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.

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.

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.

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.

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.

Implementing an allied health team intervention to improve the care of older adults in the emergency department: protocol for a process evaluation.

INTRODUCTION: Health and social care professionals (HSCPs) have increasingly contributed to enhance the care of patients in emergency departments (EDs), particularly for older adults who are frequent ED attendees with significant adverse outcomes. For the first time, the effectiveness of a HSCP team intervention for older adults in the ED has been tested in a large randomised controlled trial (Clinicaltrials.gov, NCT03739515), providing an opportunity to explore the implementation process for this type of intervention. This protocol describes a process evaluation that will to investigate the implementation, delivery and impact of an HSCP team intervention in the ED. METHODS AND ANALYSIS: Using the Medical Research Council Framework for process evaluations, we will employ a mixed-methods approach to provide a description of the process of implementation and delivery of the HSCP intervention in the ED, evaluate its fidelity, dose and reach and explore the perceptions of key staff members in relations to the mechanisms and contexts of impact at the levels of individuals, physical environment, operations, communication and the broader hospital and healthcare system. ETHICS AND DISSEMINATION: Ethical approval for this study was received from the HSE Mid-Western Regional Hospital Research Ethics Committee (Ref: 103/18). All participants will be invited to read and sign a written consent form prior to participation. The results of this review will be disseminated through publication in a peer-review journal and presented at relevant conferences.

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.