159 General discussion and future perspectives CHAPTER 7 Fourth, one of the main limitations of the teach-back study is that there was neither randomization nor a direct control group, and therefore, the isolated effect of the teach-back method cannot be fully addressed. However, we described our objectives and the factors that we wished to evaluate in our study. We also provided a detailed and appropriate analysis for these intended objectives. Although a randomized or well-controlled study design may be more conclusive, our study clearly showed that teach-back is associated with fewer ED revisits and improved retention of discharge instructions by older adults and is an important basis for a future randomized study. Reflections on the study findings The type of medical specialty of the treating physician, as an explanatory factor for the prolonged length of stay of older adults, has not been studied before. In one of our studies, we found an association between the type of attending physician (specialty) and prolonged length of stay of older adults in the ED. This finding is not surprising; residents in various specialties lack knowledge of geriatric emergency medicine (13, 14). The need for (additional) geriatric education is recognized for medical (15-17) and surgical (18-21) specialists working in the ED. However, this is not an easy task, as numerous types of specialists work in the ED, and they might have different educational needs. It would be a significant challenge to translate the geriatric competencies needed for the treatment of older adults in the ED into education for physicians of different specialties and implement this education in their residency programs. Therefore, we propose that a physician in the field of geriatric emergency medicine who feels capable in the field should evaluate older adults presenting at the ED. This could be a geriatrist or an emergency physician with sufficient training within geriatric emergency medicine. Continuous supervision by geriatrists at the ED would not be feasible due to limited availability of geriatric specialists (22, 23), whereas emergency physicians are always present in EDs. Considering these factors, it makes sense to trust an emergency physician – who is well educated in emergency geriatric medicine – with the responsibility to primarily evaluate all older adults presenting at the ED or supervise physicians of other specialties who treat this vulnerable group of patients. The findings of our systematic review should be interpreted with caution. First, although we identified two effective interventions for reducing ED crowding with older adults, it is questionable whether these interventions are easily implementable strategies for many EDs. The first effective intervention – ED physician-led triage combined with multidisciplinary care – was examined only in single-centre studies, which limits the ability to generalize findings across EDs worldwide. The second effective intervention – an ED embedded
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