Implementation of the acutely presenting older patient (APOP) screening program in routine emergency department care : A before-after study

Abstract

Objective: The aim of this study was to evaluate the effects of implementation of the acutely presenting older patient (APOP) screening program for older patients in routine emergency department (ED) care shortly after implementation.

Methods: We conducted an implementation study with before-after design, using the plan-do-study-act (PDSA) model for quality improvement, in the ED of a Dutch academic hospital. All consecutive patients ≥ 70 years during 2 months before and after implementation were included. The APOP program comprises screening for risk of functional decline, mortality and cognitive impairment, targeted interventions for high-risk patients and education of professionals. Outcome measures were compliance with interventions and impact on ED process, length of stay (LOS) and hospital admission rate.

Results: Two comparable groups of patients (median age 77 years) were included before (n = 920) and after (n = 953) implementation. After implementation 560 (59%) patients were screened of which 190 (34%) were high-risk patients. Some of the program interventions for high-risk patients in the ED were adhered to, some were not. More hospitalized patients received comprehensive geriatric assessment (CGA) after implementation (21% before vs. 31% after; p = 0.002). In 89% of high-risk patients who were discharged to home, telephone follow-up was initiated. Implementation did not influence median ED LOS (202 min before vs. 196 min after; p = 0.152) or hospital admission rate (40% before vs. 39% after; p = 0.410).

Conclusion: Implementation of the APOP screening program in routine ED care did not negatively impact the ED process and resulted in an increase of CGA and telephone follow-up in older patients. Future studies should investigate whether sustainable changes in management and patient outcomes occur after more PDSA cycles.

Keywords: Frail elderly; Geriatric assessment; Geriatric emergency medicine; Implementation science; Quality improvement.

Fig. 1

Overview of the implementation process and data collection periods. Data were collected in multiple periods during the implementation process. In the present study, we evaluated data collected from patients aged ≥ 70 years visiting the emergency department (ED) during the 2‑month observation periods “before” and “after” implementation of the APOP screening program. EHR electronic health record, SOP standard operating procedures

Fig. 2

Overview of the acutely presenting older patient (APOP) screening program. The APOP screening program consists of three parts: firstly, screening older patients for risk of functional decline/mortality and signs of impaired cognition, secondly targeted interventions for high-risk patients in the emergency department (ED) and thirdly interventions for high-risk patients who are hospitalized or discharged home

Fig. 3

Flowchart of study population. All consecutive patients aged ≥ 70 years visiting the emergency department (ED) during the 2‑month observation periods “before” and “after” implementation of the APOP screening program were included, except for patients who bypassed ED triage or patients who were triaged to the immediate urgency level. The screening rate was measured in triaged ED patients ≥ 70 years in the “after” period. Compliance with interventions was compared in the “before” and “after” period, using real-time observations of ED patients ≥ 70 years. Process of care measures were compared between all triaged ED patients ≥ 70 years in the “before” and “after” period