The “surprise question” (SQ) predicts the need for palliative care. Its predictive validity for adverse healthcare outcomes and its association with frailty among older people attending the emergency department (ED) are unknown. We conducted a secondary analysis of a prospective study of consecutive patients aged ≥70 attending a university hospital’s ED. The SQ was scored by doctors before an independent comprehensive geriatric assessment (CGA). Outcomes included length of stay (LOS), frailty determined by CGA and one-year mortality. The SQ was available for 191 patients, whose median age was 79 ± 9. In all, 56/191 (29%) screened SQ positive. SQ positive patients were frailer; the median clinical frailty score was 6/9 (compared to 4/9, p < 0.001); they had longer LOS (p = 0.008); and they had higher mortality (p < 0.001). Being SQ positive was associated with 2.6 times greater odds of admission and 8.9 times odds of frailty. After adjustment for age, sex, frailty, co-morbidity and presenting complaint, patients who were SQ positive had significantly reduced survival times (hazard ratio 5.6; 95% CI: 1.39–22.3, p = 0.015). Almost one-third of older patients attending ED were identified as SQ positive. These were frailer and more likely to be admitted, have reduced survival times and have prolonged LOS. The SQ is useful to quickly stratify older patients likely to experience poor outcomes in ED.

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Emerging evidence suggests that methadone has a specific role in the management of treatment resistant cancer-related pain.ObjectivesTo investigate the utilisation pattern, safety and efficacy of methadone prescribed as an analgesic for the management of complex cancer-related pain in an acute hospital inpatient setting.MethodsA retrospective longitudinal observational study of patients prescribed methadone as an analgesic between April 2020 and July 2021 was performed.Changes in coprescribed baseline opioid, use of breakthrough opioid analgesic, patient rated pain scores and adverse side effects were analysed.Results16 patients with complex cancer-related treatment resistant pain who were prescribed methadone were included in the study. Of the 16 patients, 14 patients had metastatic disease. Pain was classified in 14 patients as mixed nociceptive-neuropathic and in 2 patients as neuropathic. 13 patients were coprescribed methadone with a pre-established opioid. Methadone was associated with a statistically significant decrease in both opioid breakthrough analgesic by 61%±28% (p<0.001), and coprescribed opioid by 17%±12% (p=0.015). Patient rated pain scores were also significantly decreased (p<0.001).ConclusionMethadone appears to have a specific role in the management of complex cancer pain, neuropathic pain, opioid-tolerance and opioid-induced hyperalgesia, which may be attributable to N-methyl-D-aspartate receptor antagonism.

Background Nursing home residents are prone to acute illness due to their advancing age, underlying illnesses and immobility. The decision to refer a nursing home resident for acute hospital admission is a complex one, and there is no consensus among health care professionals about what constitutes an ‘appropriate admission’ to hospital from a nursing home. We aimed to explore patterns of acute nursing home patient presentations to the emergency department. Methods This was a retrospective cohort study of emergency hospital admissions to a tertiary university teaching hospital. Emergency admissions through the emergency department were included. Elective admissions, outpatient admissions, or inter-hospital transfers were excluded. Cases were validated by scrutiny of the patient medical records, and where possible an assessment of the Rockwood clinical frailty scale (CFS) was carried out. Results There were 126 nursing home residents who presented to ED over a two month period for emergency assessments. 87.3% (n=115) presented via ambulance. Just over half had a GP referral letter (53.2%). 72.3% of patients who presented to ED were admitted. 25.2% of patients were re-referred to ED within 30 days of hospital discharge. All patients were classified as frail. 21.3% of patients had died at the 90 day follow up mark. 66% of those with a CFS 8 or 9 died, in comparison to 16% of those with a CFS or either 6 or 7. Conclusion We noted high numbers of patients from nursing homes attending our emergency department. A very high proportion were admitted, along with a high number of subsequent re-presentations. Death rates were higher in those with more advanced frailty status. We would suggest advanced care planning and strategies to improve the patient experience. This study highlights the requirement for improved advance care planning in the nursing home setting. This is however a complex issue. Early discussion about end of life preferences with patients and family is required.