Patrick Leung, Hong Kong
Hong Kong is one of the regions in the world where people enjoy longevity. Due to the high prevalence of comorbidities and financial stress in older people, it is not uncommon for older people to attend the emergency department (ED) for treatment when they get sick.
Nowadays about one third of ED attendance are people aged 65 years and older and it is on the increasing trend. Most will be admitted to the hospital and this huge demand out-weighs the inpatient capacity.
The Hospital Authority (HA) in Hong Kong, which is the statutory public hospital services provider had put forward an initiative named “enhanced geriatric support at ED” to tackle this challenge in 2020. This is a joint program between the ED team and Geriatrics team with the aim to provide additional support and alternatives to older people other than hospital admission. It launched in phases across different hospitals in Hong Kong. This service commenced in my hospital in 2021 and I would like to share our experience with you.
Frail older patients are the target and will be recruited to this program. This refers to those vulnerable older people who have a clinical frailty score (CFS) ≥ 4, with geriatric syndrome or caring problem. By using a simple inclusion criteria, eligible patients will be identified and referred to the geriatric team for conducting a comprehensive geriatric assessment. The evaluation will focus on their cognitive, functional and social needs. Moreover, on site assessment by a physiotherapist and occupational therapist is available for selected cases. The goal is to safely discharge the patients and manage them in outpatient settings with enhanced support.
From October 2021 to August 2022, 2739 patients have been recruited to this program. The average age of the participants was 81.8 years old, with female predominance (1: 1.5). The majority of them were living at home (78%), among them 57% lived with their caregiver. The main reasons of their ED attendance were fall, dizziness, musculoskeletal pain, fever and lower back pain. Regarding the severity of their frailty level, more than half of the patients were pre-frail or mildly frail, with 61% had a CFS score of 4 and 17% with CFS score of 5.
After the implementation of this program, 656 patients (24% ) could be directly discharged from the ED, while another 1170 (43%) of patients were discharged after a short stay in the emergency medicine ward for 1 to 2 days of training and intervention.
488 (26%) of the patients were referred to community service support upon discharge. The services provided were diverse and ranged from telephone follow up, outpatient physiotherapy, occupational therapy to short course of training at geriatric day hospital. Only ~ 10% of patients reattended the ED within 28 days for the same reason.
The preliminary result of this program is encouraging. The majority of the vulnerable older people can be returned to their home with community support, better managed in a familiar environment and spare them the risk of deconditioning in hospital. This management model aligns with the Hong Kong Government policy of “Aging in place” and is a feasible alternative to hospital admission.