The Geriatric Emergency Department Intervention model of care: a pragmatic trial

Abstract

BackgroundTo evaluate a Geriatric Emergency Department Intervention (GEDI) model of service delivery for adults aged 70 years and older.MethodsA pragmatic trial of the GEDI model using a pre-post design. GEDI is a nurse-led, physician-championed, Emergency Department (ED) intervention; developed to improve the care of frail older adults in the ED. The nurses had gerontology experience and education and provided targeted geriatric assessment and streamlining of care. The final format included 2.4 full time equivalent nurses working 7 days from 0700 h to 1730 h (1530 h at weekends). There were three implementations periods: pre-implementation (2012); a developmental phase from January 2013 to August 2015; and full implementation from September 2015 to August 2016. The outcomes measured were disposition (discharged home, admitted or died); ED length of stay; hospital length of stay; all cause in-hospital mortality within 28 days; time to ED re-presentation up to 28 days post-discharge; in-hospital costs.The setting was a tertiary hospital ED, with 385 beds, in Queensland, Australia. Approximately 53,000 patients presented to the ED annually with 20% aged 70 years and older. All patients over the age 70 who presented to the ED between January 2012 and August 2016 (n = 44,983) were included in the trial.ResultsOlder persons who presented to the ED when the GEDI team were working had increased likelihoods of discharge (Hazard ratio (HR) = 1.19; 95% CI: 1.13–1.24) and reduced ED length of stay (HR = 1.42; 95% CI: 1.33–1.52) compared with those who presented when GEDI were not working. There was no increase in the risk of mortality (HR = 1.01; 95% CI = 0.23–4.43) or risk of same cause re-presentation to 28 days (HR = 1.21; 95% CI: 0.99–1.49). The GEDI service resulted in average cost savings per ED presentation of $35 [95% CI, $21, $49] and savings of $1469 [95% CI, $1105, $1834] per hospital admission.ConclusionsImplementation of a nurse-led physician-championed model of ED care, focused on frail older adults, reduced ED length of stay, hospital admission and if admitted, hospital length of stay and cost, without increasing mortality or same cause re-presentation. These increases were sustained over time and after the initial implementation team had changed roles.Trial registrationAustralian Clinical Trials Registration Number ACTRN12615001157561 - retrospectively registered on 29/10/2015. Data were retrieved via retrospective access to clinical information systems. First data access was on 1/7/2015.

Emergency Department Interventions for Older Adults: A Systematic Review

“…The field of geriatric emergency medicine continues to evolve rapidly. For instance, between the conclusion of our search and the peer review process of this article, an array of studies were published including a review of self‐defined geriatric EDs, a nurse transition intervention, and a pragmatic trial of an Australian‐based geriatric ED . Ongoing research is likely to result in additional articles in the near future, as evidenced by scientific abstracts presented at recent scientific meetings.…”

“…For instance, between the conclusion of our search and the peer review process of this article, an array of studies were published including a review of self-defined geriatric EDs, 47 a nurse transition intervention, 48 and a pragmatic trial of an Australian-based geriatric ED. 49 Ongoing research is likely to result in additional articles in the near future, as evidenced by scientific abstracts presented at recent scientific meetings. Additionally, in a targeted search of ClinicalTrials.gov, we found eight active studies focused on older adults in the ED.…”

Predictors of a long length of stay in the emergency department for older people

“…Whether this finding holds true for hospitals hosting an extended‐hours or 24/7 ED geriatric service is worth investigation. In addition, dedicated multidisciplinary teams situated in the ED (including the short stay ward), where community outreach/engagement is a feature, may help avoid hospital admission . However, what constitutes the structures and processes underpinning the best practice model of care requires further research.…”

Antibiotic Stewardship for Older Adults in Ambulatory Care Settings: Addressing an Unmet Challenge

“…For instance, the Geriatric Emergency Department Intervention (GEDI) is a “nursing‐led, physician‐championed” model that involves specially trained staff who aim to expedite, modify, and coordinate care for frail older adults in the ED setting. When examined in a pragmatic trial, the GEDI model was able to demonstrate sustainable reductions in ED length of stay, hospital admissions, and hospital length of stay without increasing the risk of mortality or recidivism . A logical evolution of GEDI and similar proposed models would be to incorporate antibiotic stewardship specific training with an emphasis on high‐risk prescribing scenarios for older adults (eg, asymptomatic bacteriuria, empirical antibiotics for delirium).…”