The impact of geriatric focused nurse assessment and intervention in the emergency department: A systematic review

Caregivers' burden of care during emergency department care transitions among older adults: a mixed methods cohort study

OBJECTIVE

Improving care transitions for older adults can reduce emergency department (ED) revisits, and the strain placed upon caregivers. We analyzed whether caregivers felt a change in burden following a care transition, and what may be improved to reduce it.

METHODS

This mixed-methods observational study nested within LEARNING WISDOM included caregivers of older patients who experienced an ED care transition. Burden was collected with the brief Zarit Burden Interview (ZBI-12), and caregivers also commented on the care transition. A qualitative coding scheme of patient care transitions was created to reflect themes important to caregivers. Comments were randomly analyzed until saturation and themes were extracted from the data. We followed both the SRQR and STROBE checklists.

RESULTS

Comments from 581 caregivers (mean age (SD) 64.5 (12.3), 68% women) caring for patients (mean age (SD) 77.2 (7.54), 48% women) were analyzed. Caregivers overwhelmingly reported dissatisfaction and unmet service expectations, particularly with home care and domestic help. Communication and follow-up from the ED emerged as an area for improvement. Caregivers who reported an increased level of burden following a patient's care transition had significantly higher ZBI scores than caregivers who self-reported stable burden levels.

CONCLUSION

Caregivers with increasing, stable, and improved levels of subjective burden all reported areas for improvement in the care transition process. Themes centering on the capacity to live at home and inadequate communication were most frequently mentioned and may represent serious challenges to caregivers. Addressing these challenges could improve both caregiver burden and ED care transitions.

Emergency nurses' and physicians' perceptions and self-assessed competence in providing care to older patients

AIM

This study examined emergency nurses' and physicians' perceptions and self-assessed competence in caring for older patients.

METHODS

Data were analyzed using a mixed methods approach and quantitative data were supplemented with qualitative responses. There were 451 nurses and physicians working at the two examined emergency departments, with 125 of them responding to the survey; the response rate was 27.7 %.

RESULTS

Physicians and nurses felt that acutely ill older patients are a responsibility of emergency services. Nurses were more critical than physicians (p = 0.000) of the failure to recognize older patients as a special group at the emergency department. Over half (51.8 %) of the physicians and 29.0 % of the nurses (p = 0.027) felt that older patients' special needs had been considered during facility planning. Nurses and physicians described the problems related to multimorbidity and aging relatively similarly. Both expressed a need for more knowledge in geriatrics and gerontology.

CONCLUSION

Future facility planning and care processes at the emergency department should better consider the specific needs of older patients. The results also emphasize a need to more effectively prioritize competence and educational needs of emergency staff and recognize caring for older patients as a specific competence area in the emergency department.

Patient flow in emergency departments: a comprehensive umbrella review of solutions and challenges across the health system

BACKGROUND

Globally, emergency departments (EDs) are overcrowded and unable to meet an ever-increasing demand for care. The aim of this study is to comprehensively review and synthesise literature on potential solutions and challenges throughout the entire health system, focusing on ED patient flow.

METHODS

An umbrella review was conducted to comprehensively summarise and synthesise the available evidence from multiple research syntheses. A comprehensive search strategy was employed in four databases alongside government or organisational websites in March 2023. Gray literature and reports were also searched. Quality was assessed using the JBI critical appraisal checklist for systematic reviews and research syntheses. We summarised and classified findings using qualitative synthesis, the Population-Capacity-Process (PCP) model, and the input/throughput/output (I/T/O) model of ED patient flow and synthesised intervention outcomes based on the Quadruple Aim framework.

RESULTS

The search strategy yielded 1263 articles, of which 39 were included in the umbrella review. Patient flow interventions were categorised into human factors, management-organisation interventions, and infrastructure and mapped to the relevant component of the patient journey from pre-ED to post-ED interventions. Most interventions had mixed or quadruple nonsignificant outcomes. The majority of interventions for enhancing ED patient flow were primarily related to the 'within-ED' phase of the patient journey. Fewer interventions were identified for the 'post-ED' phase (acute inpatient transfer, subacute inpatient transfer, hospital at home, discharge home, or residential care) and the 'pre-ED' phase. The intervention outcomes were aligned with the aim (QAIM), which aims to improve patient care experience, enhance population health, optimise efficiency, and enhance staff satisfaction.

