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GERIATRICS/REVIEW ARTICLE

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

Kalpana N. Shankar, MD, MSc*; Bhavnit K. Bhatia, BA; Jeremiah D. Schuur, MD, MHS

*Corresponding Author. E-mail: [email protected].

Volume 6

Study 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 patients’views of their emergency care. Thus, we performed a systematic review to synthesize the current knowledge about theelderly patient’s preferences and views of their emergency care.

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 elderly’sperspectives of hospital-based emergency care.

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.

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.]

Please see page 530 for the Editor’s Capsule Summary of this article.

A podcast for this article is available at www.annemergmed.com.

0196-0644/$-see front matterCopyright © 2013 by the American College of Emergency Physicians.http://dx.doi.org/10.1016/j.annemergmed.2013.07.509

INTRODUCTIONBackground and Importance

As the world’s population ages and life expectancy increases,1

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 medicalpractitioner’s 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 the

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views, preferences, and priorities of elderly patients and attemptto align these notions with the clinical delivery of care.

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

Subsequently, multiple dimensions within the concept ofpatient-centered care emerged from the IOM’s 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, and

Annals of Emergency Medicine 529

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Older Adults’ Views of Quality Emergency Care Shankar, Bhatia & Schuur

Editor’s Capsule Summary

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.

What question this study addressedWhat is our existing knowledge about how olderadults define quality emergency care?

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.

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.

Goals of This InvestigationAs policymakers seek to improve the quality of emergency

care for elderly adults, it is important to understand the elderlypatient’s 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.

MATERIALS AND METHODSStudy Design

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 patient’s

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view 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 athttp://www.annemergmed.com).

Data Collection and ProcessingWe reviewed titles and abstracts to identify articles that

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

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 IOM’s 6 dimensions of patient-centered care; and (3)study design of a survey/questionnaire, focus group, or individualinterviews. Our exclusion criteria were (1) non–hospital-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 (k¼0.80). Any disagreement in inclusion wasarbitrated by discussion among the investigators (K.N.S. andJ.D.S). Ultimately, 28 articles were included in our study.

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.

Initially, the IOM’s 6 dimensions of patient-centerednesswere used as the overarching themes to categorize patient

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Shankar, Bhatia & Schuur Older Adults’ Views of Quality Emergency Care

preferences. However, after we used the meta-ethnographictechnique and multiple rounds of discussion between reviewers,6 new themes, distinct from the IOM’s dimensions, emerged asthe major themes of this synthesis.7 These themes were groundedon, but independent of, the IOM’s 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’

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.

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 patient’s expectations andinvolvement were met with respect to these themes.16

Role of the Health Care ProviderThe leadership role of the health care provider (ie, physician

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

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 that


physicians did not address their community needs, creating ahome safety concern.

Content of Communication and Patient EducationContent of communication and patient education is defined

as the hospital staff’s 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

specific areas of concern included feeling patronized withconversations that were unnecessarily oversimplified,30-32

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

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 satisfaction anda negative impression of care delivery.15,20,23,24 Terminalpatients who experience a heightened sense of anxiety because ofthe severity of their condition also require a different level ofexpectation management. Many felt an overwhelming sense ofneglect and sought reassurance or information on their course inthe emergency care setting.21,34 Several comments about thisissue focused on patients feeling distanced by impersonalinteractions and used words such as “neglected,” “forgottenabout,” and “uncared for” when describing their sense ofisolation.21,28,34

The role of nursing staff was central to the patient experienceof effective communication and education. Specifically, patientsbelieved that nurses were just as responsible as physicians toeffectively communicate the treatment plan and help withcommunity resources.26,30

Last, some patients were confused about how the emergencycare setting functioned and would have appreciated havingsomeone, such as a patient advocate, explain the process tothem.15,28,35 Similarly, patients also commented on theconfusing nature and large expense of medical bills receivedafter discharge,35,36 with many wishing they had been informedof what to expect.

Barriers to CommunicationBarriers to communication entail the staff’s acknowledgement

of educational and cultural differences, as well as physical andmental disabilities, which may impede effective communication.


Table 1. Themes of Geriatric Patient-Centered Care

PrimaryAuthor

Location, Year,Demographics Study Design

Themes of Quality as Defined by Elderly Adults

Disseminationof ResultsBack to ED

Ethical Issues/Limitations

Role of HealthCare Providers

Content ofCommunication andPatient Education

Barriers toCommunication Wait Times

Physical Needs inthe EmergencyCare Setting

General Elder CareNeeds and Care

Transitions

Kelley17 Canada2010Acute regional EDParticipants: Proxy

decisionmakersand patients�75 y

N¼80

Interviews(patients orproxydecisionmakers,staff, communityinformants),observations(patients) andsurveys (staff)

Participantsenrolled solelyfor purposes ofthis study

Perceivedproviders asunderstaffedandoverworked

Assistance withpatientrequests wasalwaysappreciated

Some patientswere frightenedand soughtreassurance,which was notalways given

Enhancedcommunication isneeded, especiallyduring transferbetween services

Providers need touse simplerlanguage, takemore time toensureunderstandingof procedures,especiallyduringdischarge

Contributed to poornutrition,hydration

Patients wereunderstandingof chaotic EDenvironmentand appreciatedcare whenreceived

Lacked privacy,crowded, noisy

Patients were cold,hungry, thirsty,poorly rested

ED lacked adequateequipment,furniture

Signs, name tags,and space werechallenging

All patients feltnegatively abouthallwayplacement

Lack of assistancewith eating

Mixed experiencesBad visit lacked

physical comfort,emotionalreassurance, orinformation

Good visit waspain-free, hadquestionsanswered,patients wellrested, well fed,and reassured,and familiessatisfied

Family involvementassociated withfaster evaluations

Results presented tohospitalmanagementcommittee, EDstaff, andleadership team,and communityhealth servicesinvolved with ED

Challenge to gatherdata from busystaff and sickpatients

Interviews lackedprivacy and mayhave influencedresponses, butstill confident thatcomplete opinionsshared

Not everyoneidentified ascandidate couldbe interviewed;some eldersdeclined andothers deemedincapable by staff,especially ifcognitivelyimpaired

Study of single EDKihlgren24 Sweden

2004Regional hospital

EDParticipants:

Relatives andpatients �75 y

N¼2014 women, 6 men4 participants in

pilot study;16 in main study

Observation andinterviewsconducted bynurses

Grounded theoryapproach


Nursing careduring thewaiting stagecrucial topatient’soverall EDexperience

Patience andkindness fromnursesimportant

Not being toldreasons for longwait timesincreasedirritation,restlessness, andmistrust andincreased the needfor attention

Patientsexperiencedlack ofunderstandingof medicalterms andconfusion

Hesitation totrouble staffwith questions

Unpleasant waitingan average of4 h, causingfeelings ofabandonmentand mistrust

Unnecessarywaiting for thephysician to seethem, for testresults, and forless experiencedphysicians toconsult withother physicians

Patientsexperiencedconfusion,anxiety, andsadnessbecause of lackof nursing careduring waitingperiod

Fear of inability toreach the buzzer

Lack of privacy(whether on astretcher in aroom or waitingin a corridor)

