Toward Patient-Centered Care: A Systematic Review of Older Adults’ Views of Quality Emergency Care

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<ul><li><p>GERIATRICS/REVIEW ARTICLEToward Patient-Centered Care: A Systematic Review of OlderAdults Views of Quality Emergency Care</p><p>Kalpana N. Shankar, MD, MSc*; Bhavnit K. Bhatia, BA; Jeremiah D. Schuur, MD, MHS</p><p>*Corresponding Author. E-mail: 6Study objective: Observers have cited a quality gap between the current emergency care and the needs of elderlyadults in the emergency setting. The Institute of Medicine identified patient-centeredness as a vital aim of quality healthcare. To develop a patient-centered approach in the emergency setting, we must first understand the elderly patientsviews of their emergency care. Thus, we performed a systematic review to synthesize the current knowledge about theelderly patients preferences and views of their emergency care.</p><p>Methods: Systematic review of qualitative studies and surveys addressing the elderly patients views of their emergencycare using PUBMED and CINAHL. Using meta-ethnography, we identified 6 broad themes about the elderlysperspectives of hospital-based emergency care.</p><p>Results: Of the 81 articles initially identified, our final review included 28 articles. We developed 6 themes of qualityemergency care: (1) role of health care providers; (2) content of communication and patient education; (3) barriers tocommunication; (4) wait times; (5) physical needs in the emergency care setting; and (6) general elder care needs. Keyfindings were that emergency staff should (1) assume a leadership role with both the medical and social needs; (2)initiate communication frequently; (3) minimize potential barriers to communication; (4) check on patients duringprolonged periods of waiting; (5) attend to distress caused by physical discomforts in the emergency care setting; and(6) address general elder care needs, including the care transition and involvement of caregivers when necessary.</p><p>Conclusion: Current qualitative research on the views of the elderly patient to hospital-based emergency care revealscommon themes that should be considered in efforts to improve delivery of care to the elderly patient. [Ann Emerg Med.2014;63:529-550.]</p><p>Please see page 530 for the Editors Capsule Summary of this article.A podcast for this article is available at$-see front matterCopyright 2013 by the American College of Emergency Physicians. and Importance</p><p>As the worlds population ages and life expectancy increases,1</p><p>hospitals should prepare for the older adult population to becomea more significant part of the emergency care population. In theUnited States, the highest emergency department (ED) visit ratesare among patients aged 75 years and older, compared with allother demographics.2,3 Despite the growing presence of elders inthe ED, many observers have cited a quality gap between currentemergency care and the unique needs of older adults.4,5 Thesestudies acknowledge gaps in the structural aspects of care (eg,design of hospital-based emergency care settings),4 processes ofcare (eg, identification and treatment of falls),5 and patientoutcomes (eg, revisits after 30 days).6 These studies and qualityimprovement programs are also based on the medicalpractitioners perspective, identifying specific conditions andimplementing treatment pathways. However, there are fewerpatient-centered, hospital-based emergency care qualityinitiatives for elderly patients. Such initiatives are based on the3, no. 5 : May 2014views, preferences, and priorities of elderly patients and attemptto align these notions with the clinical delivery of care.</p><p>The Institute of Medicine (IOM) identified patient-centeredcare as one of the 6 aims of quality health care.7 The concept ofpatient-centered care evolved from extensive debates within theIOM to veer away from solely technical improvements8 to aimsthat were thought to be more comprehensive.9 As such, patient-centeredness redefined professionalism to embrace an attitude inwhich patients have an active role in their own care.9</p><p>Subsequently, multiple dimensions within the concept ofpatient-centered care emerged from the IOMs 2001report: 1) Respect for patients values, preferences, andexpressed needs 2) coordination and integration of care, 3)information, communication, and education 4) physical comfort5) emotional support- relieving fear and anxiety 6) involvementof family and friends.7,10 The crowded and hectic emergency careenvironment makes patient-centered care difficult to achieve.However, with the recognition that elderly patients have morecomplicated care demands, spend more time in the ED, andAnnals of Emergency Medicine 529</p><p>mailto:kns1@bu.edu</p></li><li><p>Older Adults Views of Quality Emergency Care Shankar, Bhatia &amp; SchuurEditors Capsule Summary</p><p>What is already known on this topicEmergency department (ED) visits by older adults areincreasing, and these patients may have unique needsthat are not fully met by typical ED care.