CONCLUSIONS

This study found that there was a wide range of interventions used to address patient flow, but the effectiveness of these interventions varied, and most interventions were focused on the ED. Interventions for the remainder of the patient journey were largely neglected. The metrics reported were mainly focused on efficiency measures rather than addressing all quadrants of the quadruple aim. Further research is needed to investigate and enhance the effectiveness of interventions outside the ED in improving ED patient flow. It is essential to develop interventions that relate to all three phases of patient flow: pre-ED, within-ED, and post-ED.

Identifying models of care to improve outcomes for older people with urgent care needs: a mixed methods approach to develop a system dynamics model

Background

We aimed to understand urgent and emergency care pathways for older people and develop a decision support tool using a mixed methods study design.

Objective(s), study design, settings and participants

Work package 1 identified best practice through a review of reviews, patient, carer and professional interviews. Work package 2 involved qualitative case studies of selected urgent and emergency care pathways in the Yorkshire and Humber region. Work package 3 analysed linked databases describing urgent and emergency care pathways identifying patient, provider and pathway factors that explain differences in outcomes and costs. Work package 4 developed a system dynamics tool to compare emergency interventions.

Results

A total of 18 reviews summarising 128 primary studies found that integrated social and medical care, screening and assessment, follow-up and monitoring of service outcomes were important. Forty patient/carer participants described emergency department attendances; most reported a reluctance to attend. Participants emphasised the importance of being treated with dignity, timely and accurate information provision and involvement in decision-making. Receiving care in a calm environment with attention to personal comfort and basic physical needs were key. Patient goals included diagnosis and resolution, well-planned discharge home and retaining physical function. Participants perceived many of these goals of care were not attained. A total of 21 professional participants were interviewed and 23 participated in focus groups, largely confirming the review evidence. Implementation challenges identified included the urgent and emergency care environment, organisational approaches to service development, staff skills and resources. Work package 2 involved 45 interviews and 30 hours of observation in four contrasting emergency departments. Key themes relating to implementation included: intervention-related staff: frailty mindset and behaviours resources: workforce, space, and physical environment operational influences: referral criteria, frailty assessment, operating hours, transport. context-related links with community, social and primary care organisation and management support COVID-19 pandemic. approaches to implementation service/quality improvement networks engaging staff and building relationships education about frailty evidence. The linked databases in work package 3 comprised 359,945 older people and 1,035,045 observations. The most powerful predictors of four-hour wait and transfer to hospital were age, previous attendance, out-of-hours attendance and call handler designation of urgency. Drawing upon the previous work packages and working closely with a wide range of patient and professional stakeholders, we developed an system dynamics tool that modelled five evidence-based urgent and emergency care interventions and their impact on the whole system in terms of reducing admissions, readmissions, and hospital related mortality.

Limitations

Across the reviews there was incomplete reporting of interventions. People living with severe frailty and from ethnic minorities were under-represented in the patient/carer interviews. The linked databases did not include patient reported outcomes. The system dynamics model was limited to evidence-based interventions, which could not be modelled conjointly.

Conclusions

We have reaffirmed the poor outcomes frequently experienced by many older people living with urgent care needs. We have identified interventions that could improve patient and service outcomes, as well as implementation tools and strategies to help including clinicians, service managers and commissioners improve emergency care for older people.

Future work

Future work will focus on refining the system dynamics model, specifically including patient-reported outcome measures and pre-hospital services for older people living with frailty who have urgent care needs.

Study registrations

This study is registered as PROSPERO CRD42018111461. WP 1.2: University of Leicester ethics: 17525-spc3-ls:healthsciences, WP 2: IRAS 262143, CAG 19/CAG/0194, WP 3: IRAS 215818, REC 17/YH/0024, CAG 17/CAG/0024.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme [project number 17/05/96 (Emergency Care for Older People)] and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 14. See the NIHR Journals Library website for further project information.