Uncomfortable bedScantily dressed

and cold duringwait

Thirsty/hungryScared, anxious,

and in pain whilewaiting

Many more worriedabout socialsituation thanmedical

N/A If staff deemedpatient cognitivelyunable to makedecision aboutparticipation,verbal consentobtained fromaccompanyingrelatives

Observer’s presencemay have affectedresults

Data collectionaffected carers’situation andapproach

Ethical dilemmawhennonparticipantobserver seespatient withunmet basicneeds

Challenge for nursesto study othernurses andmaintain role asresearchers

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Nyden25 Sweden2003Swedish ECUParticipants:

65–88 yN¼72 women, 5 men

Interviewsconducted bynurses

Life-worldinterpretativeapproach


Safe to hand overhealthproblems toprofessionalcare providers

Seek affectionaterelationshipswith nursesand appreciatehumor fromstaff

Important thatprofessional careproviders beattentive to one’sneeds

Necessary to be wellinformed, but didnot necessarilyexpect to beparticipants in thediscussions

Thought it wasembarrassingto botherprofessionalstaffunnecessarily

Long wait times ledto feelings ofinsecurity

Uncomfortabletrolleys

Desire to be seen aslegitimatepatients and tobe kindly andrespectfullyreceived helpedto maintain one’sdignity

Important not to bethirsty or hungryduring longperiods of waiting

N/A Interpreting resultsaccording to atheory likeMaslow’s theoryof motivation andpersonality caninhibit opennessand sensitivityand influencefindings

Consequently,framework wasnot applied untilfirst phase ofanalysis

Olofsson28 Sweden2012Participants:71–90 y, with �3

ED visits duringlast 12 mo and�3 clinicalconditions

N¼14; 9 women, 5men

Interviewsconductedbased on

DescriptivePhenomenological

MethodInductive

qualitativeapproach


Personaltreatment andprompt careimportant for apositive triageprocess; thisshouldcontinue aftertriage

Attentive listeningand active interestduring triagehelped create arespectfulrelationshipbetween patientand nurse

After triage, aperceived lack ofinterest and failureto listen promptedfeelings of neglectand frustration

Lack of informationabout triagedecision and how itwould affect waittime

Short triage waitpromptedconfidence; longwait timesthereafterpromptedfeelings ofabandonment

Important to triageelderly patientsagain becausehealth status canquickly change

Diabetic patientsneeded food,weredisappointedstaff had notasked aboutdiabetes statusor need for food

N/A Study focused onchronically illelders with �3clinical conditions;chronically illpatients may havedifferentexpectations andgreater needs

Parke37 Canada20122 Canadian EDs10 older adult-

family caregiverdyads, 10 RNs,4 NPs

Older adults with�1 ED visit inlast 6 mo, mildto moderatecognitiveimpairment,MMSE between18 and 23

Interview sampleN¼16, patients

aged 77–90 y,6 dyads, 4

caregiversFocus groupN¼4 caregivers

Interpretive,descriptiveexploratorydesign with 3phases:

interviews,photographicnarrativejournal, photoelicitation focusgroups

Social ecologicalperspective


Lack of informationsharing andunderstanding ofthe triage process

“Not knowing” greatlycontributed toanxiety and feelingunimportant

Dementia patientsare undertriagedbecause theyare unable toexplain theirsymptoms; ie,mental abilitiesnot consideredwhendeterminingpriorities ofcare

Should pay specialattention to theneeds of elderlywith dementiaand keep theminformed

Patients withdementia areundertriaged

This increased riskof both initialcomplaint anddementiasymptomsprogressing

Long wait timesoften involvedlittle staffcontact orcommunication,contributing toanxiety andfrustration

Caregivers left tocalm patient’sanxiety duringprolonged waittimes

Chaoticenvironment maypose safety risksfor elders withdementia whobecomeincreasinglyanxious duringprolongedperiods of waiting

Dementia should beconsidered whenassessing acuityat triage

Feeling cared aboutand having needsaddressed wascentral to feelingsafe in the ED, forelderly and theircaretakers

Neglect of basiccare needs suchas food, water,toileting, andmobility hadgreaterconsequences forelderly withdementia

N/A Study focused onelders withdementia, whomay have greatersafety and basiccare needs thanother patients

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Table 1. Continued.

PrimaryAuthor










Transitions

Spilsbury23 UK1999Large NHS Trust

EDParticipants: White

patients 76–90 yN¼126 women, 6 men

Observation andinterviewsconducted bynurses 48 h and1 mo post–EDvisit

Participantsenrolled as partof largerresearch study,Meyers andBridges 1998

Staff shouldconsidermedical historyand futurearrangements

Staff should becaring andshow respecteven if patientsare elderly

Concerned aboutunacknowledgedwaiting times andlack of informationcommunicated

Staff did not useopportunities toalleviateanxietyandmisconceptions

Patients wanted tounderstand theircourse of care butwere often noteducated on theircondition ortreatment

Some believedthey werespoken todisrespectfullyor in a mannerthatdemonstrated alack ofunderstandingof theirconditions

Staff should takesensory/physicalproblems intoaccount

Patients unable totell full story;staff shouldrecognize thatpatients andrelatives have alot to contribute

Expected long waittimes and cameprepared butstill expectedperiodic updates

Inadequate toiletfacilities andprivacy

Uncomfortabletrolleys

Items often beyondphysical reach

Inadequate naturallight

Patients mostlysatisfied,considering busyand short-staffedED

Concerned aboutlack ofassessment andits focus on onlythe physical

Concerned aboutprematuredischarges andfuture carearrangements

Often believedproblems notresolved

Felt guilt andabandonment forcoming to the ED

Ignoring sensory/physicalimpairment maylead to anxietyand isolation

Relatives mayfunction as “eyesand ears” forpatient

Concerns aboutbeingburdensome tocaretakers

Staff shouldconsider privacy,safety, andcomfort onsensitive issues

N/A Patients may havebeen better ableto critically reflecton care becauseof researcherbeing presentwhen eventsoccurred

Because researcherswere nurses,might have beenable to betterrelate toexperiences andidentifyshortcomings

There are argumentsfor and againstresearchersjudging their ownpractices

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Stuart15 Australia2003Urban hospital EDParticipants:

Members ofcommunityfocus groups

N z98 membersof all communityfocus groups

(11 in elderlygroup)

Focus groupsconducted bynonmedicalproject officer

Ethnographicmethods


Supported thework of ED staff

Patientsrecognized thedifficultiescaused byaggression,overwork, andlimitedresources

Appreciateindividualizedcare

Key issue: Staffshould provideupdates topatients andrelatives of waitingtimes, progress ofassessment/treatment, andlikely outcome

Need to be informedabout how EDfunctions,including triageprocess, patientassessment, andadmissionsprocedure

Explanations ofdiagnosis,treatment, andfollow-up oftenincomplete orconfusing,especially forpeople fromdiverselinguistic andculturalbackgrounds

Recommendpatientadvocate

Availability andappropriate useof interpreters

Should provideinformationabout triage,waiting,assessment,and admission

Long wait timeswere an issue,but mainconcern wasbeing updatedwhile waiting

Waiting areauncomfortable,frightening

Triage setup lacksprivacy, acts asbarrier tocommunication

Lack of privacywhen on astretcher

Need for signageand informationalmaterial

Need for culturalawareness

Caregivers shouldbeacknowledged,recognized asadvocates andsources ofsupport

Proposed “carerscards” tofacilitateidentification ofcarer and accessto patient

Staff discussiongroups held topresent findingsand facilitatediscussion on howto address issues

