Undertaking a Collaborative Rapid Realist Review to Investigate What Works in the Successful Implementation of a Frail Older Person's Pathway.

Éidín Ní Shé,Eilish Mcauliffe,Diarmuid O’Shea,Fiona Keogan,Mary Mccarthy,Rosa Mcnamara,Marie Cooney

doi:10.3390/ijerph15020199

Abstract

We addressed the research question “what factors enable the successful development and implementation of a frail older person’s pathway within the acute setting”. A rapid realist review (RRR) was conducted by adopting the RAMESES standards. We began with a sample of 232 articles via database searches supplemented with 94 additional records including inputs from a twitter chat and a hospital site visit. Our final sample consisted of 18 documents. Following review and consensus by an expert panel we identified a conceptual model of context-mechanism-(resources)-outcomes. There was overall agreement frailty should be identified at the front door of the acute hospital. Significant challenges identified related to organisational boundaries both within the acute setting and externally, the need to shift outcomes to patient orientated ones, to support staff to sustain the pathway by providing ongoing education and by providing role clarity. RRRs can support research such as the systematic approach to improving care for frail older adults (SAFE) study by producing accounts of what works based on a wide range of sources and innovative engagement with stakeholders. It is evident from our provisional model that numerous factors need to combine and interact to enable and sustain a successful frail older person’s pathway.

Highlights

Frail older people are vulnerable due to their loss of physiologic reserve across multiple organ systems, and can experience disproportionate loss of functional ability even when hospitalised for a relatively minor illness [1,2,3]
Five systematic/scoping reviews: This included a review of the effectiveness of ED and community transitions [6], review of interventions of comprehensive geriatric assessments in the ED [7] scoping of the structure and process for geriatric multidisciplinary teams [22], the feasibility of identifying frailty in the ED [3] and a systematic review on the feasibility and implementation of frailty identification tools within the emergency department [23]
Two editorials/summary pieces: An overview of new horizons of urgent care of frail older people [2] and on what works within emergency care for frail older people [26]

Summary

Introduction

Frail older people are vulnerable due to their loss of physiologic reserve across multiple organ systems, and can experience disproportionate loss of functional ability even when hospitalised for a relatively minor illness [1,2,3]. The literature suggests the best approach to prevent functional loss amongst older adults is to provide a comprehensive multidisciplinary integrated response [6]. For the majority of older persons in Ireland, the emergency department (ED) is the ‘front door’ of entry to acute care. A recent Department of Health special delivery unit report demonstrated that people aged over 65 year’s account for over one-third of ED attendances [7]. Res. Public Health 2018, 15, 199; doi:10.3390/ijerph15020199 www.mdpi.com/journal/ijerph

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