Örebro University
School of Medicine
Degree Project, 30 ECTS
January 2018
Elderly patients in the emergency room
- Are there differences between patients arriving by
ambulance or by own means?
Version 2
Author: Andreas Lindh, Bachelor of medicine
Supervisor: Åsa Andersson, PhD
Department of Geriatrics
Örebro University Hospital
Örebro, Sweden
2
Abstract
Introduction
Worldwide our population is aging and in Sweden, the number of patients in the emergency room continues to rise. Older patients often have multiple medical conditions and the
prevalence of polypharmacy is widespread. As high as 30% of all hospital admissions in older patients is caused by medication related adverse events.
Aim
This study will compare two groups of elderly patients that visited the ER at Örebro
University Hospital dependent on the means of transportation, also investigate who initiated the healthcare contact and the reason behind that decision. Finally, identify actions taken on non-hospitalized patients.
Material and methods
This study was designed as a retrospective study. All patients 75 years or older that visited the emergency room during 3-9th of April 2017 was included.
Results
Of the 221 included patients, 104 arrived by ambulance and 117 by own transportation. Patients arriving by ambulance were significantly more often triaged red/orange, were
hospitalized more often and exposure to polypharmacy was more common. Overall, patient’s self initiated the healthcare contact in 50% of the occasions and a falling accident was the most common reason. Of the 123 non-hospitalized patients, the most common action (47%) in the ER was doctor assessment alone.
Conclusion
Patients arriving by ambulance often hade a more complex medical situation. A majority of the patients was exposed to polypharmacy, yet a negligible number of patients had completed a pharmaceutical review within the last 12 months. Elderly patients need healthcare, a fact that is not always apparent according to Rapid Emergency Triage and Treatment System (RETTS).
3
Table of Contents
Abstract………. 2
Introduction……….. 4
Aim………... 5
Material and Method………... 5
Participants………... 5 Study procedure……… 6 Statistics……… 6 Ethics……… 7 Results………... 7 Discussion……….. 10
Strengths and limitations……….. 12
Conclusion………. 13
References………. 14
Cover letter………... 18
Populärvetenskaplig sammanfattning……… 19
4
Introduction
In a global perspective the number of older persons, 60 years and above, is growing faster than any other age group. In almost every country the share of older persons in the total population is increasing. It is estimated that by 2050 one in every five persons will be 60 years or older, compared to one person in eight 2015 [1]. Life expectancies in Sweden has been one of the highest in the world since the mid 20th century, and in the beginning of 1970, it was the highest of all countries in the world [2]. As a result, in 2016 almost one person in five was 65 years or older in Sweden. According to the Swedish Central Bureau of Statistics this will increase to one person in four by 2060 [3].
According to a report from the Swedish National Board of Health and Welfare the number of patients that visit the emergency room (ER) continues to rise. In the age group 80 years and older the number of visits per 1000 individuals is just over 700. In the age group 70-79 years the number of visits per 1000 individuals is approximately 400. This stands in comparison to around 200 visits per 1000 individuals aging from 19-59 years [4]. These numbers indicate that the group of older persons in Sweden is consuming a very high amount of health care and the proportion of this group in society will continue to rise.
In general, older patients have multiple medical problems and in population based studies the prevalence of comorbidities and number of comorbid conditions increase with age [5, 6]. This coexistence of different diseases is commonly termed multimorbidity. The World Health Organization (WHO) has defined multimorbidity as people being affected by two or more chronic health conditions simultaneously [7]. This definition has proved to be vague and in a review from the research group European General Practice Research Network (EGPRN) they found more than one hundred different definitions [8]. In an article by Sweden’s National Board of Health and Welfare they have described multimorbidity as a person that during a 12-month period was hospitalized three times or more with diagnoses from different diagnostic groups according to the international classification system ICD-10. At least one of these occasions must occur during the present calendar year for the patient to be qualified as multimorbid the actual year [9].
