Emergency departments not set up to meet basic care needs of frail older people

Emergency departments in England don’t seem to be set up to meet the basic care needs of frail older patients, suggest the findings of a small qualitative study published online in the Emergency Medicine Journal.

Treatment with dignity and respect, clear and timely explanations of what’s happening and what’s wrong, and the opportunity to have a say in their care—all key tenets of patient-centred care—often seem to be missing, the feedback suggests.

Changes in clinical practice and service design are required to meet the needs of a significant and growing number of older people living with frailty, concludes a linked editorial.

Frailty refers to reduced capacity to recover from health issues, combined with a need for help with basic activities of daily living. It’s a consequence of cumulative physiological decline associated with ageing.

Relatively little is known, however, about the impact of frailty on older people’s experiences of, and preferences for, emergency care.

In a bid to find out, the researchers carried out in-depth interviews with 24 older people (75+) living with frailty and 16 of their carers with current or recent experience of emergency care in three separate hospital emergency departments in England between January and June 2019. 

The interview sample aimed to reflect frailty, age, sex, ethnicity, mental capacity, place of residence, mode of arrival (ambulance or independent), whether seen in ‘major’ or ‘minor’ emergency departments, and on different days of the week and different times of the day.

Over two-thirds (68%) were women; 43% were aged 75–84; and over half (57%) were aged over 85. Most were white British: 12 had frailty scores of 5 (mild); the rest had scores of 6-7 (moderate to severe).

A fall was the primary reason for emergency department attendance for 1 in 3; other common conditions included breathing difficulties, heart problems, stomach/back pain or confusion.

Feedback showed that the interviewees were very reluctant to be taken to an emergency department, often because of previous negative experiences, and fear they wouldn’t come out again, and they felt helpless/resigned when attendance couldn’t be avoided. 

Staff attitudes were, on the whole, seen as very caring and reassuring. But interviewees were less enthusiastic about their experiences of very basic care.

These included not having access to, and being helped to, eat or drink, which included several patients with diabetes; little assistance with toileting; and long uncomfortable waits on hard trolleys. 

A quarter of the interviewees said they had waited 12 or more hours in the emergency department before being admitted to a ward.

Interviewees felt that communication and involvement in decision-making could be improved, including involving next of kin, who were viewed as critical to supporting vulnerable older people during sometimes very protracted waits. 

And interviewees weren’t always clear whom they had seen or whom they needed to speak to if they had queries. Staff didn’t always take time to speak slowly and clearly to ensure that information was received and understood either.

A calm, quiet environment also emerged as an important preference among the interviewees, with noisy busy departments proving particularly challenging for them.

This is a small study, involving patients/carers at just three sites, so may not be typical of  emergency departments throughout England, note the authors.

But they point out: “Our research suggests that frailty can result in a particular vulnerability in [emergency departments] if physical (environment, personal comfort, waiting) and emotional (sense of dignity, communication, involvement, family support) needs are not met.”

Emergency department care needs to be more ‘frailty friendly’, they say.

“While the [emergency department] environment and waiting times may be harder to change, healthcare professionals can help older people living with frailty by being mindful of their comfort, physical needs, the flow of information and the importance of patient/carer involvement. Indeed, in an environment where waiting times may be extending, the importance of a person centred environment becomes even greater.

“More broadly and given the challenges of more fundamental changes to the fabric of the [emergency department] and the pressures on this part of the healthcare system, policy makers and practitioners need to consider service development changes when responding to the needs of older people living with frailty requiring urgent and emergency care,” they conclude.

In a linked editorial, Mary Dawood, of Imperial College NHS Trust, London, and Rosa McNamara, of St Vincent’s University Hospital, Dublin, Ireland, point out that the number of over 60s is set to reach 1.4 billion by 2030 and 2.1 billion by 2050, while the number of over 80s is expected to quadruple to 395 million during the same period.

“Frailty in particular is an emerging and immediate global public health concern which has significant implications for clinical practice in emergency medicine,” they write.

The research findings poignantly show that “older people have the same desires and needs as younger people using the emergency department: to be treated with dignity, to be respected, to be listened to and to have regular communication with staff. 

“To our shame, these interviews have drawn into sharp focus just how disenfranchised and marginalised frail older people feel when using our services. Unlike younger fitter patients, they are less able or inclined to complain or voice dissatisfaction when their needs are not being met. 

“We urgently need to reflect on and rectify this, redesigning our services for all our patients, keeping in mind the needs of older people, although similar, are much more urgent and the ramifications of not getting it right, far greater.”

They conclude: Older people are not asking for special treatment or something that is unrealistic or undeliverable, they simply want to matter and that is what all our patients expect and hope for in our [emergency departments].”

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