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• W3204015452 abstract "We refer to our article entitled “Emergency Department Interventions for Frailty (EDIFY): Front-Door Geriatric Care Can Reduce Acute Admissions.”1Chong E. Zhu B. Tan H. et al.Emergency Department Interventions for Frailty (EDIFY): front-door geriatric care can reduce acute admissions.J Am Med Dir Assoc. 2021; 22: 923-928.e5Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Although we have described clinical effectiveness of the EDIFY program, a deeper appreciation of emergency department (ED) staff perceptions of geriatric care and support was needed to ascertain overall quality of the program. EDIFY was designed for the dual purpose of reducing the number of potentially avoidable acute admissions and delivering interprofessional geriatric interventions through comprehensive geriatric assessments, and promoting awareness and education on frailty.2Conroy S. Parker S. Acute geriatrics at the front door.Clin Med (Lond). 2017; 17: 350-353Crossref PubMed Scopus (11) Google Scholar,3Jay S. Whittaker P. Mcintosh J. Hadden N. Can consultant geriatrician led comprehensive geriatric assessment in the emergency department reduce hospital admission rates? A systematic review.Age Ageing. 2017; 46: 366-372PubMed Google Scholar The program significantly reduced acute admissions without escalating the risk of rehospitalization, ED re-attendance, or mortality.1Chong E. Zhu B. Tan H. et al.Emergency Department Interventions for Frailty (EDIFY): front-door geriatric care can reduce acute admissions.J Am Med Dir Assoc. 2021; 22: 923-928.e5Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar We conducted a survey among ED staff aimed at assessing their perceptions of knowledge and confidence in managing older persons and to explore their satisfaction with current geriatric expert support. In the absence of suitable survey instruments, a survey questionnaire was crafted by members of the study team comprising 2 geriatricians and an advanced practice nurse. The questionnaire underwent multiple rounds of pretesting, which led to multiple revisions before a final version was ready. It comprises 3 subsections: (1) demographics, (2) knowledge and confidence in managing older persons, and (3) satisfaction with current geriatric expert support. Each question is scored on an 8-point Likert scale ranging from 0 (strongly disagree) to 7 (strongly agree) to avoid participants selecting the neutral option. Participants were introduced to the survey during department meetings and were informed that participation was voluntary. Written consent was obtained and ethical approval was granted by the institutional review board. Descriptive analysis was performed and we reported categorical variables as number (percentage) and continuous variables as mean and median. Total scores for individual questionnaire items were derived with reverse ordering of scores applied to selected items to ensure consistent directionality. Between-group comparisons were then performed using unpaired t-test. Statistical analysis was performed using SPSS V21.0 (SPSS, Inc, Chicago, IL), and statistical significance was assessed using a threshold of 5%. We recruited a total of 78 participants (34.7% doctors and 62.7% nurses). Most were women (58.1%), aged 20 to 30 years old (37.7%), Chinese (49.4%), and had <5 years working experience at the ED (44.9%). Only a minority received training in geriatric care (Supplementary Table 1). Responses scored as 0 to 3 and 4 to 7 were taken as disagree and agree, respectively (Table 1). Our results revealed inconsistencies in staff perceptions of knowledge and confidence in delirium and dementia management. More than half lacked confidence in