Study protocol for IMAGE: implementing multidisciplinary assessments for geriatric patients in an emergency department observation unit, a hybrid effectiveness/implementation study using the Consolidated Framework for Implementation Research

Abstract

Background: Older adults in the emergency department (ED) are at high risk for functional decline, unrecognized delirium, falls, and medication interactions. Holistic assessment by a multidisciplinary team in the ED decreases these adverse outcomes and decreases admissions, but there are many barriers to incorporating this type of care during the ED visit. Methods: This is a hybrid type II effectiveness-implementation study using a pre-/post-cohort design (n = 380) at a tertiary care academic ED with an ED observation unit (Obs Unit). The intervention is a two-step protocol of (step 1) ED nurses screening adult patients ≥ 65 years old for geriatric needs using the Delirium Triage Screen, 4-Stage Balance Test, and the Identifying Seniors at Risk score. Patients who have geriatric needs identified by this screening but who do not meet hospital admission criteria will (step 2) be placed in the Obs Unit for multidisciplinary geriatric assessment by the hospital's geriatric consultation team, physical therapists, occupational therapists, pharmacists, and/or case managers. Not all patients may require all elements of the multidisciplinary geriatric assessment. The Consolidated Framework for Implementation Research: Care Transitions Framework was used to identify barriers to implementation. Lean Six Sigma processes will be used to overcome these identified barriers with the goal of achieving geriatric screening rates of > 80%. Implementation success and associated factors will be reported. For the effectiveness aim, pre-/post-cohorts of adults ≥ 65 years old cared for in the Obs Unit will be followed for 90 days postED visit (n = 150 pre and 230 post). The primary outcome is the prevention of functional decline. Secondary outcomes include health-related quality of life, new geriatric syndromes identified, new services provided, and Obs Unit metrics such as length of stay and admission rates.

An implementation science approach to geriatric screening in an emergency department

“…A cross‐sectional survey based on CFIR was conducted as part of a larger ongoing effectiveness‐implementation hybrid study of geriatric screening in the ED 15 . The survey was approved both by the Institutional Review Board and the nurses' union.…”

Frailty Network in an Acute Care Setting: The New Perspective for Frail Older People

“…Recent studies show that a geriatric assessment carried out in the emergency department can lead, when possible, to direct discharge from the emergency department, but also to a reduction of the length of stay in case of hospitalization [21]. Other studies are ongoing to better understand how to improve the quality of Emergency Department care for older adults in the acute care setting [22,23].…”

Leveraging the Electronic Health Record to Implement Emergency Department Delirium Screening

“…11,12 Optimizing information technology systems to support clinicians in performing geriatric screenings is an important consideration for their successful implementation. 11,13,14 Uptake of evidence-based guidelines for ED delirium screening has been limited. 15,16 This is in part due to the complexities of implementation, such as determining appropriate time points for screening, which personnel should be involved, and incorporating tools into existing workflow.…”