Healthcare workers’ experience of screening older adults in emergency care settings: a qualitative descriptive study using the Theoretical Domains Framework

Abstract

Background

In emergency care settings, screening for disease or risk factors for poor health outcomes among older adults can identify those in need of specialist and early intervention. The aim of this study was to identify barriers and facilitators to implementing older person-centred screening in emergency care settings in the Mid-West of Ireland.

Methods

This study employed a qualitative descriptive design underpinned by the theoretical domains framework (TDF). This design informs implementation strategy by establishing a theoretical foundation for focused objectives. One on one semi-structured interviews were conducted with a purposive sample of healthcare workers (HCWs) to explore their screening experiences with older adults in emergency care settings. Information power guided sample size calculation. In data analysis, verbatim interview transcripts were deductively mapped to TDF constructs forming meta-themes that revealed specific barriers and facilitators to person-centred screening for older individuals. These findings will directly inform implementation strategies.

Results

Three themes were identified; Preconditions to Implementing Older Person-Centred Screening; Knowledge and Skills Required to Implement Older Person-centred Screening and Motivation to Deliver Older Person-Centred Screening. Overall, screening in emergency care settings is a complicated process which is ideally undertaken by knowledgeable and skilled practitioners with a keen awareness of team dynamics and environmental challenges in acute care settings. These practitioners serve as champions and sources of specialist knowledge and practice. Less experienced clinicians seek supervision and support to undertake screening competently and confidently. Education on frailty and aged related syndromes facilitates screening uptake. Recognition of the value of screening is a clear motivator and leadership is vital to sustain screening practices.

Conclusions

Screening serves as an entry point for specialist intervention, necessitating a specialist multidisciplinary team (MDT) approach for effective implementation in emergency care settings. Strengthening screening practices for older adults who attend emergency care settings involves employing audit, supervision and tailored supports. Skilled and experienced practitioners play a key role in mentoring and supporting the broader MDT in screening engagement. Long-term and sustainable implementation relies on utilising existing managerial, practice development and educational resources to underpin screening practices. Communication between Emergency Department (ED) staff, the specialist team and wider geriatric team is vital to ensure a cohesive approach to delivering older person-centred care in the ED.

What this paper adds

• Strengthening of screening practices in emergency care settings is attainable through audit, supervision and leveraging existing educational supports.

• While resources for older person-centered screening exist, expansion, development and managerial support are essential

• Skilled screening practitioners are ready to mentor and support the wider multidisciplinary team in screening endeavours.

• HCWs exhibit motivation to engage in older person-centred screening, driven by both professional and personal benefits, with a predominant focus on improving care for older individuals.

• Due to its complexity, establishing preconditions to embedding older person-centred screening in these challenging environments is vital.

Background

Emergency departments and acute assessment units (AAUs) (Emergency Care Settings) serve as critical access points to vital healthcare services for many patients (Hurley et al, 2019 [1]; Weber et al, 2023 [2]). Screening for disease or risk factors within these settings can identify individuals requiring specialist intervention, leading to enhancement in both individual and population health outcomes (Barry et al, 2023 [3]; Leahy et al, 2023 [4], Weber et al, 2023 [2]). Implementation of screening tools for frailty, sepsis, falls, functional decline and healthcare utilisation in EDs underscores the growing emphasis on early disease identification and identification of associated risk factors (Kirk et al., 2016 [5]; Marcoux et al., 2017 [6]). Successful screening initiatives should prioritise evidence-based strategies, considering local epidemiology, ED capacity, financial stability, and collaboration with community services for effective implementation (Weber et al., 2023 [2]).

Up to 25% of all attendees to emergency and unscheduled care are older adults (over 65 years) (Galvin et al, 2017 [7]). These older adults often experience complex co-morbidities and unmet healthcare needs in the community setting (Seematter-Bagnoud and Bula, 2018 [8]). Identifying older adults who are at greatest risk of adverse outcomes following ED visit can serve to initiate appropriate care plans in the hospital or community setting.

Screening for functional, cognitive, affective, hearing and visual impairments, as well as nutritional status, falls risk and social status can identify patients necessitating further comprehensive geriatric assessment (CGA) or specific interventions (Seematter-Bagnoud and Bula, 2018 [8]). While older person screening tools (e.g. CFS (Clinical Frailty Scale), ISAR (Identification of Seniors At-Risk), STOPP/START Criteria, Geriatric Depression Screening) are often labelled as geriatric screening, recommendations for CGA and holistic older person care in emergency settings encompass both geriatric specific and generalised screening tools (e.g. Sepsis, MUST Nutritional Screening Tool). This approach requires thorough screening, assessment and intervention for all possible presenting complaints and underlying co-morbidities. This process can be referred to as older person-centred screening and is informed by National Guidance on the screening and assessment of older adults published in the integrated care strategy for older adults (NCPOP, 2017).

To ensure evidence-based gerontological patient screening and assessment, the team must select validated, reliable and age-appropriate tools in response to presenting symptoms (NICPOP, 2017 [9]; NICPOP, 2021 [10]; HSE, 2017 [11]). These tools are often integrated within a comprehensive geriatric assessment (CGA) framework, along with associated proformas or algorithms, guiding HCWs practice and referrals. In emergency care settings, a geriatric model of screening enhances the accuracy of differential diagnoses, particularly for key age-related syndromes linked to delirium or frailty (BGS, 2019 [12], Leahy et al, 2021 [13], Veronese et al, 2022 [14]). This model fosters a more patient-centered and efficient care approach, reducing the need for investigations and overall hospital usage (BGS, 2019 [12], Leahy et al, 2021 [13], Veronese et al, 2022 [14]). Ideally, a multidisciplinary assessment proforma should underpin the intervention plan enhancing the quality and consistency of documentation and promoting CGA initiation (Xu et al, 2021 [15]).

Barry et al (2023) [3] identified specific barriers and facilitators to screening adults in emergency care settings (ED’s, AAUs). This qualitative evidence synthesis (QES) was the first to focus specifically on screening in these healthcare settings. The findings of this QES formed the foundational synthesis upon which this current study is based. Specifically, QES findings underpinned the study methodology by providing evidence to inform the interview guide and pin-pointed the need for further exploration of this approach to screening These QES findings underscored the high motivation of HCWs to engage in screening when actively involved in implementation, provided with education, and supported to sustain practices in challenging settings. This evidence synthesis also identified that in-depth knowledge and understanding of the benefits of screening for both patients and the ED environment were crucial for sustained adherence to screening, clear preconditions for delivering screening in these settings were deemed vital. Furthermore, competing priorities related to the care of acutely ill patients were found to affected screening adherence, necessitating contingency planning in acute settings. This synthesis also emphasised the value of identifying context specific barriers and facilitators to screening, at local level, involving frontline acute service personnel for successful implementation strategies. Furthermore, this synthesis was limited in its application to older person-centred screening with the included sample groups having limited experience of using screening tools with and for older adults. Consequently, the gap for this current study was identified.

