54 Chapter 3 Intervention effects on ED throughput time One CBA study, with high risk of bias, reported a significant reduction of ED LOS for patients who were treated at a geriatric trauma unit compared to the control group [39]. Patients presented at the unit were assessed by an ED physician on established criteria for geriatric trauma service activation. Upon activation patients were seen immediately by the trauma service and a hospitalist, and quickly by relevant ancillary services. The service was organized around efficiency time-to-care goals for the medical staff. Trauma surgeons acted as coordinators for the older trauma patient to facilitate definitive management of the injury by subspecialists [39]. On the contrary, two other studies reported a significant longer ED LOS for patients who were exposed to the intervention [43, 44]. Miller and colleagues performed a RCT to measure the effects of a combined ED-based CGA, liaison services and telephone follow-up by a geriatric nurse [43]. Patients in the intervention group stayed on average 1h longer at the ED compared to patients receiving usual care. In a NRCT, Mortimer and colleagues found that older adults who were seen at the ED by a geriatric pharmacist stayed on average 2.6h longer than older adults receiving usual care management at the ED [44]. Both studies suffered from a high risk of bias (e.g., no randomization, allocation concealment, blinding of outcome assessors, possible contamination between intervention and control groups). Furthermore, one CBA study reported that older adults in an embedded frailty emergency zone with a dedicated consultant geriatrician were seen and reviewed significantly earlier (twice as fast) by a geriatrician than controls receiving emergency care by an in-reaching geriatrician service [42]. Intervention effects on ED revisits Nine studies reported a decrease in ED revisit rates for intervention groups compared to the controls [30, 32, 33, 35-37, 40-42]. One RCT, with moderate risk of bias, reported a statistically significant decrease of revisits within 6 months post index ED visit for discharged elderly patients following a 24-week homebased exercise and telephone follow-up program compared to controls receiving usual emergency care and discharge planning [35]. On the contrary, one RCT with low risk of bias reported a statistically significant increase in the average number of revisits within 10 months post index ED visit for elderly patients receiving community-based nurse case management compared to the controls receiving usual care [29].
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