Care in emergency rooms should be more gentle on people with frailty, researchers say

Emergency departments in England do not appear to be set up to meet the basic care needs of frail older patients, according to the results of a small qualitative study published online in Journal of Emergency Medicine.

Being treated with dignity and respect, clear and timely explanations of what is happening and what is wrong, and the opportunity to have a say in their care – all key tenets of patient-centred care – often seem to be lacking, the feedback points out.

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

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

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

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

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

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

A fall is the main reason for an emergency room visit for 1 in 3; other common conditions include difficulty breathing, heart problems, stomach/back pain, or confusion.

Feedback indicated that interviewees were very reluctant to be taken to an emergency department, often due to previous negative experiences and fear of not coming out again, and felt helpless/resigned when attendance could not be avoided.

The attitude of the staff was generally considered to be very caring and reassuring. But interviewees were less enthusiastic about their experience with many basic care services.

These include lack of access and assistance to eat or drink, which includes several patients with diabetes; little help with toileting; and long uncomfortable waits on hard carts.

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

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

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

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

This was a small study involving patients/carers at only three sites, so may not be representative of emergency departments across England, the authors note.

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

They say care in emergency rooms should be more gentle on people with frailty.

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

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

In a related editorial, Mary Dowd of Imperial College NHS Trust, London, and Rosa McNamara of St Vincent’s University Hospital, Dublin, Ireland, point out that the number of people over 60 is expected to reach 1.4 billion by 2030 and 2 .1 billion by 2030 2050, while the number of people over 80 is expected to quadruple to 395 million over the same period.

“Frailty in particular is an emerging and immediate public health problem worldwide that has significant implications for clinical practice in emergency medicine,” they wrote.

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

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

“We urgently need to consider and rectify 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 them right are very bigger.”

They conclude: Seniors don’t want special treatment or something that’s unrealistic or impossible, they just want to matter, and that’s what all our patients expect and hope for in our [emergency departments].”