Core requirements of frailty screening in the emergency department: an international Delphi consensus study.

INTRODUCTION: Frailty is associated with adverse outcomes among patients attending emergency departments (EDs). While multiple frailty screens are available, little is known about which variables are important to incorporate and how best to facilitate accurate, yet prompt ED screening. To understand the core requirements of frailty screening in ED, we conducted an international, modified, electronic two-round Delphi consensus study. METHODS: A two-round electronic Delphi involving 37 participants from 10 countries was undertaken. Statements were generated from a prior systematic review examining frailty screening instruments in ED (logistic, psychometric and clinimetric properties). Reflexive thematic analysis generated a list of 56 statements for Round 1 (August-September 2021). Four main themes identified were: (i) principles of frailty screening, (ii) practicalities and logistics, (iii) frailty domains and (iv) frailty risk factors. RESULTS: In Round 1, 13/56 statements (23%) were accepted. Following feedback, 22 new statements were created and 35 were re-circulated in Round 2 (October 2021). Of these, 19 (54%) were finally accepted. It was agreed that ideal frailty screens should be short (<5 min), multidimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2-4 weeks before presentation. Screening should ideally be routine, prompt (<4 h after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use and social factors were identified as the most important variables to include. CONCLUSIONS: Although a clear consensus was reached on important requirements of frailty screening in ED, and variables to include in an ideal screen, more research is required to operationalise screening in clinical practice.

Person-centred decisions in emergency care for older people living with frailty: principles and practice.

Older people living with frailty are frequent users of emergency care and have multiple and complex problems. Typical evidence-based guidelines and protocols provide guidance for the management of single and simple acute issues. Meanwhile, person-centred care orientates interventions around the perspectives of the individual. Using a case vignette, we illustrate the potential pitfalls of applying exclusively either evidence-based or person-centred care in isolation, as this may trigger inappropriate clinical processes or place undue onus on patients and families. We instead advocate for delivering a combined evidence-based, person-centred approach to healthcare which considers the person's situation and values, apparent problem and available options.

Establishing severe acute respiratory infection (SARI) surveillance in a sentinel hospital, Ireland, 2021 to 2022.

BackgroundIn 2020, due to the COVID-19 pandemic, the European Centre for Disease Prevention and Control (ECDC) accelerated development of European-level severe acute respiratory infection (SARI) surveillance.AimWe aimed to establish SARI surveillance in one Irish hospital as part of a European network E-SARI-NET.MethodsWe used routine emergency department records to identify cases in one adult acute hospital. The SARI case definition was adapted from the ECDC clinical criteria for a possible COVID-19 case. Clinical data were collected using an online questionnaire. Cases were tested for SARS-CoV-2, influenza and respiratory syncytial virus (RSV), including whole genome sequencing (WGS) on SARS-CoV-2 RNA-positive samples and viral characterisation/sequencing on influenza RNA-positive samples. Descriptive analysis was conducted for SARI cases hospitalised between July 2021 and April 2022.ResultsOverall, we identified 437 SARI cases, the incidence ranged from two to 28 cases per week (0.7-9.2/100,000 hospital catchment population). Of 431 cases tested for SARS-CoV-2 RNA, 226 (52%) were positive. Of 349 (80%) cases tested for influenza and RSV RNA, 15 (4.3%) were positive for influenza and eight (2.3%) for RSV. Using WGS, we identified Delta- and Omicron-dominant periods. The resource-intensive nature of manual clinical data collection, specimen management and laboratory supply shortages for influenza and RSV testing were challenging.ConclusionWe successfully established SARI surveillance as part of E-SARI-NET. Expansion to additional sentinel sites is planned following formal evaluation of the existing system. SARI surveillance requires multidisciplinary collaboration, automated data collection where possible, and dedicated personnel resources, including for specimen management.

Impact of assessment and intervention by a health and social care professional team in the emergency department on the quality, safety, and clinical effectiveness of care for older adults: A randomised controlled trial.