The medication uses in patients 65 years or older have increased markedly in the last 25 years [10]. The term polypharmacy is widely used, and a common definition is the concurrent use of multiple medications, often with a cutoff of five drugs or more [11, 12]. In the same time drug treatment is an essential component when trying to maintain health and improve the
5 quality of life in our cumulative, elderly population [13, 14]. Twenty-four case studies
conducted in Sweden on patients 75 years or older showed that the average drug regimen was 12 with a range between three and 20 unique drugs [15]. According to a Swedish nationwide register-based study by Wastesson et al, the frequency of polypharmacy at age 65 is 27% [12]. The aging process in the human body leads to several physiological changes and consequently the ability to absorb, metabolize and secrete drugs diminish with increasing age [16].
Consequently, the combination of theses changes, and polypharmacy leads to an increased risk of drug-drug interaction and adverse drug reactions [17]. Adverse drug reactions are a major burden to society, causing significant morbidity, morality and represent a high cost for the health care system [18]. As high as 30% of all hospital admissions in older patients is caused by medication-related adverse events [19]. Morin et al describes potentially
inappropriate medications as when the risk of harmful effects exceeds the expected benefit or when there is a safer, better tolerated or more effective alternative drug available [20]. An assessment tool with explicit criteria’s have been developed by the Swedish National Board of Health and Welfare regarding inappropriate prescriptions to elderly patients [21]. To
counteract adverse drug reactions, it is recommended that every person 75 years or older with five or more prescribed drugs are offered a pharmaceutical review once a year [22].
Aim
The aim of this study was to compare two groups of elderly patients that visited the ER at Örebro University Hospital dependent on the means of transportation, including the
prevalence of polypharmacy and multimorbidity. The study will also investigate who initiated the healthcare contact and the reason behind that decision. Regarding the non-hospitalized patients, this study will identify the actions taken in the ER.
Material and Method
This study was designed as a retrospective study and as a quality control using medical records to evaluate clinical practice. It was carried out at the Emergency department and in cooperation with the department of Geriatric medicine, both at Örebro University Hospital.
Participants
All patients 75 years or older that visited the ER at Örebro University Hospital during 3-9th of
April 2017. In the case of multiple visits or registered healthcare contacts by the same patient, the first contact during that week is the one included in this study. The age 75 as a cut off was
6 decided based on the requirement to offer pharmaceutical reviews once a year to patient 75 years or older with five or more prescribed drugs [22].
Study procedure
A review template was constructed with input from the department of Geriatric medicine and the management staff from the ambulance service at Örebro University Hospital. Patient data was collected systematically from the computer software “Kliniska Portalen”.
In the ER at Örebro University Hospital the nurses are responsible for the triage of patients, this is done based on Rapid Emergency Triage and Treatment System (RETTS) [23]. The purpose is to identify and prioritize patients with potentially serious conditions.
In this study multimorbidity was defined according to Sweden’s National Board of Health and Welfare, a person that during a 12-month period was hospitalized three times or more with diagnoses from different diagnostic groups according to the international classification system ICD-10 [24]. At least one of these occasions must occur during the present calendar year for the patient to be qualified as multimorbid the actual year [9]. Polypharmacy was defined as five or more prescribed drugs at the same time [11, 12].
Regarding the reported time-frames. Time to doctor assessment is measured from the moment the patient enters the ER and gets registered to the moment the patient meets a doctor. Total time spent in the ER is measured from the moment the patient enters the ER and gets registered to the time when the patients leaves the ER.
Statistics
T-test was used to analyze the difference in age and number of visits. The difference in time to doctor assessment and total time spent in the ER was analyzed by using Mann-Whitney’s test. Chi-squared test was used to analyze differences in gender. The level of statistical significance was set at p < 0.05.
