- Email: [email protected]
Guidelines for Care of the Elderly
CORRESPONDENCE smaller (3%). In contrast. the prevalence of nonurgent visits gave a similar result in Franche Comte and in Paris (35%).8 In summary, despite different health care systems, the worldwide need of primary health care at the ED is clear. A precise evaluation of primary health care needs on a population basis has to be conducted. Availability of quality primary care at the ED is apossibility for the so-called inappropriate users who reveal in several countries a public health problem even when UHC is available.
Alain Davido, MD Nicole Sembach, MD Thierry Lang, MD, PhD Department of Emergency Medicine H6pital Pitie Salpetriere Paris, France 1. Goldfrank LRe The troubled road to universal health care. Ann Emerg Med 1997;30:737-738. 2. O'Brien GM, Stein MD, Zierler 5, et ale Use of the ED as a regular source of care: Associated factors beyond lack of health insurance. Ann Emerg Med 1997;30:286-291. 3. Lang T, Davida A, Diakite B, et a1: Using the hospital emergency department as a regular source of care. Eur J EpidemioI1997;13:223-228.
4. Rodwin RG, Sandier 5: Health care under French national health insurance. Health Affairs 1993;1:111-131. 5. Baker DW, Stevens CD, Brook RH: Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency department. JAMA 1994;271:1909-1912.
6. Purdie F, Hanigman B, Rosen P: The chronic emergency department patient. Ann Emerg Med 1981;10:298-301. 7. Lang T, Davida A, Diakite B, et ale Non urgent care in the hospital medical emergency department: How much and which health needs does it reflect? J Epidemiol Comm Health 1996;50:456-462.
8. Shesser R, Kirsch T, Smith], et ale An analysis of emergency department use by patients with minor illness. Ann Emerg Med 1991;20:743-748.
In reply Drs Davido, Sembach, and Lang raise important points. My idealized version of health care is based on an adequate societal allocation of dollars (or francs or pesos) to do medical care correctly with acommitment for all in acommunity to share in the responsibilities, risks, and benefits of the system. Any successful system will entail rationalization of our approaches, whether in the United States, France, or elsewhere. This proposed system will entail rationing much like the Oregon Medicaid Health Plan, but must include all individuals in a true communitarian experience. Our current zeal to control administrative and medical costs and
114
curtail the overutilization of resources must be directed to more humanitarian ends. In the current American political and economic climate, moving to a system of universal health care seems difficult. My hope is that our suffering with managed care, managerial profiteering, and medical egocentrism will lead us to medical altruism and a well-financed, well-practiced system of universal health care. To succeed we must unite with many groups of physicians, like our compatriot French emergency physicians, and all members of our society in order to understand what should be done to realize the ideal system. International health research with aparticular focus on maintaining quality medical care while developing public health and universal health care is an excellent project for us all. I agree entirely with the authors that even when asystem is universal and well developed, an excellent program in emergency medicine will be very busy, very diversified, essential, and greatly appreciated.
Lewis Goldfrank, MD Department of Emergency Medicine Bellevue Hospital Center, New York, NY In reply It is interesting that universal health care does not necessarily reduce the use of the emergency department as a regular source of care in France. However, these authors found that only 14% were regular ED users compared with our finding of 25%. Additionally, the authors point out advantages for the patient such as not having to make an appointPllent and not having to pay out-of-pocket expenses. Although these are advantages, there are many disadvantages such as lack of preventive services in healthy patients, and lack of continuation of care, particularly important for those with an illness. The authors suggest that quality primary care is a possibility for those who use the ED as a regular source of care. However, emergency physicians are not trained in the practice of primary care, and EDs are not set up for the practice of primary care. In addition, there is an excellent existing primary care system in the United States that is underutilized by these patients. It would seem (both for the patient and the health care system) better to refer these
patients to primary care centers for this type of care, thus decreasing excess ED utilization and allowing EDs to focus on emergency care.
Gail M O'Brien, MD Division of General Internal Medicine Brown University Rhode Island Hospital Providence, RI 1. O'Brien GM, Stein MD, Zierler 5, et a1: Use of the ED as a regular source of care: Associated factors beyond the lack of health insurance. Ann Emerg Med 1997;30:286-291. 2. Grumbach K, Keane D, Bindman A: Primary care and public emergency department overcrowding. Am] Public Health 1993;83:372-378.
