The organizational culture of emergency departments and the effect on care of older adults: A modified scoping study

Patient involvement in decisions about discharge from the emergency department: A qualitative interview study of the healthcare professionals' experiences

BACKGROUND

Patients in the emergency department are less involved in making decisions than they would like to be. Involving patients improves health-related outcomes, but success depends on the healthcare professional's ability to act in a patient-involving manner, and therefore more knowledge is needed about the healthcare professional's perspective of involving patients in the decisions.

AIM

To explore what challenges healthcare professionals experience in their daily practice regarding patient involvement in decisions when planning discharge from the emergency department.

METHOD

Five focus group interviews were conducted with nurses and physicians. The data were analyzed using content analysis.

FINDINGS

The healthcare professionals described how they experienced that there is no choice to offer the patients in the clinical practice. First, they had to manage the department's routines, which directed them to focus on acute needs and avoid overcrowding. Second, it was too difficult to navigate the diversity of patients with different characteristics. Third, they wanted to guard the patient from a lack of genuine options.

CONCLUSION

The healthcare professionals experienced patient involvement as incompatible with professionalism. If patient involvement is to be practiced, then new initiatives are needed to improve the conversation with the individual patient about decisions regarding their discharge.

A Comparison of the Time Spent in Emergency Departments by Older Adults With and Without Mental Health Needs

Older adults present to emergency medical services with a multitude of clinical and functional needs due to polypharmacy and multipathology. Older adults with mental health needs require additional time for the more comprehensive assessment required as a result of their underlying mental health condition. This article compares the time spent in emergency departments by older adults who have a mental health need with those who do not. Information on how they access prehospital and inhospital care is examined alongside key factors that impact on time spent in emergency departments. Data were collected from hospital records of older adults presenting at emergency departments in 3 large Health and Social Care Trusts in the United Kingdom using a retrospective, secondary, official personal information database source over 1 year. A total sample of 74,766 attendance records of older adults older than 65 years were examined. adults who presented with or had a mental health condition in their diagnosis or history, which made up a subsample of 1,818 people, were found to have significant differences in the time spent in emergency departments and some notable differences in trends and admission patterns. They wait longer than the older person without mental health needs, are more likely to breach the 4-hr waiting time target, are admitted in higher numbers, and rely heavily on the ambulance service. Health and social care systems and services need to undergo transformations to ensure that all people who access services are treated fairly and effectively.

In-hospital mortality associated factors in elderly patients with invasive mechanical ventilation in the emergency department

AIMS

To identify factors associated with in-hospital mortality, to estimate the intubation rate and to describe in-hospital mortality in patients over 65 years old with invasive mechanical ventilation (IMV) in the emergency department (ED).

METHODS

Retrospective cohort study of patients over 65 years old, who were intubated in an ED of a high complexity hospital between 2016 and 2018. Demographic data, comorbidities, and severity scores on admission were described. Bivariate and multivariate analyses were performed with logistic regression according to mortality and possible confounders.

RESULTS

A total of 285 patients with a mean age of 80 years required IMV in the emergency department, for a median of 3 days, and with a mean APACHE II score of 20 points of severity. The IMV rate was .48% (95% CI .43-.54), and 55.44% (158) died. Mortality-associated factors after age and sex adjustment were stroke (OR 2.13; 95% CI 1.21-3.76), chronic kidney failure, (OR 4.,38; 95% CI 1.91-10.04), Charlson index (OR 1.19; 95% CI 1.02-1.38), APACHE II score (OR 1.07; 95% CI 1.02-1.12), and SOFA score (OR 1.14; 95% CI 1.03-1.27).

DISCUSSION

Our IMV rate was lower than that stated by Johnson et al. in the United States in 2018 (.59%). In-hospital mortality in our study exceeded that predicted by the APACHE II score (40%) and SOFA (33%). However it was consistent with that reported by Lieberman et al. in Israel and Esteban et al. in the United States.

CONCLUSIONS

Although the IMV rate was low in the ED, more than half the patients died during hospitalization. Pre-existing cerebrovascular and renal diseases and high results in the comorbidities index and severity scores on admission were independent factors associated with in-hospital mortality.

Direct in-hospital admission via ambulance (DIVA): A retrospective observational study

BACKGROUND

Prolonged stays in emergency departments increase the risk of adverse events in elderly patients. To optimize care for nonurgent patients who need in-hospital admission, a patient-focused improvement project named Direct In-hospital admission Via Ambulance (DIVA) was launched at Örebro University Hospital.

PURPOSE

This study describes the effects of DIVA. The primary outcome was time to in-hospital admission. Secondary outcomes were the in-hospital admission rate, the in-hospital length of stay and patient characteristics.

METHOD

This was a retrospective observational study. Descriptive and comparative statistics were used. All patients identified by the ambulance nurse as nonurgent but with an apparent need for in-hospital admission were candidates for direct in-hospital admission. The results were compared with those of a reference group.

