Table 3 Study intervention characteristics as mapped to the Consolidated Framework for Implementation Research Transitions of Care Framework, adapted from Rojas Smith et al. [38]

Intervention characteristics

Vision of intervention: All older patients in the ED will be screened for cognitive problems, mobility issues, and home needs, and appropriate solutions will be found using a multidisciplinary approach.

Target groups: Older adults in the Obs Unit and ED staff

Intervention source: Administrative, led by ED physicians

Evidence strength: Moderate. Positive results from similar programs at other institutions at reducing admissions and identifying unrecognized geriatric needs.

Feasibility: Stakeholders in the implementation group and frontline feel this can be successfully carried out.

Adaptability: Moderate to high. If we find screening tools insensitive or that this is impeding flow, the algorithm can be changed.

Trialability: Intervention trialed on a small scale in the Obs Unit only, but now needs to be expanded to screening everywhere in the ED.

Complexity: High, involves multiple screens, multiple consultants, and buy-in from multiple departments in the health system.

User control: High. The intervention relies on staff action.

Location of intervention activity: ED and Obs Unit.

Task standardization: Screening tools and observation ordersets have been built into the electronic medical record.

External context

External pressures: Reducing readmissions and the payer mix in the area are pressures to implement this intervention. Additionally, Geriatric ED Accreditation is an external pressure to implement this program.

External policies: Geriatric ED Accreditation and Accountable Healthcare Organization both advocate for addressing needs in the ED and coordinating with community care.

Population needs: Demographics endorse this project. Aging population in the area is of high medical complexity, and access to care and specialists is often difficult.

Community resources: Good availability of community resources for home health. Some difficulty with acute rehabilitation or skilled nursing facility placement from the ED.

Organizational characteristics

Structural: Hospital is mature, well respected, and well integrated into the community. Obs Unit is located within the ED and flexes beds with the ED. High ED boarding rates lead to a focus on reducing admissions. One barrier is that as a tertiary care facility, ED acuity is high and the focus on acuity may decrease the time needed for geriatric screening and management.

Networks and teamwork: Communication between ED team, Obs team, and consultant teams is moderate. Formally communicate via health records, informal by phone calls. Communication between case management team and community resources is strong.

Culture: Strong “flow culture” resistant to introduction of tasks that do not improve flow is a barrier to implementation. There is also some fatigue from frontline staff due to the constant march of quality improvement initiatives. Email is not a good way to disseminate information. Nursing culture does include “huddles” before every shift which is a good way to allow staff to question new projects and disseminate information.

Implementation climate: Strong organizational push for better care of older adults. Hospital has NICHE certification and a modified ACE unit. Consultants are very willing to assist with the process. ED, RN, and hospital administration in favor of the project. Climate for trialing new processes and learning initiatives good.

 Tension for change: Low. Staff feel comfortable with the current status.

 Organizational mandate: Moderate (the organization is constantly mandating things).

 Accountability: Low, no tangible consequences for not following the intervention.

 Relative priority: Moderate. Most nurses will do the screening if asked, but it is not top priority for patient care.

Readiness: Educational training not complete due to high nursing turnover. RN leadership may see this as a side project. The last QI project led by Dr. Southerland for ED nurses had 73% compliance among nurses for the survey and 81% compliance with a 1-h online training module. Therefore, the team has a track record of obtaining good compliance with training initiatives.

Access to training: RNs are given protected time for training and have dedicated nurse educators (facilitator).

Patient oriented: High patient orientation, project is focused on identifying and meeting patient needs. This is a strength in the eyes of the organization and staff (facilitator).

Human factors

 IT accessibility: Geriatric screening tools and a flowsheet are built in but may require improvement to make it more noticeable and work with flow issues (barrier). Department has IT infrastructure for quality improvement projects (facilitator).

 Physical space/equipment: No new space or equipment needed

 Staff time: Large factor, however the assessments take last than 3 min.

Characteristics—provider roles

Nurses: Frontline team for this effort and will direct care. On the other hand, RNs feel overwhelmed and overburdened with patient care needs.

 Knowledge/beliefs: Will need knowledge refreshers as some did the training 2–3 years ago. As they spend the most time with the patient, they are most likely to recognize delirium or fall risk. There is some age bias, and some staff may be reluctant to go into an older adults’ room because of fear it will take longer to perform simple tasks.