Several programsdeveloped toaddress elders’needs, includingimprovement ofwaiting roomfacilities anddevelopment ofcarers card

ED consumeradvocacy groupcreated

All focus groupmeetings heldoutside hospitaland facilitated bynonmedicalproject managerto encouragehonesty

Explained thatresults of projectwould be sharedwith ED staff tohelp them makeimprovements

Watson22 US19993 EDs in western

USParticipants:

Patients 66–86y

N¼126 women, 6 men

Interviewsconductedwithin 72 h ofED visit atpatient’s placeof residence


Thought moststaff were kind,caring, able,and efficient

Humor was veryimportant

Patients liked to betold why they werewaiting

Keeping patientsinformed in atimely fashion mayreduce anxiety andincreasesatisfaction

Patients expressed aneed tounderstand whatwas happening tothem, what toexpect, and toknow whether theircondition couldworsen

Important to useunderstandablebut notpatronizinglanguage

Patients’perceptions ofwait time,whether long,short, ordifferent fromactual wait time,is significant tosatisfaction

Some procedurespainful

Beds and cartsuncomfortable

Patients expressedtolerance,patience, andawareness ofother patients’needs but as aresult willminimize theirproblems

N/A N/A

Lyons19 UK2009RoyalInfirmary of

Edinburgh EDParticipants:

Patients66–94yN¼2011 women, 9 men

Interviewsconducted afterdischarge ortransfer toinpatient bed



Important forclinicians to bethorough inexaminations

Most patientsexpressedconfidence inclinical staff’sknowledge,authority,abilities, andjudgment

Appreciatednurses

Important to find outwhat theirproblems were andhave them dealtwith

Equally important tobe givenpersonalized careand attention,which manythought theyreceived

Perceptions ofcommunication

Perceptions varied,but mostpatients weresurprised by howquickly theywere seen andassessed

When wait timeswere long, theyrecognized thatstaff were busyand appreciatedthat they werekept informed

Environmentalfactors such astemperature,cleanliness, andprivacy

Elders definephysical care as adistinct need,includingtoileting,nutrition, andgeneral physicalcomfort

Attention topersonal hygienedefined as aspecific desire forpatients

Care of relatives

N/A Although ED nursingstaff was used toidentify patients,nonmedical EDresearch assistantused to recruitpatients toinfluencingpatients’ actions

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Table 1. Continued.

PrimaryAuthor










Transitions

spending timeto appeasethem

Definedreassuranceand empathyas a distinctneed

varied, but allagreed on theimportance ofbeing wellinformed

Good communicationwas associatedwith a good careexperience

Smith21 US20102 academic

medical centerEDs

Participants:Caregivers andpatients 20–89 y

N¼21 (14 palliativecare patients, 7caregivers)

10 women, 11 men

Interviewsconducted byinvestigator withgraduate-leveltraining inqualitativeresearch andpreviousinterviewexperiencewithin 7 days ofED visit



Patientsfrustrated bybeing askedsamequestionsrepeatedly,impersonalinteractions

Patients wanted moreinformation aboutnext steps andlong wait times

Reassurance/empathy was veryimportant

Patients wanted morespecificinformation abouttheir conditions

Long wait timesincreasedanxiety andprolonged pain

Stretchersuncomfortable

Mixed perspectiveson presence ofpalliative carephysicians in ED,but recognitionthat coordinationof care betweenpalliative careand EDphysiciansneeded

Inadequate andpalliative caremanagement

Family membersand caretakersdid not feelprepared tomanage acutesymptoms

N/A Small sample sizemay have causedselection bias

Study conducted inurban academicmedical settings;may not reflectexperiences inother settings

Limited sample sizeto patients whohad beenadmitted to EDin last 7 days

Palliative carepatientpopulation;correlation withexperiences ofother patients notexplored

Way39 UK200831 NHS Trust EDs

participating inDepartment ofHealth’s 2005NationalLeadershipProgram

Participants:Patients: 75–95y and relatives

N¼96 (69patients, 27relatives)

64 women, 25men, 7unidentified

Discoveryinterviewsconducted bynurseconsultant oremergency carepractitionermembers ofDepartment ofHealth’s

2005 EmergencyCare NationalLeadershipProgram

Discoveryinterviewsperformed up to12 mo post–EDvisit

Participants

Patients madejudgmentsabout carebased onperceptions ofthe expertise ofthe staff

Staff shouldcommunicate withboth patients andpartners

Clear communicationaffects preparationfor procedures,deciding betweentreatment options,and understandingmedical advice

Staff should explaincircumstancesunder whichpatients shouldseek medical carein the future andwhat progresspatients shouldexpect

Assessments suchas repeatedmedical historytaking can beunnecessarilytaxing to patients

Patients believedthey needed EDcare but wantedmore opinions orwere afraid ofhospitals

Important to discusseffects of healthon managing athome

Patients inclined tobe passive andthereforevulnerable

Often felt lessimportant thanother patientsand feltfrustrated whencare lacked

Preliminary findingsshared withstakeholders,including olderservice users,relatives, healthservice managers,and clinicians

Their comments wereincorporated intosubsequentrecommendationsand disseminationstrategies

Inclusion restrictedto patients judgedto be well enoughaccording to vitalsigns, possiblyexcluding homecare receivers andcognitivelyimpaired

Lack of ethnicdiversity; 64% ofparticipantsidentified as whiteBritish

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enrolled forpurposes of thisstudy (also seeBridges for finalstudy report)

Patients possessdifferent levels ofknowledge, sostaff must beprepared to helpwithdecisionmaking ifnecessary

continuityViewed friends,

family, andneighbors assources ofcompany,support, andassistance aftertreatment

Fear and anxietyexperienced bypatients heavilyinfluenced bystaff behavior

Nerney30 US2001Urban academic

EDParticipants:

Patients �65 yN¼778,490

women, 288men

79% black

Surveys: Baselineand follow-upbased on Picker-Commonwealthquestions,administered byresearchassistants

Follow-upconducted 2 wkpost dischargeor within first 3days ofhospitalization


Physicians shouldrecognize whenpatients are inpain

Important to be asinvolved in care aspatients would like

Physicians andnurses shouldclearly answerquestions

Important to havetrust betweenpatients and staff

Important to be toldwhy tests are beingdone

Physicians should bemore attentive toolder patients’concerns andquestions

Reasonable waittimes correlatedwith higherperceivedexperience withcare

Important to havepain addressedfully

N/A Only evaluated 1urban academicED withpredominantlyblack population

Many patientsrefused to takeinitial survey, weretoo sick, or weretoo busy with EDstaff

Not all variablesaffectingsatisfaction werestudied, includingtechnical aspectsof care,experience withnonclinicalpersonnel,comfort andattractiveness ofED and waitingroom

Difference in whenfollow-upadministered (2wk after dischargeor within first 3days hospitalized)may have causedbias

Liu18 US20104 large urban

hospital EDsParticipants:

