Discharge intervention reviews

The reported discharge interventions included postdischarge follow-up of patients by ED or community-based care professionals, although these were often reported incompletely.

Conroy et al 15 reported interventions delivered within 72 hours of ED attendance. These were comprehensive geriatric assessment (CGA) interventions delivered either by nurses or geriatricians and were targeted at older people with frailty. The review by Hastings et al 16 looked at evidence for interventions to improve outcomes for older people discharged from the ED. Fourteen of the studies reported by Hastings and Heflin16 were of interventions either initiated or concluded in the ED. A wide variety of interventions were reported, from CGA to single screening and assessment interventions, delivered by single practitioners or multidisciplinary teams. Karam et al 17 limited inclusion criteria to interventions delivered within the ED and including CGA and other intervention types. Lowthian et al 13 reported on discharge interventions in the form of Community Transition Strategies from the ED. All of these strategies included geriatric assessment, but this was undertaken by a variety of professional groups including nurses, allied health professionals, and health visitors. Follow-up interventions either consisted of referral to community services or direct linkages including telephone/general practitioner follow-up. Nine of the 18 primary studies included in the review of interventions to reduce ED visits by McCusker and Verdon12 were delivered in the ED; all had an ED and post discharge component.

Outcomes were reported using meta-analysis15 ,13 and narrative synthesis.12 16 17 Conroy et al 15 found no clear evidence of benefit for CGA discharge interventions across all outcomes included in the review. Hastings and Heflin16 reported at the level of individual studies only across a wide variety of outcomes. Karam et al 17 developed themes for intervention types (referral, follow-up, integrated model of care) and identification of study participants (risk screening or no risk screening). They found that the most effective interventions extended beyond referral and used a clinical risk prediction tool to identify those who would most benefit from the intervention. In the review by Lowthian et al,13 four of the nine studies were included in a meta-analysis, which found no benefit of interventions in terms of ED reattendance, mortality and emergency hospitalisation. Individual studies were effective in reducing ED reattendance and nursing home admissions—Lowthian et al 13 attributed this potentially to the methods of telephone follow-up of discharged patients. The review by McCusker and Verdon12 found that there was limited evidence of benefit of discharge interventions (two studies of borderline statistical significance) on ED visits and there was evidence of short term only increase in ED visits as a result of the intervention.

Summary—Discharge interventions varied in their components but tended to employ improved linkages between the ED and the community, either through direct linkage or referral interventions. CGA was frequently used and involved a variety of professional groups. There was limited evidence for the effectiveness of these interventions—two meta-analyses found no benefit to these interventions, and narrative synthesis reported an increase in ED readmissions in the short term among patients who had received these interventions.

Staff-focused reviews

Interventions were generally delivered by ED physicians, geriatricians working within the ED, and nurses with or without an advanced role. There was also evidence of wider MDT led interventions in a number of reviews,12 13 16–19 22 26 where professionals included research assistants, occupational therapists, discharge coordinators, social workers, physiotherapists and health visitors. Study outcomes were reported narratively and using meta-analysis. There was moderate but inconsistent agreement across the studies for the effectiveness of nurse led interventions.

Fealy et al 11 described 11 nurse-led interventions which included assessment, postdischarge referral, patient education and follow-up. Five studies reported reduction in service use and three studies reported functional improvements. Three studies found no effect. Findings were contradictory—there was evidence of reduced service use in the ED leading to increases in primary care service use. The suggested characteristics of effective interventions included preintervention screening and better links with home care.

Graf et al 18 described eight nurse-led CGA interventions which included follow-up. They reported that nurse-led CGA was effective in improving functional outcomes. There was varying evidence on ED readmissions (both reduced and increased admissions) and nursing home admissions. Three studies found no effect, attributed partly to study design limitations.

Malik et al 20 reported three different types of nurse intervention: assessment using risk screening, CGA, and nurse-led case and discharge management. This meta-analysis of nine studies found that nursing interventions did not have a significant statistical impact on any of four outcomes (hospitalisation, readmissions, length of hospital stay and ED revisits). This study did not examine functional decline. The researchers contrasted these findings with previous reviews11 16 17 which had demonstrated reduced service use as a result of these interventions, and had also reported that ED risk screening led to reduced hospitalisation and nursing home admissions. These inconsistencies are attributed to methodological weaknesses in study designs, supporting an agenda for additional research on interventions that extend from the ED to the community.

Pearce et al 21 identified only two studies which evaluated patient focused outcomes. The interventions were related to physical equipment supplied by nurses. Findings indicated that both warming blankets and seating position had a positive impact on patient comfort and well-being. The researchers noted the paucity of research around patient-centred outcomes such as nutrition, hydration and communication.

Jay et al 19 reported reduced admissions rates (ranging between 2.6% and 9.7%). The evidence for length of stay and readmission rates was mixed. A number of their included studies also reported changes in admissions rates for the control groups, indicating that CGA may have altered culture and practices around the risks of admission versus discharge.

Summary—There was conflicting evidence around the benefits of nurse-led interventions for older people in the ED. Included reviews reported reduced service use and reduced functional decline, in contrast to evidence of increased service use as a result of interventions. The strongest evidence, in the form of meta-analysis, found no effect from nurse-led interventions. There was evidence of lowered admission rates following geriatrician led CGA interventions. There were common methodological limitations reported across studies.

Population-focused reviews

Schnitker et al 23 and Sinha et al 26 reported evidence for identification and management programmes which specifically targeted older people with cognitive impairment. Schnitker et al 23 also reported staffing interventions (team and individual changes to service delivery and staff training). Neither review reported patient or health service outcomes. Both reviews described intervention characteristics that report positive outcomes, but not the outcomes themselves. Both reviews summarised that interventions were poorly represented or described within the ED literature. There was more evidence from acute care settings, although transferability of these interventions to the ED is not well understood.

Summary—There was limited evidence for population-focused interventions. The reporting of evidence made any comparison between reviews challenging. It was not possible to summarise ED interventions for older people with cognitive impairment.

Intervention component reviews

Three reviews reported on the core components of successful interventions and their outcomes. Fan et al, 24 Hughes et al 25 and Sinha et al 26 considered the key components or elements of effective interventions in addition to the overall effectiveness:

• Core operational components of interventions and the role of these components in the success of interventions.26

• Key elements of effective interventions.24

• Intervention components and intervention strategies adopted.25

In terms of intervention effectiveness, the case management interventions reported by Sinha et al 26 were reported as having positive effects (not statistically significant) on satisfaction levels, ED reattendances, admission rates (immediate and longer term), and nursing home admissions. Negative results included a small but significant negative effect on ED reattendances26 and higher ED use.24 There was a statistically significant outcome of lowering ED use or length of stay in five of 20 studies.24 Hughes et al 25 found a small positive effect of ED interventions on functional status.

Table 4 reports components that were associated with interventions found in reviews to be effective. There was considerable overlap between the three reviews, indicated by shading.

Summary—There was considerable agreement across three reviews for the components of successful interventions. Effective interventions: integrated strategies for social and medical care involvement; included screening and assessment; initiated care in the ED and bridged this with follow-up; monitored and evidenced successful practices. Care quality indicators tended to focus on care processes rather than structures or outcomes and were generally lacking in evidence and limited in testing.