An assistant workforce to improve screening rates and quality of care for older patients in the emergency department: findings of a pre- post, mixed methods study

When older people present to the Emergency Department (ED) they often require immediate support to ensure their safety as well as other needs in the ED environment [1‐4]. Providing early review of individual patient risk, comprehensive assessment and a tailored management plan minimises the risks associated with ED presentation and admission to hospital as well as the risk of ED re-presentation [5, 6]. This paper reports on the introduction of an aged care assistant workforce in a tertiary referral hospital ED in New South Wales (NSW), Australia. Titled the Older Person Technical Assistant (OPTA), the assistant position aimed to optimise the quality of care for older people in ED and reduce preventable adverse events, particularly delirium [7]. The use of a non-professional workforce to screen and provide supportive care for delirium management and prevention as well as facilitate access to comprehensive geriatric assessment for older people who present to the ED has not previously been examined.

Delirium is an acute change in mental state. It is characterised by disturbance of consciousness, attention, cognition and perception [8, 9]. With older age, particularly those over 75 years of age, there is a higher risk of developing delirium in hospital. About 10% of older people already have prevalent delirium on admission to hospital [10], with a further 8% of older people developing delirium during their hospitalisation [10, 11]. Delirium is associated with poorer hospital outcomes including increased length of stay, falls risk, pressure injuries and functional decline. This can lead to older people requiring admission to nursing homes, as well as premature death [12‐15]. Despite these known concerns, delirium is often under-recognised and under-diagnosed [9, 16‐18]. Prevention of delirium along with effective management when it occurs, improves health outcomes [19, 20] as well as cost effectiveness [21].

Predisposing and precipitating factors for developing delirium have been identified [22]. These include pre-existing dementia, sensory impairment, being acutely unwell and institutional care as well as infection, decreased mobility or the use of restraints, bladder catheterisation, malnutrition, dehydration, more than three medications, and sleep deprivation [14, 15, 22].

In Australia, the Australian Commision for Quality and Safety introduced a Delirium Clinical Care Standard in 2016 including early screening for delirium, interventions to prevent delirium as well as falls, and pressure injury prevention [8]. High quality care of older people in hospital requires delirium prevention and management [21‐25].

OPTAs saw 3542 people who presented to the ED on a total of 4563 occasions, as some patients had more than one ED visit over the 12 months. The mean number of visits per patient seen by OPTAs was 1.3 (SD = 0.7) and the maximum was 13. With a roster that covered 12 h each day, OPTAs saw 53% of patients aged over 75. This is further described in Table 1. ED length of stay was comparable between 2010/11 and 2011/12, p = 0.21, for all patients presenting over the age of 75 years. The OPTAs were less likely to see patients who were Australian Triage Category 1 as they were critically ill, requiring immediate resuscitation and Triage Category 5 as they have less urgent conditions and are usually ambulant and able to care for themselves in the ED. The patients who they saw were more likely to be admitted to hospital, reflecting a longer ED length of stay.

Medical records of 63 patients were reviewed prior to the introduction of the OPTAs. The findings are presented in Table 2. It reveals a lack of documentation of screening results and care delivery, compared with the same period after the introduction of the OPTA. There was a significant improvement in documentation of all areas of care and screening.

The results of the screening by OPTAs are presented in Table 3. The reproducibility of all screening tools were found to be very high between the OPTAs and the RNs, with Kappas and ICCs generally all above 0.9.

Table 4 outlines the delirium prevention supportive care tasks undertaken and recorded by the OPTAs, under the direction of the patient’s ED RN responsible for the patient’s care. After assessment, the RN determined whether patients were safe to eat and drink or walk to the bathroom, depending on their usual level of function and the acute illness that precipitated their ED presentation. Patients requiring one-on-one supportive care were patients who were calling out, distressed or at risk of falling out of bed. If patients were unable to walk to the bathroom, OPTAs assisted with toileting at the bedside. Orientation and general care were the most frequent activities at 67 and 39% respectively.