Patients <25 to>65 y

454 women, 274men observed

377 women, 242men not

Observation andsurveysconducted byresearchassistants andtrainedcontractedobservers

Participantsenrolled solely

Physicians showedgreater numberand intensity ofcaring behaviorsthan nurses

Making patientsaware of care-related details,working with acaring touch, andexplainingprocedures hadthe strongestpositive influenceon patient loyalty

Making patients feel

Wait time reportedas mostimportant areato patients yetconsistentlyranked as leastpositive area inperceivedexperience

Caring behaviorshave an effect onpatient loyaltyand thus have aneffect on patientexperience

Loyalty correlatedwith information-based caringbehaviors formen, with

N/A Patients with triagelevels of 1/5 or 2/5 were excludedbecause ofobservationdifficulties

Observation periodslimited to 7 AM–12AM; observationsoutside of thisrange were

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Transitions

observedN¼1,347;728 Observations

(79 elders, 649nonelders) and

619 surveys(60 elders; 559

nonelders)

for purposes ofthis study

comfortable/greeting themwarmly rankedthird inimportance.

Asking about fears/concerns andmaking patientfeel comfortablewere second orthird least positiveareas

Explaining patient’scondition rankedsecond inimportance

relationship-based caringbehaviors forwomen

abandonedStudy sites were

diverse but not allpopulations orregions werecovered

Exit surveys ofpatientsconducted atdifferent times

Baraff35 US1992Community senior

citizen centersin Boston; LA;Pittsburg;Youngstown,OH; Norwalk, CT

Participants:Senior citizens�65 y whovisited ED in thelast year

N¼5–13 patientsin each of 5groups

Focus groupinterviews

moderated byemergencyphysicians,clinical socialworkers, or anepidemiologist


Some had favorableinteractions, butmany feltabandoned

Positive interactionswith staff crucial toreducing stress

Anxiety not relieveduntil informed ofnature andseriousness ofcondition

Staff should be moresensitive toanxiety, shouldexplain delays andwhat to expect

Patients should beinformed of natureand seriousness ofillness as soon aspossible

Thought thereshould be morepatientadvocates in EDto spend timewith them,explain how thesystem works,and stand upfor them

Long wait timespainful anduncomfortable

Managed withoutcomplaining, buthard for patientsand families

Cold and noisyenvironment

Uncomfortablestretchers

Little privacy

Satisfied with overallquality of care

Patients’ primaryconcern wasfinding out whatwas wrong

Frightened byprospect of careand by illness

Fear of violence,falling, and goingout alone at night

Fear of an injuryresulting in lossof independence

Difficulty arrangingtransportationhome if notadmitted

Uncomfortablereturning homewithout escort

Multiple, confusingbills causedexasperation

N/A Focus groups requireskilledmoderators,though some hadnever conductedor participated inone

Groups may varysignificantly

Groups may bedifficult toassemble

Proper environmentneeded toconduct focusgroups

Bailey34 UK2011Large urban EDParticipants:

Patients, (46–92 y) relatives,staff members

N¼28 (15 staffmembers, 7relatives, 6

Observations andinterviews (staff,patients, andrelatives)conducted bynurse

Ethnographicmethods

Participantsenrolled solely

Staff distancedthemselvesand removedpersonhoodfrom dyingpatients

Pressure to beefficient, focuson outcomes

Once stabilized,“subtacular”trajectory patientsgiven littleinformation andfelt neglected

Subtaculartrajectorypatients isolatedfrom rest of ED

ED care prioritizes“spectacular” orsudden deathover subtaculardeath that isslower/unpreventable

Nonemergencydeaths and dyingconstitute large

N/A Attrition highbecause ofpatientdeterioration anddeath

Data gathered fromonly 1 ED; may notreflect views ofother regions

Small sample size of

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patients aged50–92 y)

Patients: 3 women,3 men

for purposes ofthis study

part of ED work,but palliative carein ED notsufficient

Presence of nurseshighly valued

ED staffinterviews andmostly nurseinterviews

Way27 UK2008NHS Trust EDParticipants:

Patients andcaregivers

N¼4 (2 patients,>75 y, 2 carers)

Discoveryinterviewsconducted bynurseconsultant 3–4days after EDvisit

Participantsenrolled solelyfor purposes ofthis study; usedas discoveryinterviews pilotbefore use inDepartment ofHealth’s 2005NationalLeadershipProgram (seeBridges, Way)

Discoveryinterviewscreated by UKcoronary heartdiseasecollaborative

Should assumefullresponsibility ofcare fromfamilymembers oncein the hospital

Most widelydiscussed issue

Repeated contactwith nursealleviates anxietycaused by delayedresponses

Adding signs fordirections toservices such astelephones wouldbe helpful

Important to makethem feelwelcome and likethey arelegitimatepatients

Transcribed textsshared with EDclinical/managementteams to reflectand discussimprovementstrategies

Ideas compiled intoaction plan andshared with themand othersinvolved with EDprovision

Use of interviewspine and itsefficiency

Challenges of homeinterviews andobtaining opinionsof patients andcaregiversseparately

Preservinganonymity

Maintainingseparate roles aspractitioner andresearcher

Richardson20 New Zealand2007Major tertiary level

teachinghospital ED

Participants:Patients: 80–102 y

N¼8249 women, 33

men

Audit andinterviews inward andpostdischarge

Mixed-methodsapproach


Participantstrusted staff tomaintain theirdignity andprivacy

Trusted that staffknew what theywere doing

Patients receivedlittle informationabout what washappening but alsoseemedunconcernedabout this

Generalreluctance tocriticize orquestion staffor procedures

Bed allocationusually occurredquickly, butpatients oftenended upwaiting muchlonger beforethey actuallymoved

Patients were notconsulted orinvolved indischargeprocess

Many implied theyknew nothingabout theirimpendingdischarge

N/A Limited patientsample

Study limited topatients admittedto medical wards,restricting sizeand causing somestaff confusion

Many patientsdeclined study,reflecting healthstatus and“noncomplaining”older patientculture

Communicationdifficulties intelephone follow-up

Difficulty getting staffto see importanceof data collectionfor future care

Unanticipated

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Table 1. Continued.