Factors Associated with Return Visits by Elders within 72 Hours of Discharge from the Emergency Department

Elders have a higher rate of return visits to the emergency department (ED) than other patients. It is critical to understand the risk factors for return visits to the ED by elders. The aim of this study was to determine the factors associated with return visits to the ED by elders. This study retrospectively reviewed the hospital charts of elders who returned to the ED within 72 h after discharge from ED. The risk factors identified in the Triage Risk Screening Tool were applied in this study. Of the elders discharged from the ED, 8.64% made a return visit to the ED within 72 h. The highest revisit rate occurred within 24 h after discharge. Factors associated with return ED visits within 24 h by elders were difficulty walking and having discharge care needs. The factor associated with ED return visits within 24-48 h was polypharmacy. Difficulty walking, having discharge care needs, and hospitalization within the past 120 days were associated with return visits made within 48-72 h following discharge. Identifying the reasons for return visits to the ED and providing a continuous review of geriatric assessment and discharge planning could reduce unnecessary revisits.

Economic evaluation of a medical ambulatory care service using a single group interrupted time-series design

RATIONALE

Increasing demand for hospital services can lead to overcrowding and delays in treatment, poorer outcomes and a high cost-burden. The medical ambulatory care service (MACS) provides out of hospital patient care, including diagnostic and therapeutic interventions for patients that require urgent attention, but which can be safely administered in the ambulatory environment. The programme is yet to be rigorously evaluated.

AIMS/OBJECTIVES

The aim of this study is to evaluate the impact of the MACS programme on emergency department (ED) presentations, hospital admissions, length-of-stay and health service costs from a health system perspective.

METHOD

We used a single group interrupted time series methodology with a multiple baseline approach to analyse the impact of the MACS clinic on ED presentations, hospital admissions, length-of-stay and cost outcomes for general practitioners (GP)-referred, ED-referred and ward-referred patients under two counterfactual scenarios: an increasing trend in health utilization based on preperiod predictions or a stabilization of utilization rates.

RESULTS

The time trend of hospital utilization differed after attending MACS for all three referral groups. The time trend for the GP-referred group declined significantly by 0.36 ED presentations per 100 patients per 30 days [95% confidence interval (CI): -0.52 to -0.2], while inpatient length of stay declined significantly by 1.56 and 3.70 days, respectively, per 100 ED-referred and ward-referred patients per 30 days (95% CI: -2.51 to -0.57 and -5.71 to -1.69, respectively). Under two different counterfactual scenarios, the predicted net savings for MACS across three patient groups were $78,685 (95% CI: $54,807-$102,563) and $547,639 (95% CI: $503,990-$591,287) per 100 patients over 18 months.

CONCLUSION

MACS was found to be cost-effective for GP and ward-referred groups, but the expected impact for ED-referred patients is sensitive to assumptions. Expansion of the service for GP-referred patients is expected to reduce hospitalizations the most and generate the largest net cost savings.

Examining the effect of interventions in emergency care for older people using a system dynamics decision support tool

BACKGROUND

Rising demand for Emergency and Urgent Care is a major international issue and outcomes for older people remain sub-optimal. Embarking upon large-scale service development is costly in terms of time, energy and resources with no guarantee of improved outcomes; computer simulation modelling offers an alternative, low risk and lower cost approach to explore possible interventions.

METHOD

A system dynamics computer simulation model was developed as a decision support tool for service planners. The model represents patient flow through the emergency care process from the point of calling for help through ED attendance, possible admission, and discharge or death. The model was validated against five different evidence-based interventions (geriatric emergency medicine, front door frailty, hospital at home, proactive care and acute frailty units) on patient outcomes such as hospital-related mortality, readmission and length of stay.

RESULTS

The model output estimations are consistent with empirical evidence. Each intervention has different levels of effect on patient outcomes. Most of the interventions show potential reductions in hospital admissions, readmissions and hospital-related deaths.

CONCLUSIONS

System dynamics modelling can be used to support decisions on which emergency care interventions to implement to improve outcomes for older people.

