Table 4 Overarching themes, organizing concepts, and associated quote examples

System-Level Impacts on the ED

The current state of the Canadian healthcare system, especially in EDs dealing with issues such as access block, crowding, staffing constraints, and competing priorities decreases the current actionability of many Quality Statements, although they may be important

Supporting:

“I believe this is extremely important however, due to staffing/time constraints, many of these are not possible to achieve”

“I agree all very important interventions but the key would be with sufficient resources and plans on how to implement with staffing challenges etc.”

“Again important but challenging to action without significant financial outlays and new direction by government and healthcare leadership.”

“Current access block in the ED, staffing constraints, high acuity, competing priorities make this very difficult to take action on”

Opposing:

“… there will always be other competing priorities in the ED…. While we have to [be] practical in what an ED can achieve, we also need to realize that older adult care and delirium identification/management/prevention is a priority… It is critical we make it a priority, or else it will always be overlooked…”

Prioritization for Transfer to Care Unit or Home

An important and valuable component of an ED care pathway/protocol for the risk reduction and management of delirium is to include prioritizing transfer of these patients to more appropriate care spaces (e.g., inpatient unit, geriatric observation unit, or home of usual residence with adequate supports)

Supporting:

“I think a more important priority is minimize ED length of stay for these patients, as prolonged time in the ED will invariably result in transfers with the department with our inability to control acuity and patient volumes”

“Truly meaningful interventions would begin with early prevention. This should translate to early transfer out of ER [emergency room]”

“I believe that patients would benefit from earlier transfer out of the ED to areas where these interventions are more easily implemented. However we should be striving to do better in the ED until this transfer is able to take place…”

Opposing:

N/A

Additional Healthcare Provider Supports

It would be beneficial to have other practitioners and staff in the ED to support aspects of care, including: (1) Nurse Practitioners and/or Geriatric Emergency Management (GEM) nurses to aid in screening, assessment, and management; (2) Pharmacists or pharmacy technicians to aid in medication reviews and communication with General Practitioners/community care; and (3) Healthcare aids to assist with non-pharmacological care such as feeding, mobilizing, and toileting

Supporting:

“I think having a dedicated resource person within a busy ED to make sure this is done would be helpful. Perhaps this is a role that a nurse practitioner could be utilized”

“I believe that having a pharmacist as part of the team in the ED is essential to review medication lists…”

“We now are trialling HCAs [healthcare aides] in ER to assist with ADLs [activities of daily living] etc. & I think with the extra set of hands to do “comfort rounds”, monitoring is invaluable. Without them, time constraints limit my ability to continuously monitor for deteriorating”

Opposing:

N/A