Implementation of evidence-based care processes (EBP) into the Emergency Department (ED) is challenging and there are only a few studies of real-world use of theory-based implementation frameworks. ...We report final implementation results and sustainability of an EBP geriatric screening program in the ED using the Consolidated Framework for Implementation Research (CFIR).
The EBP involved nurses screening older patients for delirium (Delirium Triage Screen), fall risk (4 Stage Balance Test), and vulnerability (Identifying Seniors at Risk Score) with subsequent appropriate referrals to physicians, therapy specialists or social workers. The proportions of screened adults ≥65 years old were tracked monthly. Outcomes are reported January 2021 - December 2022. Barriers encountered were classified according to CFIR. Implementation strategies were classified according to the CFIR-Expert Recommendations for Implementing Change (ERIC).
Implementation strategies increased geriatric screening from 5% to 68%. This did not meet our pre-specified goal of 80%. Change was sustained through several COVID-19 waves. Inner Setting barriers included culture and implementation climate. Initially, the ED was treated as a single Inner Setting, but we found different cultures and uptake between ED units, including night vs day shifts. Characteristics of Individuals barriers included high levels of staff turnover in both clinical and administrative roles and very low self-efficacy from stress and staff turnover. Initial attempts with individualized audit and feedback were not successful in improving self-efficacy and may have caused moral injury. Adjusting feedback to a team/unit level approach with unit-wide stretch goals worked better. Identifying early adopters and conducting on-shift education increased uptake. Lessons learned regarding ED culture, implementation in interconnected health systems, and rapid cycle process improvement are reported.
The pandemic exacerbated barriers to implementation in the ED. Cognizance of a large ED as a sum of smaller units and using the CFIR model resulted in improvements.