The differences in proportions for dichotomized variables were calculated with the method described by Newcombe & Altman [25]. Results are reported using 95% confidence intervals for the difference in proportions. The 95% confidence interval will be significant if it does not include zero.
T-test, Mann-Whitney test and the Chi-squared test were made in SPSS Statistics 22. Differences in proportions were calculated with the program Confidence Interval Analysis.
7 Ethics
This study was a part of quality and improvement work in the Emergency department and the department of Geriatric medicine. The head of the Emergency department has approved the study. Thus, no ethical approval was required from the Ethics committee. The ethical aspects of this study principally concern the personal integrity. All processing of personal data has been conducted de-identified and the results is presented at a group level, this insures that no individual can be distinguished from the group.
Results
During the entire week, there were 262 registered visits to the ER by patients 75 years or older. Out of these 262 visits, there were 225 unique patients, first occasion healthcare contacts. The main reason for multiple registered contacts where a change between different medical specialty. There were also four patients in the “transportation by own means” group that lacked documentation, thus these patients were excluded from the study. Concerning these four patients, there was three women and one man, none of them were triaged red or orange and there was no significant difference in age (84 years compared to 80 years of age, p = 0,23).
Figure 1: Flowchart of the 221 included patients. Ambulance
n = 104
Unique patient healthcare contacts
n = 225
Transportation by own means
n = 117
No documentation
8 Comparison
The patients that arrived by ambulance to the ER was compared to those that arrived by own transportation (table 1). In several of the compared parameters, significant differences were identified. In the entire study population, the majority was exposed to polypharmacy (81%) but there was no significant difference in the incidence of pharmaceutical reviews or exposure to potentially inappropriate medications [21]. Large variation regarding time spent in the ER was discovered.
Table 1: Comparing the 221 included patients dependent on means of transportation.
Ambulance Own Difference p 95% CI transport
n = 104 n = 117
Average age, years (SD) 84 (6) 83 (6) 1 0,05 Youngest – Oldest 75 – 99 75 – 96
Women, n (%) 63 (61) 53 (45) 16 0,02*
Triage red/orange, n (%) 52 (50) 28 (24) 26 13;38*
Time, minutes median (IQR)
To doctor assessment 38 (79-89) 69 (43-113) -31 <0,001*
min – max 2 – 359 0 – 359
Total time spent in ER 233 (133-342) 219 (143-324) 14 0,66
min – max 41 – 534 32 – 733
Hospitalized, n (%) 59 (57) 39 (33) 24 10;36*
Type of housing, n (%)
Ordinary housing 80 (77) 111 (95) -18 -27; -9*
Ordinary housing with
home care 36 (35) 22 (19) 16 4;27*
Residential care 24 (23) 6 (5) 18 9;27*
Polypharmacy, n (%) 92 (89) 88 (75) 14 3;23*
Pharmaceutical review
within last 12 months 6 (6) 6 (5) 1 -6;8
Potentially inappropriate
medications, n (%) 49 (47) 41 (35) 12 -1;25
Number of visits to the ER,
last 12 months, mean (SD) 2 (2) 2 (3) 0 0,74
Multimorbid, n (%) 9 (9) 10 (9) 0 -8;8
9 Who initiated the healthcare contact?
Figure 2 illustrates who initiated the healthcare contact regarding the included patient’s. In half of the occasions (50%) it was the patients own decision to visit the ER.
Figure 2: Who initiated the healthcare contact? n = 221.
Reason for healthcare contact
There was a great variation in reasons why the patients sought medical attention. Table 2 gives an account over the most common causes. In total, the 221 patients stated 47 different reasons.
Table 2: Reason for the healthcare contact, n = 221.
n (%) Falling accident 35 (16) Abdominal pain 23 (10) Dyspnea 23 (10) Chest pain 20 (9) Extremity pain 14 (6) Fever 12 (5) Vertigo 8 (4)
Reduced general condition 7 (3)
Arrhythmias 6 (3)
Fainting 5 (2)
10 None hospitalized patients
More than half of the patients, 123 (56%), was not hospitalized. Figure 3 account for all the actions taken on these 123 patients. For most of the patients, 58 (47%), there was no action taken other than doctor assessment.
