;305(1):50e58. 7. Studenski S. Bradypedia: is gait speed ready for clinical use? J Nutr Health Aging. 2009;13(10):878e880. 8. Hwang U, Morrison RS. The geriatric emergency department. J Am Geriatr Soc. 2007;55(11):1873e1876. 9. Conroy S. Emergency room geriatric assessmenteurgent, important or both? Age Ageing. 2008;37(6):612e613. 10. Huded JM, Dresden SM, Gravenor SJ, Rowe T, Lindquist LA. Screening for fall risks in the emergency department: a novel nursing-driven program. West J Emerg Med. 2015;16(7):1043e1046. 11. Carpenter CR, Griffey RT, Stark S, Coopersmith CM, Gage BF. Physician and nurse acceptance of technicians to screen for geriatric syndromes in the emergency department. West J Emerg Med. 2011;12(4):489e495. 12. University of Pittsburgh Medical Center. Using gait speed to measure patient’s health. Available at: http://youtu.be/MRDV6ndIoME; Accessed 13.09.13. 13. Fritz S, Lusardi M. White paper: “walking speed: the sixth vital sign”. J Geriatr Phys Ther. 2009;32(2):46e49. 14. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)ea metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377e381. 15. Stiffler KA, Finley A, Midha S, Wilber ST. Frailty assessment in the emergency department. J Emerg Med. 2013;45(2):291e298. 16. Hwang U, Shah MN, Han JH, Carpenter CR, Siu AL, Adams JG. Transforming emergency care for older adults. Health Aff (Millwood). 2013;32(12):2116e 2121. 17. Munoz-Mendoza C, Cabrero-Garcia J, Reig-Ferrer A, Cabanero-Martinez M. Evaluation of walking speed tests as a measurement of functional limitations in elderly people: a structured review. Int J Clin Health Psychol. 2010;10(2):359e 378. 18. Peel NM, Kuys SS, Klein K. Gait speed as a measure in geriatric assessment in clinical settings: a systematic review. J Gerontol A Biol Sci Med Sci. 2013;68(1): 39e46. 19. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington (DC): National Academies Press; 2011. 20. Cummings SR, Studenski S, Ferrucci L. A diagnosis of dismobilityegiving mobility clinical visibility: a mobility working group recommendation. JAMA. 2014;311(20):2061e2062.