55 Interventions to relieve ED crowding by older adults CHAPTER 3 Meta-analysis The high risk of bias in most of the included studies and heterogeneity of the treatment effect (I² >70%), differences in follow-up measurement periods, and the multi-component character of most studied interventions hindered appropriate and reliable meta-analytic pooling for effect estimates. Discussion To our knowledge, this is the first comprehensive systematic review of literature evaluating the effectiveness of interventions on reducing ED crowding by older adults. We identified two types of interventions that showed to be effective in alleviating ED crowding. First, the combination of initial triage of older adults by the ED physician and multidisciplinary care – according to time-efficiency goals – within a specific hospital-based geriatric emergency unit contributes to a reduced LOS of older adults in the ED. This finding corresponds with literature on improving ED patient flow. The use of doctor-led triage [45], rapid assessment [46], and streaming (i.e., allocating similar patient types to a particular work stream were they are assessed by dedicated staff in a specific geographical area within the ED) [47], have all been shown to improve patient flowand thus alleviate ED crowding. Second, older adults treated in an emergency care setting with an embedded geriatrician receive more timely geriatric assessment compared to an in-reaching geriatrician service. This finding is in line with previous studies addressing the value of putting geriatricians at the “front door” of the hospital; it allows early specialist review, reduces the undertaking of multiple similar patient assessments by medical staff and improves the timeliness and appropriateness of ED disposition decisions [48]. Literature shows that many ED physicians and nurses are not well-trained in geriatric emergency medicine and feel less comfortable when dealing with older adults [49, 50]. Consequently, the management of older adults in the ED often requires more time and resources compared to younger adults [51]. The presence of a geriatrician could help ED staff in becoming more capable and confident in dealing with older adults in a timely manner. Despite these positive findings, robust evidence for effective interventions in alleviating ED crowding by the older patient population remains limited. Significant effects are based on single studies, limiting the ability to generalize findings across ED settings. Moreover, individual studies with positive effects on reducing crowding are not supported by other studies evaluating a similar type of intervention on the same outcome. Many interventions showed reduced ED revisits for older adults, but lacked statistical significance. Some interventions
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