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Implementing an allied health team intervention to improve the care of older adults in the emergency department: protocol for a process evaluation.

ABSTRACT: INTRODUCTION:Health and social care professionals (HSCPs) have increasingly contributed to enhance the care of patients in emergency departments (EDs), particularly for older adults who are frequent ED attendees with significant adverse outcomes. For the first time, the effectiveness of a HSCP team intervention for older adults in the ED has been tested in a large randomised controlled trial (Clinicaltrials.gov, NCT03739515), providing an opportunity to explore the implementation process for this type of intervention. This protocol describes a process evaluation that will to investigate the implementation, delivery and impact of an HSCP team intervention in the ED. METHODS AND ANALYSIS:Using the Medical Research Council Framework for process evaluations, we will employ a mixed-methods approach to provide a description of the process of implementation and delivery of the HSCP intervention in the ED, evaluate its fidelity, dose and reach and explore the perceptions of key staff members in relations to the mechanisms and contexts of impact at the levels of individuals, physical environment, operations, communication and the broader hospital and healthcare system. ETHICS AND DISSEMINATION:Ethical approval for this study was received from the HSE Mid-Western Regional Hospital Research Ethics Committee (Ref: 103/18). All participants will be invited to read and sign a written consent form prior to participation. The results of this review will be disseminated through publication in a peer-review journal and presented at relevant conferences.

SUBMITTER: Cassarino M

PROVIDER: S-EPMC6661884 | biostudies-literature | 2019 Jul

REPOSITORIES: biostudies-literature

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Implementing an allied health team intervention to improve the care of older adults in the emergency department: protocol for a process evaluation.

Cassarino Marica M Cronin Úna Ú Robinson Katie K Quinn Rosie R Boland Fiona F Ward Marie E ME MacNamara Rosa R O'Connor Margaret M McCarthy Gerard G Ryan Damien D Galvin Rose R

BMJ open 20190716 7

<h4>Introduction</h4>Health and social care professionals (HSCPs) have increasingly contributed to enhance the care of patients in emergency departments (EDs), particularly for older adults who are frequent ED attendees with significant adverse outcomes. For the first time, the effectiveness of a HSCP team intervention for older adults in the ED has been tested in a large randomised controlled trial (Clinicaltrials.gov, NCT03739515), providing an opportunity to explore the implementation process ...[more]

PMID: 31315881

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Project description:BackgroundDizziness and vertigo-like symptoms, often caused by common peripheral vestibular disorders such as benign paroxysmal positional vertigo (BPPV), may significantly impact function and quality of life. These symptoms often result in emergency department (ED) presentations. Evidence-based clinical practice guidelines strongly recommend using physical assessment and treatment manoeuvres for the assessment, diagnosis and treatment of these symptoms. This study aimed to evaluate the process of implementing specialised vestibular physiotherapy (SPV) in an emergency department from the clinician's perspective.MethodsThis implementation study utilised a retrospective mixed-methods process evaluation to understand how SVP operated in an Australian emergency department. The i-PARiHS framework was embedded within the methodology and analytical approach of the study to ensure a comprehensive approach closely aligned to implementation science. Nine clinicians retrospectively completed the Organisational Readiness for Change Assessment (ORCA), Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM) and Feasibility of Intervention Measure (FIM). Seven clinicians also participated in a focus group or interview.ResultsA range of barriers and facilitators to the implementation process were identified by participants, some of which spanned multiple domains of the i-PARiHS framework. Relationships with service leaders, champions and medical staff were pivotal facilitators to implementation, along with a generally held perception that SVP was acceptable and feasible. The main barrier identified was a lack of capacity to deliver and facilitate this innovation within the physiotherapy workforce and the broader multidisciplinary recipients.ConclusionsThis study demonstrates that the process of implementing an SVP service in an ED context was generally well-received by clinicians but also involved some challenges and barriers. Services looking to implement SVP in the ED should aim to build stakeholder relationships; develop a shared vision with clear goals and intended outcomes; embed the innovation in organisation processes, procedures and policies; and increase workforce capacity to deliver and facilitate SVP to guide their approach to this innovation.

Project description:BackgroundCOVID-19 necessitated the rapid implementation and uptake of virtual health care; however, virtual care's potential role remains unclear in the urgent care setting. In December 2020, the first virtual emergency department (ED) in the Greater Toronto Area was piloted at Sunnybrook Health Sciences Centre by connecting patients to emergency physicians through an online portal.ObjectiveThis study aims to understand whether and how ED physicians were able to integrate a virtual ED alongside in-person operations.MethodsWe conducted semistructured interviews with ED physicians guided by the Normalization Process Theory (NPT). The NPT provides a framework to understand how individuals and teams navigate the process of embedding new models of care as part of normal practice. All physicians who had worked within the virtual ED model were invited to participate. Data were analyzed using a combination of inductive and deductive techniques informed by the NPT.ResultsA total of 14 physicians were interviewed. Participant experiences were categorized into 1 of 2 groups: 1 group moved to normalize the virtual ED in practice, while the other described barriers to routine adoption. These groups differed in their perception of the patient benefits as well as the perceived role in the virtual ED. The group that normalized the virtual ED model saw value for patients (coherence) and was motivated by patient satisfaction witnessed (reflexive monitoring) at the end of the virtual appointment. By contrast, the other group did not find virtual ED work reflective of the perceived role of urgent care (cognitive participation) and felt their skills as ED physicians were underutilized. The limited ability to examine patients and a sense that patient issues were not fully resolved at the end of the virtual appointment caused frustration among the second group.ConclusionsAs further digital integration within the health care system occurs, it will be essential to support the evolution of staff skill sets to ensure physicians are satisfied with the care they are providing to their patients, while also ensuring the technology and process are efficient.