BACKGROUND: Older adults frequently attend the emergency department (ED) and experience high rates of adverse events following ED presentation. This randomised controlled trial evaluated the impact of early assessment and intervention by a dedicated team of health and social care professionals (HSCPs) in the ED on the quality, safety, and clinical effectiveness of care of older adults in the ED. METHODS AND FINDINGS: This single-site randomised controlled trial included a sample of 353 patients aged ≥65 years (mean age = 79.6, SD = 7.01; 59.2% female) who presented with lower urgency complaints to the ED a university hospital in the Mid-West region of Ireland, during HSCP operational hours. The intervention consisted of early assessment and intervention carried out by a HSCP team comprising a senior medical social worker, senior occupational therapist, and senior physiotherapist. The primary outcome was ED length of stay. Secondary outcomes included rates of hospital admissions from the ED; hospital length of stay for admitted patients; patient satisfaction with index visit; ED revisits, mortality, nursing home admission, and unscheduled hospital admission at 30-day and 6-month follow-up; and patient functional status and quality of life (at index visit and follow-up). Demographic information included the patient's gender, age, marital status, residential status, mode of arrival to the ED, source of referral, index complaint, triage category, falls, and hospitalisation history. Participants in the intervention group (n = 176) experienced a significantly shorter ED stay than the control group (n = 177) (6.4 versus 12.1 median hours, p < 0.001). Other significant differences (intervention versus control) included lower rates of hospital admissions from the ED (19.3% versus 55.9%, p < 0.001), higher levels of satisfaction with the ED visit (p = 0.008), better function at 30-day (p = 0.01) and 6-month follow-up (p = 0.03), better mobility (p = 0.02 at 30 days), and better self-care (p = 0.03 at 30 days; p = 0.009 at 6 months). No differences at follow-up were observed in terms of ED re-presentation or hospital admission. Study limitations include the inability to blind patients or ED staff to allocation due to the nature of the intervention, and a focus on early assessment and intervention in the ED rather than care integration following discharge. CONCLUSIONS: Early assessment and intervention by a dedicated ED-based HSCP team reduced ED length of stay and the risk of hospital admissions among older adults, as well as improving patient satisfaction. Our findings support the effectiveness of an interdisciplinary model of care for key ED outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT03739515; registered on 12 November 2018.

Silver Book II: an international framework for urgent care of older people in the first 72 hours from illness or injury.

The new edition of the Silver Book, Silver Book II, provides a framework for the urgent care of older people in the first 72 hours from illness or injury. It incorporates principles of geriatric medicine, quality improvement (including patient reported outcome measures) and interdisciplinary care in a balanced, practical and evidence-rich manual on unscheduled and emergent care for older adults. Silver Book II shows how frailty, comprehensive geriatric assessment and shared decision-making can be locally adapted according to national practice and policy across the world. The challenge for all providers is adapting our models of care to meet the changing needs of older patients and their caregivers as well as changes in the delivery of medical care in the 21st century.

Stakeholders' perspectives on models of care in the emergency department and the introduction of health and social care professional teams: A qualitative analysis using World Cafés and interviews.

BACKGROUND: There is some evidence that health and social care professional (HSCP) teams contribute to enhanced patient and process outcomes in increasingly crowded emergency departments (EDs), but the views of service users and providers on this model of care need investigation to optimize implementation. OBJECTIVE: This qualitative study investigated the perspectives of key ED stakeholders about HSCP teams working in the ED. METHODS: Using a participatory design, we conducted World Café focus groups and individual interviews in two Irish hospital sites with 65 participants (purposive sampling) including ED patients and carers/relatives, ED doctors and nurses, HSCPs and pre-hospital staff. Data were thematically analysed using NVivo software. RESULTS: Participants reported that ED-based HSCP teams could improve quality and integration of care and staff experience (Theme 1) and would be appropriate for older adults with complex needs and non-urgent complaints (Theme 2). Concerns were raised about operational and relational barriers to implementation (Theme 3), and changes in processes and culture were considered necessary for HSCPs to work successfully in the ED (Theme 4). In contrast to service providers, service users' concerns centred on the importance of positive communication and relations (Theme 5). CONCLUSIONS: Our study indicates potential acceptability of HSCP teams working in the ED, especially to care for older adults; however, operational and relational aspects, particularly developing interdisciplinary and integrated care, need addressing to ensure successful implementation. Differences in priorities between service users and providers (relational vs operational) highlighted the usefulness of gathering views from multiple stakeholders to understand ED processes.

