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.

Marica Cassarino,Dominic Trépel,Stephen White,Íde O’Shaughnessy,Fiona Steed,Eimear Smalle,Rosie Quinn,Collette Devlin,Gerard Mccarthy,Fiona Boland,Andrew O’Regan,Marie E Ward,Katie Robinson,Rosa Mcnamara,Damien Ryan,Margaret O’Connor,Rose Galvin,Stephanie A Eucker

doi:10.1371/journal.pmed.1003711

Abstract

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. 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. 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. ClinicalTrials.gov NCT03739515; registered on 12 November 2018.

Highlights

Emergency departments (EDs) face significant challenges in delivering highquality and timely patient care set against a background of increasing patient numbers and limited hospital resources [1,2]
A recent systematic review [16] indicated that care coordination teams of health and social care professionals (HSCPs), which provide early assessment and intervention to older adults in the emergency departments (EDs) can lead to safer discharges and increase patient and staff satisfaction; the quality of the evidence is mixed, primarily due to weaknesses in study designs and heterogeneity of patient groups and outcomes of interest
ED stakeholders have reported positive perceptions of HSCPs working in the ED, in particular the added value of having HSCPs with specialised skills working in an interdisciplinary manner to provide timely care to older adults, while at the same time reducing the workload of the ED medical staff [17,18]

Summary

Introduction

Emergency departments (EDs) face significant challenges in delivering highquality and timely patient care set against a background of increasing patient numbers and limited hospital resources [1,2]. ED stakeholders have reported positive perceptions of HSCPs working in the ED, in particular the added value of having HSCPs with specialised skills working in an interdisciplinary manner to provide timely care to older adults, while at the same time reducing the workload of the ED medical staff [17,18]. This evidence suggests that ED-based HSCP teams could be a viable and effective solution to improve the flow and outcomes of ED patients, those who might benefit the most from interdisciplinary holistic assessment [19]. No robust investigations of the effectiveness of this model of care have been carried out to date [16]

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Conclusion