56 Chapter 3 also demonstrated opposite effects, such as a prolonged ED LOS and increase of ED revisits. These effects may be explained by the time needed to carry out the intervention (e.g., an ED-based geriatric nurse of pharmacist responsible for cross-checking medications and organizing appropriate referrals). Although ED crowding by older adults is considered to be a global problem and threat to patient safety [16], the amount and quality of experimental research dedicated to this urgent problem is surprisingly poor. We found only one CBA study that explicitly addressed the problem of crowding as the leading motive for intervention development and testing [37]. Moreover, only four studies evaluated intervention effects on ED throughput efficiency (e.g., ED LOS, time to geriatric review). Studies evaluating interventions on two other important components for explaining ED crowding – ED input and output efficiency were not found. These findings call for a more valid and comprehensive evaluation of interventions targeting ED crowding reduction by older adults visiting the ED. Our operationalisation of ED crowding measures (Table 1) and the overviews of measuresprovidedbyothers [2, 22-24],mayguideresearchers inselectinguniform and valid outcomes. In addition to the measurement of effects, more insight is needed into the feasibility of interventions and the factors that hinder and promote successful implementation to better inform policy-makers on selecting and implementing interventions based on the local needs and possibilities. For example, the introduction of a geriatric emergency unit, efficiency goals and embedding a geriatrician at the ED may involve significant costs and changes in work routines. The commitment from many different medical specialties and strong leadership may then be important factors determining the intervention’s success [39]. Study Limitations Our review had several limitations. First, we used a wide set of internationally accepted measures of ED crowding to objectively assess publications on their relevance. However, to date, there are no uniform criteria to define and measure ED crowding. As a consequence, potentially relevant studies using other measures for ED crowding might have been overlooked. Second, marked heterogeneity among studies, particularly in interventions and outcome measurement periods, precluded meta-analysis and made it difficult to draw firm conclusions. Second, comparison of effects between studies were hindered by varying population groups. Among the 16 included studies, four different thresholds of old age were used to mark the older patient. Some studies focused on subgroups of older adults (i.e., with a chronic disease, with a fall history and with a traumatic injury). Third, comparison of effects between studies were hindered because the majority of studies implemented and evaluated
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