This qualitative descriptive study was designed to delve deeper into the specific barriers and facilitators of older person-centered screening. The study's aim was to identify such factors in emergency care settings in the mid-west of Ireland, with the intention of informing implementation strategies. The primary setting has an ED and AAU which operates 24/7 and provides acute care to undifferentiated medical and surgical patients. The additional settings comprise of AAUs [16] which provide care to lower acuity patients with undifferentiated medical complaints. On average 15-20% of patients who attended these settings are over the age of 65 and on average 80,000 people attend the ED each year. Currently, patients who attend AAU’s stay between 6 and 24 hours. The study settings represented in this study are inclusive of EDs and AAUs with high attendance rates and diverse acute presentations. Consequently, this will ensure that study findings are representative of HCWs experience in emergency care settings with similar patient care structures and services offering a national perspective. Within these settings, older person-centred screening is undertaken by both a specialist geriatric team and members of the wider MDT. The specialist team practice 7 days a week, twelve hours a day (08:00-20:00) Predominantly, this older person-centred screening is done by the nursing and medical team or members of the allied health team (OT, physiotherapist). All older adults who attend are screened for risk of adverse outcomes using the ISAR (Score Over 2), this is undertaken as part of the primary assessment either in triage or as part of the initial nursing or allied health assessment. If found to be At-Risk a more comprehensive form of screening and assessment is undertaken (CGA), this is inclusive of frailty and adverse outcomes, falls and fracture risk, functional decline and co-morbidities, malnutrition risk, depression/delirium and psychosocial, polypharmacy and medication risk, cognitive screening and more generalised acute care screening including sepsis, infection control related screening and screening related to risk factors such as smoking and alcohol and drug misuse. Consequently, to ensure a comprehensive exploration of older person-centred screening, members of the MDT team from both the geriatric specialist team and wider MDT were interviewed.

Methods

Design

A qualitative descriptive approach, grounded in the TDF framework, was employed (See Supplementary File One TDF). This design allows direct exploration of issues critical to the research area, offering a participant-centric perspective that is beneficial for healthcare staff (Doyle et al, 2020 [17]). This approach is particularly relevant where accessible and understandable findings that are directly applicable to healthcare practice and policy are required (Doyle et al, 2020 [17]). Furthermore, in qualitative studies, the TDF serves as a flexible framework which is especially useful for diverse health professionals across various clinical settings and for assessing barriers and pinpointing targeted resources for behaviour change in implementation projects (Philps et al, 2015 [18]). The TDF was designed to understand and improve implementation of an intervention and has largely been applied to health professional behaviours (Sargent et al, 2017 [19]; Duncan et al, 2012 [20]; Islam et al, 2012 [21]). As a well-established framework, the TDF integrates behaviour theories within domains that inhibit or enable behaviour, facilitating the identification of relevant barriers and facilitators in healthcare workers' behaviour in clinical practice settings (Lawrie et al, 2021 [22]). Crucially, TDF domains and constructs provide a theoretical basis for implementation studies, offering insights into the poor diffusion of evidence into practice and guiding the progression from theory-based investigation to intervention (Atkins et al, 2017 [23]). Adhering to the COREQ standardized reporting guidelines ensured the study's standardized conduct and reporting (See Supplementary File Two).

Ethical approval

Ethical approval was obtained from the HSE Mid-West Regional Hospital Research Ethics Committee (Ref: 088/2020) to undertake this study. Informed consent was obtained from all study participants.

Sampling

Combining sampling strategies are essential for achieving implementation goals and aligning with conceptual frameworks (Palinkas et al, 2015 [24]). To ensure comprehensive data from participants with relevant experience was attained, a purposive sampling approach was used. In addition, snowball sampling identified additional suitable participants, resulting in a final sample size of 18. Participants were included if they had over 5 years’ experience screening older adults in emergency care settings (ED or AAU’s, inclusive of Medical Assessment Units (MAUs). This included HCWs who provided care specifically for older adults in these settings, members of the geriatric team, and HCWs who worked within the ED and were part of screening processes in triage and as part of the general assessment of older adults who attended these settings. This sampling method facilitated discussion on the social determinants of screening implementation, aligning seamlessly with the Theoretical Domains conceptual framework. Potential participants were contacted via e-mail by an independent gatekeeper. Those expressing interest were sent an information leaflet and consent form by the primary author (LB). When explicit consent was obtained, all participants were contacted to discuss the interview process. To optimise participation, interviews were scheduled at convenient times and location for participants. Most chose virtual or phone interviews to adhere to infection control precautions.

Information power guided sample size determination, emphasizing that the more pertinent information the sample holds, the fewer participants are needed (Malterud et al., 2016 [25]). The adequacy of the final sample size was continuously assessed during the research process. Evaluation at the data analysis stage confirmed the sample size's appropriateness and depth for informing new research findings and addressing study aims (Malterud et al, 2016 [25]). Therefore, the sample size was evaluated further at the data analysis stage of the study and deemed appropriate and in-depth enough to inform the development of new research findings and address study aims.

Data collection

All clinical research activities relevant to the study were conducted in the research unit of the associated large acute hospital. To maintain participant anonymity, all interviews were conducted in a private soundproof room away from the clinical area. For participants opting for phone or online interviews, this choice ensured proximity to data storage facilities and on-site resources. One on one semi-structured interviews were conducted with eighteen HCWs. The interview guide (Table 1) was based around themes from a qualitative evidence synthesis on the topic area (Barry et al, 2023 [3]) and developed collaboratively with members of the research team (LB, RG, AL). A pilot interview was conducted to refine the interview guide and interview process. Consequently, four additional topic areas were added and are included under the “Areas to Prompt Discussion” section of the interview guide (See Table 1). Out of the total interviews, four were conducted in person, ten over the phone, and four online using Zoom. All the interviews were recorded using Dictaphones and transcribed verbatim. No repeat interviews were required. No participant that was recruited dropped out of the study.