RESULT

In total, 127 patients were included, with 45 patients in the DIVA group and 82 patients in the reference group. In the DIVA group, 24 patients were directly admitted. The median time to in-hospital admisson was 49.5 min for direct admitted patients and 278.5 min for the reference group. There was a statistical significant difference between the groups (p < 0.01).

CONCLUSION

The current study indicates that time to in-hospital admission could be reduced by DIVA.

Nursing competence in municipal in-patient acute care in Norway: a cross-sectional study

BACKGROUND

The primary health care services are becoming increasingly complex, which presents challenges for the municipal nursing services. In Norway, municipal in-patient acute care (MipAC) has been introduced in all municipalities, and the competence at the services has been questioned. Few studies have examined the nursing services in the units. This study aims to get an overview of the nursing competence in those units across geographical regions, and different groups of organisation and localisation.

METHODS

A cross-sectional study was conducted, and an ad hoc questionnaire was distributed to first-line leaders in all the MipAC units in Norway. Data were collected in the period between 6 March 2019 to 6 June 2019. Measures to get an overview of the nursing competence were ratio of registered nurses (RNs) in staff, count of shifts with only one RN on duty and count of RNs with master's degrees/specialisation. Descriptive comparative statistics were used.

RESULTS

Of all 226 first-line leaders invited to participate, 207 (91.6%) responded to the questionnaire. Overall a considerable variance across the sample was revealed. The median ratio of RNs in staff was 56 (IQR = 40-70), the count of shifts with only one RN on duty median 28 (IQR = 5-49), and the count of RNs with a master's degree or specialisation median 3 (IQR = 0-5). The regions of Northern and Central Norway, MipACs located in nursing home and MipACs organised at long-term care units, showed significantly lower nursing competence in staff compared to the remaining institution and organisations.

CONCLUSION

This study generates knowledge that can inform planning, priorities and interventions that may be initiated at all organisational and political levels concerning the MipAC services. An overall conclusion is that advanced nursing competence is lacking. The study also highlights the most urgent direction for improvements regarding nursing competence in the services. It seemed to be MipACs in Northern and Central Norway, and those located at nursing homes organised together with long-term care units, that needed improvements the most.

Caring for an older person with dementia in the Emergency Department (ED): An Appreciative Inquiry exploring family member and ED nurse experiences

AIMS AND OBJECTIVES

To generate insights about what matters and is valued by family members of older people with dementia in the emergency department. To explore the experiences of emergency nurses looking after older people with dementia in an episode of care.

BACKGROUND

In the emergency department, older people with dementia are at risk of suboptimal care. Little is known of the experiences of family members of being with an older person with dementia in the emergency department or the experiences of emergency nurses looking after older people with dementia in this environment.

DESIGN AND METHODS

Phase 1 Data Analysis of the Discovery Phase of an Appreciative Inquiry study. Study participants were family members of older people with dementia and emergency nurses. Data collection methods included interviews with family members of older people with dementia and 30 hr of participant observation working alongside emergency nurses. This study was guided by the Standards for Reporting Qualitative Research.

RESULTS

Two themes emerged from the analysis: What matters to family members with four subthemes and challenges for family members and nurses in the emergency department with two subthemes.

CONCLUSION

This study demonstrates that some emergency nurses are connecting with family members even in the briefest of clinical encounters. It is feasible for more emergency nurses to do the same more of the time.

RELEVANCE TO CLINICAL PRACTICE

The older person with dementia must be given a triage category of no less than 3 (to be seen by the doctor within the hour) on arrival in the department. Further education is needed to assist emergency nurses to establish rapport and incorporate family member insights as part of care planning and assessment of the needs of the older person with dementia.

At Risk for Emotional Harm in the Emergency Department: Older Adult Patients' and Caregivers' Experiences, Strategies, and Recommendations

Background: Emergency departments (ED) serve a critical role in addressing the health care needs of older adults, although organizational and provider characteristics can result in unintended negative outcomes for this population, such as emotional harm. This study aimed to describe the patient experience of older adults in the ED and generate recommendations for enhancing their experience. Methods: Data from focus groups and individual interviews of older adults and caregivers who had visited the ED were thematically analyzed. Results: Ten focus groups and individual interviews of 41 older adults and 15 caregivers were conducted. Health system and provider factors affecting the patient experience were identified. Participants negotiated their experience using diverse strategies. Recommendations for improving the ED experience were generated. Conclusions: Older adults attending the ED are at risk for health care-related emotional harm unrelated to their entrance complaint, which could be mitigated by addressing organizational and attitudinal factors.

Emergency care units and dimensions of accessibility to health care for the elderly

ABSTRACT Objective: to understand the conception of the elderly and their caregivers about the accessibility to health mediated by the service in Emergency Care Units. Methodo: a qualitative study conducted with 25 elderly patients and caregivers at Emergency Care Units in a city of Paraná, using Grounded Theory as a methodological reference. Results: According to the participants, the resources available in these services guarantee medical consultation and provide access to exams and medicines. Such resources have attracted patients and caused excess demand, which implies a set of compromising factors for the quality of care in these services. Final considerations: Investments in the restructuring of the care network, especially in primary care, with an increase in the number of consultations and the creation of a bond, can contribute to the emergency care units achieving the goal of access to qualified assistance to the elderly population.