Figure 3: Actions taken on none hospitalized patients.
Discussion
One of the aims of this study was to compare a group of elderly patients that visited the ER at Örebro University Hospital dependent on means of transportation. It was discovered that the group that arrived by ambulance had a more complex medical situation and a large proportion was exposed to polypharmacy. Overall, patient’s self initiated the healthcare contact in 50% of the occasions and a falling accident was the most common reason. Of the 123
non-hospitalized patients, the most common action (47%) in the ER was doctor assessment alone. During the selected week, April 3-9, 2017, there was 221 unique, first time visits by patients 75 years or older. According to a report from the Swedish National Board of Health and Welfare between 20-30% of the patients in an ER usually arrives by ambulance [26]. Regarding the patients in this study, as many as 104 (47%) patients arrived by ambulance. The most probable explanation for this larger proportion is the fact that the study population consists of elderly patients which in general have a more complex medical history [5, 6].
11 Bearing in mind that the population in Sweden is aging and the number of visits to the ER is rising [3, 4], this means that in the future, a larger share of the patients in an Swedish ER will be elderly and that the workload for the ambulance service will increase.
When comparing the group of patients by means of transportation as table 1 illustrates, several significant differences where identified. Taking in consideration factors like triage outcome according to RETTS [24], proportion of hospitalized patients and exposure to polypharmacy [11, 12], it is safe to state that the patients arriving by ambulance have a more complex medical situation then the patients arriving by own means. If triage outcome
according to RETTS [24] is the sole indicator of the current medical condition, the
percentages concerning both patient groups in this study are in the upper range. Usually the patients arriving by ambulance is triaged red or orange in 30-50% of the cases and the corresponding number for patients that arrived by own transportation is 10-20% [26]. This result enhances the fact that the number of patients with serious medical conditions in the ER will continue to rise.
An acknowledgment that the system for prioritizing patients with the most urgent medical condition is working as intended is the fact that the patients arriving by ambulance met a doctor for assessment significantly faster. The time to doctor assessment, 69 minutes in median regarding the patients that arrived by own transportation, corresponds well to all the patients regardless of age in the ER at Örebro University Hospital and is slightly above the median time in the country as a whole [4]. Worth noting in the report mentioned above is the fact that the total time spent in the ER for patients 80 years or older is 3 hours 39 minutes in median. That is 25 minutes longer in median than the patients aging 19-79 years old. Also, 10% of the patients 80 years or older waits longer than 7 hours 18 minutes in the ER before being discharged or hospitalized [4]. These numbers correlate with this study, total time spent in the ER was in median 3 hours 53 minutes and 3 hours 39 minutes respectively. This is a topical subject and a study by Myredal et al [27] shows that many of the included patients could have had their care needs met outside the emergency hospital. If this solution is to be reality the cooperation between the county councils and the municipalities needs to be
strengthened, something that the study also states. Basically, there are two angles to approach the problem, one being to increase the level of care in residential care centers, and the second is an improved system to identify which patients that needs to visit the ER. In Region Örebro county, as a part of the larger ViSam project [28], a study has been made regarding the test of a decision support system in municipal home care. This study shows that 94% of the elderly
12 patients that were referred to the hospital were ultimately hospitalized [29]. Out of the two options the latter is the more generalizable.
A disturbing fact is that only six percent in the group that arrived by ambulance and five percent in the group that arrived by own transportation had completed a pharmaceutical review within the last year. Considering that a large proportion of the patients, 47% and 35% respectively, was exposed to potentially inappropriate medications [21] and that it is estimated that as high as 30% of all hospital admissions in older patients is caused by medication-related adverse events [19], the very low incidence of pharmaceutical reviews is a large concern. A Swedish study by Johnell et al concerning patients 75 years or older suggests that the number of prescribed drugs is strongly connected to the prevalence of potentially inappropriate medications [30]. A study by Weng et al [31] supports the same conclusion. What these results suggest is that an increase in incidence of pharmaceutical reviews could have a positive impact on the health condition in our elderly patients.
