The healthcare systems are under increasing pressure due to a rise in emergency consultations, staff shortages, an ageing population and rising costs. Emergency departments are seeing more vulnerable patients, including elderly people, who are often on multiple medications and at risk of medication errors.
To improve safety, the integration of pharmacists specialising in emergency medicine has proven beneficial: their presence in the team improves the detection of medication-related problems, speeds up and optimises treatment, reduces rehospitalisations and lowers healthcare costs. However, in most countries, these pharmacists are still rarely found in emergency departments, mainly due to a lack of resources and clinical prioritisation criteria tailored for them and adapted to this environment.
Frailty screening tools and scores, such as ISAR, can be used to identify the elderly patients most at risk, predict adverse events such as fall or mortality, and thus adapt their care in the emergency department. Indeed, elderly frail patients often take many medications and consequently are at risk of medication errors, adverse events, inappropriate prescriptions or serious drug interactions. These patients may therefore require a specialised review on their medication by clinical pharmacists when they are admitted to the emergency department, but their high number make it impossible to care for all of them.
We aim thus to evaluate the association between frailty (according to the ISAR score) and medication-related problems among elderly patients admitted to the emergency department. Researchers will examine whether this score can predict the presence of inappropriate prescribing and high-risk drug interactions. If so, pharmacists would then have a quick and easy tool to prioritise patients who would benefit most from a specialised review of their medications when they visit the emergency department.
There will not be any intervention and this study will not influence patients care. Once patients agree to participate, researchers will prospectively collect medical data from elderly patients admitted to the emergency department and analyse their medical history, home medication, reason for admission, frailty score using ISAR, and perform a pharmaceutical analysis based on these data.
Patients aged ≥ 75 years admitted to the adult emergency department
Patients able to give informed consent as documented by signature or a therapeutic representative, if applicable .
Patients initially admitted to the emergency resuscitation room.
Patients admitted to the minor accidents and emergencies room.
Patients admitted to the stroke unit, as they just pass through the emergency department to directly proceed to the CT-scanner.
Missing data for proper file analysis (e.g., missing usual home medication)
The study population will consist of all geriatric patients residing in the area of the Riviera-Chablais Hospital (Rennaz, Canton of Vaud, Switzerland). This hospital cares for nearly 200,000 people and its adult emergency department receives 35,000 patients per year (20% of whom are aged 75 and over).
Cohort
Other
Pharmaceutical analysis based on the Electronic Patient Record
Other interventionAfter inclusion, each patient's data will be collected and analysed by the investigator in the following 5 days. The said data will be: * Independent variables (demographic data, laboratory results, comorbidities, home medication treatment, reason for admission) * The ISAR score, using the electronic patients record * The number of inappropriate prescriptions, using STOPP/START version 3 online tool. * The number of high-risk drug interactions (categories D "Consider therapy modification" and X "Avoid combination"), using Lexicomp™ Interact online tool. * The number of drug-related problems, using the PCNE classification version 9.1, including usual home patient's treatment as well as treatment received in the ED. * The likelihood of a medication-related emergency consultation, using AT-HARM 10 score.
The rate of inappropriate prescription (PIP) as a function of their ISAR score.
The rate of inappropriate prescription (PIP) will be compared as a function of their ISAR score, using Poisson regression analysis. PIPs will be defined according to the STOPP/START online tool version 3, developed for geriatric patients.
The rate of high-risk drug-drug interactions (DDIs) as a function of their ISAR score.
The rate of high-risk drug-drug interactions (DDIs) will be compared as a function of their ISAR score, using Poisson regression analysis. High-risk DDIs will be detected with the Lexicomp™ Interact online tool and only categories D ("Consider therapy modification") and X ("Avoid combination") will be considered.
The predictive performance of the ISAR score for the detection of PIPs and high-risk DDIs.
Determining optimal ISAR threshold for predicting medication problems further improves its use in clinical settings. If possible, sensitivity, specificity, positive predictive value, negative predictive value, and Youden index will be calculated.
The number of drug-related problems (DRPs) in function to the ISAR score.
After pharmaceutical analysis of the electronic patient file, DRPs will be classified according to the Pharmaceutical Care Network Europe Association (PCNE) V9.
The likelihood of a medication-related emergency visit in function to the ISAR score.
The likelihood of a medication-related emergency visit will be measured with the AT-HARM 10 score. This score gives a binary result ("possibly" or "unlikely" medication-related visit) and is a useful tool to exclude patients who are unlikely to be admitted due to a medication issue.
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