Table 1 Interview guide

Data analysis

All interviews were audio-recorded and transcribed verbatim by two clinical nurse researchers (LB and GC) to ensure accuracy and consistency of approach. Both researchers had previous experience conducting qualitative interviews. The first Research Nurse (GC) had 25+ years' experience working in acute medical services including the ED and 3 years working in research. The second Research Nurse (LB) had 15+ years' experience working in acute and medical services with 6+ years working in research. Both interviewers had attained postgraduate qualifications in nursing relevant to their areas of practice. NVivo 12 facilitated data management where each transcript was uploaded and quotes deductively mapped on to TDF constructs within each domain. Similar to the process outlined by Fitzgerald et al (2023) [26], the definition and narrative description of each theme, aligned with the study’s overall aim guided the final selection of relevant data excerpts (LB and RG). Transcripts were coded independently but double coded to ensure consistency, limit bias and enhance rigour in the data analysis process. A third reviewer was employed to address any conflicts during the coding process. This team member would re-review the transcript and the current codes and discuss any discrepancies with the coding pair until consensus was reached (Raskind et al, 2019 [27]). Barriers and facilitators to older person-centred screening were identified under each theme supported by illustrative quotes to emphasise key study findings.

Trustworthiness

To bolster the transferability, confirmability, credibility and dependability of findings while mitigating bias, several criteria were rigorously followed. These criteria, originally identified by Guba & Lincoln (1975) [28] are outlined in Table 2 and are highlighted in the recommendations of Bradshaw et al. (2017) [16].

Table 2 Criteria for Trustworthiness

Overview of Findings

Eighteen participants from both the core geriatric specialist team and wider MDT team within these settings were interviewed. Table 3 details the roles of HCWs who took part in the study. Interview duration ranged from 19 to 58 minutes. The mean interview time was 38 minutes. Overall, three themes were identified; Preconditions to Implementing Older Person-Centred Screening; Knowledge and Skills Required to Implement Older Person-centred Screening and Motivation to Deliver Older Person-Centred Screening. Sub-themes identified as barriers and facilitators were categorised under each theme.

Table 3 Abbreviations for HCWs below correspond with those used in findings section

Participants described screening for frailty and adverse outcomes [13], falls and fracture risk [5], functional decline and co-morbidities [28], malnutrition risk [26], depression/delirium and psychosocial screening modalities [26] polypharmacy and medication risk [20] cognitive screening [17] and more generalised acute care screening including sepsis, infection control related screening and screening related to risk factors such as smoking and alcohol and drug misuse. Each HCW interviewed was representative of the core MDT who deliver older person-centred screening within the ED and AAUs. The social worker, geriatric advanced nurse practitioner, senior physiotherapist, senior pharmacist, emergency department consultant, geriatric specialist registrar and senior occupational therapist were a Geriatric Specialist team who provided CGA, inclusive of older person- centred screening, within these settings. The other HCWs interviewed were part of the wider team who were consistently involved in the screening process. Ellipses used in the quotations are reflective of participant pauses to think about the questions posed, any significant expressions or emotions are added in brackets to articulate the participants response and experience.

Theme One: Preconditions to implementing older person-centred screening

This theme was expressed under 7 theoretical domains and identified one barrier and five facilitators. The formation of this theme is illustrated in Fig. 1 below. HCWs described how preconditions to screen require a co-ordinated MDT approach. Furthermore, the importance of contingency planning and the management of competing priorities and goals was emphasised by those interviewed. In this instance, contingency planning referred to the unpredictable nature of the workload, staffing and patient presentation in these acute emergency settings. Consequently, the requirement for planning to ensure an effective response to the requirement for older person-centred screening should stressors, or competing priorities and goals emerge to interrupt this process within these emergency settings was described by HCWs. In addition, HCWs recognised that leadership and championing screening ensured reinforcement of practices and helped address environmental barriers.

Fig. 1

Mapping of Domains, Themes, Barriers and Facilitators: Theme One Preconditions to Implementing Older Person-Centred Screening

HCWs clearly delineated preconditions crucial for the successful implementation of older person-centred screening. These preconditions serve as both barriers and facilitators for both initial and long-term implementation. The importance of multi-level leadership, involving various disciplines within the MDT including nursing and medical staff in emergency care settings, is emphasised by participants to ensure the consistent and appropriate delivery of screening.

Facilitator: Preparing for successful implementation

To seamlessly integrate screening, HCWs described key facilitators or preconditions to ensure successful implementation, these were: Defining operating procedures for staff, documenting processes, and clarifying roles in screening criteria, pathways and patient outcomes. Clearly defined roles and responsibilities within the MDT team, reinforced through team-based meetings, were deemed vital by HCWs to ensure effective screening practices in the ED. This was primarily facilitated through MDT team-based meetings. As one manager identified:

“These things, they take a bit of time... there HAS to be a lead HAS to...clear criteria...similar to our triaging, put in with it... education for staff undertaking it and a clear plan for what will happen as a result...algorithms, these are the easiest to use here....staff are used to these, all staff, we have one for sepsis for covid for infection control. Trial it...deliberate plan and plan the follow-up...no point if it isn’t monitored in some way...and the guideline the policy...feasible operating procedures...for the whole team, done with the team and signed off. There has to be something in it for staff too, if they see that this can make things better, for older patients, for the unit, then it will stick” Clinical Nurse Manager 2 Acute Assessment Unit

Facilitator: Co-ordinated MDT team-based approach

The value and requirement for a cohesive and co-ordinated MDT team-based approach to screening, assessing and intervention was described by all HCWs interviewed. This included distinct definition of MDT roles in the delivery of bio-psychosocial screening and intervention. Participants described, how a dedicated and well-organized strategy, supported by robust leadership, not only guaranteed a comprehensive care provision but also engendered a profound sense of satisfaction and security among team members in their respective roles. This was described by a social worker on the team:

“For this type of screening, with this group (Older People) and the problems they present with you need that team-based approach. Different members of the MDT team will cover different aspects of the screening and assessment process and the documentation. For it to be consistent, that’s the level of input you need...the level of commitment you need from the whole team. This has to be done in a really organised manner so this was another strength, with (Geri SpR) as our lead this was easy...and a lovely team to be part of. an example, we would cover the psychosocial aspects, the OT and PT would cover other aspects of this and include the assessment of mobility, home-care services, the doctor and pharmacist look at the meds...Social Worker 1

Facilitator: Contingency planning and competing priorities

A robust and collaborative team dynamic can ensure that HCWs can compensate for competing priorities in the ED. Contingency planning was viewed as vital to ensure a seamless approach to delivering screening and intervention. This dynamic was well described by a registrar on the team:

“We planned for lots of problems that we know might emerge in the ED, the acuity of patients, what if a patient deteriorates, needs input from the surgeons, tests positive for covid, what if we test positive for covid, what if someone is off ill. We had exit strategies, contingency plans in place, cover for staff” Geriatric Specialist Registrar 1

Barrier: Impact of Covid on screening

All the HCWs interviewed described the impact of the Covid pandemic on the implementation of screening. This included the challenges associated with caring for older adults with higher acuity presenting complaints, navigating communication challenges associated with PPE usage and difficulties in accessing healthcare services when covid-19 positive.