</p><p>What question this study addressedWhat is our existing knowledge about how olderadults define quality emergency care?</p><p>What this study adds to our knowledgeFrom 28 articles, this systematic review identifiedeffective and frequent communication, reduction ofwait times, attending to physical discomfortsexperienced while in the ED, and addressing themore general needs of the patient as important issues.</p><p>How this is relevant to clinical practiceEmergency physicians and administrators attemptingto improve the quality of emergency care for olderadults ought to consider the themes identified in thissystematic review.consume more medical resources,11,12 patient-centered carebecomes ever more important. Delivering emergency care in apatient-centered manner will improve the overall experience,enhance the effectiveness of care delivery, and guide clinicaldecisions based on the unique needs of the elderly patientpopulation.</p><p>Goals of This InvestigationAs policymakers seek to improve the quality of emergency</p><p>care for elderly adults, it is important to understand the elderlypatients perspective on the quality of their care. Thus, our aimwas to summarize the current knowledge about older adultpatients preferences and views of the quality of their hospital-based emergency care. Specifically, we conducted a systematicreview of the qualitative and survey-based medical literature toaddress this question. By identifying elders views of theiremergency care, providers can structure and improve care in amanner that is truly centered on the needs of older adults.</p><p>MATERIALS AND METHODSStudy Design</p><p>Weperformed a systematic review to identify articles addressingelderly patients (65 years) attitudes and experiences ofemergency care, using qualitativemethods or surveys.13To broadlydefine emergency care across both domestic and internationalsettings, for the purposes of this review, we defined hospital-basedemergency care or emergency care as the site at which care wasprovided.We first identified articles addressing the elderly patients530 Annals of Emergency Medicineview of emergency care by including hospital-based emergency careand excluding out-of-hospital emergency care (eg, ambulance-based care). With the help of a medical research librarian, onereviewer (B.K.B.) searched the MEDLINE (PubMed) andCINAHL (EBSCOhost) databases for records that included textand controlled vocabulary terms for emergency services, theelderly, and patient satisfaction. This search was further restrictedby text and controlled vocabulary terms for articles dealing withquality of care and patient safety. The search was limited to articlesdescribing qualitative or survey research only. No date or languagelimits were applied. Final searches were performed inMarch 2013.CINAHL was chosen as a second search engine because it is theleading nursing and allied health database, and we wanted toinclude research addressing all aspects of patient care. Detailedsearch strategies are presented in Appendix E1 (available online at Collection and ProcessingWe reviewed titles and abstracts to identify articles that</p><p>investigated attitudes of older patient populations, usingqualitative methods or surveys. We also reviewed the referenceswithin each of these articles and contacted authors to obtainfurther references. Abstracts were excluded if they excluded eldersor if they did not use qualitative methods or surveys.Primary Data AnalysisAccording to these criteria, 81 of 1,338 references met our</p><p>preliminary search criteria. Excluding review articles and articlesfor which only abstracts were available reduced the number ofreferences to 63. A second physician reviewer (K.N.S. or J.D.S.)screened the 63 potential articles to determine final inclusion orexclusion. Our inclusion criteria were (1) a hospital-basedemergency care population; (2) outcomes pertaining to 1 or moreof the IOMs 6 dimensions of patient-centered care; and (3)study design of a survey/questionnaire, focus group, or individualinterviews. Our exclusion criteria were (1) nonhospital-basedemergency care population; (2) no outcomes pertaining to any ofthe IOM aims of quality; (3) no outcomes specific to elders; and(4) review articles. The reviewers had 90% agreement on thestudies to include (k0.80). Any disagreement in inclusion wasarbitrated by discussion among the investigators (K.N.S. andJ.D.S). Ultimately, 28 articles were included in our study.</p><p>Included articles were reviewed in detail to identify specificviews and attitudes of the quality of their hospital-basedemergency care. The technique of meta-ethnography was used todraw together the data from all studies.14 This technique involveslisting of concepts, themes, and metaphors from each study;these were then organized, related, and linked to one another.We analyzed each patient-identified issue emerging from a givenstudy. Through this process, we synthesized the issues into a largenumber of broader ideas and subsequently integrated andcollapsed these ideas into specific themes.