Continuity of the Therapeutic Limitation Code: Analysis of the Variables of Admission in the Emergency Service That Are Associated With a Therapeutic Limitation Upon Exit

Demographically, the geriatric population is expanding. It is also increasingly found in the emergency services.However, emergency services are not designed to accommodate these patients, whose needs are specific. This population is defined by complex physical and psychosocial needs, included in a comprehensive geriatric assessment too complex to be carried out in the emergency services.

Many publications focused on ways to prevent potentially avoidable visits to geriatric patients in emergency services. People rely upon a therapeutic limitation code established for these patients to determine the intensity of the care that may be given to them. However, few geriatric patients arriving in the emergency services were already given such a code.

As a consequence, the intensity of the care given to these emergency patients is influenced by the perception of the functional and cognitive status of the patient, even if part of this perception is incorrect. Moreover, it is also well established that the outcome of geriatric patients with severe pathologies at admission is often poor and that there is a need to find alternatives to the intensive treatment offered.

The goal of this study will be to determine the prevalence of the presence of a therapeutic limitation code in geriatric patients at hospital admission / admission to the emergency department, and when they leave the hospital. This will be carried out for all geriatric patients residing or placed in nursing homes at the end of the hospitalization.The investigators postulate that establishing a therapeutic limitation code for these fragile patients, before they leave the hospital for a nursing home, would reduce the number of future admissions of these patients in the emergency department.

Study Overview

• Status: Completed
• Conditions: Geriatrics
• Intervention / Treatment: Other: Medical files analysis

Detailed Description

Demographically, the geriatric population is expanding. It is also increasingly found in the emergency services.However, emergency services are not designed to accommodate these patients, whose needs are specific. This population is defined by complex physical and psychosocial needs, included in a comprehensive geriatric assessment too complex to be carried out in the emergency services. The multidisciplinary care they need takes time.

Several options are investigated worldwide to properly manage these fragile patients:

• Scales of frailty and functional decline screening
• Specialized care units: the Mobile Geriatric Team, the Emergency short-stay units, the acute care geriatric unit, the geriatric nurse liaison model, or a service specific geriatric emergency.

Many publications focused on ways to prevent potentially avoidable visits to geriatric patients in emergency services. People rely upon a therapeutic limitation code established for these patients to determine the intensity of the care that may be given to them. However, few geriatric patients arriving in the emergency services were already given such a code.

As a consequence, the intensity of the care given to these emergency patients is influenced by the perception of the functional and cognitive status of the patient, even if part of this perception is incorrect. Moreover, it is also well established that the outcome of geriatric patients with severe pathologies at admission is often poor and that there is a need to find alternatives to the intensive treatment offered.

The goal of this study will be to determine the prevalence of the presence of a therapeutic limitation code in geriatric patients at hospital admission / admission to the emergency department, and when they leave the hospital. This will be carried out for all geriatric patients residing or placed in nursing homes at the end of the hospitalization.The investigators postulate that establishing a therapeutic limitation code for these fragile patients, before they leave the hospital for a nursing home, would reduce the number of future admissions of these patients in the emergency department.

Furthermore, this study offers the prospective to establish in the future a systematic implementation of the therapeutic limitation code for geriatric patients residing in nursing homes, therefore anticipating the various issues specific to his population in the emergency department.

• Study Type: Observational
• Enrollment (Actual): 100

Contacts and Locations

Study Locations

• Belgium
  • Brussels, Belgium, 1020
    • CHU Brugmann

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 75 years and older (Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

100 consecutive geriatric patients admitted in the emergency department of the Brugmann Hospital, Horta site, from 01/04/2015 till 11/02/2016.

Description

Inclusion Criteria:

• Patients admitted in the hospital via the emergency department and placed in a nursing home upon hospital discharge
• Patients will an available global geriatric evaluation (either realized in the geriatric ward, either realized by the geriatric team)

Exclusion Criteria:

• if multiple hospitalizations occur during the study length, data related to the first hospitalization only will be analyzed.

Study Plan

How is the study designed?