Project description:BackgroundED overcrowding represents a significant public health problem in developed countries. Frequent users of the emergency departments (FUEDs; reporting 5 or more ED visits in the past year) are often affected by medical, psychological, social, and substance use problems and account for a disproportionately high number of ED visits. Past research indicates that case management (CM) interventions are a promising way to reduce ED overcrowding and improve FUEDs' quality of life. There is, however, very limited knowledge about how to disseminate and implement this intervention on a large scale to diverse clinical settings, including community hospitals and non-academic centers. This paper describes the protocol of a research project aiming to implement a CM intervention tailored to FUEDs in the public hospitals with ED in the French-speaking region of Switzerland and evaluate both the implementation process and effectiveness of the CM intervention.MethodsThis research project uses a hybrid study design assessing both implementation and clinical outcomes. The implementation part of the study uses mixed methods a) to describe quantitatively and qualitatively factors that influence the implementation process, and b) to examine implementation effectiveness. The clinical part of the study uses a within-subject design (pre-post intervention) to evaluate participants' trajectories on clinical variables (e.g., quality of life, ED use) after receiving the CM intervention. We designed the study based on two implementation science frameworks. The Generic Implementation Framework guided the overall research protocol design, whereas the RE-AIM (reach, efficacy, adoption, implementation and maintenance) framework guided the implementation and effectiveness evaluations.DiscussionThis research project will contribute to implementation science by providing key insights into the processes of implementing CM into broader practice. This research project is also likely to have both clinical and public health implications.Trial registrationNCT03641274 , Registered 20 August 2018.

Project description:IntroductionEmergency department (ED) crowding adversely affects multiple facets of high-quality care. The Commonwealth of Massachusetts mandates specific, hospital action plans to reduce ED boarding via a mechanism termed "Code Help." Because implementation appears inconsistent even when hospital conditions should have triggered its activation, we hypothesized that compliance with the Code Help policy would be associated with reduction in ED boarding time and total ED length of stay (LOS) for admitted patients, compared to patients seen when the Code Help policy was not followed.MethodsThis was a retrospective analysis of data collected from electronic, patient-care, timestamp events and from a prospective Code Help registry for consecutive adult patients admitted from the ED at a single academic center during a 15-month period. For each patient, we determined whether the concurrent hospital status complied with the Code Help policy or violated it at the time of admission decision. We then compared ED boarding time and overall ED LOS for patients cared for during periods of Code Help policy compliance and during periods of Code Help policy violation, both with reference to patients cared for during normal operations.ResultsOf 89,587 adult patients who presented to the ED during the study period, 24,017 (26.8%) were admitted to an acute care or critical care bed. Boarding time ranged from zero to 67 hours 30 minutes (median 4 hours 31 minutes). Total ED LOS for admitted patients ranged from 11 minutes to 85 hours 25 minutes (median nine hours). Patients admitted during periods of Code Help policy violation experienced significantly longer boarding times (median 20 minutes longer) and total ED LOS (median 46 minutes longer), compared to patients admitted under normal operations. However, patients admitted during Code Help policy compliance did not experience a significant increase in either metric, compared to normal operations.ConclusionIn this single-center experience, implementation of the Massachusetts Code Help regulation was associated with reduced ED boarding time and ED LOS when the policy was consistently followed, but there were adverse effects on both metrics during violations of the policy.

Project description:IntroductionEmergency department (ED) visits for behavioural conditions are rising, with 1.7 million associated episodes of patient agitation occurring annually in acute care settings. When de-escalation techniques fail during agitation management, patients are subject to use of physical restraints and sedatives, which are associated with up to 37% risk of hypotension, apnoea and physical injuries. At the same time, ED staff report workplace violence due to physical assaults during agitation events. We recently developed a theoretical framework to characterise ED agitation, which identified teamwork as a critical component to reduce harm. Currently, no structured team response protocol for ED agitation addressing both patient and staff safety exists.Methods and analysisOur proposed study aims to develop and implement the agitation code team (ACT) response intervention, which will consist of a standardised, structured process with defined health worker roles/responsibilities, work processes and clinical protocols. First, we will develop the ACT response intervention in a two-step design loop; conceptual design will engage users in the creation of the prototype, and iterative refinement will occur through in situ simulated agitated patient encounters in the ED to assess and improve the design. Next, we will pilot the intervention in the clinical environment and use a controlled interrupted time series design to evaluate its effect on our primary outcome of patient restraint use. The intervention will be considered efficacious if we effectively lower the rate of restraint use over a 6-month period.Ethics and disseminationEthical approval by the Yale University Human Investigation Committee was obtained in 2019 (HIC #2000025113). Results will be disseminated through peer-reviewed publications and presentations at scientific meetings for each phase of the study. If this pilot is successful, we plan to formally integrate the ACT response intervention into clinical workflows at all EDs within our entire health system.

Dataset Information

Implementing an allied health team intervention to improve the care of older adults in the emergency department: protocol for a process evaluation.

Publications

Implementing an allied health team intervention to improve the care of older adults in the emergency department: protocol for a process evaluation.

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