“Covid....oh God...older people they were sicker coming in, they were afraid coming in with covid, so this made screening and assessment more complicated, sometimes you had to wait until they had stabilised...got their fluids, their painkillers before you approached them...communication barriers too, with all the PPE we were wearing for patients who were hearing or visually impaired, or cognitive impaired, developing that rapport was a lot more difficult.. Infection control... if a patient tested positive for covid that changed everything in terms of referring them...them accessing services...what diagnostics and follow-up they could avail of. That was a major challenge, even when we were having surges of covid...that limited the patients we could see, areas in the department were further restricted, sometimes we couldn’t access the AAU” Physiotherapist 2

Facilitator: Championing and leading screening practices

The pre-implementation planning phase was a vital aspect of successful implementation described by the nursing, medical and allied health staff interviewed. MDT members recognised that the initial implementation of screening required the governance and collaborative skills of doctors involved in this process, however, these participants also described that subsequent leadership can emerge from senior clinicians from their respective specialist areas. All participants recognised the importance of leadership to ensure effective screening practices were implemented and valued a model of shared governance, decision-making and leadership and an even distribution of the workload.

“Months and months in advance I approached all relevant stakeholders. This included focus groups with PPI groups, meetings with consultants, ED consultants, ED and AAU nurses and nurse managers, Directors of nursing and leads from within allied health, the senior pharmacist. You have no idea how difficult this was but that’s the level of input you need so you can make decisions in these areas and integrate something new (Screening)” Geriatric Specialist Registrar 1

Once established within these settings, MDT members described how leadership can come from senior team members who screen, assess and plan care relevant to their area of expertise and practice.

“Leadership also comes then from senior team members in their respective areas...the OTs and PTs, the Pharmacist the SW” Geriatric Advanced Nurse Practitioner 1

Leadership and associated decision-making from within the MDT team initially implementing the screening was viewed positively by the HCWs interviewed.

“This method of leadership and decision-making worked and the Geri SpR worked very hard to get everyone possible on board. From our side we disseminated information with our staff, sent our memos, liaised with nursing management and reviewed the paperwork that was going to be used. I know that later we all met and the team met to tease out any other problems that they envisioned with the process. It was a collaboration...” Emergency Department Consultant 1

To ensure longer-term implementation of screening, the nursing, medical and occupational therapists interviewed described the need for sustained leadership and someone to champion screening practices routinely. Having resources in place to support team members who may be struggling with the process was considered crucial.

“If it’s really going to be used then it has to be consistently led by someone...championed, we have had champions before and that worked for the sepsis screening I think and delirium and I think that would work with this. Keeping with it...adhering to it (screening) has to be assessed, we already have been pulled up on when we don’t do it but also supported if we are struggling with it...time with older adults aswell with everything we have to do with them...screening wise...we need time without pressure” Emergency Department Nurse 2

Barrier: Environmental and resource related barriers

The impact of ED and AAU related stressors on screening was discussed by all HCWs. This included feeling overwhelmed by paperwork and delays in the digital integration of screening tools and pathways. Participants recognised that Proforma based documentation can mitigate some of these environmental and resource related barriers.

HCWs described documentation saturation and felt overwhelmed by the sheer volume of paperwork and screening and assessment tools that needed to be employed when caring for older adults.

“Barriers...we are just overwhelmed with documentation; it starts to lose all meaning after a while its more pathways and assessment tools and screening tools..." Emergency Department Nurse 1

To prevent repetition and streamline the approach to older person-centred screening, a standardised approach facilitated by tailored documentation was favoured by HCWs. A proforma based framework was familiar to staff and could be inclusive of all relevant tools in one document. Participants described that the creation and implementation of this proforma needs to be undertaken collaboratively and represent the contribution of the MDT team.

“This would help and if all the team could use it even better. This would bring together everything relevant to the patient and help track the care received...the screening, the diagnostics the individual assessments” Geriatric Advanced Nurse Practitioner 2

Barriers relating to the integration of screening and assessment tools within hospital information technology systems were also described by participants. GDPR (General Data Protection Regulation) considerations were a barrier to the linkage of hospital systems which were often housed on different platforms.

"This requires linkage of hospital-based systems, permissions... all of them are independent of each other with different logins, licencing...we would have to consider data sharing, GDPR considerations. You could potentially add an indicator to commence screening suitable patients...but would that be helpful...I don’t know” Health Information Technologist

This delayed the digital integration of screening and, although in progress, was a longer-term goal. Therefore, hardcopy documentation was still favoured by participants to underpin current screening and intervention practices.

HCWs further described the environmental challenges experienced. Persistent overcrowding in both the ED and AAUs was identified as a substantial obstacle, compounded by elevated staff turnover and complexities in time management. In particular, HCWs recognised that the high turnover of staff impacted on all teams within these settings and was inclusive of both ED and AAU staff and the geriatric specialist team. Designated areas for older adults within these emergency care settings was perceived by HCWs as a catalyst for streamlining the screening and intervention process.

 Emergency Department Consultant 2 added, 

“It’s a tense place to work no doubt about that. Staff turnover is high...always is down here so that makes consistency very difficult. Overcrowding is always an issue here unfortunately and in the AAU, there are trolleys too… so no one escapes it. It is how we manage it...our time-keeping, setting our patients on the right pathway, we have to get better at that. We hope we will have designated areas for older adults here (ED) and in the AAU, that would make all of this a lot easier”

A private area to engage in screening and assessment was perceived as a significant facilitator of screening practices and was described articulately by one nurse practitioner, 

“Having our own areas to screen and assess these older adults would make it far more private and dignified for them and much easier for us. If they have any communication challenges, challenging behaviour, delirium...their own area would make it a lot easier to orientate them, assess them, allow family members in...” Geriatric Advanced Nurse Practitioner 1

Facilitator: Reinforcement of screening practices

HCWs detailed a robust governance structure and articulated comprehensive short- and long-term implementation plans. Most endorsed the positive impact of reinforcing screening through audit and feedback. Nurses and allied health team discussed utilising existing educational programmes and mentorship. Specialist ANPs and the older person specialist team, were viewed as valuable sources of knowledge and practice and this was discussed by this nurse practitioner:

“Audit and then feedback on screening practices, that could work...they did something similar here for delirium screening (ANP and Clinical Skills Facilitator (Practice Nurse Educator) CSF Led) and that had the desired effect...we don’t make use of our clinical skills facilitators and education available within the hospital, the clinical frailty programme...that’s an example, the resources are there, just to use them” Geriatric Advanced Nurse Practitioner 2

One Emergency Department Advanced Nurse Practitioner added,

“The ANPs (Older Person Nurse Specialists) regularly deliver education sessions and we have the expertise within the department here to support our colleagues”

Theme 2: Knowledge and skills to implement older person-centred screening

This theme was expressed under 8 theoretical domains and identified one barrier and three facilitators. The formation of this theme is illustrated in Fig. 2 below. HCWs expressed that the knowledge and skills to screen are multifaceted and require in-depth knowledge of the screening process and pathways and skill in delivering geriatric screening and assessment.