The Australian Commission on Safety and Quality in Healthcare Delirium Clinical Care Standard [8] provides guidance for appropriate care and reducing unwarranted variation by defining the care that patients can be expected to be offered or receive. It outlines seven focus areas for acute hospitals for delirium, including early screening; early assessment; early interventions to prevent delirium; early identification for the underlying cause; prevention of other hospital risks, pressure injuries and falls given their higher risk for patients with delirium; minimisation of the use of anti-psychotics for patients with delirium; and better transition home for patients with delirium. The challenge for EDs is having prevention and management of delirium recognised as a priority, in competition with other pressing demands. The OPTA role supports RNs to deliver better quality patient care in many of the seven focus areas within the Delirium Clinical Care Standard. Informed by nursing assessment and screening results, OPTAs delivered care that had regularly not previously occurred in the ED, like access to meals and fluids. Having a dedicated non-professional workforce with a limited scope of practice that focused on older patients, allowed for earlier responsiveness to the needs of older people, supporting delirium prevention. In patients with delirium the OPTA role assisted with the prevention of falls and pressure injuries through supportive care as well as providing one-on-one care for patients who were agitated and distressed, aiming to reduce the need for anti-psychotic medication in an ED environment that is disturbing [11]. The purpose of OPTAs was primarily to focus on improving screening and care intervention for delirium management in the ED but there was secondary opportunity for broader improvements in comprehensive assessment and care. This was dependent on the extent to which others in the care team framed OPTA work as essential screening that informs other assessment and care processes rather than seeing OPTA work as adding ‘niceties’ to an ED environment.

The validation results demonstrate that the OPTAs were able to perform screening tests in the ED with the Kappas generally above 0.90 with the screen for delirium; CAMI at 0.88 is also a high correlation. OPTAs were also able to deliver high levels of supportive care that promotes delirium prevention. Having an assistant workforce that was focused on delirium prevention highlight to other staff that delirium prevention was a high clinical priority. The documented rate of screening and supportive care improved significantly across all areas. Staff in the ED reported greater awareness of falls risk in the ED with more systematised screening by the OPTAs.

All older patients did not require interventions and screening. If patients presented to the ED with minor problems and were discharged home from the ED they did not need OPTA support. If they presented to ED out of the hours of the OPTA, they were not seen. Patients who were screened and had care interventions by OPTAs were much more likely to be admitted to hospital; it is not clear whether this was a consequence of the identification of more issues by the OPTAs or that the OPTAs were instructed by RNs to focus on those with more higher needs. OPTAs documented significantly higher rates of family and carers in attendance in the ED though it still remained low at 29%. Having OPTAs undertaking screening meant that the ASET RNs did not need to undertake this activity and were able to use information from OPTAs to determine which patients needed more comprehensive assessment.

Previous research suggests that multicomponent strategies delivered by a trained, non-professional group of health care workers such as the OPTAs, are effective in reducing incidence, duration and number of episodes of delirium [7, 35, 36]. This study has demonstrated that an assistant workforce can accurately use screening tools and record findings, as well as assist with supportive care of patients and their families, without any increase in the overall ED length of stay for this group. We were not able to determine the impact of the OPTAs on the prevention and management of delirium. An assumption in this study was that delivering preventative care and screening more reliably with a dedicated workforce such as the OPTAs enhances quality care and prevents delirium although this could not be directly measured in our audit.

Care strategies that prevent delirium and other risks associated with ED presentation are foundational to quality patient experience and healthcare. Assessment, monitoring and provision of patient care needs including access to hydration and food, mobilisation, orientation and reorientation, ensuring contact with family and supporting family are important pillars of excellent nursing care [37‐40]. Prioritising these care needs, guided by a shared philosophy and clarity in roles and responsibilities is essential for improving the ED experience for older people.

Limitations of the design were that delirium and other outcomes such as falls and pressure injuries were not measured. It is thought, however, that the activity undertaken by the OPTAs is likely to have reduced these known risks for older people in the ED.

It is more important to ensure that delirium prevention strategies are embedded in care responsibilities within the ED rather than a single workforce group. The OPTA raised the profile for the need for supportive care of older people in the ED with scope of practice limited and focused on their care. OPTAs assisted in raising the profile of delirium prevention and management within the ED that had not been previously prioritised. Documentation gaps for aspects of care of older people in the ED were identified in this study. If delirium prevention strategies are to be prioritised, documentation of these strategies as well as improved documentation of delirium and other undesired consequences of hospitalisation needs to occur.

The findings of this study highlight that a non-professional workforce, the OPTAs, can undertake screening in the ED and support the management and prevention of delirium, however, the uptake of the screening provided by OPTAs and including a dedicated workforce focused on older people in the model of care in the ED is dependent upon the extent to which other groups, particularly RNs accept and include OPTA screening in decision making without replicating the screening.

Older people in the ED require screening in order to ensure risk factors are identified and addressed. Preventative strategies in ED require dedicated staff, screening embedded in care, comprehensive and systematic assessment, management and documentation of care and ongoing treatment. The Older Person Technical Assistant can support this.