The effectiveness of interventions to reduce adverse outcomes among older adults following Emergency Department discharge: umbrella review

Background

Population ageing is increasing rapidly worldwide. Older adults are frequent users of health care services including the Emergency Department (ED) and experience a number of adverse outcomes following an ED visit. Adverse outcomes include functional decline, unplanned hospital admission and an ED revisit. Given these adverse outcomes a number of interventions have been examined to improve the outcomes of older adults following presentation to the ED. The aim of this umbrella review was to evaluate the effectiveness of ED interventions in reducing adverse outcomes in older adults discharged from the ED.

Methods

Systematic reviews of randomised controlled trials investigating ED interventions for older adults presenting to the ED exploring clinical, patient experience and healthcare utilisation outcomes were included. A comprehensive search strategy was employed in eleven databases and the PROSPERO register up until June 2020. Grey literature was also searched. Quality was assessed using the A MeaSurement Tool to Assess Systematic Reviews 2 tool. Overlap between systematic reviews was assessed using a matrix of evidence table. An algorithm to assign the Grading of Recommendations Assessment, Development and Evaluation to assess the strength of evidence was applied for all outcomes.

Results

Nine systematic reviews including 29 randomised controlled trials were included. Interventions comprised of solely ED-based or transitional interventions. The specific interventions delivered were highly variable. There was high overlap and low methodological quality of the trials informing the systematic reviews. There is low quality evidence to support ED interventions in reducing functional decline, improving patient experience and improving quality of life. The quality of evidence of the effectiveness of ED interventions to reduce mortality and ED revisits varied from very low to moderate. Results were presented narratively and summary of evidence tables created.

Conclusion

Older adults are the most important emerging group in healthcare for several economic, social and political reasons. The existing evidence for the effectiveness of ED interventions for older adults is limited. This umbrella review highlights the challenge of synthesising evidence due to significant heterogeneity in methods, intervention content and reporting of outcomes. Higher quality intervention studies in line with current geriatric medicine research guidelines are recommended, rather than the publication of further systematic reviews.

Trial registration

UMBRELLA REVIEW REGISTRATION: PROSPERO (CRD42020145315).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03007-5.

A physiotherapy-led transition to home intervention for older adults following emergency department discharge: protocol for a pilot feasibility randomised controlled trial

Background

Older adults frequently attend the emergency department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. This paper reports a protocol designed to evaluate the feasibility of conducting a three arm randomised controlled trial (RCT) within the ED setting and in the patient’s home. The interventions are comprehensive geriatric assessment (CGA), ED PLUS and usual care.

Methods

The ED PLUS pilot trial is designed as a feasibility RCT conducted in the ED and Acute Medical Assessment Unit of a university teaching hospital in the mid-west region of Ireland. We aim to recruit 30 patients, aged 65 years and over presenting to the ED with undifferentiated medical complaints and discharged within 72 h of index visit.

Patients will be randomised by a computer in a ratio of 1:1:1 to deliver usual care, CGA or ED PLUS during a 6-month study period. A randomised algorithm is used to perform randomization. CGA will include a medical assessment, medication review, nursing assessment, falls assessment, assessment of mobility and stairs, transfers, personal care, activities of daily living (ADLs), social supports and baseline cognition. ED PLUS, a physiotherapist led, multidisciplinary intervention, aims to bridge the transition of care between the index visit to the ED and the community by initiating a CGA intervention in the ED and implementing a 6-week follow-up self-management programme in the patient’s own home following discharge from the ED. The outcomes will be parameters of the feasibility of the intervention and trial methods and will be assessed quantitatively and qualitatively.

Discussion

Rising ED visits and an ageing population with chronic health issues render ED interventions to reduce adverse outcomes in older adults a research priority. This feasibility RCT will generate data and experience to inform the conduct and delivery of a definite RCT.

Trial registration

The trial was registered in Clinical Trials Protocols and Results System as of 21^st July 2021, with registration number NCT049836020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00954-5.

Root causes and preventability of emergency department presentations of older patients: a prospective observational study

OBJECTIVE

More older patients are presenting to the emergency department (ED). It is important to know why these patients present and if the ED is the best place for them to receive the care they need. The primary aim of this study was to identify organisational-related, technical-related, healthcare worker-related and patient-related factors leading to ED presentations of older patients. The secondary aim was to determine patients' and caregivers' perspectives on what kinds of ED presentations are potentially preventable.

