163 General discussion and future perspectives CHAPTER 7 Regarding evaluation of the geriatric education program, we chose to evaluate self-reported levels of competence and confidence and a perform pre-post analysis of patient charts, although we knew that self-assessment of competence was unreliable (48). Direct observation and standardized assessment of emergency physicians’ competence would be the ideal design to evaluate whether education results in an improved ability to care for older adults and medical decision-making. Given the busy work schedules in our ED, this type of assessment was not feasible, but it should ideally be part of future studies evaluating the effectiveness of geriatric education programs. Future perspectives for the care of older adults in the emergency department Care for older adults is not a specific topic in Dutch emergency medicine residency training programs. Emergency physicians who wish to develop their clinical skills to treat older adults after residency have limited options. We believe that the development of emergency physicians with expertise in treating this group of patients may lead to both logistical and clinical benefits in ED care. Our point of view is that (standardized) geriatric care relevant for the ED should be included in residency training programs. In addition, emergency physicians should have more educational options post-residency to develop their clinical skills on the topic of care for older adults. Additional education post-residency is not an easy task, and since the balance between workload and quality of care is fragile, a shift in either direction should be prevented accordingly. We believe that standardized and validated screening instruments (e.g., Clinical Frailty Score (49), Acutely Presenting Older Patient Tool (50)) should be utilized in all EDs to identify older adults who are fragile. In addition to the use of screening tools, emergency physicians could and should be educated to prepare them to autonomously treat older adults. Needless to say, autonomous treatment by an emergency physician will not be suitable for all older adults with multimorbidity and acute presentation in the ED. Some (complex) geriatric complaints/illnesseswill still bemore appropriately treated by a geriatrician in the ED. In our ED, emergency physicians screen older adults for trauma-related injuries. One specific category of injured patients is older adults with a fractured hip. In an attempt to innovate and improve emergency care and decrease the length of stay of these patients, emergency physicians in our EDwere, for example, educated to performan ultrasound-guided femoral nerve block for analgesia rather than waiting for a consultant anaesthesiologist. A study in our ED examining emergency physicians performing ultrasound-guided femoral nerve block found that emergency physicians were effectively trained to perform this procedure (51). The emergency physician
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