Doctoral thesis on the URGENT care model

On 25 October, Pieter Heeren successfully defended his doctoral thesis on the

URGENT care model that aims to improve care for older adults during and after an emergency department (ED) stay. The general aims of his work focused on evaluating the effectiveness of this care model and exploring improvement opportunities.

Pieter's work nourishes the rationale, content and proof of concept for geriatric emergency care in both the Belgian and the international context. It includes the first intervention study on geriatric emergency care in Belgium and one of the first nurse-led geriatric emergency care models in Europe. In addition, the thesis describes important disparities in care for older adults within and between EDs. Therefore, he established an interdisciplinary consensus on minimum operational standards for geriatric care in Belgian EDs.

Pieter graduated in 2012 as Master of Science in Health Care Management and Policy at KU Leuven. First, he worked as a nurse on a cardiology ward in University Hospitals Leuven, which he combined with a halftime position as a research assistant at AccentVV as from 2013. Since 2014, Pieter has been working on the URGENT project. Initially, he combined a halftime position as URGENT project coordinator with an appointment as a nurse practitioner in the inpatient geriatric consultation team. In 2017, Pieter obtained a PhD fellowship of Research foundation – Flanders (FWO) to conduct his doctoral studies on a full-time basis.

Throughout the years, Pieter became a guest lecturer at University Colleges Leuven-Limburg (UCLL) and the co-chair of the Geriatric Section in the European Society for Emergency Medicine (EUSEM). This year, Pieter obtained a one-year postdoctoral position of KU Leuven Internal Funds to continue his work. We wish you the best of luck in your further career, Pieter!

Pieter Heeren received his PhD under the supervision of Prof. dr. Dr. Dr. Dr. Koen Milisen(supervisor), Prof. dr. dr. Johan Flamaing (co-supervisor) and prof. Marc Sabbe (co-promoter), who are all affiliated to the Department of Public Health and Primary Care at KU Leuven.

SUMMARY PhD Pieter Heeren

Emergency departments (EDs) are traditionally conceived on a fast-paced, complaint-oriented approach. While this has proven effective for managing the general population, it has shown to deliver suboptimal care and outcomes to the growing group of older adults. Creating a patient-oriented approach by integrating the concept of comprehensive geriatric assessment (CGA) in emergency medicine is considered the best available strategy to optimize care and outcomes of older ED patients. However, the effects of ED-based CGA remain inconclusive. The starting point of this dissertation was a newly developed CGA-based care model for older patients in the ED of University Hospitals Leuven in Belgium (ie URGENT). To explore the scaling possibilities of the URGENT care model, this doctoral dissertation described its effectiveness and potential improvement opportunities. These goals were accomplished with five studies. First, a single-centre, quasi-experimental study (sequential design with two cohorts) was conducted to evaluate the effectiveness of the URGENT care model. It showed that a geriatric emergency nurse can improve in-hospital patient management, but failed to introduce substantial out-hospital case-management. The URGENT care model shortened ED length of stay and increased the hospitalization rate. No effect was found on the unplanned ED readmission rate. Second, the diagnostic accuracies of three geriatric screening tools were described and compared regarding their ability to predict four outcomes (ie prolonged ED length of stay, hospitalization (following index ED stay) and unplanned ED readmission at 30 and 90 days). All instruments had similar areas under the receiver operating characteristics curve (range between 0.49-0.62), indicating that none of the tools should be used as a stand-alone index. Third, sixteen studies were included in a scoping review to explore the structure and processes of emergency observation units with a geriatric focus. These units were located in the ED, immediately next to the ED or remote from the ED (ie hospital-based). All studies reported that staffing consisted of at least three healthcare professions. Observation duration varied between 4 and 72 hours. Four studies reported to assess a patients' medical, functional, cognitive and social capabilities. if deemed necessary, post-discharge follow-up (eg community/primary care services and/or outpatient clinics) was provided in eleven studies. Fourth, a multicentre survey reported that Flemish ED head nurses and ED chief physicians agree that older patients need a different approach and that initiatives are necessary to improve both geriatric care in EDs and continuity of care after ED discharge. In addition, this study also reported that most Flemish EDs have already taken initiatives in this matter (eg improved accessibility of geriatric practitioners, integration of geriatric-friendly protocols and equipment). Although these initiatives are valuable, it has introduced important disparities in care between EDs. Fifth, Delphi study methodology was used to develop a consensus on minimal operational standards for geriatric care in Belgian EDs. a broad, interdisciplinary consensus was established focusing on the target population, specific goals, availability of geriatric practitioners and quality assurance. In addition, these statements also determined which protocols, materials and accommodation criteria should be available in two different ED types: the conventional ED and the observational ED. Overall, although the evidence base of geriatric emergency care still needs strengthening, Belgian EDs have already started integrating geriatric-focused initiatives in clinical practice. As these have introduced important disparities in care within and between EDs, efforts are necessary to harmonise and optimize geriatric emergency care. While the established consensus may serve as a starting point for formulating a formal framework for geriatric emergency care in Belgium, collaborations between governments, EDs and professional organizations should be set up to organize bottom-up initiatives. Future research should explore how to optimize risk-stratification in the population of interest and demonstrate how geriatric emergency care contributes to the performance of healthcare systems.

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