 Skills/competency: Very skilled at screening questions, as this is a part of ED triage.

 Role: Initial screening (step 1) and informing the physician team.

 Self-efficacy: Very high. Emergency RNs take on a great amount of responsibility and are allowed to place triage orders.

Physicians: Frontline team, the same physicians and advanced practice providers work in the ED and Obs Unit.

 Knowledge/beliefs: Focused on acute care mindset only. Will often ignore other issues that do not specifically cause problems in the ED setting (e.g., delirium, fall risk, polypharmacy). Education/knowledge level of the intervention is low.

 Skills/competency: Frequently use ordersets and order consultations.

 Role: (step 2) Determine appropriate multidisciplinary geriatric assessments to order.

 Self-efficacy: Very high.

Consultant teams: Good culture of seeing patients quickly. Intervention should assist with their care and possibly speed their evaluations.

Time: No dedicated staff time for this project other than nurse educator and PI (Dr. Southerland).

Characteristics—patients

Socioeconomic effects: Socioeconomic barriers may impede access to care and follow-up. Plan to control for this by using zip code-level socioeconomic status and type of health insurance as variables in the logistic regression.

Cultural: We will only be able to recruit English-speaking patients into the pre-/post-cohorts, and so will not be able to assess the effect of cultural differences.

Patient needs: May minimize symptoms. May not be receptive to interventions such as rehabilitation placement or home care options.

Caregiver needs: May or may not have caregivers available. If available, case manager assesses for caregiver burden and assists with arranging care needs and medical equipment, if applicable.

Other: Patients may be hesitant to speak out (elder abuse, cultural differences) or criticize their care during interviews.

Process of implementation

Lean Six Sigma

Planning: Baseline focus groups to identify barriers. Workflow analysis to address the flow culture needs. Time for planning and lean meetings during the pre-implementation phase.

Acquiring resources: No new resources or staff acquired.

Process roles

 Process ownership: Dr. Southerland to be the ED physician lead, Erin Farrell (ED nurse manager), Peg Gulker, and Cole Briggs are nurse leaders.

 Organizational leaders: Chief Nursing Officer Beth Steinberg and Executive Director of the hospital, Dr. Susan Moffatt-Bruce.

 Opinion leaders/champions: Some opinion leaders already identified (charge RNs) but need to find staff RN champions for each unit.

 External change agents: Could consider involving local payer groups (Medicare groups)

 Integrators: Case managers may play a large role in furthering care by coordinating between the consultants and outpatient resources.

 Patients and caregivers: Study plans discussed with the ED Patient Advisory Board who were very positive and encouraging.

Reflecting and evaluating: Quantitative feedback arranged in the form of a Geriatric ED dashboard. Currently monthly, but will change data reports to weekly during implementation.

Measures of implementation

Acceptability: Focus group interviews to determine barriers and examine shifts in culture. Before/after surveys of RNs and ED MDs to determine changes in knowledge and awareness.

Appropriateness: Will be examined with the effectiveness data.

Intervention cost: Not measuring. No new staff/costs for the ED, but potentially new healthcare costs for patients.

Fidelity: Adherence to protocol based on chart audits by research staff. Study will also report how the initial protocol is adapted during implementation.

Reach: Number of patients affected (15,000 older adult patients per year in the ED).

Sustainability: Phased withdrawal of implementation procedures (chart audits, weekly meetings, etc.). Sustainability measures included including assessments at 1 and 2 years out.

Evolvability: Number of rapid cycles needed to achieve > 80% screening rate. Changes to original protocol needed to meet changing ED environment or patient needs.

Outcomes

Patient centered: Multiple patient-centered outcomes include health-related quality of life, unmet needs identified and addressed, and functional status.

Patient experience: Plan to assess via randomized semi-structured patient interviews in the post-cohort.

Provider experience: The sustainability surveys address this and evaluate how easy and routine the intervention has become.

Processes of care: Team will record ED admission rates and length of stay in the ED.

Care coordination: How often are post-ED visit appointments made? How often is follow up completed in specialty clinics (falls, geriatrics, etc.)?

Safety: Plan to record any patient complications or family concerns that arise during the screening/assessment process.

Healthcare utilization: Readmissions, ED revisits, adherence to recommendations for physical therapy, occupational therapy, and geriatric referrals.

Unintended consequences: Any increased pressures on workflow, difficulties with consultants, or overload of the Obs Unit staff.