3. Oerlet R, Kinser D, Ray L, et ale Prospective identification and triage of an emergency department: A 5-year study. Ann Intern Med 1995;25:215-223.
4. Woo/handler 5, Himmelstein D: Reverse targeting of preventive care due to lack of health insurance ]AMA 1988; 259:2872-2874.
Guidelines for Care of. the Elderly To the Editor: The American Physical Therapy Association's PT Bulletin recently referenced the article, "Practice Guideline for the ED Management of Falls in Community-Dwelling Elderly Persons" in the October 1997 issue of Annals of Emergency Medicine. I am a physical therapist who works with many community-dwelling elderly persons who have sustained injuries after a fall. One of my primary interventions is educating the patient in preventing future falls. Therefore I was very interested to find out how emergency physicians will also help in this plight. I think Dr Baraft and his colleagues have made avery good start, and I hope EDs around the country use these guidelines. As a physical therapist. I do have a few critiques and suggestions that should be taken into consideration as other EDs accept these guidelines: 1. The article lists the "Get-Up-and-Go Test" as part of the essential physical examination. This is a wonderful and easy test to perform and a good way to look at strength, gait. and balance. It should be done on all elderly patients who come into the ED (provided the patient has not sustained injuries that would not allow him or her to walk). However, the authors did not accurately describe the test. It is more than just having the patient hop off the gurney and
ANNALS DF EMERGENCY MEDICINE
321
JULY 1998
CORRESPONDENCE walk. The actual testing procedure is as follows: Patient is asked to sit comfortably in a (standard, non-roll ing) chair. Patient is then asked to rise (stand-up). Patient is asked to stand still. Patient is asked to walk towards a wall. Before they reach the wall the patient is asked to turn without touching the wall and return to the chair. Patient is asked to turn around and sit down.' What the clinician should look for is abnormality of gait and balance. Does the patient appear as if he or she is going to fall? Does he or she walk very cautiously? Can the patient get out of the chair without help? Can she or he stand still without abnormal sway? Does she or he stumble or grab for objects to hold onto? If any of these areas are abnormal. the patient should be referred to a physical therapist for further evaluation and treatment. 2. Home environmental assessments are best done by a physical or occupational therapist rather than a home nurse, as the article implies. 3. Typically, occupational therapists do not assess patients for assistive devices for ambulation; the physical therapist does. However. the occupational therapist may teach the patient how to adapt the new assistive device in activities of daily living (cooking, bathing, laundry. dressing. and so on). 4. Patients should not be given a sheet of generic exercises for strengthening and balance purposes. Exercises should be tailored to fit the individual's needs. These needs may not only be what exercises should be done. but, especially with the elderly, these needs may include visual impairments, cardiac conditions. how to safely and effectively progress through the exercises. position exercises are done in. and so on. A physical therapist is best trained at assessing and teaching and individualizing programs. Overall, I would like to stress the importance of a physical therapy referral for any person (especially elderly) who has sustained a fall not caused by an accident-even if the patient has not been injured. This may help to prevent future falls and result in fewer injuries.
Katherine Meirink, PT St Mary's Hospital of Ozaukee County Rehabilitative Services Cedarburg. WI 53012
JULY 1998
32:1
ANNALS OF EMERGENCY MEDICINE
1. Mathias 5, Nayak USL, Isaacs B: Balance in elderly patients: The "Get-up-and-go" Test. Arch Phys Med
Rehabil1986;67:387-389.
To the Editor: I am writing to correct what I perceive to be an omission in the article by Baraff et al in the October issue of Annals. 1 Although I believe the overall guidelines are excellent, there is one item of history that was omitted. The document states that "Syncope should be considered as a case of all unwitnessed fa lis ... " [p 4841. and one page later there is a notation: "Approximately 50% of older patients who fall report that they tripped and felL" Many of these patients fall because of syncope. yet say that they "must have tripped" or "must have fallen." This should be somehow delineated in the guidelines. Perhaps a statement to the effect that the emergency physician should obtain an accurate history of the fall itself. and if the patient does not recall what happened during the actual act of falling, assume that the patient had asyncopal episode. I would venture to guess that about 50% of older adults who say they tripped and fell actually do not recall the fall at all and in fact probably had a syncopal episode. Overall. I believe this is an excellent guideline and I look forward to more in the future.
