Review
Structure and processes of interdisciplinary geriatric consultation teams in acute care hospitals: A scoping review

https://doi.org/10.1016/j.ijnurstu.2015.09.015Get rights and content

Abstract

Background and objectives

Interdisciplinary geriatric consultation teams are implemented in the acute hospital setting in several high-income countries to provide comprehensive geriatric assessment for the increasing numbers of older patients with a geriatric profile hospitalized on non-geriatric units. Given the inconclusive evidence on this care model's effectiveness to improve patient outcomes, health care policy and practice oriented recommendations to redesign the structure and process of care provided by interdisciplinary geriatric consultation teams are needed. A scoping review was conducted to explore the structure and processes of interdisciplinary geriatric consultation teams in an international context. As nurses are considered key members of these teams, their roles and responsibilities were specifically explored.

Design

The revised scoping methodology framework of Arksey and O’Malley was applied.

Data sources

An electronic database search in Ovid MEDLINE, CINAHL and EMBASE and a hand search were performed for the identification of descriptive and experimental studies published in English, French or Dutch until April 2014.

Review methods

Thematic reporting with descriptive statistics was performed and study findings were validated through interdisciplinary expert meetings.

Results

Forty-six papers reporting on 25 distinct interdisciplinary geriatric consultation teams in eight countries across three continents were included. Eight of the 12 teams (67%) reporting on their composition, stated that nurses and physicians were the main core members with head counts varying from 1 to 4 members per profession. In 80% of these teams nurses were required to have completed training in geriatrics. Advanced practice nurses were integrated in eleven out of fourteen interdisciplinary geriatric consultation teams from the USA. Only 32% of teams used formal screening to identify patients most likely to benefit from their intervention, using heterogeneous screening methods, and scarcely providing information on the responsibilities of nurses. Nurses were involved in the medical, functional, psychological and social assessment of patients in 68% of teams, either in a leading role or in collaboration with other professions. Responsibilities of interdisciplinary geriatric consultation teams’ nurses regarding in-hospital follow-up or transitional care at hospital discharge were infrequently specified (16% of teams).

Conclusions

This scoping review identified that the structure and processes of care provided to geriatric patients by interdisciplinary geriatric consultation teams are highly heterogeneous. Despite nurses being key team members, only limited information on their specific roles and responsibilities was identified. More research in this area is required in order to inform health care policy and to formulate practice oriented recommendations to redesign the interdisciplinary geriatric consultation team care model aiming to improve its effectiveness.

Introduction

Demographic changes with an increasing aging of the population and the growing burden of chronic conditions affect the number and proportion of older patients in the acute hospital setting (Organization for Economic Co-operation and Development (OECD) Health, 2004). A specific subset of these older patients, namely those with a geriatric profile (hereafter called ‘geriatric patients’), are at an increased risk for adverse outcomes both during and after hospital admission (Covinsky et al., 2003, Covinsky et al., 2011). According to the ‘European Union of Medical Specialists’ geriatric patients present with a multitude of complex and interrelated problems such as frailty, active multiple pathology, atypical appearances of diseases, polypharmacy, functional decline and psychosocial problems. This patient profile requires a holistic and interdisciplinary approach to care, including a key contribution of the nursing profession (European Union of Medical Specialists – Geriatric Medicine Society, 2008). Therefore, to address the complex care needs of these geriatric patients the process of ‘comprehensive geriatric assessment’ (CGA) has been developed, which was defined by Rubenstein et al. as “a multidimensional interdisciplinary diagnostic process focusing on determining a frail elderly person's medical, functional, psychological and social capability in order to develop a coordinated and integrated plan for treatment and long term follow up” (Rubenstein et al., 1991). Hence, CGA encompasses phases of patient identification, assessment and implementation of interventions (e.g. a plan for treatment and follow-up) (Deschodt, 2013). To date, CGA is considered one of the cornerstones of modern geriatric medicine (Rubenstein et al., 1991).

Different models of care can be applied to offer CGA to hospitalized patients. First, it can be delivered in geriatric units where specialist interdisciplinary care is organized for geriatric patients. Care on these dedicated units has been shown beneficial: as compared with conventional care it has been associated with a decrease in falls (Fox et al., 2012), delirium (Fox et al., 2012), in-hospital mortality (Ellis et al., 2011a, Ellis et al., 2011b), functional decline (Baztan et al., 2009, Van Craen et al., 2010), and new nursing home admissions (Van Craen et al., 2010). However, not all hospitals have implemented acute geriatric units, and the capacity of such units is often insufficient to accommodate the high number of admitted older patients (Deschodt et al., 2015, Malone et al., 2014). In Belgium for example, where acute geriatric units are implemented since 1984, 81% of all patients aged ≥75 years were hospitalized on non-geriatric acute care units in 2011 (Deschodt et al., 2015).