Fig. 2

Mapping of Domains, Themes, Barriers and Facilitators: Theme Two Knowledge and Skills to Implement Older Person-centered Screening

Facilitator: In-depth knowledge of screening, intervention and referral pathways

Overall, HCWs described older person-centred screening was described as complex, encompassing both specific screening for older individuals and broader screening targeting the recognition of risk factors and disease in emergency care settings. Participants acknowledged that although screening tools are relatively straight forward to complete and employ individually, they cannot be used in isolation and are inextricably linked to more comprehensive forms of geriatric assessment and subsequent intervention pathways.

HCWs also recognised that achieving proficiency in emergency care screening necessitates a clear understanding of diverse screening tools, assessment methods, intervention strategies, and referral pathways. Furthermore, participants described that it is crucial to possess in-depth knowledge of hospital-based IT systems and relevant documentation to ensure effective screening practices. This proficiency demands skilled practitioners and a significant commitment from all parties involved, this was described in detail by this nurse practitioner:

“For it to work... I would think...you need that experience.. It’s not as simple as screen and move on, you need knowledge of when to escalate care, which team members need to see the patient and what aspects of care need to be a priority. We screen for ... frailty, falls risk, malnutrition risk, sepsis, delirium...that doesn’t count for much if you don’t know how to organise the patients care and intervene...and refer patients as needed. It’s just how you organise the care depending on the acuity of the patient and their presenting complaint” Geriatric Nurse Practitioner 2

When prompted to delineate the requisites for delivering screening, HCWS emphasised the necessity for practitioners adept in both caring for older adults and operating in emergency care settings. They also underscored the significance of possessing specific knowledge related to age-related syndromes.

“That is a challenge, for this type of screening you need experience working in geriatrics... it just all makes more sense...with older people, and experience in working within the ED and AAUs. At a minimum you would need... knowledge of all screening tools and how to use these,... awareness of frailty syndromes, age-related syndromes and screening pathways. Community services too, a good relationship and knowledge of what is available for older people” Geriatric Advanced Nurse Practitioner 1

Barrier: Older person-centred screening viewed as complex

All participants had experience in screening adults (Over 18) and older adults (Over 65). Therefore, the differences between screening these patient cohorts were emphasised by the HCWs interviewed. Participants described requiring more information to inform decisions pertaining to the care of older adults. In addition, participants recognised older person-centred screening as distinct from other patient cohorts. To screen these patients appropriately, HCWs required in-depth knowledge of the patient including their medical and social history, previous hospital attendances

“I suppose in contrast to... other patients...you have to take a lot more into consideration. Communication challenges are more common, you need more time with them, you need more time to gather information from notes, pharmacists, primary care, their family. There always seems to be a surprise...medications you weren’t aware of, falls that weren’t reported, hospital attendances that you weren’t told about...all these things are important when screening...just to name a few and are not always readily available...that’s where your experience is a value...skill in taking a patient history, history from family and friends and the aspects of physically assessing your patients...” Emergency Department Nurse 1

Occupational Therapist 2 also discussed screening integrated within pathways and proformas. This was described as a complex collaborative process which required a skilled MDT approach.

“Screening here is also integrated into our pathways... so is part of a wider assessment tool...one linked off the other so it’s not as simple as just plucking out the tool and quickly flying through it...it’s part of the care plan...the progress of the patient. You can’t just perform it on its own...and without your peers...so it’s more complicated than you would think... a collaborative process yes”

Previous attendances and both hard copy and systems-based documentation can inform the screening process but presents challenges for HCWs. HCWs described how this process is time sensitive and requires a knowledgeable practitioner to access and navigate multiple hospital systems and patients notes/correspondence. Consequently, participants recognised that establishing an older adults full history may be timely and therefore a collaborative approach to this aspect of assessment is also warranted.

“With older patients you often have a good history here with notes...but you have to source these...review these...that takes time...we have the...the hospital systems are something that need to be managed aswell...they don’t link...so you need to use all of them to get...MAXIMS, IPIMS, I-lab, EPMS...useful information but that takes time again...to access the data. They have their uses but it’s a difficulty...” Geriatric Advanced Nurse Practitioner 2

Facilitator: Consultants of specialist knowledge and practice

To enhance screening implementation, nursing and medical staff highlighted the importance of leveraging departmental expertise to support and bolster their peers professional growth. Peer-led education and up-skilling was favoured and ensured facilitation that was attuned to the challenged that present in emergency care settings.

“We have the expertise...do we use them...not as much as we should...considering the number of older people we have in the department...no. We have staff members here who could lead the education of their peers, we have done this before...and well...we did this with sepsis. They understand the problems here and how difficult it can be to catch everyone to up-skill. We can work around it, use education days......workshops.... online resources.....it is possible...and feasible” Emergency Department Clinical Nurse Manager

Facilitator: Flexible educational resources

For robust support in screening processes, staff expressed a preference for team-based workshops and online resources. This provided staff with an opportunity to collaborate and actively problem solve with their colleagues. Online resources offering flexible access, were particularly valued in challenging environments.

We are well used to online learning, particularly with covid, it means you can do this at work or at home whenever you get an opportunity...even on your phone. Short workshop days, one or two hours, have them running all day so we can dip in and out, even earlier in the morning where you can catch night staff...that’s how you can do this here, it needs to be readily available...if we have an emergency here we might have to leave mid-way through so we need flexible access to resources and someone that can catch us up...”

Theme 3: Motivation to deliver older person-centred screening

This theme was expressed under 12 theoretical domains and identified five barriers and facilitators. The formation of this theme is illustrated in Fig. 3 above. The motivation to screen was an overarching theme and HCWs articulated the impact of personal and professional interests and a challenging environment on the screening process.

Fig. 3

Mapping of Domains, Themes, Barriers and Facilitators: Theme Three Motivation to Deliver Older Person-centred Screening

Facilitator: Positive experience of screening

Overall, HCWs felt positive about screening in emergency care settings and motivated to enhance the care provided to older people through screening.