The most common cause for initiating the healthcare contact was as a result of a falling accident. Although beyond the scope of this study, the question this raises is if there is a connection to the fact that 81% was exposed to polypharmacy and 41% even to potentially inappropriate medications. Regarding the two succeeding causes, abdominal pain and dyspnea, there is a possibility that some of these cases could be explained by adverse drug reactions. Overall there was a large variation in reasons, also regarding the degree of priority. In 19% of the occasions the healthcare contact was initiated by nursing staff, either at
residential- or home care. Bearing in mind the decision support system [29], this suggests there is room for improvement. On the same subject, further enhancing the possible gains from improvement is the fact that 123 (56%) of the patients was not admitted to hospital. Also, the by far most common action taken, (47%), on these patients was nothing but doctor assessment.
Finally, there was no difference in the prevalence of multimorbidity [9], nine percent for both patient groups. This is a reasonable figure as the prevalence for all the hospital patients in the country 75 years or older is seven percent [32].
Strengths and limitations
This study was designed as a retrospective review; thus, the hospital and ambulance staff were not notified in advance. If the staff would have been notified it is possible that the risk of incorrect or inadequate documentation could have been reduced. Regarding the
13 pharmaceutical reviews there is a risk of missed patients because there is no way of
confirming that every occasion is documented in the computerized medical records. And since the pharmaceutical review should be offered there is also a possibility that some patients were indeed offered but declined. There is also a possibility that the reported number of drugs concerning a patient is higher since not every care giver shares the same medical journals. Overall, the greatest limitation of this study is the human factor regarding correct and accurate documentation.
The risk that the included patients is fewer than the actual number of patients 75 years or older that visited the ER is very small since every patient gets registered electronically and with a temporary paper journal that follows the patient during the visit in the ER. Another strength is that one single person did the entire review systematically using a predetermined template.
Conclusion
One of the main challenges for the Swedish healthcare system in the future will be to cater for the healthcare needs of our aging population. Patients that arrived by ambulance often had a more complex medical situation. Elderly patients need healthcare, this is not always apparent according to RETTS. Several studies report that under-triaging is a problem, especially amongst our elderly patients [33].
A majority (81%) of the included patients was exposed to polypharmacy. Yet a negligible number of patients had completed a pharmaceutical review within the last 12 months. This is remarkable, especially since it is estimated that as high as 30% of all hospital admissions in older patients is caused by medication-related adverse events.
In general, elderly patients spends a longer time overall in the emergency room regardless if they were discharged or hospitalized, and this study confirms this fact.
14
References
1. United Nations, Department of Economics and Social Affairs, Population Division (2015). World Population Ageing 2015 [Internet]. New York: United Nations; 2015. [cited 2017 Sep 8]. Available from:
http://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA201 5_Report.pdf
2. de Munter J. Hög medellivslängd i Sverige [Internet]. Stockholm: Statistiska Centralbyrån; 2017 [updated; 2017 Mar 6; cited 2017 Sep 8]. Available from: https://www.scb.se/sv_/Hitta-statistik/Artiklar/Hog-medellivslangd-i-Sverige/# 3. Lundkvist L. Sveriges framtida befolkning 2016–2060 [Internet]. Stockholm:
Statistiska Centralbyrån; 2016. [cited 2017 Sep 8]. Available from:
https://www.scb.se/Statistik/BE/BE0401/2016I60/BE0401_2016I60_SM_BE18SM16 01.pdf
4. Socialstyrelsen. Väntetider och patientflöden på akutmottagningar [Internet]. Stockholm: Socialstyrelsen; 2017. [cited 2017 Sep 8]. Available from:
http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/20493/2017-2-16.pdf 5. Karlamangla A, Tinetti M, Guralnik J, Studenski S, Wetle T, Reuben D. Comorbidity in Older Adults: Nosology of Impairment, Diseases, and Conditions. The Journals of Gerontology: Series A. 2007 Mar 1;62(3):296-300.