PrimaryAuthor










Transitions

patient loadaffected ability togather data

Difficulty collectingdata withoutpeople employedspecifically to doso

Considine40 Australia20103 Victorian EDsParticipants:

Patients andcaregivers

N¼30 (10 per site;12 caregivers,18 patients)

Interviews up to 1wk after ED visitby trainedresearchers

Recursive model ofinterviewing


Confusion abouttriage process andwhether caredelivered on first-come, first-servedbasis

Mixedperspectives;some frustratedby long waittimes, othershappy withquick, smoothtransitions

Longer timesattributed tosicker patients,crowding, heavyload for smallstaff,inappropriateuse of ED bysome patients

Some believedserviceequitable;others believedfactors such asarriving byambulance,behavior,socioeconomicstatus, and ageinfluenced waittimes

Crowded, oftenbecause of lesssick patientstaking up space

Patients reluctant touse ED careunless theydeemed healthcondition“serious enough”

N/A Conveniencesampling used

No critically illpatients includedbecause ofinformed consentrequirement

3 participantsdeclined/couldnot be interviewed

12/30 participantswere caregivers

Hedges36 US19926 EDs: 3 urban, 3

suburbanParticipants: Elderly

patients�65 yand nonelderlycontrols 21–64 y

N¼571 (399elderly; 172nonelderly)

Surveysadministered bytrained researchassociates inperson or overthe telephone


Elderly patients didnot perceive staffto be as busy orinattentive asyoung patients

Elders thought visitwas confusing andexpensive

Wait times weretoo long

Elderly patientsconcerned aboutan uncomfortableenvironment andwhetherprocedures wouldbe painful

Elderly patientsgenerallysatisfied, butelder patientsmore likely tothink complaint isnot completelyresolved afterleaving the ED

Elderly patientscame to the ED

N/A Tendency to excludethose who arrivedby ambulance orwere admitted

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61% women inelderly

58% women innonelderly

because they felttoo sick to waitfor a regular visit

More elders askedabout self-care byemergencyphysician

More elders notedchange in abilityto care forthemselves

Perez-Carceles32

Spain2007Urban teaching

hospital EDParticipants:

Patients 15–87y

N¼300 (239elderly; 61nonelderly)

138 women, 162men

Cross-sectionalself-administered

surveysParticipants

enrolled solelyfor purposes ofthis study

Two thirds of patientssatisfied withattention received

Patients felt mostsatisfied ifinformed ofprocedures,conditions, andtreatment

Older patients lesslikely to be givenreasoning behindtests andinformation onpossiblediscomfort

Older patients hadweakestcorrelationbetween real andperceiveddiagnosis

Older patients leastinformed ofprognosis

More patientsthought waittimes were shortthan excessivelylong

N/A N/A

Bridges33 UK200831 NHS Trust EDs

participating inDepartment ofHealth’s 2005NationalLeadershipProgram

Participants:Patients 75–95y and relatives

N¼96 (69patients, 27relatives)

64 women, 25men, 7unidentified

Discoveryinterviewsconducted bynurseconsultant oremergency carepractitionermembers ofDepartment ofHealth’s

2005 EmergencyCare NationalLeadershipProgram

Discoveryinterviewsperformed up to12 mo post–EDvisit

Participants

Older people candelay seeking helpand often needhelp deciding whatto do and when toseek care

Need a person-centeredapproach thattakes impairedcognition andcommunicationdifficulties intoaccount whileremainingrespect

Continuity of careimportant

The urgent caresetting canprovoke anxietyand fear ofhospitals andhospital-acquiredinfections

Older people mayfeel they do notmatter

Value personalizedcare and helpwith activitiessuch as going tothe toilet

Relatives play animportant role inproviding

Policy and practicerecommendationsdeveloped throughconsultation withstakeholders,including olderservice users,relatives, NHSpractitioners andmanagers, Helpthe Aged and AgeConcern England

Limited interviewertraining (1.5 days)

Short length of someinterviews

Patients may havefelt limited byinterviewer’sposition

Some interviewsoccurred 6–12mo post–ED visit,possibly causingrecall issues

Most patients whiteBritish, 75–79 y,living in their ownhome

Seriously orcognitively ill wereexcluded

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Table 1. Continued.

PrimaryAuthor










Transitions

enrolled forpurposes of thisstudy (also seeWay)

company andreassurance

Good dischargeplanning isimportant

Muntlin31 Sweden2008University hospital

ED, Level Itrauma center

Participants:Patients 18–91y

N¼200 (54elderly, 146nonelderly)

99 women, 101men

Surveysadministered byresearch nurses


Older patients hadsignificantly higherperceived qualityin terms ofinformation,respect, andpersonal carereceived

Older patients hadsignificantlyhigher perceivedquality of generalED atmosphere

N/A Difficult to measurepatientsatisfactionbecause of lack ofvalid instrumentsand study design

Patients whoconsented tostudy wereyounger thanthose whodeclined; couldhave offeredassistance toelders

Background datagathered aboutoccupation werelimited

Could have beenmore specificquestions aboutprivacy, nutrition,and ED care roomcharacteristics

Would have beenvaluable toinclude non–Swedish-speakingpatients, givenlarge immigrant/refugeepopulation

Ethical concernsabout askingpatients to takesurvey whilevulnerable in ED

Themessl-Huber38

Sweden2007Hospitals in 4

differentgeographicareas

Participants:Patients80–92y

InterviewsParticipants


Hesitant to“botherpeople,”perceiving thatstaff are busyand under timeconstraints

Reluctant to

Half of patients fullysatisfied, halfthought care wasadequate

Most appreciatedhealth and socialservices butthought the

N/A Patients limited toacute hospitals inparticipatingregions andsubject toconsultant’ssubjectiveselection

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N¼1812 women, 6 men

activate carersin emergencysituations orask for serviceson discharge

services did notcater to theirneeds, wantedthem to be moreflexible, orthought their ownfrailties did notallow them toenjoy the services

Thought thatassistanceimplieddependence andfrailty, affectingself-esteem

Trust central to whopatients contactfor health needs,preferring tocontact informalcarers

Currie26 UK1984Accident and

EmergencyDepartment ofthe Royal

Infirmary,Edinburgh

Participants:Patients �70 y

N¼10070 women, 30

men

Pro forma surveysParticipants


Providers shouldassumeresponsibility topersonallyassess need forcommunityservices

Medical recordsshould commenton function,supportarrangements,mental status,and need for asocial worker

More than halfreportedincreaseddependency inprevious outdoor,indoor, and dailyliving activities

Many would havebenefited fromavailablecommunityservices

Many patients withincreaseddependencyreceivedadditional helpfrom relatives

N/A N/A

McLeod29 Sweden, UK20062 EDs serving

conurbationsParticipants: White

patients �65 ywith �3 EDvisits during 18mo

InterviewsParticipants


Social workers’ rolein acting as acommunicationgo-between wasimportant forpatientspractically andpsychologically

Social services werevital source ofsupplementarycare in ED

Better referralsystems andexpandedcommunityservices are

N/A Had wanted 12patients but hadonly 10 in the UK

Of the 10, wanted 6women and 4men to match thegeneral EDpopulation buthad 5 men and 5

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Table 1. Continued.