DESIGN

This is a prospective observational study. A root cause analysis was performed by the Prevention and Recovery Information System for Monitoring and Analysis method. It used basic administrative data collected from patient records and interviews of patients, general practitioners (GPs) and physicians at the ED.

SETTING

The ED of an academic hospital in the Netherlands.

PARTICIPANTS

100 older patients (aged ≥70 years) who attended the ED between November 2017 and March 2018.

RESULTS

In 100 patients presenting to the ED, 159 factors that contributed to presentation were identified; most of these factors were related to underlying diseases (59%) and patient-related factors (18%). These presentations were considered potentially preventable by 23% of the physicians at the ED and 21% of the GPs, but only 10% of the patients. In only four cases was there overall agreement between the patients and the healthcare workers.

CONCLUSION

The most frequent underlying factors contributing to an ED presentation in older patients are disease-related and patient-related. The low percentage of ED presentations considered potentially preventable shows that a 'preventable ED presentation' is difficult to define and therefore interventions to reduce them are unlikely to be simple. Novel solutions within the acute care pathway are required in order to deliver care of optimal quality and safety to older patients.

Frailty screening of Tunisian older adults: feasibility and usefulness in the Emergency Department

Introduction

Frail older adults are at an increased risk for adverse outcomes after an Emergency Department (ED) visit. Several tools exist for the screening of frailty among these patients. However, no tool has been validated in Tunisia. This study aims to evaluate the usefulness of frailty screening in predicting the outcome of older adults presenting to the ED.

Methods

This is a prospective, monocentric study. We evaluated the eligible patients at the ED and after their discharge. Follow-up phone calls were scheduled at 1, 2, 3, and 6 months after the ED visit. All patients aged 65 years or older; and visiting the ED during the inclusion period were involved. We used the ADL index and ISAR scale for assessing frailty.

Results

We enrolled 184 patients; they were living alone in 25% of cases. Half of them had medical care insurance. The ADL index was maximum (6 = total dependency) in 20% of cases. The ISAR score was above 1 point in 38%. Unplanned hospitalizations have accounted for 34%. In univariate analysis, the ADL index and ISAR score were statistically higher in the group of “unplanned hospitalization”. In multivariate analysis, the ISAR score and ADL index have not been associated with unplanned hospitalization.

Conclusion

Our results did not demonstrate the relevance of the ISAR or ADL scales in predicting the mortality or the need for unplanned hospitalization in multivariate analysis. This study did indicate an increased mortality in the “frail” patients in the univariate analysis. Further studies with larger samples and different tools are necessary.

Improving outcomes for older people in the emergency department: a review of reviews

Background

There has been a recognised trend of increasing use of emergency and urgent care and emergency departments (EDs) by older people, which is marked by a substantial evidence base reporting interventions for this population and guidance from key organisations. Despite this, outcomes for this population remain suboptimal. A plethora of reviews in this area provides challenges for clinicians and commissioners in determining which interventions and models of care best meet people’s needs. The aim of this review was to identify effective ED interventions which have been reported for older people, and to provide a clear summary of the myriad reviews and numerous intervention types in this area.

Methods

A review of reviews, reporting interventions for older people, either initiated or wholly delivered within the ED.

Results

A total of 15 review articles describing 83 primary studies met our content and reporting standards criteria. The majority (n=13) were systematic reviews (four using meta-analysis.) Across the reviews, 26 different outcomes were reported with inconsistency. Follow-up duration varied within and across the reviews. Based on how authors had reported results, evidence clusters were developed: (1) staff-focused reviews, (2) discharge intervention reviews, (3) population-focused reviews and (4) intervention component reviews.

Conclusions

The evidence base describing interventions is weak due to inconsistent reporting, differing emphasis placed on the key characteristics of primary studies (staff, location and outcome) by review authors and varying quality of reviews. No individual interventions have been found to be more promising, but interventions initiated in the ED and continued into other settings have tended to result in more favourable patient and health service outcomes. Despite many interventions reported within the reviews being holistic and patient focused, outcomes measured were largely service focused.

