31 Identifying and Responding to Elder Mistreatment in the Emergency Department: Results from a Multi-Site Feasibility Study

Abstract

Elder mistreatment (EM) is a prevalent problem in the US that has devastating consequences for victims’ health and quality of life and additional costs for families, health care systems, and social services systems. Emergency departments (ED) disproportionately care for older persons with known risk factors for EM and are well positioned to identify and address EM. However, ED systems issues such as staff overload and lack of EM-focused training, screening and response protocols, have prevented widespread adoption of best practices that would increase identification of and appropriate intervention for older adults experiencing or at risk for EM. The National Collaboratory to Address Elder Mistreatment designed an integrated Elder Mistreatment Emergency Department Toolkit (the Toolkit) to help ED staff identify and respond to suspicion of or risk for EM. The Toolkit uses a two-stage screening approach (brief then triggered) and a structured response which was implemented in EDs within five US hospitals. In order to better understand factors influencing implementation of the toolkit, a feasibility study was conducted to answer three research questions: 1. Is the Toolkit feasible to implement in the ED? 2. Are EDs better able to identify and manage cases of elder mistreatment when they implement the Toolkit? 3. How does implementation of the Toolkit affect other aspects of ED operations? To answer these questions, this study utilized a mixed-methods approach. Quantitative data included staff’s baseline and follow-up assessments of ED practices related to EM; staff changes in knowledge before and after participation in training about screening for and responding to suspected cases of EM; aggregated hospital-level data on indicators of ED functioning; and patient-level data on screening rates and EM risk factors. ED staff provided rich qualitative information on the extent to which the Toolkit achieved seven feasibility criteria: practicality, acceptability, utility, implementation, integration, adaptability, and initial efficacy. We present preliminary findings organized by evaluation question. Staff training resulted in significant increases (p < 0.05) in knowledge and efficacy. Staff at all sites were receptive to the two-stage screening approach and found tools easy to use. The Toolkit was implemented differently in terms of which ED staff conducted the two-staged screening (ie, triage nurse, bedside nurse, social work). The proportion of patients screened at each site varied widely (18% to 87%), but screening rates increased over time at all sites. Of the older adults who were brief screened (n=15, 710), 1% screened positive in the brief screening stage and were then screened intensively using the triggered screen. Of these, 32% (n=42) were designated as suspected cases of elder mistreatment. An elder mistreatment screening and response toolkit may be successfully implemented in EDs. Training led to increases in staff knowledge about EM following training. Rates of screening increased, and ED providers found the toolkit useful. We found variations between EDs in how the toolkit was adapted, deployed, and integrated into ED workflow.