Emergency department clinician satisfaction with an APRN‐led geriatric emergency medicine service consult team

Older adults comprise 20% of annual emergency department (ED) visits, with the time period after discharge shown to confer increased risk of functional decline and morbidity.1-5 ED clinicians report that completion of a comprehensive patient-centered care plan for these complex patients is increasingly challenging given patient volumes and limited time and resources.6 An embedded Geriatric Emergency Medicine service (GEMs) can help address these challenges. To date, clinician attitudes and perceptions of such a service have not been studied. This information could guide the successful implementation of a GEMs team. This study describes ED clinician attitudes after implementation of the Advanced Practice Registered Nurse (APRN) led GEMs consult service in a large academic health center. Consultations were conducted between March 1, 2017 and November 30, 2019 at a large tertiary academic medical center with 1541 beds and an annual ED volume of 80,600 visits, with approximately 24% being older adults. Consults were placed by ED clinicians. The GEMs APRN completed a thorough evaluation based on the Age Friendly Health System 4 M's framework (Mentation, Mobility, Medications and What Matters).7, 8 Cognitive testing included the Confusion Assessment Method and if negative for delirium, a Mini Mental Status Examination (MMSE).9 GEMs team recommendations included pharmacological and non-pharmacological recommendations. The GEMs APRN helped facilitate a comprehensive discharge plan for patients discharged and provided recommendations for prevention of potentially avoidable iatrogenic complications (delirium, deconditioning, etc.) for patients admitted to the hospital. A 9-question electronic QUALTRICS survey was created and beta tested by the GEMs team in collaboration with Geriatric Medicine faculty. The survey was distributed to ED clinicians via email. Sample questions included: “Overall, how satisfied are you with the GEMs team?” and “How often did the GEMs team recommendations change the treatment plan for your patients?”. Respondents ranked helpful reasons for consulting including: assessment of the patient who presented with a fall, assistance with care coordination, agitation with dementia, goals of care, medication recommendations, or concerns for abuse/neglect. There was an optional open-ended free text question for comments regarding the GEMs team. Clinicians had 14 days to anonymously complete the survey. A total of 2547 distinct patients were evaluated. Patient characteristics and hospital course information are shown in Table 1. Of the 461 clinicians who received the survey, 154 responded (response rate 33%). Respondents included 49 physicians (31.8%), 25 advanced practice providers (16.2%), 63 registered nurses (40.9%), 14 care managers (9.1%), and 3 “other” (1%). A total of 125 (81%) respondents had consulted the GEMs program. Satisfaction rates were: extremely satisfied (108, 86%), somewhat satisfied (9, 7%), neither satisfied nor dissatisfied (8, 6.4%), somewhat dissatisfied (0, 0%), and extremely dissatisfied (0, 0%). Most respondents (72%) felt that the GEMs team's recommendations changed the treatment plan at least half of the time. (Figure 1). The most helpful reasons ranked for consult were “Falls” (31%), Care coordination (30%), “Agitation and Dementia” (18%), “Goals of Care” (14%), “Concern for Abuse or Neglect” (4%), “Medication recommendations” (2%), and “Other” (1%). An illustrative comment from the free text question was, “The GEMs providers have added additional support to the assessment of the elderly in the ED as well as an educational opportunity for ED providers. They have been an asset in providing direction to providers for the appropriate care transition in coordination with Care Managers. They have prevented unnecessary admissions…and have assisted in educating providers about this. They truly are an integral part of the team in providing appropriate care, medication advice and assistance with care transition for the patient and the family.” Another comment, “This is by far and away one of the best interventions for patient's we've introduced in years.” Supplemental Text S1 includes a copy of the final survey responses to all questions and additional answers to the open ended commentary question. This work is the first to demonstrate ED clinician satisfaction with and perceived helpful reasons for GEMs consultation. Our study demonstrated high satisfaction among ED clinicians and identified valued consultations, including assistance with fall-related injuries, care coordination, and behavioral and psychological symptoms of dementia. In addition, most clinicians felt the GEMs team recommendations changed the care plan. This is valuable information for creating innovative frameworks to provide quality patient centered care within a potentially chaotic ED environment. This study has potential limitations to consider, namely that the included survey respondents were from one academic hospital. However, the wide array of roles among respondents is a strength that adds to its generalizability. This study demonstrates that an APRN-led GEMs program is a viable and well received model to enhance care of the older adult in the ED. Laura T. Moreines: overall study concept and design, survey design and delivery, data management, interpretation of data and preparation of manuscript. Cameron J. Gettel: overall study concept and design, preparation of manuscript. Alexandra M. Hajduk: overall study concept and design, preparation of manuscript. Shannon Kukulka: overall study concept and design, survey design. James M. Lai: overall study concept and design. Jennifer A. Ouellet: overall study concept and design, survey design, data management, interpretation of data and preparation of manuscript. Laura Moreines: Geronotological Advanced Practice Nurses Association, Foundation Virginia Lee Cora Research Project Grant. Dr. Cameron Gettel: Pepper Scholar with support from the Claude D. Pepper Older Americans Independence Center at Yale School of Medicine (P30AG021342) and the National Institute on Aging (NIA) of the National Institutes of Health (NIH; R03AG073988). Dr. Jennifer Ouellet: Grant support from John. A Hartford Foundation (2018-0064 Patient Priorities Care) and the Yale HRSA GWEP (6 U1QHP28745-03-06). The authors declare that there is no conflict of interest. None. Text S1. Include final results for all survey questions Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. 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