diagnosing delirium (Q1 and Q3; median = 3), agreed that restraints used on patients with delirium would protect them from harm (Q7; median = 4), and were not familiar with advanced dementia care services (Q8; median = 3). Participants were well aware of the role of advanced care planning (Q14 and Q15; median = 5) and felt they had good understanding of frailty (Q17 and Q18; median = 5). Although 62.8% of participants agreed that the current geriatric expert support is adequate (Q20; median = 4.5), only 26.9% felt well equipped to care for older persons (Q21; median = 2). Overall, 84.6% were satisfied with the current geriatric expert support (Q24; median = 5).Table 1Summary of Results From the Survey Questions Using an 8-Point Likert ScaleSurvey QuestionsScore Range 0 (Strongly Disagree) to 7 (Strongly Agree)nAgree∗“Disagree” if score is 0–3; “agree” if score is 4–7. (%)Mean (SD)Median (IQR)A. Understanding/Confidence in managing older persons at the EDDisagree vs Agree∗“Disagree” if score is 0–3; “agree” if score is 4–7. Delirium and dementiaQ1. I would be able to identify if my patients had delirium by administering the Confusion Assessment Method (CAM).7748.73.5 (1.9)3 (2–5)Q2. I would be able to distinguish the difference between delirium and dementia.7867.94.3 (1.6)4.5 (3–6)Q3. I am familiar with the DELIRIUM acronym in identifying possible delirium risk factors/causes.7848.73.3 (1.9)3 (2.-5)Q4. Delirium does not lead to significant adverse outcomes for hospitalized older patients.7719.22.0 (1.7)1 (1–3)Q5. All delirium cases should not be managed at home or in the community.7862.84.0 (1.9)4 (3–6)Q6. I would be able to manage behavior-related issues due to delirium/dementia in the ED setting.7850.03.4 (1.6)3.5 (2–5)Q7. Physical and/or chemical restraints used on a patient with delirium will protect them from harming themselves.7862.83.8 (1.8)4 (2–5)Q8. I am familiar with advanced dementia care and the relevant resources available in the hospital and in the community.7837.22.9 (1.6)3 (2–4) Falls, function, and community resourcesQ9. I would be able to identify older patients with high falls risk.7891.05.2 (1.2)5 (5–6)Q10. I would be able to know the difference between predisposing and precipitating factors leading to falls in the elderly.7882.14.7 (1.3)5 (4–6)Q11. I would be able to assess older patients' functional status and decide on further treatment plans.7870.54.2 (1.5)4 (3–5)Q12. Older patients presenting with functional decline will always require admission.7855.13.7 (1.7)4 (2–5)Q13. I am familiar with the available community resources and confident in allocating the right resource for my patients.7765.43.8 (1.5)4 (3–5) Advanced care planningQ14. I am aware the existence of Advanced Care Planning (ACP) and the potential impact on care planning.7787.25.1 (1.5)5 (4–6)Q15. If a patient's ACP decision was for “limited interventions,” there is a chance that the patient can be discharged from the ED if appropriate community support is rendered.7785.94.9 (1.5)5 (4–6) Continence careQ16. I would be able to manage patients with issues pertaining to urinary and bowel control.7666.74.1 (1.5)4 (3–5) FrailtyQ17. I am well informed about the concept of frailty and its impact on my patients.7773.14.4 (1.4)5 (3–5.5)Q18. I would be able to identify frailty in older patients presenting to the ED.7779.54.7 (1.3)5 (4–6) Geriatric careQ19. My knowledge in geriatric care will allow me to provide the best care for my patients in ED.7778.24.6 (1.5)5 (4–6)Total Score (range: 0–133)†Reverse ordering of scores applied for Q4, Q5, Q7, and Q12.77.0 (15.2)78 (66–88)B. Satisfaction with current geriatric expert support at the ED Q20. I feel that the care of my older patients in the ED is adequate with the current geriatric