Community frailty response service: the ED at your front door.

We describe the expansion and adaptation of a frailty response team to assess older people in their usual place of residence. The team had commenced a weekend service to a limited area in February 2020. As a consequence of demand related to the COVID-19 pandemic, we expanded it and adapted the model of care to provide a 7-day service to our entire catchment area. Five hundred and ninety two patient reviews have been completed in the first 105 days of operation with 43 patients transferred to hospital for further investigation or management following assessment.

Development and delivery of an allied health team intervention for older adults in the emergency department: A process evaluation.

BACKGROUND: There is encouraging evidence that interdisciplinary teams of Health and Social Care Professionals (HSCPs) can enhance patient care in the Emergency Department (ED), especially for older adults with complex needs. However, no formal process evaluations of implementations of ED-based HSCP interventions are available. The study aimed to evaluate the development and delivery of a HSCP team intervention for older adults in the ED of a large Irish teaching hospital. METHODS: Using the Medical Research Council (MRC) Framework for process evaluations, we investigated implementation and delivery, mechanisms of impact, and contextual influences on implementation by analysing the HSCP team's activity notes and participant recruitment logs, and by carrying out six interviews and four focus groups with 26 participants (HSCP team members, ED doctors and nurses, hospital staff). Qualitative insights were analysed thematically. RESULTS: The implementation process had three phases (pre-implementation, piloting, and delivery), with the first two described as pivotal to optimise care procedures and build positive stakeholders' involvement. The team's motivation and proactive communication were key to promote acceptability and integration in the ED (Theme 1); also, their specialised skills and interdisciplinary approach enhanced patient and staff's ED experience (Theme 2). The investment and collaboration of multiple stakeholders were described as essential contextual enablers of implementation (Theme 4). Delivering the intervention within a randomised controlled trial fostered credibility but caused frustration among patients and staff (Theme 3). DISCUSSION: This process evaluation is the first to provide in-depth and practical insights on the complexities of developing and delivering an ED-based HSCP team intervention for older adults. Our findings highlight the importance of establishing a team of HSCPs with a strong interdisciplinary ethos to ensure buy-in and integration in the ED processes. Also, actively involving relevant stakeholders is key to facilitate implementation. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03739515; registered on 12th November 2018.

Home FIRsT: interdisciplinary geriatric assessment and disposition outcomes in the Emergency Department.

BACKGROUND: Older people in the Emergency Department (ED) are clinically heterogenous and some presentations may be better suited to alternative out-of-hospital pathways. A new interdisciplinary comprehensive geriatric assessment (CGA) team (Home FIRsT) was embedded in our acute hospital's ED in 2017. AIM: To evaluate if routinely collected CGA metrics were associated with ED disposition outcomes. DESIGN: Retrospective observational study. METHODS: We included all first patients seen by Home FIRsT between 7th May and 19th October 2018. Collected measures were sociodemographic, baseline frailty (Clinical Frailty Scale), major diagnostic categories, illness acuity (Manchester Triage Score) and cognitive impairment/delirium (4AT). Multivariate binary logistic regression models were computed to predict ED disposition outcomes: hospital admission; discharge to GP and/or community services; discharge to specialist geriatric outpatients; discharge to the Geriatric Day Hospital. RESULTS: In the study period, there were 1,045 Home FIRsT assessments (mean age 80.1 years). For hospital admission, strong independent predictors were acute illness severity (OR 2.01, 95% CI 1.50-2.70, P<0.001) and 4AT (OR 1.26, 95% CI 1.13 - 1.42, P<0.001). Discharge to specialist outpatients (e.g. falls/bone health) was predicted by musculoskeletal/injuries/trauma presentations (OR 6.45, 95% CI 1.52 - 27.32, P=0.011). Discharge to the Geriatric Day Hospital was only predicted by frailty (OR 1.52, 95% CI 1.17 - 1.97, P=0.002). Age and sex were not predictive in any of the models. CONCLUSIONS: Routinely collected CGA metrics are useful to predict ED disposition. The ability of baseline frailty to predict ED outcomes needs to be considered together with acute illness severity and delirium.

