Emergency departments not meeting basic care needs of frail older people

Emergency departments in England do not 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, concluded a linked editorial.

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. 

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 from 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, or 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 small study, involving patients/carers at just three sites, may not be typical of  emergency departments throughout England, the authors noted.

But they said: ‘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 added.

‘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.’

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