PROSPERO registration number

PROSPERO CRD42018111461.

Does health and social care provision for the community dwelling older population help to reduce unplanned secondary care, support timely discharge and improve patient well-being? A mixed method meta-review of systematic reviews

Background: This study aimed to identify and examine systematic review evidence of health and social care interventions for the community-dwelling older population regarding unplanned hospital admissions, timely hospital discharge and patient well-being. Methods: A meta-review was conducted using Joanna Briggs and PRISMA guidance. A search strategy was developed: eight bibliographic medical and social science databases were searched, and references of included studies checked. Searches were restricted to OECD countries and to systematic reviews published between January 2013-March 2018. Data extraction and quality appraisal was undertaken by one reviewer with a random sample screened independently by two others. Results: Searches retrieved 21,233 records; using data mining techniques, we identified 8,720 reviews. Following title and abstract and full-paper screening, 71 systematic reviews were included: 62 quantitative, seven qualitative and two mixed methods reviews. There were 52 reviews concerned with healthcare interventions and 19 reviews concerned with social care interventions. This meta-review summarises the evidence and evidence gaps of nine broad types of health and social care interventions. It scrutinises the presence of research in combined health and social care provision, finding it lacking in both definition and detail given. This meta-review debates the overlap of some of the person-centred support provided by community health and social care provision. Research recommendations have been generated by this process for both primary and secondary research. Finally, it proposes that research recommendations can be delivered on an ongoing basis if meta-reviews are conducted as living systematic reviews. Conclusions: This meta-review provides evidence of the effect of health and social care interventions for the community-dwelling older population and identification of evidence gaps. It highlights the lack of evidence for combined health and social care interventions and for the impact of social care interventions on health care outcomes. Registration: PROSPERO ID CRD42018087534; registered on 15 March 2018.

Improving care for older adults in the Emergency Department warrants greater investment in geriatric nursing-Stat!

Older adults use the Emergency Department (ED) more than any other age group besides infants. Despite high utilization, both the physical environment and care processes in the traditional ED are poorly suited to address the complex needs of older adults. As a result, older adults often experience poor outcomes in the ED. Geriatric nursing has been at the forefront of efforts to develop Geriatric Emergency Department Interventions (GEDI's) to try to address these deficits and improve care. As frontline providers with frequent patient contact, nursing brings critical viewpoints to these issues. This article provides some resources and other ideas for how frontline nurses can improve care for older adults in the ED. Ultimately, to have meaningful impacts on care of older adults in the ED, there is a dire need for greater financial investment specific to geriatric nursing education, training, and research in the ED.

Clinical impact of a comprehensive nurse-led discharge intervention on patients being discharged home from an acute medical unit: Randomised controlled trial

BACKGROUND

Acute medical units have increasingly been implemented in modern healthcare to ensure a fast track for treatment and care, thus increasing the number of patients being discharged. To avoid early readmissions, new approaches to discharging patients from these settings are needed.

OBJECTIVE

To investigate the clinical impact of a comprehensive nurse-led discharge intervention on patients being discharged home from an acute medical unit.

OUTCOMES

The primary outcome was 30-days hospital readmission. Secondary outcomes were utilisation of healthcare, including contacting emergency departments, the general practitioner or after-hours physicians; patient experience; and health-related quality of life.

DESIGN

This study was a non-blinded randomised clinical controlled trial with a 1 year enrolment period from November 2014 to 2015. Group assignment was performed by computer generated codes.

SETTING

The setting was a 34-bed acute medical unit at a Danish University Hospital.

PARTICIPANTS

Non-surgical patients aged 18+ with more than one contact to hospitals during the last 12 months were eligible for inclusion. Furthermore, patients had to have been discharged home and had a follow-up appointment after discharge.

METHODS

The intervention consisted of (1) an assessment of the patient's overall situation, (2) an assessment of their comprehension of discharge recommendations, (3) a simple discharge letter targeting the individual patient's health literacy and (4) a follow-up telephone call 2 days post-discharge. The study was carried out by a research nurse and the 1st author. Data was collected from medical records, registers and questionnaires. Intention-to-treat and per protocol analysis were performed.