PrimaryAuthor










Transitions

N¼15 (10 in UK, 5in Sweden)

necessarySocial work

contributes toquality of carethrough patientadvocacy,communicationof importantinformation, andemotionalsupport

womenAlso wanted 2

minority patientsbut were unableto recruit them

Because of refusal toconsent, minimalcontact with EDsocial workers,and death, hadonly 5 patients inSweden

Had 3 men and 2women, notmatching thegeneral EDpopulation again

Guttman41 Canada2004University

hospital–affiliated ED,tertiary carecenter

Participants:>75 yN¼1,724 (905

interventionpatients, 819controls)

Intervention: 531women, 374men

Control: 500women, 319men

Telephoneinterviews


Patients with nursedischargecoordinators weremore satisfied withthe clarity ofinformationprovided

More interventionpatients (patientswho had adiscussion abouthealth careneeds,education,referral tooutpatient facility,24-h nurse follow-up, and backupconsultation 1 wkafter discharge)felt better 8 daysafter visit andhad fewerunscheduledadmissionswithin 14 days ofdischarge

N/A Limitations of pre-post design,including seculartrends andselection biasHawthorne effect:improvedoutcomesbecause ofincreasedattention itself

No scale testing forclarify ofinformationprovided

Patientssocioeconomicallysimilar, butpatients inintervention groupwere sicker,suggesting self-selection bias foradditional nursingservices

Impractical toimplement tooltargeting allpatients >75 y

Further research

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need

edforcost/

bene

fitan

alysis

Farnsw

orth

43

UK

1995

York

District

HospitalA&

EParticipan

ts:>75

yN¼2

316wom

en,7men

Surveys

administered

10–20da

yspo

stdischa

rge

bycommun

itysisters

Participan

tsen

rolledsolely

forpu

rposes

ofthis

stud

y

Patientssatisfied

with

their

man

agem

ent,bu

tsomerecruited

additio

nalhe

lp(professiona

las

wellas

family

mem

bers/

friend

s)Con

cerned

abou

tcoping

atho

me

N/A

N/A

Lowen

stein4

2US

1986

Urban

teaching

hospita

lED

Participan

ts:

Elde

rly�6

5y

Non

elde

rly<65y

N¼4

68(234

elde

rly,234

none

lderly)

Cha

rtan

dbilling

record

review

,teleph

one

survey

14–21

days

postdischa

rge

Participan

tsen

rolledsolely

forpu

rposes

ofthis

stud

y

Cam

eto

EDbe

causethey

believedtheir

illne

sswas

seriou

sAp

preciated

discha

rge

instructions/

follow-up

inform

ation

N/A

Onlyassessed

asing

leurba

nED

;results

may

not

applyto

othe

rteaching

and

commun

ityED

sthat

differ

incases,

severity,

andreferral

patterns



In general, older patients will have increased needs forcommunication and accommodations from emergency carestaff.15,21,24,25,27,33-35 These needs are heightened when thelanguage requirements are different from the usual language usedin the emergency care setting. For instance, Stuart et al15 notedthe underuse of interpreters for elderly patients who spoke otherlanguages, which reinforced feelings of inadequacy amongsocioeconomically disadvantaged, minority groups. Families ofpatients speaking foreign languages were also often used asinterpreters, despite its being awkward “on matters that may besensitive or culturally inappropriate to discuss with them.”15,37

Similarly, accommodations for patients who have more physicaldisabilities than are present in the typical older patientpopulation will also require special provisions.23,33 Bridges33

stressed the need to be considerate of patients with physicaldisabilities, such as vision impairment or deafness, and those withimpaired cognition, such as dementia.37 In addition, becausemany physically and cognitively challenged patients were relianton their caregivers27,33 to help communicate their medical issues,many caregivers felt the need to be included during theemergency stay.33

Additionally, elders wanted to be clearly informed andeducated15,20,23,24 about their conditions, without the use ofcomplex language or medical jargon.17,18,22,25,30,32,35 Forexample, admitted patients believed that physiciansinappropriately assumed levels of knowledge about diseaseseverity and treatment options without verifying the knowledgelevel of the patient. Furthermore, with elderly patients reluctantto ask staff questions for fear of being bothersome or askingunnecessary ones,20,25,38 such assumptions can compromise asuccessful patient-physician interaction.

Wait TimesWait times refer to the amount of time spent waiting to

consult a physician and did not include time spent waiting fornursing staff. Prolonged wait times can be especially difficult tomanage for the frail elderly because many have psychosocial andmedical challenges requiring special accommodations that aregenerally not available in the emergency care setting. In general,prolonged wait times were bothersome and shorter wait timeswere associated with a more positive experience.18,30 Long waittimes were considered “unnecessary” and generated feelings ofdiscomfort, nervousness, mistrust, and confusion.17,21,24,25,35

These negative feelings were further intensified by feelings ofabandonment and anxiety, especially when there was a lack ofnursing care during these prolonged periods.24,28

Physical Needs in the Emergency Care SettingElderly patients are generally frailer, thus requiring assistance

with basic functions such as toileting, walking, and nutrition.Consequently, they find many aspects of the standard emergencycare environment uncomfortable. AlthoughMuntlin et al31 foundthat older patients had higher overall ratings of quality withemergency care than younger adults, many studies identified


Table 2. Themes of Geriatric Patient-Centered Care With Abbreviated Summaries

Primary AuthorLocation,

Year Study Design



Communicationand PatientEducation

Barriers toCommunication

WaitTimes

Physical Needsin the Emergency

Care Setting

GeneralElder CareNeeds and

CareTransitions

Kelley17 Canada2010

Interviews,observations,and surveys

U U U U U U

Kihlgren24 Sweden2004

Observationand interviews

U U U U U U

Nyden37 Sweden2003

Interviews U U U U U U

Olofsson28 Sweden2012

Interviews U U U U

Parke37 Canada2012

Interviews,photographicnarrative journal,photo elicitationfocus groups

U U U U U

Spilsbury23 UK1999

Observationand interviews

U U U U U U

Stuart15 Australia2003

Focus groups U U U U U U

Watson22 US1999

Interviews U U U U U U

Lyons19 UK2009

Interviews U U U U U

Smith21 US2010

Interviews U U U U U

Way39 UK2008

Interviews U U U U

Nerney30 US2001

Surveys U U U U

Liu18 US2010

Observationand surveys

U U U U

Baraff35 US1992

Focus groupinterviews

U U U U U

Bailey34 UK2011

Observations andinterviews

U U U U

Way27 UK2008

Interviews U U U U

Richardson20 New Zealand2007

Audit andinterviews

U U U U U

Considine40 Australia2010

Interviews U U U U

Hedges36 US1992

Surveys U U U U

Perez-Carceles32 Spain2007

Surveys U U

Bridges33 UK2008

Interviews U U U

Muntlin31 Sweden2008

Surveys U U

Themessl-Huber38 Sweden2007

Interviews U U

Currie26 UK1984

Surveys U U

McLeod29 Sweden, UK2006

Interviews U U

Guttman41 Canada2004

Telephoneinterviews

U U


546 Annals of Emergency Medicine Volume 63, no. 5 : May 2014

Table 2. Continued.