support.7662.84.2 (1.5)4.5 (3–5) Q21. I am well equipped to care for my older patients and do not need additional geriatric support.7826.92.5 (1.7)2 (1–4) Q22. I am comfortable in communicating with the geriatric team for advice on the care of my patients in the ED.7874.44.6 (1.5)5 (3–6) Q23. The geriatric team has been very helpful in explaining and teaching me about my patients' conditions and the rationale for their management plans.7780.85.0 (1.4)5 (4–6) Q24. Please rate your current satisfaction level with your current geriatric support in ED.7784.65.1 (1.2)5 (4–6)Total Score (range: 0–35)†Reverse ordering of scores applied for Q4, Q5, Q7, and Q12.21.2 (5.4)21 (17.8–25)IQR, interquartile range; Q, question.∗ “Disagree” if score is 0–3; “agree” if score is 4–7.† Reverse ordering of scores applied for Q4, Q5, Q7, and Q12. Open table in a new tab IQR, interquartile range; Q, question. Between-group comparisons revealed that geriatric-trained staff had greater confidence in differentiating predisposing and precipitating factors for falls, assessment of functional status, allocating the right community resources, and frailty identification (all P < .05). Doctors were also more aware of the potential sequelae of delirium (Q3; P < .001) and the impact of advanced care planning (Q14; P = .011); however, there were no differences in total scores between groups (Supplementary Table 2). Our findings show that most ED staff valued having additional geriatric expert support and highlights the need to improve delirium management and knowledge on advanced dementia care at the ED. Because of time pressures at the ED, addressing complex multidimensional needs of older persons often do not take precedence.2Conroy S. Parker S. Acute geriatrics at the front door.Clin Med (Lond). 2017; 17: 350-353Crossref PubMed Scopus (11) Google Scholar,3Jay S. Whittaker P. Mcintosh J. Hadden N. Can consultant geriatrician led comprehensive geriatric assessment in the emergency department reduce hospital admission rates? A systematic review.Age Ageing. 2017; 46: 366-372PubMed Google Scholar Hence, care models designed specifically to deliver frailty-centric care at the ED are needed to improve functional outcomes and reduce ED re-attendance among older persons.1Chong E. Zhu B. Tan H. et al.Emergency Department Interventions for Frailty (EDIFY): front-door geriatric care can reduce acute admissions.J Am Med Dir Assoc. 2021; 22: 923-928.e5Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar,4Foo C.L. Siu V.W. Tan T.L. et al.Geriatric assessment and intervention in an emergency department observation unit reduced re-attendance and hospitalisation rates.Australas J Ageing. 2012; 31: 40-46Crossref PubMed Scopus (52) Google Scholar, 5Foo C.L. Siu V.W. Ang H. et al.Risk stratification and rapid geriatric screening in an emergency department - a quasi-randomised controlled trial.BMC Geriatr. 2014; 14: 98Crossref PubMed Scopus (22) Google Scholar, 6Devriendt E. De Brauwer I. Vandersaenen L. et al.Geriatric support in the emergency department: A national survey in Belgium.BMC Geriatr. 2017; 17: 68Crossref PubMed Scopus (11) Google Scholar, 7Ang S.H. Rosario B.H. Ngeow K.Y.I. et al.Direct admission from the emergency department to a subacute care ward: An alternative to acute hospitalization.J Am Med Dir Assoc. 