Dan Mayer. MD Associate Professor Department of Emergency Medicine Office of Medical Education Albany Medical College Albany, NY 1. Baraff Lj, Della Penna R, Williams N, et al: PraLtice guideline for the ED management offalls in communitydwelling elderly persons. Ann Emerg Med 1997;30:480-489.
To the Editor: In the summer of 1997 we surveyed the directors of all119 training programs in emergency medicine accredited by the Accreditation Council for Graduate Medical Education to determine how elderly persons are assessed and managed in these settings. All programs that failed to complete and return a one-page questionnaire were contacted a second time. There was 88 responses (74% of all programs). although not every question was completed by every program. Not a single program used a separate intake instrument to assess elderly patients (14
did not provide an answer to this item), and only 3 of 84 (4 provided no answer) collected data in a standardized manner about an older person's functional status before the visit. Eighty-seven of the 88 responding programs stated that they did not have a standardized discharge form from the emergency department for older persons (1 program did not complete the question). Geriatric medicine appears to have had strikingly little influence on emergency medicine. notwithstanding the very significant use of emergency medical services by the older segment of the population and their special physiologic, clinical. and social presentations in that setting and their care needs. 1-3 This is true notwithstanding the recommendations of the Geriatric Emergency Medicine Task Force, which endorses the need for a comprehensive model of care to include assessment of mental status on all older patients. 4 Also of interest, only 48% of those returning the questionnaire reported providing any special training in dealing with elderly patients. Not asingle program stated that it has a designated treatment area for elders. and only about 20% followed up on older persons seen in the ED and not admitted and for the overwhelming majority of those who did. the patient's physician was the individual who was responsible. What is most assuredly required is a standardized assessment capability for elders that is both targeted yet comprehensive and allows for acare plan that fits each individual's unique needs. 5 Th is is true regardless of whether the person requires admission to the hospital. for emergency care is not to be viewed as "standalone" care. We would bring to the attention of the readers of this journal the work of InterRAl, a not-far-profit corporation comprised of scientists and clinicians not only in the United States but in much of the developed world. whose purpose it is to design assessment tools that are person-specific rather than site-specific and that allow for both targeted individual management and population-based studies. Members of this group, founded approximately 5years ago, designed the Minimum Data Set (MDS) now mandated for use in all nursing homes in the United States and used increasingly worldwide. 6 Related assessment instruments for home care, acute hospital care, mental health care, board and day care, and step-down
115
Alain Davido, MD Nicole Sembach, MD Thierry Lang, MD, PhD Department of Emergency Medicine H6pital Pitie Salpetriere Paris, France 1. Goldfrank LRe The troubled road to universal health care. Ann Emerg Med 1997;30:737-738. 2. O'Brien GM, Stein MD, Zierler 5, et ale Use of the ED as a regular source of care: Associated factors beyond lack of health insurance. Ann Emerg Med 1997;30:286-291. 3. Lang T, Davida A, Diakite B, et a1: Using the hospital emergency department as a regular source of care. Eur J EpidemioI1997;13:223-228.
4. Rodwin RG, Sandier 5: Health care under French national health insurance. Health Affairs 1993;1:111-131. 5. Baker DW, Stevens CD, Brook RH: Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency department. JAMA 1994;271:1909-1912.
6. Purdie F, Hanigman B, Rosen P: The chronic emergency department patient. Ann Emerg Med 1981;10:298-301. 7. Lang T, Davida A, Diakite B, et ale Non urgent care in the hospital medical emergency department: How much and which health needs does it reflect? J Epidemiol Comm Health 1996;50:456-462.
8. Shesser R, Kirsch T, Smith], et ale An analysis of emergency department use by patients with minor illness. Ann Emerg Med 1991;20:743-748.
In reply Drs Davido, Sembach, and Lang raise important points. My idealized version of health care is based on an adequate societal allocation of dollars (or francs or pesos) to do medical care correctly with acommitment for all in acommunity to share in the responsibilities, risks, and benefits of the system. Any successful system will entail rationalization of our approaches, whether in the United States, France, or elsewhere. This proposed system will entail rationing much like the Oregon Medicaid Health Plan, but must include all individuals in a true communitarian experience. Our current zeal to control administrative and medical costs and
114
curtail the overutilization of resources must be directed to more humanitarian ends. In the current American political and economic climate, moving to a system of universal health care seems difficult. My hope is that our suffering with managed care, managerial profiteering, and medical egocentrism will lead us to medical altruism and a well-financed, well-practiced system of universal health care. To succeed we must unite with many groups of physicians, like our compatriot French emergency physicians, and all members of our society in order to understand what should be done to realize the ideal system. International health research with aparticular focus on maintaining quality medical care while developing public health and universal health care is an excellent project for us all. I agree entirely with the authors that even when asystem is universal and well developed, an excellent program in emergency medicine will be very busy, very diversified, essential, and greatly appreciated.