Primary AuthorLocation,

Year Study Design



Communicationand PatientEducation

Barriers toCommunication

WaitTimes

Physical Needsin the Emergency

Care Setting

GeneralElder CareNeeds and

CareTransitions

Farnsworth43 UK1995

Surveys U

Lowenstein42 US1986

Chart andbilling recordreview,telephonesurveys

U


specific structural areas that could be more patient-centered,including items being out of reach (eg, call lights), the noise level,lack of natural light, safety concerns within the ED (eg, loose cordsor wires), inadequate toilet facilities, and unpleasant waitingrooms.15,17,19,22-25,35,36 When patients did have these needsaddressed, the response was overwhelmingly positive. Patients alsomade specific suggestions about their comfort, such as placingphysical aids that directed them to services (eg, telephone use in theroom) or distribution of printed material.15,39

Two commonly cited causes of physical discomfort includedstretchers and privacy issues. Stretchers were often mentioned asuncomfortable and causing new-onset back pain not adequatelyaddressed during the stay.21,22,24,35 Studies also mentioned othertypes of uncomfortable furniture as a source of discomfort.Patients experienced a general lack of privacy duringexaminations and procedures but specifically cited the lack ofprivacy during triage, while lying in the hallway, and duringtoileting as definite areas of concern.15,17,19,20,23,24,35

General Elder Care Needs and Care TransitionsGeneral elder care needs are defined as the need to feel

welcome in the emergency care setting, palliative care, role ofcaretakers, and anxiety. Overall, elderly patients often feltunimportant, isolated, or abandoned during their emergency carestay and admitted they were less vocal about their own issues as aresult.22-25,33,39,40 As such, many studies had comments fromelderly patients about issues of being reluctant to initiateconversations or ask questions for fear of being troublesome tostaff.24,25,33,39 Additionally, the lack of interpreters and writteninformation for linguistically diverse backgrounds resulted infeelings of isolation,15 with many patients actively seeking atherapeutic relationship with nursing staff to help alleviateanxiety, a quality that heavily influenced the overall perception ofcare.19,24,30,34,39

Elderly patients with prolonged stays also believed that theirnutritional needs were not routinely met.17,19,24,25,28,37 Patientsoften discussed their thirst or hunger when they were discussingthe lack of attention from health care staff, again highlightingtheir feelings of abandonment. Additionally, 4 studiesemphasized the role of the staff to specifically address issues of


pain, palliative, and end-of-life care.21,24,30,34 Although manybelieved it important that pain be recognized and treated early, incomparative studies elders were less likely to voice concerns ofpain than younger adults.24 Furthermore, patients perceived anoverall lack of palliative care provided in the emergency caresetting to help control their pain, and if these specialists wereconsulted, there was little coordination of care.21,34 Last, bothpatients and families with end-of-life needs also addressed issuesof segregation from the rest of the ED, with a resultant disregardaround wider end-of-life care needs.21,24,30,34

The transition after emergency care was a common concernand generated anxiety among many elders. Several wereconcerned about potential premature transitions back into thecommunity, without staff recognizing the need for home supportafter discharge, transportation home, and continuity ofcare.20,23,27,29,33,35,36,38 Additionally, there was littlecoordination of care with consulting services, such as palliativecare.21 Patients with coordinated discharge plans that offeredclear instructions and follow-up telephone numbers viewed theircare as high quality.33,41 Another study demonstrated similarfindings with decreased unscheduled readmissions among thosewho had a stepwise discharge process.42

Home caregivers were frequently mentioned as a source ofsafety for elderly patients in the emergency care setting. Becauseelderly patients voice their concerns less often than youngerpatients,22 they are less likely to indicate when additional help isneeded or understand their care transition planning without thehelp of their caregivers.30 Most studies found that elderly patientsbelieved their caregivers were their safeguard back into thecommunity and may be their only advocate or source of supportin the hospital.15,17,19,23,26,27,33,38,43 The role of the homecaregiver is of great importance because many elderly patientsoften underestimate their own home care needs26 and the socialservices they may require on discharge.26,29,38,43

LIMITATIONSOur review had 5 major limitations. First, of the 26 articles

reviewed, 6 were US-based studies and 20 were from westernEuropean countries, Canada, and Australia. This mixcontributed to various degrees of patient perceptions and



inherent differences in expectations and definitions of“satisfaction” with care. For instance, although prolonged waittimes were generally distressing to all patients, regardless ofcountry of origin, patients from US-based studies consistentlyattributed longer wait times with poorer satisfaction. However,aside from prolonged wait times, other US-based opinionscorrelated well with opinions expressed from the other countries.

Second, this review includes articles that primarily usedqualitative and survey methods. Although these methods arehelpful to identify new information and reveal richness ofexperience, they do not provide representative estimates of thepopulation and may not reach ethnic minorities.

Third, the inclusion criterion was limited to qualitative studiesexamining one of the IOM’s dimensions of patient-centered care.This may have restricted the qualitative data explored becausethere may be viewpoints not captured within these dimensions.However, these dimensions were developed from previousliterature stemming from patients’ perspectives and thus shouldencompass the majority of literature exploring perspectives ofemergency care.

Fourth, this article used the technique of meta-ethnography tosynthesize qualitative data. Although this technique has beenrecommended to help arrive at higher-order interpretations, weacknowledge that thematic development is heavily dependent onthe reviewer because it fails to offer a robust guide to samplestudies for inclusion. However, rigorous efforts were made todevelop and adhere to an inclusion criterion in selecting studiesfor this review. Last, because the goal of this study was toexamine the patients’ perspective, the results do not acknowledgeperspectives from the health care staff that were addressed in afew of the studies.

DISCUSSIONThis systematic review of the qualitative data on elderly

patients’ views of emergency care identifies dominant themes thatelders considered important for effective delivery of care. Thisprovides evidence that administrators can apply when settingstandards and structuring emergency facilities that are responsiveto the needs of older adults. In total, we identified 6 majorthemes elders believed influenced their perception of emergencycare quality: role of health care providers, content ofcommunication and patient education, barriers tocommunication, wait times, physical needs, and general eldercare needs. These themes led to a number of potential strategiesto improve the emergency care for elders.

First, health care providers should assume a leadership rolewith both the medical and social needs of the patient. Althoughthe physician’s first priority should be the patient’s medicalcare, it is important for providers to acknowledge a patient’ssocial situation and seek help from others to troubleshoot theseissues if the physician has limited capacity to address thishimself or herself.

Second, provider communication significantly decreasedanxiety and managed expectations (especially for terminal


patients), built trust between the physician and patient, andimproved the overall experience. Thus, it may be worthwhile forphysicians and nurses to initiate communication frequently andprovide updates on the emergency care plan.

Third, given the elderly patient’s hesitancy to ask questions,health care providers should minimize any potential barriers ofcommunication by proactively soliciting questions from elders andtailoring conversations based on the patient’s level of knowledge.Furthermore, it is important to provide education in a manner thatis clear, comprehensible, and culturally sensitive to the patient.

Fourth, emergency care settings should be mindful of theelderly patient waiting for a prolonged period of time to betreated by a health care provider. Given the level of anxiety thispatient population experiences, elderly patients requiringprolonged emergency care stays should have staff check on themregularly and communicate with them about the status of theirevaluations.

Fifth, elderly patients were particularly sensitive to the distresscaused by a variety of physical discomforts, includinguncomfortable stretchers and lack of privacy. Although acomplete redesign of emergency facilities can make them moreelder-friendly, simple interventions such as using recliners inplace of stretchers can have a dramatic effect on pain andsatisfaction.44

Sixth, physicians should be cognizant that elders experiencehigher anxiety levels in the emergency care setting and thataddressing basic elder needs such as pain control and nutrition,clear care transition planning, and involving the patient’scaregiver can help alleviate some of this anxiety. Specifically,emergency physicians should recognize that an elderly patient’stransition into the community generally entails a higher level ofcoordination between patients, their social supports (such ascaregivers), and their health care providers. Caregivers should alsobe recognized as vital members of the care team who can aid withanxiety reduction and facilitate medical decisionmaking. To date,both pediatric emergency facilities and geriatric practices haveembraced the model of family-centered care that heavily involvesthe family as caregivers.45 Unfortunately, there is little emergencycare literature and few policy statements advocating for adultemergency care settings to incorporate this type of model intotheir care delivery system and is an area for improved patient-centered care.