RESULTS

In all, 200 participants were enrolled (101 intervention; 99 control). Of these, 17 were excluded due to transfer to another hospital department and 4 did not receive the full intervention, resulting in 86 in the intervention group and 93 in the control group. At 30 days post-discharge, 22/101 (22%) in the intervention group had at least one readmission vs. 19/99 (19%) in the control group. The total number of all-cause readmissions in the follow-up period was 0.28 (SD: 0.67) in the intervention group vs. 0.26 (SD: 0.63) in the control group. There were no statistically significant differences in baseline characteristics or any of the primary and secondary outcomes.

CONCLUSION

A comprehensive nurse-led discharge model focusing on the individual patient's situation and needs was not capable of reducing readmissions and healthcare utilisation. No statistically significant effects on quality of life or patients' experiences of the discharge from the acute medical unit were observed.

Geriatric Education Programs for Emergency Department Professionals: A Systematic Review

OBJECTIVES

To evaluate geriatric education programs for emergency department (ED) professionals based on: content and teaching methods and learning outcome effects and factors promoting or hindering program implementation.

DESIGN

Systematic review.

SETTING

ED.

PARTICIPANTS

Physicians, nurses, and medical residents working in the ED.

METHODS AND MEASUREMENT

Five major biomedical databases were searched for (quasi) experimental studies, published between 1990 and April 2018, evaluating geriatric education programs for ED professionals. Data were synthesized around study quality, learning participants, teaching content and methods, and Kirkpatrick learning outcomes.

RESULTS

Nine before‐after studies were included. Learners were mostly ED residents and, to a smaller extent, ED nurses and physicians. Study quality was moderate, with the lowest scores on sampling and instrument validity. Programs varied from a 1‐day workshop to a 2‐year curriculum, mostly combining didactic lectures with active and experiential learning formats. Topics commonly addressed included managing: geriatric syndromes, trauma and falls, medication, atypical presentations, and care transitions. Statistically significant improvements were mostly found in learners' knowledge acquisition (six studies). Significant improvements were also found in single studies on: self‐reported geriatric screening, documentation of geriatric care, and appropriate urinary catheter placement. Factors promoting program implementation included: solving competing educational demands and busy work schedules, embedding the program in preexisting curricula, and close collaboration between emergency and geriatric medicine faculties.

CONCLUSIONS

Various geriatric education programs improve the geriatric knowledge of ED professionals and seem to positively impact their clinical practice. However, more program evaluations with larger study samples, and use of valid and reliable outcome measures, are needed to provide robust evidence on the effectiveness of such programs. J Am Geriatr Soc, 1–8, 2019. J Am Geriatr Soc 67:2402–2409, 2019

Interventions to Promote Early Discharge and Avoid Inappropriate Hospital (Re)Admission: A Systematic Review

Increasing pressure on limited healthcare resources has necessitated the development of measures promoting early discharge and avoiding inappropriate hospital (re)admission. This systematic review examines the evidence for interventions in acute hospitals including (i) hospital-patient discharge to home, community services or other settings, (ii) hospital discharge to another care setting, and (iii) reduction or prevention of inappropriate hospital (re)admissions. Academic electronic databases were searched from 2005 to 2018. In total, ninety-four eligible papers were included. Interventions were categorized into: (1) pre-discharge exclusively delivered in the acute care hospital, (2) pre- and post-discharge delivered by acute care hospital, (3) post-discharge delivered at home and (4) delivered only in a post-acute facility. Mixed results were found regarding the effectiveness of many types of interventions. Interventions exclusively delivered in the acute hospital pre-discharge and those involving education were most common but their effectiveness was limited in avoiding (re)admission. Successful pre- and post-discharge interventions focused on multidisciplinary approaches. Post-discharge interventions exclusively delivered at home reduced hospital stay and contributed to patient satisfaction. Existing systematic reviews on tele-health and long-term care interventions suggest insufficient evidence for admission avoidance. The most effective interventions to avoid inappropriate re-admission to hospital and promote early discharge included integrated systems between hospital and the community care, multidisciplinary service provision, individualization of services, discharge planning initiated in hospital and specialist follow-up.