“We know from the data and from our own experience, that this works for older people. If we intervene here...and early...keep them out of here...that’s better for everyone involved. It is not so taxing to screen here...none of us find it that hard, we now need to make it part of what we do for every patient that needs it” Emergency Department Consultant 2

Facilitator: Tangible impact of screening

HCWs were clearly motivated by the improvement of the patient experience and care provision. This enhanced interest in the screening and intervention process and reinforced engagement. This enhancement of patient care and experience served as a valuable counterbalance to the stressors experienced by HCWs. In particular, the reduction of time spent in the ED and AAUs was a motivation for staff and was viewed as particularly beneficial for older adults.

“Motivate me...ah anything that would help patients anything...but we are all the same. We are as frustrated as they are with waiting times and delayed care. It is an encouragement....encouraging to see that the model of care works for older people. They are the ones who are on trolleys here for the most part... We can see that this process works, they are identified by the team (Screened by Nursing/HSCP Team) early on which picks them out and prioritises referral and care in here and then in the community, for e.g. the Community Intervention Team (CIT) or PHN referral. Diagnostics are followed through with, someone is chasing these up all the time...but that’s what it takes. We have older patients going home now who would previously have been admitted or at the very least here for days languishing.” Geriatric Specialist Registrar 1

Facilitator: Identifying and expressing care priorities through screening

HCWs recognised the value of screening in articulating and quantifying the complex care needs of older people. HCWs also described how varying levels of acuity and co-morbidity required complex screening, assessment and intervention to meet the needs of this specialist group.

“Screening it’s putting a number on what we can see, it’s quantifying it, describing it...like describing frailty, what that means, it’s a way of showing how nothing with this group is a quick fix... and to get real results, sustainable...you have to be...so thorough. We see different levels of frailty, varying acuity and co-morbidity all the time, we can adapt the care we provide through the screening, we know we can improve the care. But it's all or nothing” Occupational Therapist 1

Facilitator: Actualisation of theory to practice

The value of observing the translation of theory to practice was described by all HCWs.

“People who resist change...that you can’t help...but most welcome progress. I think all the research that has been conducted here (ED/AAU) has given real legitimacy to this, we know the screening works and these patients get the care they need as a result” Physiotherapist 1

The potential of the screening process if expanded was also described.

“In the long-term, we would love to see all older people who attend and who are in need benefitting from some form of CGA, tailored to them. We know from experience and from the research here that this would be very resource intensive...require a lot of team and resource developments. We know that certain groups benefit more than others; patients with heart failure...in the palliative phase of their disease, respiratory disorders. That was unexpected but is exciting when you realise how far-reaching this could be” Geriatric Specialist Registrar 1

The opportunity that early intervention presents for this patient cohort is well recognised by the HCWs interviewed. For example, limiting polypharmacy among older patients in these settings was highly valued and was a clear example of how applying screening criteria could improve care for older patients. The STOPP START screening method provides explicit criteria that facilitate medication review in multi-morbid older people in most clinical settings. In this instance, the STOPP START criteria were applied and medication reconciliation was undertaken by a designated pharmacist. The value of this approach to screening was described by the pharmacist.

“Able to intervene that early...it’s such an opportunity. We know that medication reconciliation at this stage can make an impact and pre-empt a lot of problems we see later on during the admission or even in the community when discharged. You can’t overemphasise the impact that medications can have on function. Limiting polypharmacy is such an important part of reducing risk for these patients... ” Pharmacist 1

Facilitator: Older person involvement in developing screening practices

HCWs recognised the value of PPI involvement when developing and sustaining screening practices.

“Involving older adults has been so important. Going forward I would love to see this maintained. The practical aspects of what we are doing, communication, follow-up...the implementation and what translates to patients, we have anecdotal insight and feedback but nothing like hearing it from the horse’s mouth” Geriatric Specialist Registrar 1

Older adults’ insight was valued and their perspective of the care they receive was viewed as vital when establishing practices within emergency care settings.

“The value of working directly with older people...voicing what is important to older adults in this process is what can make the difference between our success and failure. They are far more attuned to the care they are receiving than what we might give them credit for” Geriatric Consultant

Barrier: Maintaining motivation in challenging environments

HCWs described challenges in maintaining motivation to screen in stressful ED environments. A lack of time, high turnover of staff and, consequently, an increasing number of junior staff eroded HCWs motivation to maintain screening and intervention practices. HCWs recognised that the orientation and support of new staff was a priority as was the delivery of evidence-based care to older adults, both were costly to staff in terms of time and resources. Staffs’ resilience and commitment to ensuring best practice despite these challenges was also emphasised.

“We have the same challenges here as elsewhere but maybe more so......we have a huge turnover of staff...time pressures, more and more junior staff (Including new recruits) with less experience who are already overwhelmed, overcrowding...it’s not the way it should be but we are used to working here. It’s no reason not to keep up with best practice but it just doesn’t ahh...help matters” Geriatric Specialist Registrar 2

Barrier: Sustaining long-term “buy-in” among staff

Follow through and support to sustain long-term implementation of new practice initiatives was valued by HCWs. A lack of “buy-in” by staff after an initial implementation phase can undermine staff confidence and cause frustration among those staff who are already overburdened with documentation and ever-evolving practice developments.

“You mean with more initiatives...there has to be belief that this won’t be just a onetime thing....we have seen it before.....a new tool or pathway is introduced and it just falls flat after an initial push.....that can be so disappointing...frustrating and undermine your confidence that other initiatives are actually going to work...” Advanced Nurse Practitioner Acute Assessment Unit

Barrier: Conflicting goals within the ED

HCWs from both the ED and AAU described experiencing conflicting interests both personally and within the wider MDT team. Navigating team dynamics, local culture and a stressful environment were also discussed.

“Being able to navigate through...manage the team dynamics... personalities and politics within these settings is absolutely a challenge. You have to remember that these areas are highly charged with people (MDT team members/patients) with different goals and views of what they want to achieve...for some it’s about flow...getting them out moving them on...for others it’s about quality...we are screening to pin-point the most vulnerable...at-risk and taking the time to ensure the best outcome possible for them...mainly that we don’t have the older patients back again before the week is out. It’s about finding the middle ground between those conflicting goals and your own priorities. We want the care to follow through with an impact...for some it may be out of sight out of mind...that’s not us” Emergency Department Nurse 1

Personal interests related to professional roles and responsibilities also impacted on the cohesive and consistent delivery of screening. Those with experience and interest in working with older adults were keenly aware of the value of screening, ensuring this was followed through with the wider team in emergency care settings was considered challenging.

