A Physiotherapy-Led Transition to Home Intervention for Older Adults Following Emergency Department Discharge: A Pilot Feasibility Randomised Controlled Trial (ED PLUS)

Abstract

Mairéad Conneely,1 Siobhán Leahy,2 Margaret O’Connor,3 Gillian Corey,3 Ahmed Gabr,3 Anastasia Saleh,3 Blessing Okpaje,3 Íde O’ Shaughnessy,1,3 Aoife Synnott,3 Aoife McCarthy,3 Alison Holmes,1 Katie Robinson,1 Lorna Ryan,1 Anne Griffin,1 Louise Barry,4 Dominic Trépel,5 Damian Ryan,6 Rose Galvin1 On behalf of Ageing Research Centre Public and Patient Involvement (PPI) Panel of older adults1School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland; 2Department of Sport, Exercise & Nutrition, School of Science & Computing, Atlantic Technological University, Galway, Ireland; 3Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland; 4School of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland; 5Trinity Institute of Neurosciences, School of Medicine, Trinity College Dublin, Dublin, Ireland; 6Limerick EM Education Research Training (ALERT), Emergency Department, University Hospital Limerick, Limerick, IrelandCorrespondence: Mairéad Conneely, Email [email protected]: Older adults frequently attend the emergency department (ED) and experience high rates of subsequent adverse outcomes including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. Our aim was to evaluate the feasibility of a physiotherapy-led integrated care intervention for older adults discharged from the ED (ED PLUS).Patients and Methods: Older adults presenting to the ED of a university teaching hospital with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED PLUS. ED PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient’s home. Feasibility and acceptability were assessed quantitatively and qualitatively. All clinical and process outcomes were assessed by a research nurse blinded to group allocation. Data analyses were primarily descriptive.Results: Twenty-nine participants were recruited indicating a 67% recruitment rate. At 6 months, there was 100% retention in the usual care group, 88% in the CGA group and 90% in the ED PLUS group. ED PLUS participants expressed positive feedback, and there was a trend towards improved function and quality of life and less ED revisits and unscheduled hospitalisations in the ED PLUS group.Conclusion: ED PLUS bridges the transition of care between the index visit to the ED and the community and is feasible using systematic recruitment strategies. Despite recruitment challenges in the context of COVID-19, the intervention was successfully delivered and well received by participants. There was a lower incidence of functional decline and improved quality of life in the ED PLUS group.Trial Registration: The trial was registered in Clinical Trials Protocols and Results System as of 21st July 2021, with registration number NCT04983602.Plain Language Summary: Older people need support when they are discharged from the Emergency Department (ED) to their home as a visit to the ED is linked to negative outcomes. This study reports on a trial to reduce negative outcomes in older people discharged from the ED by an assessment in the ED and treatment in the home. Twenty-nine patients attending the ED of University Hospital Limerick were randomly assigned to three groups as follows: One group got the normal care and treatment; Group two received a comprehensive assessment by a dedicated geriatric doctor in the ED and were referred to other health professionals as needed; a third group, called ED PLUS, also received a comprehensive assessment by a dedicated geriatric doctor in the ED and an additional six-week treatment program led by a physiotherapist. The physiotherapist visited the older adult in their own home within twenty-four hours of discharge to start treatment based on what the older adult needed to do to live safely in their own home and again at week four and week six. The same geriatric doctor who saw the older adult in the ED telephoned the older adult in week two to check medications and discussed the case with the physiotherapist. A dietitian and occupational therapist telephoned the older adults to check nutritional intake and if any aids were needed in the home. All older adults in the ED PLUS group had improved quality of their life, improved mobility and did not need to go back to the hospital or ED at six weeks and six months unlike the two other groups. The COVID-19 pandemic affected recruitment, but all ED PLUS patients were extremely satisfied.Keywords: emergencies, recruitment, integrated care, care transitions, public and patient involvement

Keywords

• emergencies
• recruitment
• integrated care
• care transitions
• public and patient involvement.