Satisfaction with care was a dominant outcome described bymany articles and is intimately tied to the achievement of patient-centered care.7 Higher satisfaction and trust was associated withclear leadership roles from health care providers, appropriatetreatment of pain, and nurses communicating and spending timewith their patients. Conversely, poor satisfaction was related touncomfortable stretchers, lack of privacy, and prolonged waitingtimes without information about the expected course. Moreover,insensitivity toward cultural issues and disabilities, such ascognitive impairment, led to dissatisfaction. However, cautionshould be applied in equating satisfaction scores to the patientperception of quality. Although satisfaction metrics allow insightinto items such as education and comfort, they may not always



relate to a patient’s understanding of other aspects of quality suchas cultural barriers or safety issues.

The aging population and increasing emphasis on patient-centered health care means that hospital-based emergency carefacilities should examine the quality of their services for olderadults. Using the meta-ethnographic approach, this studyprovides a synthesis of the qualitative and survey researchperformed on the needs and concerns of the elderly patient andcan serve as a guide for improved delivery of care to the elderlypatient. Although some of these areas may require addingphysical resources to the ED, such as providing more geriatric-friendly stretchers or recliners, most areas require changes inculture, attitude, and practice of the staff to engage elderlypatients in a more meaningful way.

The authors acknowledge Paul Bain, PhD, MS, librarian,Countway Library of Medicine, Harvard Medical School.

Supervising editor: Timothy F. Platts-Mills, MD

Author affiliations: From the Department of Emergency Medicine,Boston Medical Center, Boston, MA (Shankar); Rush MedicalCollege, Chicago, IL (Bhatia); and the Department of EmergencyMedicine, Brigham and Women’s Hospital, Boston, MA (Schuur).

Author contributions: JDS conceived the study and developed theinitial inclusion and exclusion criteria. BKB undertook the initialliterature review. KNS and JDS undertook the review of articlesincluded to develop the final list of articles included and excludedin the study and provided the statistical advice to determineagreement on articles. KNS and BKB drafted the article, and allauthors contributed substantially to its revision. KNS takesresponsibility for the paper as a whole.

Funding and support: By Annals policy, all authors are required todisclose any and all commercial, financial, and other relationshipsin any way related to the subject of this article as per ICMJE conflictof interest guidelines (see www.icmje.org). The authors have statedthat no such relationships exist and provided the following details:Dr. Schuur was funded by a Jahnigen Career development awardfunded by the Atlantic Philanthropies and the American GeriatricsSociety.

Publication dates: Received for publication January 9, 2013.Revisions received July 3, 2013, July 22, 2013; Accepted forpublication July 30, 2013. Available online September 17, 2013.

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APPENDIX E1. SEARCH TERMS

SEARCHES PERFORMED

1. Boolean combination of elders, ED, and patient satisfaction(see expanded search terms below)

2. Boolean combination of elders, ED, quality of care, andqualitative research (see expanded search terms below)

3. Boolean combination of the terms “elders,” “emergencydepartment,” “patient safety,” and “qualitative research” (seeexpanded search terms below)

4. “Qualitative research,” “ED,” “elders,” and “patient safety” asfree text

MEDLINE (PUBMED) SEARCH TERMSElders

“aged”[MeSH] OR “Health Services for the Aged”[Mesh] OR“elders”[tw] OR “elderly”[tw] OR “geriatric”[tw] OR “frail”[tw]OR “older adult”[tw] OR “older adults”[tw] OR “olderpeople”[tw] OR “senior”[tw] OR “seniors”[tw]

ED“Emergency Service, Hospital”[Mesh] OR “Emergency

Medicine”[Mesh] OR “emergencies”[MeSH Terms] OR“Emergency treatment”[Mesh] OR “emergency medicalservices”[mesh] OR “emergency department”[All Fields] OR“emergency departments”[All Fields] OR “emergencydepartment”[tw] OR “emergency room”[All Fields] OR“emergency rooms”[All Fields] OR “emergency ward”[All Fields]OR “emergency wards”[All Fields]

Patient Satisfaction“Patient Satisfaction”[Mesh] OR “Consumer

Satisfaction”[Mesh] OR “Patient Acceptance of HealthCare”[mesh] OR “patient satisfaction”[tw] OR ((“patient”[tiab]OR “patients”[tiab]) AND (“belief”[tiab] OR “opinion”[tiab]OR “attitude”[tiab] OR “beliefs”[tiab] OR “opinions”[tw] OR“attitudes”[tw] OR “perceptions”[tw] OR “perception”[tw]))OR “patient experience”[tw] OR “patient experiences”[tw]

Quality of Care“Quality Indicators, Health Care”[Mesh] OR “quality of health

care”[mesh:noexp] OR “quality of health care”[tiab] OR “quality ofcare”[tw] OR “Healthcare Quality”[tw] OR “Health careQuality”[tw]OR “quality indicator”[tw]OR “quality indicators”[tw]

Qualitative Research“Interviews as Topic”[mesh] OR “qualitative research”[mesh]

OR “Narration”[mesh] OR “interview”[tw] OR “interviews”[tw]


OR “focus group”[tw] OR “focus groups”[tw] OR“Narration”[tw] OR “Narrative”[tw] OR “account”[tw] or“accounts”[tw] OR “qualitativ*”

Patient Safety(“patients”[MeSH Terms] OR “patients”[All Fields] OR

“patient”[All Fields]) AND (“safety”[MeSH Terms] OR“safety”[All Fields])

CINAHL (EBSCOHOST) SEARCH TERMSElders

(MH “Agedþ”) OR (MH “Health Services for theAged”) OR “elders” OR “elderly” OR “geriatric” OR“frail” OR “older adult” OR “older people” OR “senior”OR “seniors”

ED(MH “Emergency Service”) or (MH “Emergency Medicine”)

or (MH “Emergencies”) or (MH “Emergency Care (SabaCCC)”) or (MH “Emergency Medical Services”) OR “emergencydepartment” OR “emergency departments” OR “emergencydepartment”OR “emergency room”OR “emergency rooms”OR“emergency ward” OR “emergency wards”

Patient Satisfaction(MH “Patient Satisfaction”) or (MH “Consumer Satisfaction”)

or (MH “Patient Attitudes”) or “patient satisfaction” OR((“patient” OR “patients”) AND (“belief” OR “opinion” OR“attitude” OR “beliefs” OR “opinions” OR “attitudes” OR“perceptions” OR “perception”)) OR “patient experience” OR“patient experiences”

Quality of Care(MH “Quality of Health Care”) OR (MH “Quality of Care

Research”) OR “quality of health care” OR “quality of care” OR“healthcare quality” OR “health care quality” OR “qualityindicator” or “quality indicators”

Qualitative Research(MH “Interviewsþ”) OR (MH “Narratives”) OR (MH

“Focus Groups”) OR “interview” OR “interviews” OR “focusgroup” OR “focus groups” OR “narration” OR “narrative” OR“account” OR qualitativ*

Patient Safety(MH “Patient Safetyþ”) OR “patient safety”

Annals of Emergency Medicine 550.e1