Abstract
BackgroundOlder people who present to the Emergency Department (ED) experience high rates of prevalent and incident delirium. This study aimed to determine whether an assistant workforce in the ED could effectively conduct screening to inform assessment and care planning for older people as well as enhance supportive care activities for prevention of delirium.MethodsUsing a pre-post design, data was collected before and after the introduction of Older Person Technical Assistants (OPTAs) in the ED. OPTA activity was recorded during the intervention period and a medical record audit undertaken prior to and 9 months after implementation.Data were analysed using descriptive statistics for OPTA activities. Weighted Kappa scores were calculated comparing concordance in screening scores between OPTAs and Aged Services Emergency Team Registered Nurses. Changes in the rates of documented screening and supportive care were analysed using Chi-square tests.Focus groups were conducted to explore clinicians’ experiences of the OPTA role.ResultsThree thousand five hundred fourty two people were seen by OPTAs in 4563 ED Presentations between 1st July 2011 and 2012. The reproducibility of all screening tools were found to be high between the OPTAs and the RNs, with Kappas and ICCs generally all above 0.9.The medical record audit showed significant improvement in the rates of documented screening, including cognition from 1.5 to 38% (p < 0.001) and review of pain from 29 to 75% (p < 0.001). Supportive care such as being given fluids or food also improved from 13 to 49% (p < 0.001) and pressure care from 4.8 to 30% (p < 0.001). This was accomplished with no increase in ED length of stay among this age group.Focus group interviews described mixed responses and support for the OPTA role.ConclusionsAn assistant workforce in an ED setting was found to provide comparable screening results and improve the rates of documented screening and supportive care provided to older people with or at risk of developing delirium in the ED. There is a need for a shared philosophy to the care of older people in the ED.Trial registrationAustralian New Zealand Clinical Trials Registration number is ACTRN12617000742370. It was retrospectively registered on 22nd May 2017.
Highlights
Older people who present to the Emergency Department (ED) experience high rates of prevalent and incident delirium
This paper reports on the introduction of an aged care assistant workforce in a tertiary referral hospital ED in New South Wales (NSW), Australia
Older Person Technical Assistant (OPTA) saw 3542 people who presented to the ED on a total of 4563 occasions, as some patients had more than one ED visit over the 12 months
Summary
This study aimed to determine whether an assistant workforce in the ED could effectively conduct screening to inform assessment and care planning for older people as well as enhance supportive care activities for prevention of delirium. The use of a non-professional workforce to screen and provide supportive care for delirium management and prevention as well as facilitate access to comprehensive geriatric assessment for older people who present to the ED has not previously been examined. Delirium is associated with poorer hospital outcomes including increased length of stay, falls risk, pressure injuries and functional decline. This can lead to older people requiring admission to nursing homes, as well as premature death [12,13,14,15]. Prevention of delirium along with effective management when it occurs, improves health outcomes [19, 20] as well as cost effectiveness [21]
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