Geriatric Emergency Department Intervention Model of Care: A Program of Evaluative Research

Elizabeth J Marsden

doi:10.25907/00063

Background: Emergency departments (EDs) are chaotic environments in which frail older adult residents from residential aged care facilities (RACFs) often endure prolonged lengths of stay (LoS) due to complex medical needs and competing interests in the ED. In addition, they may be subjected to excessive tests and iatrogenic complications both during and after hospitalisation. Given the size of Australia’s ageing population, the expected number of presentations of this group of patients to the ED will increase. The Geriatric Emergency Department Intervention (GEDI) model described below is an ED-managed, emergency physician-championed, specialised geriatric nursing assessment and management team purposely designed to address the issues associated with frail older adults presenting to the ED. This team provide front-loaded geriatric-focused assessment, implement geriatric-tailored management strategies whilst in the ED and on admission (such as recognition and management of delirium), communicate early with collateral resources and facilitate appropriate early discharge planning. The aim of the GEDI model is to maximise the quality of care for this vulnerable patient cohort while decreasing hospitalisation and reducing hospital LoS, mortality and re-presentation. Methods: A program evaluation of the GEDI model was undertaken utilising a pragmatic embedded mixed methods approach. The quantitative component was deemed the dominant element and was supported by the secondary embedded qualitative component. The research was based on a structures, processes and outcomes framework to ascertain the overall effectiveness of the program. The first study was a quantitative pre-post comparison of the GEDI service in the ED, comparing the healthcare data outcomes before and after the service was introduced. A quasi-experimental design using historical controls was employed. Data were collected during three time periods: pre-GEDI (before GEDI was implemented in the study ED), peri-GEDI (during implementation of GEDI in the study ED) and full GEDI (a fully staffed and implemented service in the study ED). Data were extracted retrospectively via a medical records audit of coded state-based health service databases, namely the Emergency Department Information Service and the Hospital-based Corporate Information System. The primary outcome was disposition that is either discharged, admitted or died. The secondary outcomes were: ED LoS in minutes, Hospital LoS in days, All-cause in-hospital mortality within 30 days of ED presentation, ED re-presentations within 72 hours and 28 days and Time to ED re-presentation within 28 days. Demographic and clinical independent variables were used to describe the sample and to build multivariable models to compare outcomes. The second study was a descriptive qualitative study of the structures and processes required for the operation of GEDI as well as ED staff perspectives and satisfaction with the GEDI model. Data were collected via semi-structured, audio-recorded interviews of the GEDI and ED staff. Participants were asked to respond to open-ended, semi-structured questions framed around an a priori system of categorising qualitative data adapted from The Nursing Role Effectiveness model. Data were analysed utilising a conventional content analysis approach. Interviews were transcribed, read and re-read with sections of text assigned labels relevant to the a priori categories. Results: This research has resulted in three published peer-reviewed journal articles. The first paper, a study protocol, describes the research design. The second and third papers publish the results of the quantitative and qualitative studies, respectively. The quantitative quasi-experimental study found a significant increase in the likelihood of safe discharge from the ED (hazard ratio 1.15, 95% CI: 1.05, 1.26) given that there were no differences in hospital mortality or ED re-presentation between the three time periods. Further, there was a reduction in the ED LoS (hazard ratio 1.49, 95% CI: 1.24, 1.78) for RACF residents following the implementation of the GEDI intervention, with no change in hospital LoS between the three time periods. The qualitative study revealed important structures and processes deemed essential for the successful outcomes of the GEDI model to be achieved. The structural components included adequate funding, an ED physician champion and nurses with gerontology experience and geriatric-specific resources. The processes identified included a targeted approach to assessment, a patient-centred approach to care, and staff with inter-facility, intra-facility and interpersonal communication skills. Discussion: There is a paucity of evidence in the literature to support the implementation of geriatric-focused interventions in the ED, despite the associated patient morbidity and mortality experienced in the current ‘one size fits all’ adult ED model of care. This study provides initial evidence of the effectiveness and suitability of the Geriatric Emergency Department Intervention. Further implementation and more widespread evaluation will potentially refine the model and provide higher-quality and safer care for older adults with acute non-life-threatening conditions. This ongoing intervention and evaluation process are consistent with the ‘wicked’ nature of healthcare problems associated with frail older adults.

Geriatric Emergency Department Intervention Model of Care: A Program of Evaluative Research

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