6. Wolff J L, Starfield B, Anderson G. Prevalence, Expenditures, and Complications of Multiple Chronic Conditions in the Elderly. Arch Intern Med. 2002 Nov
11;162(20):2269-2276.
7. World Health Organization. Primary Health Care – Now More Than Ever [Internet]. Geneva: World Health Organization; 2008. [cited 2017 Sep 14]. Available from: http://www.who.int/whr/2008/whr08_en.pdf
8. Le Reste J Y, Nabbe P, Rivet C, Lygidakis C, Doerr C, Czachowski S, et al. The European General Practice Research Network Presents the Translations of Its Comprehensive Definition of Multimorbidity in Family Medicine in Ten European Languages. PloS One. 2015 Jan 21;10(1).
9. Socialstyrelsen. De mest sjuka äldre – Avgränsning av gruppen [Internet]. Stockholm: Socialstyrelsen; 2011. [cited 2017 Sep 14]. Available from:
https://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/18470/2011-10-20.pdf
15 10. Socialstyrelsen. Läkemedelsorsakad sjuklighet hos äldre – Kartläggning och förslag
till åtgärder [Internet]. Stockholm: Socialstyrelsen; 2014. [cited 2017 Sep 16]. Available from:
http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/19621/2014-12-13.pdf 11. Mortazavi S S, Shati M, Keshtkar A, Malakouti S K, Bazargan M, Assari S. Defining
polypharmacy in the elderly: a systematic review protocol. BMJ Open. 2016 Mar 24;6(3).
12. Wastesson J W, Canudas-Romo V, Lindahl-Jacobsen R, Johnell K. Remaining Life Expectancy With and Without Polypharmacy: A Register-Based Study of Swedes Aged 65 Years and Older. J Am Med Dir Assoc. 2016 Jan 1;17(1):31-35.
13. Statens beredning för medicinsk utvärdering. Äldres läkemedelsanvändning – hur kan den förbättras? [Internet]. Stockholm: Statens beredning för medicinsk utvärdering; 2009. [cited 2017 Sep 19]. Available from:
http://www.sbu.se/contentassets/2f078e7c9b594bf7b50a9ad5757589fe/lakemedel_aldr e_fulltext.pdf
14. Socialstyrelsen. Kvaliteten i äldres läkemedelsanvändning – Läkarens roll [Internet]. Stockholm: Socialstyrelsen; 2011. [cited 2017 Sep 19]. Available from:
http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/18360/2011-6-12.pdf 15. Gurner U, Fastbom J, Österman J. Vi har inte tid – ring akuten! [Internet]. Stockholm:
Stiftelsen Stockholms läns Äldrecentrum; 2004. [cited 2017 Sep 21]. Available from: http://www.aldrecentrum.se/global/rapporter/2004/2004_1_vi_har_inte_tid.pdf 16. Fastbom J. Fokusrapport – Äldres läkemedel [Internet]. Stockholm: Stockholms läns
landsting; 2005. [cited 2017 Sep 28]. Available from:
http://www.vardgivarguiden.se/globalassets/utbildning-och-utveckling/vardutveckling/fokusrapporter/aldres-lakemedel.pdf?IsPdf=true
17. Mallet M, Spinewine A, Huang A. The challenge of managing drug interactions in elderly people. Lancet. 2007 Jul 14;370(9582):185-191.