A European Research Agenda for Geriatric Emergency Medicine: a modified Delphi study.

PURPOSE: Geriatric Emergency Medicine (GEM) focuses on delivering optimal care to (sub)acutely ill older people. This involves a multidisciplinary approach throughout the whole healthcare chain. However, the underpinning evidence base is weak and it is unclear which research questions have the highest priority. The aim of this study was to provide an inventory and prioritisation of research questions among GEM professionals throughout Europe. METHODS: A two-stage modified Delphi approach was used. In stage 1, an online survey was administered to various professionals working in GEM both in the Emergency Department (ED) and other healthcare settings throughout Europe to make an inventory of potential research questions. In the processing phase, research questions were screened, categorised, and validated by an expert panel. Subsequently, in stage 2, remaining research questions were ranked based on relevance using a second online survey administered to the same target population, to identify the top 10 prioritised research questions. RESULTS: In response to the first survey, 145 respondents submitted 233 potential research questions. A total of 61 research questions were included in the second stage, which was completed by 176 respondents. The question with the highest priority was: Is implementation of elements of CGA (comprehensive geriatric assessment), such as screening for frailty and geriatric interventions, effective in improving outcomes for older patients in the ED? CONCLUSION: This study presents a top 10 of high-priority research questions for a European Research Agenda for Geriatric Emergency Medicine. The list of research questions may serve as guidance for researchers, policymakers and funding bodies in prioritising future research projects.

Impact of early assessment and intervention by teams involving health and social care professionals in the emergency department: A systematic review.

BACKGROUND: Dedicated Health and Social Care Professional (HSCP) teams have been proposed for emergency departments (EDs) in an effort to improve patient and process outcomes. This systematic review synthesises the totality of evidence relating to the impact of early assessment and intervention by HSCP teams on quality, safety and effectiveness of care in the ED. METHODS: A systematic literature search was conducted in April 2019 to identify experimental studies examining the effectiveness of ED-based HSCP teams providing services to adults aged ≥ 18 years old and including two or more of the following disciplines: occupational therapist, physiotherapist, medical social worker, clinical pharmacist, or speech and language therapist. Data extraction and quality appraisal of each study were conducted independently by two reviewers. RESULTS: Six studies were included in the review (n = 273,886), all describing interdisciplinary Care Coordination Teams (CCTs) caring for adults aged ≥ 65 years old. CCT care was associated with on average 2% reduced rates of hospital admissions (three studies), improved referrals to community services for falls (one study), increased satisfaction (two studies) with the safety of discharge (patients and staff), and with the distribution of workload (staff), improved health-related quality of care (one study). No statistically significant differences between intervention and control groups emerged in terms of rates of ED re-visits, ranging between 0.2% and 3% (two studies); hospital length of stay (one hour difference noted in one study) or mortality rates (0.5% difference in one study). Increased rates of unplanned hospitalisations following the intervention (13.9% difference) were reported in one study. The methodological quality of the studies was mixed. DISCUSSION: We found limited and heterogeneous evidence on the impact of HSCP teams in the ED, suggesting a reduction in hospital admissions as well as improved patient and staff satisfaction. More robust investigations including cost-effectiveness evaluations are needed.

A randomised controlled trial exploring the impact of a dedicated health and social care professionals team in the emergency department on the quality, safety, clinical and cost-effectiveness of care for older adults: a study protocol.

