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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.

Dedicated Health and Social Care Professional (HSCP) teams have been proposed for emergency departments (EDs) in an effort to improve patient and process outcomes. This systematic review synthesises the totality of evidence relating to the impact of early assessment and intervention by HSCP teams on quality, safety and effectiveness of care in the ED. A systematic literature search was conducted in April 2019 to identify experimental studies examining the effectiveness of ED-based HSCP teams providing services to adults aged ≥ 18 years old and including two or more of the following disciplines: occupational therapist, physiotherapist, medical social worker, clinical pharmacist, or speech and language therapist. Data extraction and quality appraisal of each study were conducted independently by two reviewers. Six studies were included in the review (n = 273,886), all describing interdisciplinary Care Coordination Teams (CCTs) caring for adults aged ≥ 65 years old. CCT care was associated with on average 2% reduced rates of hospital admissions (three studies), improved referrals to community services for falls (one study), increased satisfaction (two studies) with the safety of discharge (patients and staff), and with the distribution of workload (staff), improved health-related quality of care (one study). No statistically significant differences between intervention and control groups emerged in terms of rates of ED re-visits, ranging between 0.2% and 3% (two studies); hospital length of stay (one hour difference noted in one study) or mortality rates (0.5% difference in one study). Increased rates of unplanned hospitalisations following the intervention (13.9% difference) were reported in one study. The methodological quality of the studies was mixed. We found limited and heterogeneous evidence on the impact of HSCP teams in the ED, suggesting a reduction in hospital admissions as well as improved patient and staff satisfaction. More robust investigations including cost-effectiveness evaluations are needed.

There is encouraging evidence that interdisciplinary teams of Health and Social Care Professionals (HSCPs) can enhance patient care in the Emergency Department (ED), especially for older adults with complex needs. However, no formal process evaluations of implementations of ED-based HSCP interventions are available. The study aimed to evaluate the development and delivery of a HSCP team intervention for older adults in the ED of a large Irish teaching hospital. Using the Medical Research Council (MRC) Framework for process evaluations, we investigated implementation and delivery, mechanisms of impact, and contextual influences on implementation by analysing the HSCP team's activity notes and participant recruitment logs, and by carrying out six interviews and four focus groups with 26 participants (HSCP team members, ED doctors and nurses, hospital staff). Qualitative insights were analysed thematically. The implementation process had three phases (pre-implementation, piloting, and delivery), with the first two described as pivotal to optimise care procedures and build positive stakeholders' involvement. The team's motivation and proactive communication were key to promote acceptability and integration in the ED (Theme 1); also, their specialised skills and interdisciplinary approach enhanced patient and staff's ED experience (Theme 2). The investment and collaboration of multiple stakeholders were described as essential contextual enablers of implementation (Theme 4). Delivering the intervention within a randomised controlled trial fostered credibility but caused frustration among patients and staff (Theme 3). This process evaluation is the first to provide in-depth and practical insights on the complexities of developing and delivering an ED-based HSCP team intervention for older adults. Our findings highlight the importance of establishing a team of HSCPs with a strong interdisciplinary ethos to ensure buy-in and integration in the ED processes. Also, actively involving relevant stakeholders is key to facilitate implementation. ClinicalTrials.gov, NCT03739515; registered on 12th November 2018.

Correspondence to Dr Rosa McNamara, Emergency Department, St Vincent's University Hospital, Dublin, Ireland; rosamncamara@svhg.ie Emergency medicine (EM) is the front door for people in crisis and this remains true for those of all ages and for crises that are medical, psychological and social. Training in palliative care for EM has in the past been limited; while most clinical staff are well versed in how to manage death following sudden catastrophic events such as cardiac arrest or trauma, there is less focus on managing patients who have chronic illness with limited life expectancy who present in crisis. [...]goals-of-care conversations rather than simplistic binary decisions about resuscitation status should be normalised throughout the health system including the ED.

’Seek ye counsel of the aged for their eyes have looked on the faces of the years and their ears have hardened to the voices of life. Even if their counsel is displeasing to you, pay heed to them.’ —Khalil Gibran. We are at a turning point in emergency medicine. The last few years of the global health crisis have added to a system that was already under strain. Many of our departments are overwhelmed and our staff burned out. Ironically, some of this burnout can be attributed to the stress of not being able to deliver the quality care that we know our patients deserve. The things that older people in this paper wanted should be available to everyone in the ED—a calm quiet environment, needs for privacy, comfort and food and drink met, reasonable waiting times and communication about the plan of care. To do this we know will require adequate staffing of our EDs and adequate capacity in our hospitals and community health services to transitional care when the ED encounter is complete. Integration of emergency care into older adults’ care networks coupled with well-supported pathways back to community-based care are likely to be key.