“But of course, let’s call a spade a spade, it’s about your own interests aswell...is this related to my role...is geriatrics your area...what you are passionate about...you either love working with older people, or you don’t, and I think there are enough of us there that have...well we should be left to this care when we have interest... and then collaborate with other teams and advocate on older patient’s behalf... if that’s what’s needed...that is a good way of describing it we do what’s needed for them, no matter what that may be. Screening, it’s a big part of this and is already fully embedded in the model of care. This just needs follow through and to be kept up with...” Geriatric Advanced Nurse Practitioner 2

Barrier: Experiencing judgement from colleagues

The screening and associated referrals and interventions was described as time-consuming. Those delivering this process felt a sense of scrutiny from colleagues when dedicating extended periods to patient care in an environment where efficiency is typically prioritised. Nevertheless, as this care model became more consistently implemented, staff noted an improvement in overall understanding among peers.

“The time we take with each person, that can be viewed negatively sometimes, less so in recent times as there is more understanding for this way of working but it’s always in the back of your mind” Occupational Therapist 2

Barrier: Maintaining evidence based practice

The team structure and approach must be informed by the needs of older people and evolve with research and practice developments. This can be challenging in emergency care settings where a lack of time, staff and resources to update clinical practice is a consistent problem.

“Over the last few years there have been major changes...but as new screening tools are put in place and new recommendations are published...here we must augment our team, the documentation, our policies and guidelines. I think this is our strength...in geriatrics, currently,...a lot of progression over the last few years, this is obviously a good thing but brings its own challenges when trying to make changes” Occupational Therapist 1

Discussion

Summary of main findings

The establishment of preconditions for successful screening, at local level, is vital to ensure seamless implementation in Emergency Care Settings (ECSs). This involves fostering a coordinated MDT approach through collaborative decision-making, goal setting, and establishing effective communication processes before implementation among the specialist geriatric team, wider MDT team and older adults. Furthermore, reinforcement of screening practices through education, audit and supervision and ensuring robust multi-level leadership and championing of screening practices were also vital facilitators. This collaborative approach in challenging ECSs underscores the importance of contingency planning for sustained screening practices. The impact of covid on screening practices was clearly evident, however, a skilled, experienced and adaptable MDT team limited this impact on the screening process.

The complexity of older person-centred screening was identified as a barrier to implementation in a setting where high staff turnover and time pressures were routinely experienced by HCWs. In-depth knowledge of relevant documentation and IT systems including IPIMS, EPMS, I-Lab, NIMIS and MAXIMS were vital and older person-centred screening, applied in ECSs, demands skilled and committed practitioners. Predominantly, hard copy documentation is relied on for the screening process (Proforma), IT based systems inform this process through access to patient history, medical records, diagnostics and online referrals where appropriate. Therefore, the MDT team require knowledge and experience in using both hardcopy and online forms of documentation and accessing of patient related information. A distinct barrier to the linkage of IT systems was data protection, permissions for different systems to access patient information was a challenge to the progression of IT services in providing one accessible system. Interviewing a Health Information Technologist allowed for clear identification of these challenges.

To ensure screening practitioners had the competence and skills required, experience in caring for older adults and working within emergency care settings was favoured, along with specific knowledge of age-related syndromes. To facilitate implementation, the utilisation of departmental expertise to support peers’ professional growth was emphasised. Online resources and ream-based workshops were favoured when facilitating screening-based education.

Maintaining motivation in high stress environments, where conflicting goals routinely emerge, was a significant challenge for HCWs. However, the positive impact of screening on older adults served as a clear motivator, allowing specialist MDT members to consolidate their role and articulate patient care priorities effectively. e.g. Using frailty and falls risk screening to identify those at-risk and subsequent implementation of a care plan and referral pathway. The involvement of older persons in the process, along with Patient and Public Involvement (PPI), was considered vital for specialised care provision. A designated proforma was favoured for underpinning the screening and intervention process ensuring a seamless and collaborative approach. Furthermore, while long-term buy-in and evidence-based practice were challenging in a documentation-saturated environment, the overwhelming positive experience of both HCWs and older adults during effective screening implementation helped mitigate identified barriers.

Results in the context of current literature

Older person specific barriers and facilitators to the delivery of screening in emergency care settings have been identified. These are consistent across both the ED and AAU as a uniform approach and pathway are employed in both settings. Building on the results from the Barry et al (2023) [3] evidence synthesis, this study offers distinct and pragmatic recommendations for older person-centred screening which can be categorised under three core themes which pertain to preconditions to screen, knowledge and skills to screen and motivation to screen. Similar to the foundational QES, implementation focused barriers and facilitators were identified under each theme, however, the results of this study were focused on the application of older person-centred screening and thus were focused on the unique challenges and opportunities this older person focused care presents.

The HCWs interviewed acknowledged the nuanced nature of older person-centred screening embedded within complex proformas and pathways. An MDT approach is essential, aligning HCWs with screening, assessment, and intervention roles. Brief bio-psychosocial screening to identify problems that are commonly overlooked in older patients needs to be employed routinely, however, results should then pin-point further assessments and management according to the patient’s beliefs, preferences, and expectations (Seematter-Bagnoud and Bula, 2018) [8]. Similarly, the HCWs interviewed recognised this type of screening as a gateway to specialist intervention and advocated for greater involvement of older adults in shared decision-making and implementation planning. In this instance, older person-centred screening informed shared decision-making where older adults were involved in a collaborative process with the MDT to reach a joint informed decision about their care. Considering this, a collaborative and co-ordinated MDT approach to care delivery is required to navigate challenging settings while delivering evidence-based care guided by screening. This collaborative process is also required to ensure an older person-centred approach where patient advocacy is valued and grounded in shared decision-making. This complex approach highlights the needs of a diverse and heterogenous group of older patients. Elder et al (2021) [29] acknowledged contextual barriers influencing the screening of older adults, embedded within busy ED’s. Screening of older adults in emergency care settings does not occur in isolation but is embedded within the context of the busy ED and undertaken by staff with competing goals and interests (Elder et al, 2021) [29]. The barriers identified are reflective of the challenges experienced in the ED and identify feasible and contextually significant methods of overcoming these challenges.

Within this study, involvement of the initial geriatric specialist team and the wider MDT within these settings was viewed as vital to ensure longer-term implementation of screening. Ideally, older person-centred screening should be delivered by HCWs with experience both in emergency care settings and working with older adults (HSE, 2017 [11]; NICPOP, 2017 [9]; NICPOP, 2021 [10]). Although geriatric providers are ideal, the scarcity necessitates equipping all healthcare team members, including primary care physicians, with tools for quick geriatric evaluations (Little, 2017 [30]). Distinct preconditions for embedding older person-centered screening in both short and long term within specialist and ED teams are identified.

The role of audit and supervision in reinforcing screening practices in emergency care settings was described by participants from nursing, medicine and allied health. This included the consistent and appropriate delivery of screening to older adults in line with protocols, attendance at relevant CPD sessions and appropriate referrals and interventions associated with screening practices (Algorithm based). Southerland et al. (2022) [31] stressed the crucial utility of audit and feedback in stressful situations, favouring group feedback for alignment with screening goals. Consequently, routine scheduling of audit and structured feedback is deemed effective for reinforcing older person-centered screening.