Medical Students as Systems Ethnographers: Exploring Patient Experiences and Systems Vulnerabilities in the Emergency Department

OBJECTIVES

The objectives were 1) to design systems ethnography roles for first-year medical students that could enhance student learning with regard to healthcare systems, ethnography, and systems thinking and 2) to describe strategies for other education programs seeking to implement systems ethnography roles in clinical settings.

METHODS

Fourteen medical students were educated about ethnography and systems thinking and linked with patients in the emergency department (ED) for 12 to 15 hours to observe patient experiences and clinical processes. Students submitted written assignments, participated in a debriefing exercise with ED and medical education leadership, and completed an electronic survey regarding educational benefits and perceived clinical value conferred to the ED using 5-point Likert-scale questions. Qualitative methods were used to analyze both students' assignments and notes taken during the debriefing session, including small-group report-outs and discussions, and to identify vulnerabilities in the patient experience.

RESULTS

Students identified one overarching theme of the patient experience-prolonged waiting in close proximity to the fast-paced, hectic "world" of the ED. Four key categories of systems vulnerabilities were identified through student observations: 1) patient experience; 2) communication and collaboration; 3) processes, physical space, and resources; and 4) professionalism. Students reported improved appreciation for challenges experienced by patients (3.92/5), importance of communication between providers and patients (3.92/5), and improved understanding of the patient experience while receiving care (3.77/5).

CONCLUSIONS

These results demonstrate how innovative systems ethnography experiences for medical students can provide unique educational opportunities while at the same time adding value by highlighting shortcomings in the care environment that can be used for system improvement.

Elder-friendly emergency services in Brazil: necessary conditions for care

OBJECTIVE

To identify and analyze the aspects necessary to provide an elder-friendly emergency service (ES) from the perspective of nurses.

METHOD

This is a descriptive, quantitative study using the Delphi technique in three rounds. Nurses with professional experience in the ES and/or researchers with publications and/or conducting research in the study area were selected. The first round of the Delphi panel had 72 participants, the second 49, and the third 44. An online questionnaire was used based on a review of the scientific literature with questions organized into the central dimensions of elder-friendly hospitals. A five-point Likert scale was used for each question and a 70% consensus level was established.

RESULTS

There were 38 aspects identified as necessary for elderly care that were organized into central dimensions.

CONCLUSIONS

The study's results are consistent with the findings in scientific literature and suggest indicators for quality of care and training for an elder-friendly ES.

OBJETIVO

Identificar e analisar aspectos necessários para um atendimento amigo do idoso nos serviços de emergência (SE), na perspectiva de enfermeiros.

MÉTODO

Estudo descritivo, quantitativo, com utilização da Técnica Delphi, em três rodadas. Foram selecionados enfermeiros com experiência profissional em SE e/ou pesquisadores com publicações e/ou desenvolvendo pesquisas na área de estudo. A primeira rodada do painel Delphi contou com 72 participantes, a segunda com 49 e a terceira com 44. Foi utilizado questionário on-line, baseado na revisão da literatura científica, com questões organizadas em dimensões centrais de hospitais amigos do idoso. Foi utilizada uma escala de Likert de 5 pontos para cada questão e estabelecido nível de consenso de 70%.

RESULTADOS

Foram identificados 38 aspectos necessários para o atendimento ao idoso, organizados em dimensões centrais.

CONCLUSÕES

Os resultados do estudo são consistentes com os achados na literatura científica e sugerem indicadores para qualidade do cuidado e para formação de SE amigos do idoso.

Family involvement in emergency department discharge education for older people

AIMS AND OBJECTIVES

To report findings concerning family involvement in emergency department discharge education for older people.

BACKGROUND

The current trend of population ageing in Western countries has caused an increase in emergency department visits. Due to the continuing improvement in the mental and physical status of older people, they are frequently discharged home. Proper discharge education enables older people and their families to better understand how they can cope with the medical issue at home. Given the lack of research, we know relatively little about the significance of family involvement in older people's emergency department discharge education.

DESIGN

A descriptive qualitative design was used.

METHODS

Qualitative thematic interviews of seven older patients, five family members and fifteen nurses were conducted. Data were analysed using content analysis.

RESULTS

Family involvement in discharge education was seen as turbulent. The experiences were twofold: family involvement was acknowledged, but there was also a feeling that family members were ostracised. Families were seen as a resource for nurses, but as obliged initiators of their own involvement.

CONCLUSIONS

Our findings suggest that family members are not considered participants in emergency department care. For a family-friendly approach, actions should be taken on both individual and organisational levels.

RELEVANCE TO CLINICAL PRACTICE

The findings support healthcare providers and organisation leaders in promoting family involvement in discharge education for older people. Families can be encouraged to be involved without feeling responsible for the interaction.