Home Health Emergency departments in England are not designed to meet the basic care...

Emergency departments in England are not designed to meet the basic care needs of frail older people


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Findings from a small qualitative study published online at Journal of Emergency Medicine.

Being treated with dignity and respect, clear and timely explanations of what is and isn’t happening, and the opportunity to have a say in their care – all key tenets of patient-centred care – often seem to be lacking, the reviews suggest.

Changes in clinical practice and service design are required to meet the needs of a large and growing population elderly people who live with frailtyconcludes the linked editorial.

Frailty refers to a reduced ability to recover from health problems combined with a need for assistance with basic daily activities. This is a consequence of the cumulative physiological decline associated with aging.

Relatively little is known, however, about the impact of frailty on older adults’ experiences and preferences in acute care.

In an attempt to find out, researchers conducted in-depth interviews with 24 older people (75+) with frailty and 16 of their carers with current or recent acute care experience in three separate emergency departments in England between January and June 2019

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

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

A fall was the primary reason for an emergency department visit for 1 in 3; other common conditions included difficulty breathing, heart problems, abdominal/back pain, or confusion.

Feedback showed that interviewees were very reluctant to go to the emergency department, often due to previous negative experiences and fear of never getting out, and they felt helpless/resigned when a visit could not be avoided.

The attitude of the staff in general was seen as very caring and encouraging. But interviewees were less enthusiastic about their experience of primary care.

These included no access to or assistance with eating or drinking, including several patients with diabetes; little toilet assistance; and long uncomfortable waits on hard trolleys.

A quarter of those surveyed said they waited 12 hours or more in an emergency room before being admitted to a ward.

Interviewees felt that communication and participation in the decision-making process could be improved, including the involvement of next of kin, who were seen as very important in supporting vulnerable older people during the sometimes very long wait.

And interviewees did not always understand who they were seeing or who they needed to talk to when they had questions. Staff also did not always take the time to speak slowly and clearly to ensure that information was received and understood.

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

The authors note that this is a small study involving patients/carers at just three sites, so it may not be typical of emergency departments across England.

But they note: “Our research shows that weakness can lead to particular vulnerability [emergency departments] when the physical (environment, personal comfort, expectation) and emotional (sense of dignity, communication, participation, family support) are not satisfied’.

They say care in emergency rooms should be more “patient friendly”.

“For now [emergency department] environment and waiting times may be more difficult to change, health professionals can help older people living with frailty by being mindful of their comfort, physical needs, information flow and the importance of patient/caregiver involvement. Indeed, in an environment where wait times can increase, the importance of a person-centered environment becomes even greater.

“In a broader sense and taking into account the problems associated with more fundamental changes in the structure [emergency department] and pressures on this part of the health system, policy and practice must take into account changes in service development, responding to the needs of older people living with frailty and requiring immediate and emergency care,” they concluded.

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

“In particular, frailty is an emerging and urgent public health problem with significant implications for the clinical practice of emergency medicine,” they write.

The results of the study show that “older people have the same wants and needs as younger people who use emergency department: treat with dignity, respect, listen and communicate regularly with staff.

“To our shame, these interviews highlighted how disenfranchised and marginalized frail older people feel when using our services. Unlike younger, fitter patients, they are less able or inclined to complain or express dissatisfaction when their needs are not satisfied.

“We urgently need to think about and fix this by redesigning our services for all our patients, bearing in mind that the needs of older people, although similar, are much more urgent and the consequences of not getting it right are much greater.”

They conclude: “Older people are not asking for special treatment or something unrealistic or impossible; they just want to make a difference, and that’s what all our patients expect and hope for in ours [emergency departments].”

A watch-and-wait strategy may be better than emergency surgery for patients with severe weakness

Additional information:
Acute care for older people living with frailty: patient and carer perspectives, Journal of Emergency Medicine (2022). DOI: 10.1136/emermed-2022-212420

Citation: Emergency departments in England not set up to meet basic needs of frail older people (2022, 6 September) Retrieved 6 September 2022 from https://medicalxpress.com/news/2022-09-emergency-departments-england- basic- fragile.html

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