Lewis Goldfrank, MD Department of Emergency Medicine Bellevue Hospital Center, New York, NY In reply It is interesting that universal health care does not necessarily reduce the use of the emergency department as a regular source of care in France. However, these authors found that only 14% were regular ED users compared with our finding of 25%. Additionally, the authors point out advantages for the patient such as not having to make an appointPllent and not having to pay out-of-pocket expenses. Although these are advantages, there are many disadvantages such as lack of preventive services in healthy patients, and lack of continuation of care, particularly important for those with an illness. The authors suggest that quality primary care is a possibility for those who use the ED as a regular source of care. However, emergency physicians are not trained in the practice of primary care, and EDs are not set up for the practice of primary care. In addition, there is an excellent existing primary care system in the United States that is underutilized by these patients. It would seem (both for the patient and the health care system) better to refer these
patients to primary care centers for this type of care, thus decreasing excess ED utilization and allowing EDs to focus on emergency care.
Gail M O'Brien, MD Division of General Internal Medicine Brown University Rhode Island Hospital Providence, RI 1. O'Brien GM, Stein MD, Zierler 5, et a1: Use of the ED as a regular source of care: Associated factors beyond the lack of health insurance. Ann Emerg Med 1997;30:286-291. 2. Grumbach K, Keane D, Bindman A: Primary care and public emergency department overcrowding. Am] Public Health 1993;83:372-378.
3. Oerlet R, Kinser D, Ray L, et ale Prospective identification and triage of an emergency department: A 5-year study. Ann Intern Med 1995;25:215-223.
4. Woo/handler 5, Himmelstein D: Reverse targeting of preventive care due to lack of health insurance ]AMA 1988; 259:2872-2874.
Guidelines for Care of. the Elderly To the Editor: The American Physical Therapy Association's PT Bulletin recently referenced the article, "Practice Guideline for the ED Management of Falls in Community-Dwelling Elderly Persons" in the October 1997 issue of Annals of Emergency Medicine. I am a physical therapist who works with many community-dwelling elderly persons who have sustained injuries after a fall. One of my primary interventions is educating the patient in preventing future falls. Therefore I was very interested to find out how emergency physicians will also help in this plight. I think Dr Baraft and his colleagues have made avery good start, and I hope EDs around the country use these guidelines. As a physical therapist. I do have a few critiques and suggestions that should be taken into consideration as other EDs accept these guidelines: 1. The article lists the "Get-Up-and-Go Test" as part of the essential physical examination. This is a wonderful and easy test to perform and a good way to look at strength, gait. and balance. It should be done on all elderly patients who come into the ED (provided the patient has not sustained injuries that would not allow him or her to walk). However, the authors did not accurately describe the test. It is more than just having the patient hop off the gurney and
ANNALS DF EMERGENCY MEDICINE
321
JULY 1998
CORRESPONDENCE walk. The actual testing procedure is as follows: Patient is asked to sit comfortably in a (standard, non-roll ing) chair. Patient is then asked to rise (stand-up). Patient is asked to stand still. Patient is asked to walk towards a wall. Before they reach the wall the patient is asked to turn without touching the wall and return to the chair. Patient is asked to turn around and sit down.' What the clinician should look for is abnormality of gait and balance. Does the patient appear as if he or she is going to fall? Does he or she walk very cautiously? Can the patient get out of the chair without help? Can she or he stand still without abnormal sway? Does she or he stumble or grab for objects to hold onto? If any of these areas are abnormal. the patient should be referred to a physical therapist for further evaluation and treatment. 2. Home environmental assessments are best done by a physical or occupational therapist rather than a home nurse, as the article implies. 3. Typically, occupational therapists do not assess patients for assistive devices for ambulation; the physical therapist does. However. the occupational therapist may teach the patient how to adapt the new assistive device in activities of daily living (cooking, bathing, laundry. dressing. and so on). 4. Patients should not be given a sheet of generic exercises for strengthening and balance purposes. Exercises should be tailored to fit the individual's needs. These needs may not only be what exercises should be done. but, especially with the elderly, these needs may include visual impairments, cardiac conditions. how to safely and effectively progress through the exercises. position exercises are done in. and so on. A physical therapist is best trained at assessing and teaching and individualizing programs. Overall, I would like to stress the importance of a physical therapy referral for any person (especially elderly) who has sustained a fall not caused by an accident-even if the patient has not been injured. This may help to prevent future falls and result in fewer injuries.