Design Details

• Observational Models: Other
• Time Perspectives: Retrospective

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Geriatric patients; 100 consecutive geriatric patients admitted in the Emergency Department of the Brugmann Hospital, Horta site, from 01/04/2015.	Other: Medical files analysis; Retrospective analysis of the medical files according to medical, social and geriatric criteria.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Prevalence of a therapeutic limitation code (hospital admittance)	The medical files of the patients admitted in the emergency department of the hospital, from 01/04/2015, will be examined in order to determine if they had a therapeutic limitation code upon admittance.	Patients hospitalized from 01/04/2015 till 11/02/2016 (11 months)
Prevalence of a therapeutic limitation code (hospital discharge)	The medical files of the patients admitted in the emergency department of the hospital, from 01/04/2015, will be examined in order to determine if received a therapeutic limitation code upon hospital discharge.	Patients hospitalized from 01/04/2015 till 11/02/2016 (11 months)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
social status	Retrospective analysis of patient medical files. The investigators will evaluate if the social status of the patient is linked to a therapeutic limitation decision upon hospital discharge.	Patients hospitalized from 01/04/2015 till 11/02/2016 (11 months)
autonomy status	Retrospective analysis of patient medical files.The investigators will evaluate if the autonomy of the patient is linked to a therapeutic limitation decision upon hospital discharge. Patient autonomy is evaluated by the results of either of these two tests: the Sherpa test or the Katz scale.	Patients hospitalized from 01/04/2015 till 11/02/2016 (11 months)
cognitive status	Retrospective analysis of patient medical files.The investigators will evaluate if the cognitive status of the patient is linked to a therapeutic limitation decision upon hospital discharge. The patient cognitive status is evaluated by the results of either the confusion assessment method or the mini mental state evaluation test.	Patients hospitalized from 01/04/2015 till 11/02/2016 (11 months)
diagnosis	Retrospective analysis of patient medical files.The investigators will evaluate if the admission motive/established diagnosis is linked to a therapeutic limitation decision upon hospital discharge.	Patients hospitalized from 01/04/2015 till 11/02/2016 (11 months)
hospitalisation length	Retrospective analysis of patient medical files.The investigators will evaluate if the hospitalisation length is linked to a therapeutic limitation decision upon hospital discharge.	Patients hopitalized from 01/04/2015 till present date (11 months)
Albumine	Retrospective analysis of patient medical files.The investigators will evaluate if the nutrition status (albumine measurement) is linked to a therapeutic limitation decision upon hospital discharge.	Patients hospitalized from 01/04/2015 till 11/02/2016 (11 months)
Hydratation level	Retrospective analysis of patient medical files.The investigators will evaluate if the hydration level (combined sodium and creatinine/urea measurement) is linked to a therapeutic limitation decision upon hospital discharge.	Patients hospitalized from 01/04/2015 till 11/02/2016 (11 months)
Unintentional weigh loss	Retrospective analysis of patient medical files.The investigators will evaluate if an unintentional weigh loss is linked to a therapeutic limitation decision upon hospital discharge.	Patients hospitalized from 01/04/2015 till 11/02/2016 (11 months)
Presence of comorbidities	Retrospective analysis of patient medical files.The investigators will evaluate if the presence of comorbidities (dementia or severe cardiac decompensation or cancer or pneumonia or severe cardio-vascular diseases or hepatic insufficiency) is linked to a therapeutic limitation decision upon hospital discharge.	Patients hospitalized from 01/04/2015 till 11/02/2016 (11 months)

Collaborators and Investigators

• Sponsor: Brugmann University Hospital
• Investigators: Principal Investigator: Axelle Gregory, MD, CHU Brugmann

Publications and helpful links

General Publications

• KATZ S, FORD AB, MOSKOWITZ RW, JACKSON BA, JAFFE MW. STUDIES OF ILLNESS IN THE AGED. THE INDEX OF ADL: A STANDARDIZED MEASURE OF BIOLOGICAL AND PSYCHOSOCIAL FUNCTION. JAMA. 1963 Sep 21;185:914-9. doi: 10.1001/jama.1963.03060120024016. No abstract available.
• Folstein MF, Robins LN, Helzer JE. The Mini-Mental State Examination. Arch Gen Psychiatry. 1983 Jul;40(7):812. doi: 10.1001/archpsyc.1983.01790060110016. No abstract available.
• Yesavage JA. Geriatric Depression Scale. Psychopharmacol Bull. 1988;24(4):709-11. No abstract available.
• Clement JP, Nassif RF, Leger JM, Marchan F. [Development and contribution to the validation of a brief French version of the Yesavage Geriatric Depression Scale]. Encephale. 1997 Mar-Apr;23(2):91-9. French.
• Goring H, Baldwin R, Marriott A, Pratt H, Roberts C. Validation of short screening tests for depression and cognitive impairment in older medically ill inpatients. Int J Geriatr Psychiatry. 2004 May;19(5):465-71. doi: 10.1002/gps.1115.
• Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990 Dec 15;113(12):941-8. doi: 10.7326/0003-4819-113-12-941.
• Katz S. Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc. 1983 Dec;31(12):721-7. doi: 10.1111/j.1532-5415.1983.tb03391.x.
• Katz PR, Karuza J, Kolassa J, Hutson A. Medical practice with nursing home residents: results from the National Physician Professional Activities Census. J Am Geriatr Soc. 1997 Aug;45(8):911-7. doi: 10.1111/j.1532-5415.1997.tb02958.x.
• Katz PP, Yelin EH. Activity loss and the onset of depressive symptoms: do some activities matter more than others? Arthritis Rheum. 2001 May;44(5):1194-202. doi: 10.1002/1529-0131(200105)44:53.0.CO;2-6.
• Katz PP, Morris A. Use of accommodations for valued life activities: prevalence and effects on disability scores. Arthritis Rheum. 2007 Jun 15;57(5):730-7. doi: 10.1002/art.22765.
• Derouesne C, Poitreneau J, Hugonot L, Kalafat M, Dubois B, Laurent B. [Mini-Mental State Examination:a useful method for the evaluation of the cognitive status of patients by the clinician. Consensual French version]. Presse Med. 1999 Jun 12;28(21):1141-8. French.

Study record dates

Study Major Dates

• Study Start (Actual): February 1, 2016
• Primary Completion (Actual): December 1, 2017
• Study Completion (Actual): December 1, 2017

Study Registration Dates

• First Submitted: February 11, 2016
• First Submitted That Met QC Criteria: February 16, 2016
• First Posted (Estimate): February 17, 2016

Study Record Updates

• Last Update Posted (Actual): January 18, 2018
• Last Update Submitted That Met QC Criteria: January 17, 2018
• Last Verified: January 1, 2018

More Information

Terms related to this study

• Keywords: therapeutic limitation code; emergency unit admittance
• Additional Relevant MeSH Terms: Pathologic Processes; Disease Attributes; Emergencies
• Other Study ID Numbers: CHUB-Therapeutic limitations

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No