Background Older people are frequent emergency department (ED) users who present with complex issues that are linked to poorer health outcomes following the index visit, often have increased ED length of stay, and tend to have raised healthcare costs. Encouraging evidence suggests that ED teams involving health and social care professionals (HSCPs) can contribute to enhanced patient flow and an improved patient experience by improving care decision-making and thus promoting timely and effective care. However, the evidence supporting the impact of HSCP teams assessing and intervening with older adults in the ED is limited and identifies important methodological limitations, highlighting the need for more robust and comprehensive investigations of this model of care. This study aims to evaluate the impact of a dedicated ED-based HSCP team on the quality, safety, and clinical- and cost-effectiveness of care of older adults when compared with usual care. Methods The study is a single-site randomised controlled trial whereby patients aged ≥65 years who present to the ED of a large Irish hospital will be randomised to the experimental group (ED-based HSCP assessment and intervention) or the control group (usual ED care). The recruitment target is 320 participants. The HSCP team will provide a comprehensive functional assessment as well as interventions to promote a safe discharge for the patient. The primary outcome is ED length of stay (from arrival to discharge). Secondary outcomes include: rates of hospital admissions from the ED, ED re-visits, unplanned hospital admissions and healthcare utilisation at 30 days, and 4 and 6 months of follow-up; patient functional status and quality of life (at baseline and follow-up); patient satisfaction; cost-effectiveness in terms of costs associated with ED-based HSCP compared with usual care; and perceptions on implementation by ED staff members. Discussion This is the first randomised controlled trial testing the impact of HSCPs working in teams in the ED on the quality, safety, and clinical- and cost-effectiveness of care for older patients. The findings of this study will provide important information on the effectiveness of this model of care for future implementation. Trial registration ClinicalTrials.gov, NCT03739515 . Registered on 12 November 2018.

The EDITH (Emergency Department in the Home) service provides an alternative to Emergency Department attendance for the older adult by providing emergency care in the person’s home. This includes both medical and occupational therapy assessment with a focus on admission avoidance, implementing alternative care pathways and supporting patients to live at home. Currently there is an inpatient Delirium Pathway for the acute hospital setting, however there is no counterpart for the pre hospital setting. Therefore, a decision was made to develop a specific pathway for the EDITH service; a Delirium Pathway for pre hospital care. The Delirium Pathway was developed following a focus group within the OT team. Key areas for assessment and consideration were identified. National and international guidelines regarding delirium management were reviewed and informed the development of the Delirium Pathway. Due to the unique nature of the pre hospital service, it was imperative that the pathway consisted of both medical and non-medical interventions of delirium such as; home environment optimisation, family/care giver education including therapeutic use of activity and functional engagement.  The Delirium Pathway is based on current research and both national and internal guidelines such as Dementia and Delirium guidelines (NICE 2010, SIGN 2018.) The Delirium Pathway was benchmarked against similar pathways within acute and community settings, and subsequently adapted to suit the needs of the EDITH patient cohort and home environment. Clinical guidance was sought from emergency department consultant with interest in geriatric medicine. Input was also gained from stakeholders such as advanced nurse practitioner, registrars and OT colleagues. Trial use of the pathway was completed over a two month period.  Feedback was sought from stakeholders and necessary amendments to the Delirium Pathway were made. The pathway was then officially rolled out alongside education sessions on the utilisation of same. This project has resulted in the development of a bespoke Delirium Pathway for pre hospital care which provides guidance and support to clinicians and family. Utilisation of the Delirium Pathway has enabled patients with a delirium to be managed within the home environment. This is a move towards alternative care pathways as traditionally these patients would have warranted a hospital admission.  Key areas captured within the pathway include; assessment for delirium, use of 4AT screening tool, investigations for cause, management plan incorporating both pharmacological and non-pharmacological management, follow up and onward referrals. A planned audit will provide an opportunity to explore improved perceived outcomes for patients and their families experiencing delirium by supporting them to safely manage delirium in the home environment. The development and implementation of the Delirium Pathway encourages better long term outcomes if the delirious patient is safe to be managed at home. Thus, in line with the ethos of the EDITH service, shifting the assessment and management from the hospital to home environment.  

Older people living with frailty are frequent users of emergency care and have multiple and complex problems. Typical evidence-based guidelines and protocols provide guidance for the management of single and simple acute issues. Meanwhile, person-centred care orientates interventions around the perspectives of the individual. Using a case vignette, we illustrate the potential pitfalls of applying exclusively either evidence-based or person-centred care in isolation, as this may trigger inappropriate clinical processes or place undue onus on patients and families. We instead advocate for delivering a combined evidence-based, person-centred approach to healthcare which considers the person’s situation and values, apparent problem and available options.

Background There is some evidence that health and social care professional (HSCP) teams contribute to enhanced patient and process outcomes in increasingly crowded emergency departments (EDs), but the views of service users and providers on this model of care need investigation to optimize implementation. Objective This qualitative study investigated the perspectives of key ED stakeholders about HSCP teams working in the ED. Methods Using a participatory design, we conducted World Café focus groups and individual interviews in two Irish hospital sites with 65 participants (purposive sampling) including ED patients and carers/relatives, ED doctors and nurses, HSCPs and pre‐hospital staff. Data were thematically analysed using NVivo software. Results Participants reported that ED‐based HSCP teams could improve quality and integration of care and staff experience (Theme 1) and would be appropriate for older adults with complex needs and non‐urgent complaints (Theme 2). Concerns were raised about operational and relational barriers to implementation (Theme 3), and changes in processes and culture were considered necessary for HSCPs to work successfully in the ED (Theme 4). In contrast to service providers, service users’ concerns centred on the importance of positive communication and relations (Theme 5). Conclusions Our study indicates potential acceptability of HSCP teams working in the ED, especially to care for older adults; however, operational and relational aspects, particularly developing interdisciplinary and integrated care, need addressing to ensure successful implementation. Differences in priorities between service users and providers (relational vs operational) highlighted the usefulness of gathering views from multiple stakeholders to understand ED processes.