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Three Part Question

In [elderly patients attending the Emergency Department (ED)], does [the experience of patients in the ED] correlate with [their expectations of the service provided]

Clinical Scenario

An 80-year-old man presents to ED with a mechanical fall. He has sustained a minor head injury and complains of left hip pain. On further questioning, he had three recent falls in the past week. He mentions that he is not coping at home. Investigations reveal no evidence of intracranial injury or bony injury to the hip. You wonder if the service has met with his expectations, and dealt with the underlying problems he presented with.

Search Strategy

Google Scholar interface on world wide web.
Pubmed interface on world wide web.
(((((((elderly OR geriatric OR older OR aged)) AND (satisfaction$ OR perception$ OR perspective$ OR experience$))) AND (("emergency department$" OR "emergency unit$" OR "emergency service$” OR prehospital OR ambulance$))) AND Humans[Mesh] AND English[lang])) AND (elderly[Title] OR geriatric[Title] OR older[Title])

Search Outcome

144 papers of which 7 were relevant to the question posed.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Baraff et al 1992 US	Five focus groups (each having five to 13 members, aged 65 or older who had received ED care in the past year)	Qualitative study – Focus group interviews on elderly patients’ experiences during their visits to the ED with moderators asking open-ended questions pertaining to selected aspects of ED visit experience	Staff Interactions	Negative comments centered on the process of communication of staff with patients	The focus groups were formed based on patients’ geographical limitations; most lived in care homes. Some of the visits to the ED were not recent.
			ED Environment	Emergency departments were too cold and were not offered blankets
			Waiting Period	Participants reported that they spent a considerable amount of time in the ED, much of it waiting for care. However they understood as this was an unscheduled visit and that more critically ill patients are treated first
			Transportation	Trouble with transportation if they were not escorted.
Watson et al 1999 US	12 patients, aged 66 or older, who presented with conditions requiring immediate care, discharged within 2 hours of their ED arrival	Qualitative descriptive study – interviews on elderly patients’ experiences during their visits to the ED	Needs for information	Elderly patients want to be informed about their condition and the entire process of their care	Small sample size. Single center.
			Waiting period	Majority felt the waiting time were too long. They wished to be informed about the reason they are waiting
			Perceptions of professional competence and caring service	25% of them felt humour is an important component during communication to create a better rapport
Nerney et al 2001 US	778 patients, aged 65 or older, who completed questionnaires during their presentation to an inner-city ED.	Prospective Survey of older patients attending the ED– included questions on demographic characteristics, medical history, health related quality of life and a follow up satisfaction survey	Overall rating of ED care on a 5-point Likert scale of “excellent”, “very good”, “good”, “fair”, or “poor	40% “Excellent” 30% “Very good” 2% “Poor”	Single center. Many refused the questionnaires – potential selection bias
Kihlgren et al 2004 Sweeden	20 patients, aged 75 years or over who presented to the ED – observed and interviewed	Prospective Qualitative study – Observation followed by interview. Observation focused on care given, accompanying relatives and the environment. Interviews were on older patients’ experiences in the ED, using open-ended questions.	ED Settings	Participants felt there was a lack of privacy, and the beds were very hard and uncomfortable.	Small sample size.
			Waiting Period	They felt abandoned during the waiting period and worried if the staffs had forgotten them. They also felt the waiting times were too long and they were not informed of the anticipated duration of the waiting times. They were afraid to leave the examination/waiting room to look for a toilet or a telephone as the doctor might come.
Richardson et al 2007 New Zealand	82 patients, aged 80 years or over who presented to emergency departments and were likely to be admitted to one of the designated medical wards	Mixed quantitative and qualitative methods, including an audit and interview Audit focused on assessing area workload and acuity in particular nursing-to-patient ratio at particular time and area Interviews were semi-structured with open-ended questions on the admission, transfer and discharge experience of patients	Admission Process	Patients felt they were under informed regarding their admission, but they also appeared unconcerned about this.	Limited to patients that are admitted to specific medical wards.
			Waiting Period	Despite long waiting times, the majority of patients showed acceptance of the situation and a rationalization of relative “need” which led to acquiescence
Considine et al 2010 Australia	27 patients, aged 65 years or over, from 3 EDs	Prospective qualitative study – Observations and Interviews with patients or their carers on their experience of care provided in the ED	Waiting Period	Some felt the waiting times were too long, especially the time spent on the ambulance trolley Others felt the wait was warranted as there were other patients who were more unwell	Small sample size. Interviews took into account current visits as well as previous visits to the ED
Olofsson et al 2012 Sweeden	14 patients, aged 70 years or over who had visited ED more than three times in the past 12 months	Qualitative study - interviews using open-ended questions focusing on older patients’ experiences in the ED	General experience	Sincere interest from the nurse during triage contributed to a respectful relationship A perceived lack of interest in patients contributed to frustration and disappointments	Small sample size. Questions asked were too general. No specific area of experience were examined.

Comment(s)

The above studies included 2 surveys, while the rest were qualitative studies, using semi-structured interviews, focus groups or observational techniques. Recurring themes emerged as part of elderly patients’ expectations during their visits to the emergency department. These included the need for more information regarding their diagnosis, investigations and reason for admission or discharge. While waiting times were also identified as an issue, older patients were more understanding in relation to this, if they knew what they are waiting for and were given an approximate estimate of how long they might have to wait.

Clinical Bottom Line

These studies identified some of the expectations of older patients attending the ED. More work is needed to determine to what extent these expectations are being met and what interventions can be implemented to improve the experience of older patients in the ED.

References

1. Baraff, L. J., Bernstein, E., Bradley, K., Franken, C., Gerson, L. W., Hannegan, S. R., … Wolfson, a B. Perceptions of emergency care by the elderly: results of multicenter focus group interviews Annals of Emergency Medicine 1992, 21(7), 814–8
2. Watson, W. T., Marshall, E. S., & Fosbinder, D. Elderly patients’ perceptions of care in the emergency department Journal of Emergency Nursing: JEN : Official Publication of the Emergency Department Nurses Association 1999, 88-92
3. Nerney, M. P., Chin, M. H., Jin, L., Karrison, T. G., Walter, J., Mulliken, R.,Friedmann, P. D. Factors associated with older patients’ satisfaction with care in an inner-city emergency department Annals of Emergency Medicine 2001, 38(2), 140–145
4. Kihlgren, A. L., Nilsson, M., Skovdahl, K., Palmblad, B., & Wimo, A. Older patients awaiting emergency department treatment Scandinavian Journal of Caring Sciences 2004, 18(2), 169–176
5. Richardson, S., Casey, M., & Hider, P. Following the patient journey: Older persons’ experiences of emergency departments and discharge Accident and Emergency Nursing 2007, 15(3), 134–140
6. Considine, J., Smith, R., Hill, K., Weiland, T., Gannon, J., Behm, C., McCarthy, S. Older peoples’ experience of accessing emergency care Australasian Emergency Nursing Journal 2010, 13(3), 61–69
7. Olofsson, P., Carlström, E. D., & Bäck-Pettersson, S. During and beyond the triage encounter: Chronically ill elderly patients’ experiences throughout their emergency department attendances International Emergency Nursing 2012, 20(4), 207–213