18. Onder G, van der Cammen T, Petrovic M, Somers A, Rajkumar C. Strategies to reduce the risk of iatrogenic illness in complex older adults. Age and Ageing. 2013 May 1;42(3):284-291.
19. Parameswaran Nair N, Chalmers L, Peterson G M, Bereznicki B J, Castelino R L, Bereznicki L R. Hospitalization in older patients due to adverse drug reactions –the need for a prediction tool. Clin Interv Aging. 2016 May 2;11:497-505.
16 20. Morin L, Fastbom J, Laroche M-L, Johnell K. Potentially inappropriate drug use in
older people: a nationwide comparison of different explicit criteria for population-based estimates. Br J Clin Pharmacol. 2015 Aug;80(2):315-324.
21. Socialstyrelsen. Indikationer för god läkemedelsterapi hos äldre [Internet]. Stockholm: Socialstyrelsen; 2010. [cited 2017 Oct 10]. Available from:
https://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/18085/2010-6-29.pdf 22. Socialstyrelsen. Läkemedelsgenomgångar för äldre ordinerade fem eller fler
läkemedel – en vägledning för hälso- och sjukvården [Internet]. Stockholm: Socialstyrelsen; 2013. [cited 2017 Oct 10]. Available from:
https://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/19019/2013-3-18.pdf 23. Ziegler B, Almroth H, Bergman J, Jansson E, Rylander L, Wickbom A. Tidig
teambedömning avlastar akutmottagningen. Läkartidningen. 2014;111:CPYX. 24. World Health Organization. Classifications [Internet]. Geneva: World Health
Organization; 2016 [updated 2016 Nov 29; cited 2017 Oct 15]. Available from: http://www.who.int/classifications/icd/en/
25. Newcombe RG, Altman DG. Proportions and their differences. In: Altman DG, Machin TN, Bryant TN, Gardner MJ, eds. Statistics with Confidence. London: BMJ Books; 2000. p. 45–56.
26. Socialstyrelsen. Väntetider och patientflöden på akutmottagningar [Internet]. Stockholm: Socialstyrelsen; 2015. [cited 2017 Nov 11]. Available from:
http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/19990/2015-12-11.pdf 27. Myredal A, Mauritzon I, Blom M, Ivarsson K. Många över 80 år hade kunnat få vård
utanför sjukhuset. Läkartidningen. 2016;113:DTAE.
28. Region Örebro Län. ViSam [Internet]. Örebro: Region Örebro Län; [date unknown; cited 2017 Nov 13]. Available from: http://www.visamregionorebro.se/
29. Kihlgren A, Svensson F, Lövbrand C, Gifford M, Adolfsson A. A Decision support system (DSS) for municipal nurses encountering health deterioration among older people. BMC Nurs. 2016;15:63.
30. Johnell K, Fastbom J, Rosén M, Leimanis A. Inappropriate Drug Use in the Elderly: a Nationwide Register-Based Study. Annals of Pharmacotherapy. 2007;41(7-8):1243-1248.
17 31. Weng M C, Tsai C F, Sheu K L, Lee Y T, Lee H C, Tzeng S L, et al. The impact of
number of drugs prescribed on the risk of potentially inappropriate medication among outpatient older adults with chronic diseases. QJM. 2013 Nov 1;106(11):1009-1015. 32. Fratiglioni L, Marengoni A, Meinow B, Karp A. Multipla hälsoproblem bland
personer över 60 år [Internet]. Stockholm: Statens offentliga utredningar; 2010. [cited 2017 Nov 29]. Available from:
http://www.regeringen.se/49b6a5/contentassets/7afc092007d84613b0ffae14c7367e12/ multipla-halsoproblem-bland-personer-over-60-ar-sou-201048
33. Sandman L, Ekerstad N, Lindroth K. Triage som prioriteringsinstrument på akutmottagning – en etisk analys av RETTS [Internet]. Linköping:
Prioriteringscentrum, Linköpings Universitet; 2012. [cited 2017 Dec 7]. Available from:
https://www.imh.liu.se/halso-och- sjukvardsanalys/prioriteringscentrum/publikationer/prioriteringscentrums-publikationer-ovrigt-publicerat-material/1.444597/2012-2_Sandman.pdf
18
Cover letter
Dear editor!