Interdisciplinary geriatric consultation teams (IGCTs) are therefore proposed as an alternative or complementary model of care for providing inhospital CGA (Deschodt, 2013). IGCTs are mobile teams with the following main activities: the provision of an interdisciplinary CGA for patients with a geriatric profile; the formulation of recommendations to the care team of the non-geriatric unit during the hospitalization period; the formulation of recommendations to the general practitioner with the aim to prevent hospital readmissions and other negative outcomes post-discharge; and the dissemination of a geriatric approach throughout the hospital (Deschodt et al., 2015). Importantly, IGCTs are not directly responsible for the care management and clinical outcomes (Braes et al., 2009). They provide recommendations for patient care, which should be carried out by the team of the non-geriatric unit. Examples of frequently provided recommendations are treating fluid overload or dehydration; performing additional laboratory or technical investigations; preventing or treating postoperative delirium; prevention of pressure ulcers, discontinuing or starting-up medication, regulation of bowel or bladder function, adjusting nutritional intake, and arranging discharge management (Deschodt et al., 2011a). IGCTs are considered to have a high face validity by IGCT members, their clients (patients and relatives, teams of non-geriatric units), nursing managers, health policy and governmental decision-makers (Braes et al., 2009, Deschodt et al., 2015). Hence, the IGCT care model is currently structurally implemented in the health care system of European high-income countries such as Belgium, France and the Netherlands (Belgisch Staatsblad, 2014, Ministère de la Santé et des Solidarités, 2007, Unie Katholieke Bond van Ouderen et al., 2014). Moreover, the care model is being applied on a regional level in the Ontario province, Canada (Lewis, 2008).

On the other hand, results on the efficacy and effectiveness of IGCTs are inconclusive. More specifically, a recent meta-analysis showed no effect of IGCTs on patient's functional status, length of stay, and readmission rates, and an inconclusive effect on mortality (Deschodt et al., 2013). The suboptimal adherence to IGCT recommendations by non-geriatric unit teams (Agostini et al., 2001, Deschodt, 2013, McVey et al., 1989) and heterogeneity in the structure and process of IGCT care (Deschodt et al., 2013, Hogan and Fox, 1990) can potentially explain this lack of evidence. Consequently, a more comprehensive perspective on IGCTs in different health care systems is needed to allow key stakeholders in clinical practice (e.g. careworkers and managers in the in-hospital setting) and health policy developers to further fine-tune and improve the IGCT care model. Because to date no comprehensive review summarizing the state of the art in this regard is available, we conducted a scoping review aiming to explore the structure and processes of IGCTs in acute care hospitals within an international context. As nurses are put forward as key members of IGCTs (Deschodt et al., 2012a), we explicitly explored the roles and responsibilities of nurses within these teams.

Section snippets

Materials and methods

Given our aim to examine the extent rather than the depth of evidence regarding the structure and processes of IGCTs (Davis et al., 2009), a scoping review was performed. Scoping reviews are considered especially useful in policy directed nursing research (Davis et al., 2009, Harris et al., 2015, Sun and Larson, 2015). Our review process was based on the refined version of the methodological model of Arksey and O’Malley (2005) and is visualized in Fig. 1 (Levac et al., 2010, Armstrong et al.,

Identification and selection of relevant papers

After removal of duplicates (n = 1153), the database and hand search resulted in 7156 potentially relevant papers. Based on title and abstract evaluation, 6851 papers were excluded. An additional 259 papers were excluded based on their full text, of which eight due to non-availability of the full text. Hence, the database and hand search resulted in the inclusion of 46 papers (Supplementary material 3).

Characteristics of included studies

The 46 papers reported on 25 distinct IGCTs in eight different countries: fourteen in the USA,

Substantial findings

This scoping review demonstrated that IGCTs provide care for geriatric patients through highly heterogeneous structures and processes of care. Despite confirmation of the notion that nurses are key members of these interdisciplinary teams, limited information on their specific roles and responsibilities is currently available in the international literature.

Given that the IGCT model aims to provide CGA to geriatric patients, interpreting the study results according to the aforementioned

Conclusions

In conclusion, this scoping review indicates that IGCTs intervene through highly heterogeneous structures and processes, whereby several areas for future improvement and research are apparent. Despite the confirmation that nurses are key members of IGCTs, only limited information on their specific roles and responsibilities in IGCT care has been reported in the literature. Overall, this points out that the development of recommendations aiming to improve the effectiveness of the IGCT care model

Acknowledgements

We thank the employees of the Belgian Health Care Knowledge Center and members of the Belgian College of Geriatricians and the Belgian Association for Gerontology and Geriatrics (BVGG/SBGG) who participated in the validation phase of this scoping review.
Authors’ contributions: All authors substantially contributed toward the conception and design of the study and interpretation of the data. Study selection, data charting, data analyses and drafting of the manuscript were primarily performed by

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  • Cited by (0)

    This paper was submitted as an entry for the European Academy of Nursing Science's Rosemary Crow award, sponsored by the International Journal of Nursing Studies. The award is open to current doctoral students or recent graduates of the academy's programme.

    1

    Joint first authorship.

    2

    Present address: Institute of Nursing Science, Faculty of Medicine, University of Basel, Bernouillistrasse 28, CH-4056 Basel, Switzerland.

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