</p><p>Initially, the IOMs 6 dimensions of patient-centerednesswere used as the overarching themes to categorize patientVolume 63, no. 5 : May 2014</p><p></p></li><li><p>Shankar, Bhatia &amp; Schuur Older Adults Views of Quality Emergency Carepreferences. However, after we used the meta-ethnographictechnique and multiple rounds of discussion between reviewers,6 new themes, distinct from the IOMs dimensions, emerged asthe major themes of this synthesis.7 These themes were groundedon, but independent of, the IOMs 6 dimensions of patient-centered care previously mentioned. Each article was thenrereviewed and classified as either containing or not containingeach theme. Drafts of the table were circulated for review beforethe table was finalized. We chose to record themes and importantdetails as summaries but acknowledge that in summarizing werisked losing details of the encounter (Tables 1 and 2).RESULTSTwenty-eight articles were identified that addressed elders</p><p>views of quality of emergency care through qualitative methods orsurveys, including 8 from the United Kingdom, 7 from the UnitedStates, 5 fromSweden, 3 fromCanada, 2 fromAustralia, and 1 eachfromNewZealand, Spain, and both Sweden and the UK. Twenty-one articles used qualitative methods, 2 with focus groups and 19with interviews. Seven articles were based on patient surveys, 2 thatwere elder specific and 5 that included all ages but reported onelders views independently. Most articles used a definition of aged65 years and older to identify the elderly patient; however, someused aged greater than 75 years. The study by Stuart et al15 was theonly one that did not clarify the definition of elderly.</p><p>We classified 6 broad themes of quality that elders identifiedaround emergency care: (1) role of health care providers(defined primarily as the emergency physicians and nurses);(2) content of communication and patient education; (3) barriersto communication; (4) wait times; (5) physical needs in theemergency care setting; and (6) general elder care needs (Tables 1and 2). Although many articles refer directly to these specificthemes as a reflection of quality, many also used the construct ofsatisfaction to imply whether the patients expectations andinvolvement were met with respect to these themes.16</p><p>Role of the Health Care ProviderThe leadership role of the health care provider (ie, physician</p><p>and nurse) is central to elders experience of emergency care.Eleven of the 26 studies examined this topic. Overall, patientsexperienced an appreciation for health care providers andexpressed confidence in their abilities to provide care.15,17-22</p><p>Additionally, patients appreciated the caring nature of both thephysician and nursing staff and use of humor to make them feelwelcome during their emergency care stay. 18,19,22-25 However,there were multiple social issues inadequately addressed by healthcare providers. These included assuming full responsibility of allpatient-related issues (and not solely those pertaining to thepresenting complaint), helping with medical decisionmaking andorchestrating efforts to address any social needs (such as help withtoileting or feeding).23,26-28 Patients also commonly believedthat physicians should assume more responsibility formanaging the disposition planning when either discharging oradmitting.21,26,27,29 Specifically, discharged patients believed thatVolume 63, no. 5 : May 2014physicians did not address their community needs, creating ahome safety concern.Content of Communication and Patient EducationContent of communication and patient education is defined</p><p>as the hospital staffs effectively communicating and educatingpatients on the ongoing emergency care activities and plan, andhelping patients become better informed about their conditionor ongoing evaluation. Communication was specificallyaddressed in 23 articles. Many of these studies found thatpatients experienced various levels of communication, with theconsensus that effective communication improved the overallexperience and decreased anxiety irrespective of whether thephysician or nurse was the source of information. Although someelders were satisfied with the quality of communication,30,31</p><p>specific areas of concern included feeling patronized withconversations that were unnecessarily oversimplified,30-32</p><p>repetitive questioning and assessments,21,27,33 not receivingenough information or updates on their condition,15,23 andreceiving little or no reassurance about their trajectory and nextsteps for care.15,17-19,34</p><p>Many patients also did not feel properly educated on thenature of their condition, how to identify whether theircondition was worsening, why tests were being performed, andwhen to return or consult their physician.20,22,23,27 Ineffectiveeducation or confusing explanations during the care process ordisposition planning were associated with worse satisfactio...</p></li></ul>


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