2020; 21: 1346-1348Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Our study had a number of limitations. First, most participants had fewer than 5 years of working experience at the ED and most had no training in geriatric care. Hence, our findings may not be reflective of EDs with a larger proportion of staff experienced in geriatric care. Second, our results are reflective of an ED that has received support from the EDIFY program for more than a year. Therefore, no comparisons can be made before the introduction of the EDIFY program to the ED. Third, the large number of tests performed for between-group comparisons may have resulted in some observed differences occurring purely by chance. Hence, these findings should be interpreted with caution. In conclusion, the rising trend of older persons making up a significant proportion of ED attendances calls for EDs to better equip themselves in the provision of geriatric care. The EDIFY program is noticeably an important piece of the puzzle in realizing a frailty-ready ED. We express our deepest gratitude to the staff of the Emergency Department of Tan Tock Seng Hospital for their unwavering support in the EDIFY program and their participation in this survey study. We also thank Ms E.F. Goh, Ms H. Tan, Dr J.D.C. Molina, Ms S. Cheong, Ms P. Kaur, Dr M.J. Pereira, Ms S.H.X. Ng, Dr J.Q. Chia, Dr A. Chong, Dr C.L. Foo, and Dr M. Chan for playing a vital role in the success of the EDIFY program and study, and Professor W.S. Lim for providing advice on data analysis. Last but not least, we thank the Ng Teng Fong Healthcare Innovation Programme (Project Code: NTF_JUL2017_I_C2_CQR_02), National Healthcare Group, Singapore, for funding this study. Supplementary Table 1Baseline Demographics of all ED Staff ParticipantsnAll ParticipantsAge range, n (%)77 20–3029 (37.7) 31–4028 (36.4) 41–5017 (22.1) 51 and older3 (3.9)Gender, n (%)77 Male32 (41.6) Female45 (58.1)Ethnicity, n (%)77 Chinese38 (49.4) Malay13 (16.9) Filipino17 (22.1) Indian7 (9.1) Burmese1 (1.3) Others1 (1.3)Occupation, n (%)76 Doctor26 (34.7) Nurse47 (62.7) Allied health2 (2.7)Years of service in the ED, n (%)77 < 535 (44.9) 5–1021 (26.9) 11–1513 (16.7) 16–207 (9) >211 (1.3)GDGM trained, n (%)74 No71 (95.9) Yes3 (4.1)GEMS trained, n (%)77 No59 (76.6) Yes18 (23.4)GDGM, graduate diploma in geriatric medicine; GEM, geriatric emergency medicine. Open table in a new tab Supplementary Table 2Comparison in Results of Survey Questions Between Geriatric-Trained and Non–Geriatric-Trained, and Between Doctors and Nurses/Allied Health Staff at the EDSurvey QuestionsScore Range 0 (Strongly Disagree) To 7 (Strongly Agree)Geriatric-Trained (n = 18)Non–Geriatric-Trained (n = 59)Doctors (n = 26)Nurses or Allied Health Professionals (n = 49)Mean (SD)Mean (SD)P Value∗Unpaired t-test performed.Mean (SD)Mean (SD)P Value∗Unpaired t-test performed.A. Knowledge/Confidence in managing older persons at the ED Delirium and dementiaQ1.I would be able to identify if my patients had delirium by administering the Confusion Assessment Method (CAM).3.9 (1.9)3.3 (1.9).2524.1 (1.5)3.3 (2.0).088Q2.I would be able to distinguish the difference between delirium and dementia.4.8 (1.3)4.2 (1.6).1994.7 (1.3)4.2 (1.6).153Q3.I am familiar with the DELIRIUM acronym in identifying possible delirium risk factors/causes.3.9 (1.8)3.1 (1.9).0873.4 (1.7)3.3 (2.0).896Q4.Delirium does not lead to significant adverse outcomes for hospitalized older patients.†Reverse ordering of scores applied for Q4, Q5, Q7, and Q12.4.4 (1.8)5.2 (1.7).1086.2 (1.0)4.4 (1.7)<.001Q5.All delirium cases should not be managed at home or in the community.†Reverse ordering of scores applied for Q4, Q5, Q7, and Q12.2.3 (1.3)3.1 (2.0).1122.8 (2.1)3.0 (1.8).616Q6.I would be able to manage behavior-related issues due to delirium/dementia in the ED setting.3.7 (1.7)3.3 (1.5).3403.6 (1.5)3.3 (1.6).390Q7.Physical and/or chemical restraints used on a patient with delirium will protect them from harming themselves.