The knowledge and skills required to deliver older person-centred screening are complex. Screening in a stressful and busy environment requires skilled screening practitioners, who can adapt to the challenges experienced by older adults and respond efficiently and appropriately to the problems this heterogenous group present with. To screen appropriately, along with in-depth knowledge of screening practices, knowledge of frailty and age-related syndromes are required. This was reflected in the literature where an understanding of the concept of frailty and application of this knowledge to the biological, cognitive, psychological and social changes commonly associated with ageing is necessary (NICPOP, 2017 [9]; NICPOP, 2021 [10]; Veronese et al, 2022 [14]). This is further supported by Moloney et al (2024) who explored the use of frailty screening tools in EDs in Ireland. They found that dedicated staff with frailty management expertise, bespoke education initiatives, and clearly defined frailty screening pathways may help address the barriers identified (Moloney et al, 2024 [32]). Mooijaart (2021) [33] also described the need for staff education on the principles of geriatric emergency medicine when implementing screening. Therefore, the authors propose that the education provided to underpin screening should be facilitated by both ED and specialist staff in these areas to ensure optimal uptake. To ensure that screening is delivered appropriately, mentorship and education from experienced practitioners, organised and effective use of education resources (e.g. Clinical Skills Facilitators and Practice Development Resources) to underpin screening within these settings and a leadership-based approach to implementation from conceptualisation to actualisation of screening implementation is required.

In agreement with Seematter-Bagnoud and Bula, (2018) [8] geriatric conditions are well recognised by older patients and HCWs as significant for health and well-being but are often overlooked due to many patient and physician-related factors. In particular, time constraints and a lack of specific training to undertake complex older person screening, assessment and intervention (CGA) (Seematter-Bagnoud and Bula, 2018 [8]; Barry et al, 2023 [3]) Distinct environmental and human resource related barriers such as time, judgment of other staff, high staff turnover and competing priorities are identified in this study. Feasible methods of overcoming these challenges include the appropriate use of existing resources, organisation of team-based resources, multi-level leadership and specialist mentorship and education.

Finally, sustaining a motivated workforce for effective screening is imperative. This involves tackling environmental and MDT-related barriers and supporting staff for consistent and appropriate screening (Barry et al, 2023 [3]). This study underscores the importance of maintaining older person-centered screening through continual and collaborative reinforcement of evidence-based practices. Visibility of screening impact and addressing conflicting screening goals are essential components. The value of proformas in informing and underpinning older person-centred care are well recognised within the literature (Xu et al, 2021 [15]; BGS, 2019 [12]; HSE, 2017 [11]). Participants within this study unanimously favoured a comprehensive CGA proforma. This format, familiar to healthcare workers, was found to prevent repetition and ensure transparent and consistent patient care reporting.

Clinical implications

Skilled screening practitioners can assist in developing practice but need time and resources to do so. Practice development initiatives can be underpinned by existing educational and human resources. Vital reinforcement of screening practices can be achieved through audit, supervision, support and mentorship roles. Knowledgeable and experienced screening practitioners can navigate environmental challenges, complex team dynamics and workplace cultures that yield resistance to change. Team collaboration and the coordinated delivery of care can be underpinned by developing documentation specific to the screening and intervention process. A pathway or proforma based document was considered suitable for acute settings and was familiar to all staff. Algorithm based frameworks to inform MDT team decision-making were also favoured by participants. Communication between ED staff, the specialist team and wider geriatric team is vital to ensure a cohesive approach to delivering older person-centred care. Group meetings and workshop-based collaboration were favoured to achieve these communication goals.

Strengths and limitations

The study was underpinned by a robust QES which informed the study design and data collection methods. Utilising the TDF to map and synthesize the data collected ensured that study findings and recommendations had greater application to implementation strategy. A diverse group of experienced study participants provided rich data upon which study findings were based, this enhanced the generalisability and significance of study findings to settings with similar MDT approaches and older person-centred screening pathways. These findings are representative of a comprehensive approach to older person-centred screening inclusive of a biopsychosocial model of screening and assessment. This further enhances the generalisability of findings to numerous screening modalities. In terms of information power, study findings were found to adequately address the study aims (LB and RG).

This study was conducted in one hospital group in the mid-west of Ireland, considering the effect of local contextual barriers and facilitators on implementation strategy (Barry et al, 2023 [3]), this may limit the generalisability of study findings. Consequently, those implementing screening may need to consult both the evidence base and local stakeholders to ensure optimal uptake. In addition, these findings are not inclusive of a PPI perspective of screening which is a significant limitation. Finally, the recent expansion of older person services in the community (Older Person Integrated Care Hubs) and significant improvements in the linkage of acute and community services, emphasises the need for greater involvement of community-based stakeholders in implementation strategies.

This study was undertaken during the Covid-19 pandemic between May of 2020 and May of 2021. This offers a unique perspective of screening during this period but also presented the research team with some methodological barriers. Initially focus groups were the data collection methodology proposed, however, to ensure infection control precautions were adhered to, one on one interviews were conducted with staff. As a result, to achieve information power, a broad range of interviews with the sample group were conducted. This ensured that the perspective of all relevant staff were represented within study findings.Covid-19, as a barrier to screening, is recognised within the findings and further articulates the complicated process of caring for patients who presented with Covid-19 to ECSs.

Areas for further research

Older person-centred screening is often inextricably linked to a specialised intervention such as a CGA or care in a specialised unit within emergency care settings. Exploring the experience of MDT members, in delivering both screening and interventions within these settings, may offer further insight into the resources required to underpin this type of complex care. Furthermore, PPI involvement is a vital aspect of implementation strategy. Exploring older adults and family members experience of the screening and intervention process in emergency care settings may offer greater insight into their perception of and satisfaction with this care. Therefore, consultation with additional stakeholders is required to further inform older person-centred screening and intervention in these acute settings.

Conclusion

Screening older adults in the ED is a complex and challenging process which requires knowledgeable and skilled practitioners. Outside of those with relevant experience in delivering older person-centred screening, HCWs within these settings need supervision and support to deliver screening confidently and competently. Resources to underpin the delivery of screening are not utilised appropriately to support staff and require organisation and reinforcement by experienced leaders and champions to sustain this important aspect of care. Empowering HCW's to sustain screening in busy acute settings requires leadership and in-depth knowledge and skill in screening processes. A leadership-based approach, with screening champions to underpin the process, motivates and sustains the MDT and ensures a consistent and evidence-based approach in the long-term.