BACKGROUND: Older people are frequent emergency department (ED) users who present with complex issues that are linked to poorer health outcomes following the index visit, often have increased ED length of stay, and tend to have raised healthcare costs. Encouraging evidence suggests that ED teams involving health and social care professionals (HSCPs) can contribute to enhanced patient flow and an improved patient experience by improving care decision-making and thus promoting timely and effective care. However, the evidence supporting the impact of HSCP teams assessing and intervening with older adults in the ED is limited and identifies important methodological limitations, highlighting the need for more robust and comprehensive investigations of this model of care. This study aims to evaluate the impact of a dedicated ED-based HSCP team on the quality, safety, and clinical- and cost-effectiveness of care of older adults when compared with usual care. METHODS: The study is a single-site randomised controlled trial whereby patients aged ≥65 years who present to the ED of a large Irish hospital will be randomised to the experimental group (ED-based HSCP assessment and intervention) or the control group (usual ED care). The recruitment target is 320 participants. The HSCP team will provide a comprehensive functional assessment as well as interventions to promote a safe discharge for the patient. The primary outcome is ED length of stay (from arrival to discharge). Secondary outcomes include: rates of hospital admissions from the ED, ED re-visits, unplanned hospital admissions and healthcare utilisation at 30 days, and 4 and 6 months of follow-up; patient functional status and quality of life (at baseline and follow-up); patient satisfaction; cost-effectiveness in terms of costs associated with ED-based HSCP compared with usual care; and perceptions on implementation by ED staff members. DISCUSSION: This is the first randomised controlled trial testing the impact of HSCPs working in teams in the ED on the quality, safety, and clinical- and cost-effectiveness of care for older patients. The findings of this study will provide important information on the effectiveness of this model of care for future implementation. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03739515 . Registered on 12 November 2018.

Undertaking a Collaborative Rapid Realist Review to Investigate What Works in the Successful Implementation of a Frail Older Person's Pathway.

We addressed the research question "what factors enable the successful development and implementation of a frail older person's pathway within the acute setting". A rapid realist review (RRR) was conducted by adopting the RAMESES standards. We began with a sample of 232 articles via database searches supplemented with 94 additional records including inputs from a twitter chat and a hospital site visit. Our final sample consisted of 18 documents. Following review and consensus by an expert panel we identified a conceptual model of context-mechanism-(resources)-outcomes. There was overall agreement frailty should be identified at the front door of the acute hospital. Significant challenges identified related to organisational boundaries both within the acute setting and externally, the need to shift outcomes to patient orientated ones, to support staff to sustain the pathway by providing ongoing education and by providing role clarity. RRRs can support research such as the systematic approach to improving care for frail older adults (SAFE) study by producing accounts of what works based on a wide range of sources and innovative engagement with stakeholders. It is evident from our provisional model that numerous factors need to combine and interact to enable and sustain a successful frail older person's pathway.

Effectiveness of early assessment and intervention by interdisciplinary teams including health and social care professionals in the emergency department: protocol for a systematic review.

INTRODUCTION: Finding cost-effective strategies to improve patient care in the emergency department (ED) is an increasing imperative given growing numbers of ED attendees. Encouraging evidence indicates that interdisciplinary teams including health and social care professionals (HSCPs) enhance patient care across a variety of healthcare settings. However, to date no systematic reviews of the effectiveness of early assessment and/or interventions carried by such teams in the ED exist. This systematic review aims to explore the impact of early assessment and/or intervention carried out by interdisciplinary teams including HSCPs in the ED on the quality, safety and cost-effectiveness of care, and to define the content of the assessment and/or intervention offered by HSCPs. METHODS AND ANALYSIS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standardised guidelines, we will conduct a systematic review of randomised controlled trials (RCTs), non-RCTs, controlled before-after studies, interrupted time series and repeated measures studies that report the impact of early assessment and/or intervention provided to adults aged 18+ by interdisciplinary teams including HSCPs in the ED. Searches will be carried in Cumulative Index of Nursing and Allied Health Literature, Embase, Cochrane Library and MEDLINE from inception to March 2018. We will also hand-search the reference lists of relevant studies. Following a two-step screening process, two independent reviewers will extract data on the type of population, intervention, comparison, outcomes and study design. The quality of the studies will be appraised using the Cochrane Risk of Bias Tool. The findings will be synthesised in a narrative summary, and a meta-analysis will be conducted where appropriate. ETHICS AND DISSEMINATION: Ethical approval will not be sought since it is not required for systematic reviews. The results of this review will be disseminated through publication in a peer-review journal and presented at relevant conferences. TRIAL REGISTRATION NUMBER: CRD42018091794.