†Reverse ordering of scores applied for Q4, Q5, Q7, and Q12.2.7 (1.5)3.4 (1.8).1243.4 (1.7)3.1 (1.9).496Q8.I am familiar with advanced dementia care and the relevant resources available in the hospital and in the community.3.5 (1.5)2.7 (1.5).0512.6 (1.3)3.0 (1.7).290 Falls, function, and community resourcesQ9.I would be able to identify older patients with high falls risk.5.6 (1.0)5.1 (1.2).1225.0 (1.3)5.4 (1.1).256Q10.I would be able to know the difference between predisposing and precipitating factors leading to falls in the elderly.5.2 (1.1)4.5 (1.4).0444.7 (1.4)4.7 (1.2).959Q11.I would be able to assess older patients' functional status and decide on further treatment plans.5.0 (1.1)3.9 (1.6).0064.2 (1.4)4.2 (1.6).975Q12.Older patients presenting with functional decline will always require admission.†Reverse ordering of scores applied for Q4, Q5, Q7, and Q12.2.7 (1.3)3.5 (1.8).0593.3 (1.7)3.4 (1.7).815Q13.I am familiar with the available community resources and confident in allocating the right resource for my patients.4.6 (1.1)3.6 (1.6).0153.8 (1.7)3.8 (1.5).944 Advanced care planningQ14.I am aware the existence of advanced care planning (ACP) and the potential impact on care planning.5.2 (1.3)5.1 (1.6).7395.7 (0.9)4.8 (1.7).011Q15.If a patient's ACP decision was for “limited interventions,” there is a chance that the patient can be discharged from the ED if appropriate community support is rendered.5.1 (1.4)4.9 (1.5).6615.3 (1.4)4.7 (1.5).139 Continence careQ16.I would be able to manage patients with issues pertaining to urinary and bowel control.4.4 (1.5)4.0 (1.5).3644.0 (1.6)4.2 (1.5).505 FrailtyQ17.I am well informed about the concept of frailty and its impact on my patients.4.9 (1.2)4.2 (1.4).0514.7 (1.1)4.3 (1.5).257Q18.I would be able to identify frailty in older patients presenting to the ED.5.3 (1.0)4.5 (1.4).0214.7 (0.9)4.6 (1.5).765 Geriatric careQ19.My knowledge in geriatric care will allow me to provide the best care for my patients in ED.5.3 (1.1)4.4 (1.5).0344.7 (1.2)4.6 (1.6).870Total Score (range: 0–133)†Reverse ordering of scores applied for Q4, Q5, Q7, and Q12.82.2 (12.6)75.3 (15.8).09280.8 (11.5)76.1 (15.4).180B. Satisfaction with current geriatric expert support at the ED Q20.I feel that the care of my older patients in ED is adequate with the current geriatric support.4.5 (1.4)4.1 (1.6).3584.6 (1.3)4.0 (1.6).147 Q21.I am well equipped to care for my older patients and do not need additional geriatric support.2.9 (1.6)2.3 (1.7).2062.3 (1.4)2.6 (1.8).426 Q22.I am comfortable in communicating with the geriatric team for advice on the care of my patients in ED.4.9 (1.3)4.6 (1.5).3304.9 (1.4)4.5 (1.5).320 Q23.The geriatric team has been very helpful in explaining and teaching me about my patients' conditions and the rationale for their management plans.5.5 (1.0)4.9 (1.5).0955.1 (1.5)5.0 (1.3).676 Q24.Please rate your current satisfaction level with your current geriatric support in the ED.5.3 (1.1)5.0 (1.2).4615.3 (1.1)5.0 (1.3).233Total Score (range: 0–35)†Reverse ordering of scores applied for Q4, Q5, Q7, and Q12.23.1 (4.5)20.7 (5.5).09221.8 (5.0)21.1 (5.6).614IQR, interquartile range; Q, question.One missing response for whether participant is geriatric trained and 3 missing responses for participant's occupation. Hence, excluded from this analysis.∗ Unpaired t-test performed.† Reverse ordering of scores applied for Q4, Q5, Q7, and Q12. Open table in a new tab GDGM, graduate diploma in geriatric medicine; GEM, geriatric emergency medicine. IQR, interquartile range; Q, question. One missing response for whether participant is geriatric trained and 3 missing responses for participant's occupation. Hence, excluded from this analysis." @default.
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• W3204015452 title "Emergency Department Staff Perceptions of Emergency Department Interventions for Frailty (EDIFY)" @default.
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