Katherine Meirink, PT St Mary's Hospital of Ozaukee County Rehabilitative Services Cedarburg. WI 53012
JULY 1998
32:1
ANNALS OF EMERGENCY MEDICINE
1. Mathias 5, Nayak USL, Isaacs B: Balance in elderly patients: The "Get-up-and-go" Test. Arch Phys Med
Rehabil1986;67:387-389.
To the Editor: I am writing to correct what I perceive to be an omission in the article by Baraff et al in the October issue of Annals. 1 Although I believe the overall guidelines are excellent, there is one item of history that was omitted. The document states that "Syncope should be considered as a case of all unwitnessed fa lis ... " [p 4841. and one page later there is a notation: "Approximately 50% of older patients who fall report that they tripped and felL" Many of these patients fall because of syncope. yet say that they "must have tripped" or "must have fallen." This should be somehow delineated in the guidelines. Perhaps a statement to the effect that the emergency physician should obtain an accurate history of the fall itself. and if the patient does not recall what happened during the actual act of falling, assume that the patient had asyncopal episode. I would venture to guess that about 50% of older adults who say they tripped and fell actually do not recall the fall at all and in fact probably had a syncopal episode. Overall. I believe this is an excellent guideline and I look forward to more in the future.
Dan Mayer. MD Associate Professor Department of Emergency Medicine Office of Medical Education Albany Medical College Albany, NY 1. Baraff Lj, Della Penna R, Williams N, et al: PraLtice guideline for the ED management offalls in communitydwelling elderly persons. Ann Emerg Med 1997;30:480-489.
To the Editor: In the summer of 1997 we surveyed the directors of all119 training programs in emergency medicine accredited by the Accreditation Council for Graduate Medical Education to determine how elderly persons are assessed and managed in these settings. All programs that failed to complete and return a one-page questionnaire were contacted a second time. There was 88 responses (74% of all programs). although not every question was completed by every program. Not a single program used a separate intake instrument to assess elderly patients (14
did not provide an answer to this item), and only 3 of 84 (4 provided no answer) collected data in a standardized manner about an older person's functional status before the visit. Eighty-seven of the 88 responding programs stated that they did not have a standardized discharge form from the emergency department for older persons (1 program did not complete the question). Geriatric medicine appears to have had strikingly little influence on emergency medicine. notwithstanding the very significant use of emergency medical services by the older segment of the population and their special physiologic, clinical. and social presentations in that setting and their care needs. 1-3 This is true notwithstanding the recommendations of the Geriatric Emergency Medicine Task Force, which endorses the need for a comprehensive model of care to include assessment of mental status on all older patients. 4 Also of interest, only 48% of those returning the questionnaire reported providing any special training in dealing with elderly patients. Not asingle program stated that it has a designated treatment area for elders. and only about 20% followed up on older persons seen in the ED and not admitted and for the overwhelming majority of those who did. the patient's physician was the individual who was responsible. What is most assuredly required is a standardized assessment capability for elders that is both targeted yet comprehensive and allows for acare plan that fits each individual's unique needs. 5 Th is is true regardless of whether the person requires admission to the hospital. for emergency care is not to be viewed as "standalone" care. We would bring to the attention of the readers of this journal the work of InterRAl, a not-far-profit corporation comprised of scientists and clinicians not only in the United States but in much of the developed world. whose purpose it is to design assessment tools that are person-specific rather than site-specific and that allow for both targeted individual management and population-based studies. Members of this group, founded approximately 5years ago, designed the Minimum Data Set (MDS) now mandated for use in all nursing homes in the United States and used increasingly worldwide. 6 Related assessment instruments for home care, acute hospital care, mental health care, board and day care, and step-down
115