Please, consider the manuscript “Elderly patients in the emergency room – Are there differences between patients arriving by ambulance or by own means?” for publication in your journal.
In this retrospective study we compared a group of elderly patients in the emergency room dependent on means of transportation. We believe that our findings may be of great interest to your readers because of the following reasons:
• One of the main challenges for the Swedish healthcare system in the future will be to cater for the needs of our aging population.
• Patients that arrived by ambulance often had a more complex medical situation. Elderly patients need healthcare, this is not always apparent according to RETTS. • A majority (81%) of the included patients was exposed to polypharmacy. Yet a
negligible number of patients had completed a pharmaceutical review within the last 12 months. This is remarkable, especially since it is estimated that as high as 30% of all hospital admissions in older patients is caused by medication-related adverse events.
• In general, elderly patients spends a longer time overall in the emergency room regardless if they were discharged or hospitalized, and this study confirms this fact.
Yours sincerely,
Andreas Lindh, Bachelor of medicine Örebro University
19
Populärvetenskaplig sammanfattning
Världen över blir vår befolkning allt äldre. Statistiska centralbyrån beräknar att 25% av Sveriges befolkning kommer att vara 65 år eller äldre år 2060. Antalet patienter som besöker akutmottagningar ökar också och vår äldre befolkning konsumerar en stor mängd sjukvård. Äldre patienter har ofta multipla medicinska problem samt en större mängd förskrivna läkemedel. Åldrandet av den mänskliga kroppen leder till en rad fysiologiska förändringar som innebär en minskad förmåga att ta upp, bearbeta och utsöndra läkemedel. Detta leder till att äldre har en ökad risk för läkemedelsbiverkningar, studier har visat att så mycket som 30% av alla sjukhusinläggningar av äldre patienter orsakas av läkemedel i någon omfattning. För att motverka detta skall alla patienter 75 år eller äldre med fem eller fler läkemedel erbjudas en läkemedelsgenomgång.
Vid akutkliniken, i samarbete med Geriatriska kliniken, på Universitetssjukhuset i Örebro genomfördes det nyligen en journalgranskningsstudie. Ett utav syftena var att jämföra en grupp äldre patienter, 75 år eller äldre, beroende på transportsätt till akutmottagningen. Syftet var också att undersöka kontakorsak, vem initierade vårdkontakten och vad hände med de som ej blev inlagda. 221 patienter ingick i studien.
De som åkte ambulans blev i större utsträckning inlagda, de prioriterades att träffa läkare snabbare och de hade oftare fem eller fler läkemedel. I 50% av fallen var det patienten själv som initierade vårdkontakten. Falltrauma var den vanligaste kontakorsaken och av de 123 icke-inlagda patienterna var läkarbedömning den vanligaste åtgärden. Trots omfattande läkemedelsanvändning hade endast fem procent genomfört en läkemedelsgenomgång de senaste 12 månaderna.
20
Ethical consideration
One of the main concerns regarding a retrospective review of medical records is the lack of consent from the patient. This could be perceived as a violation by the individual but was completed with support of the patient-data law. As a result, the individual patient did not have the opportunity to correct any inaccurate information documented in the medical record. Out of the four basic principles, the principle of autonomy is the one that goes unmet. To
compensate this, every precaution was made when handling and collecting patient data. The data was processed and presented de-identified. There were also no commitments required from the patients. Hopefully, the knowledge gained from this study will be used to improve the healthcare of the elderly, something an ever-increasing number of patients will benefit from. The eventual perception of loss of integrity could hereby at least partially be justified by another basic ethical principle, the principle of beneficence.
