Objectives To evaluate the expectations and preferred outcomes from emergency care among older people or their caregivers.
Methods A review protocol was registered. Medline, Embase, CINAHL, PsychInfo, BNI, AgeInfo and the Cochrane Database of Systematic Reviews were searched in their full date ranges to September 2018. Included articles were hand-searched for further citations. Citations were screened for (1) older people aged over 65 years, (2) ED settings and (3) reporting expectations or preferred outcomes for emergency care (as opposed to experience or satisfaction). Quality appraisal and data extraction of eligible articles were undertaken by two reviewers. Themes were synthesised through content analysis and described narratively.
Results Older people wished to have prompt waiting times, efficient care, clear communication and comfortable environments. They had additional and unique expectations for holistic care and support in decision-making. The ED provoked a sense of vulnerability among older people who were likely to have had frailty.
Conclusion The lack of dominant themes among included studies suggests that older people should be treated as individuals rather than a homogenous group. Establishing individuals’ preferred outcomes could improve person-centred care.
PROSPERO registration number CRD42018107050.
- emergency department
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What this paper adds
What is already known on this subject?
Patients’ healthcare expectations influence their subsequent experience and satisfaction. Understanding these could support individualised and person-centred care.
Previous reviews have reported the majority of ED patients to prioritise communication and timeliness above other aspects of care.
Older people have specific and complex needs that may be poorly served in fast-flowing EDs; they may have unique expectations for their healthcare and concerns about being in the ED.
What this study adds?
This systematic review of both qualitative and quantitative studies demonstrates that like, younger patients, older people want efficient, comfortable, and informative ED care.
Older patients feel vulnerable in the ED and hope to receive holistic care and to be supported and involved in decision-making.
Systematic reviews investigating emergency care experiences and satisfaction find that patients consider informative and compassionate communication and relief of pain to be the fundamentally important elements of ED care.1–3 Experience and satisfaction are influenced by patients’ expectations, which can be subdivided to health outcome goals, healthcare preferences and health priorities.4
Healthcare preferences can be difficult to explore, with recall bias, evolving or changing perspectives over time, and fears of jeopardising treatment presenting methodological challenges. Due to their higher prevalence of cognitive impairment and communication barriers, these perspectives may be even harder to obtain from older people and particularly those living with frailty, who are among the most vulnerable of ED users.5 These people often have non-specific illness presentations and complex physical, psychological and social needs, which may be poorly served by fast-flowing ED care. There is some evidence that older people may respond better to interventions based on communication and elicitation of their priorities for multidisciplinary care rather than to technological innovation.6 7
Patient satisfaction improves when professionals understand their patients’ expectations.8 Expectations among a cohort of predominantly younger ED patients included timeliness, cleanliness and communication above many other aspects of care.9 There is less research reporting expectations for emergency care among older people and their carers.10 Those living with frailty are known to have poorer outcomes from acute care,11 and so may well have specific concerns and expectations. Understanding these could facilitate an individualised and tailored approach to person-centred care for older people.
This review summarises published evidence for expectations and preferred outcomes from ED care among older people.
The full protocol was registered with PROSPERO. The search strategy was informed by a review of reviews in the field and the assistance of a medical librarian. The full date ranges of the Cochrane Database of Systematic Reviews, Medline, Embase, CINAHL, PsycInfo, BNI and AgeInfo databases were searched with exploded MeSH headings and relevant keywords, restricted to English language. Search terms were adjusted for each database; indicative terms are presented in online supplementary appendix 1. Databases were searched from inception to 20 September 2018, and references were managed using Endnote software. The reference lists of included full-texts were hand-searched for additional papers.
Duplicate articles were removed. One reviewer (JvO) screened all titles and abstracts, and then identified eligible full texts using predefined inclusion criteria (table 1). The outcome of interest was healthcare expectations, which were defined as the preferred outcomes that older people hoped to gain during their ED attendance. Where these could be inferred from the later perceptions of experience and satisfaction (respectively occurring during or after ED attendance), these studies were included. We excluded systematic reviews, having completed a preparatory review of reviews.
A 25% random sample of citations were screened by a second reviewer (LK); Cohen’s kappa statistic was calculated for inter-rater reliability.
LK second-screened all identified full texts. Cohen’s kappa statistic was again calculated, and disagreements resolved through consensus with a third reviewer (AM). Reasons were recorded for exclusion of ineligible articles at the full-text stage online supplementary appendix 2.
We deviated from our protocol, in which we stated that we would include only those studies with participants who had frailty as defined by clinical judgement or scoring tool. We found no articles which codified frailty in-keeping with recent developments in emergency medicine, for example, by using the Clinical Frailty Score. The majority of studies used age as a pragmatic eligibility criterion, while some recruited patients with proxy markers of frailty including multiple comorbidities, frequent ED attendances or residence in a care home. Up to a quarter of participants could be expected to have had frailty,12 although the proportion may be under-represented in these studies that mainly excluded patients with cognitive impairment.
Quantitative and qualitative full-texts were appraised by two reviewers using the mixed-methods appraisal tool.13
Data extraction and synthesis
Two reviewers independently extracted data from each article into a standardised form online supplementary appendix 3. Qualitative content analysis was undertaken,14 by assigning and categorising identifiers to text instances in the manuscripts. Categories were grouped and reviewed until themes emerged among people’s reported perceptions, which the reviewers then discussed until consensus was reached. A meta-analysis was not planned; the reviewers were familiar with recent literature and anticipated identifying qualitative studies or heterogeneous quantitative methods.
Following deduplication, 7233 citations were identified from database searches. Seven thousand one hundred and thirty-five articles were excluded during title and abstract screening (Figure 1). Of 98 full-texts, 16 were excluded for ineligible populations, 6 for non-ED settings and 23 (predominantly conference proceedings) had ineligible publication type or insufficient data for extraction and appraisal. Healthcare expectations were not established in 27 papers. Hand-searching reference lists of eligible manuscripts yielded 25 further citations, although none satisfied criteria for inclusion. Inter-rater agreement for citation exclusion in the 25% sample was perfect (k=1). Agreement for full text exclusion was also strong (k=0.83).
Overview of included studies
Twenty-six papers published between 1992 and 2018 were included. There were no studies of older people attending hospitals in Africa, Asia and South America. Six studies prospectively explored older patients’ expectations for emergency care (table 2). Four used qualitative interview methods15–18 and two analysed interview or survey data quantitatively.19 20 Healthcare preferences were determined from 20 further papers (reporting 19 studies) which had experience-based or satisfaction-based outcomes (table 3). For example, older people reporting feeling controlled and ignored21 was interpreted as their preference to be included in decision-making processes. Researchers used qualitative interviews21–32 and focus groups,33–35 quantitative analyses of survey36–38 and interview data,39 and a mixed-methods study of audit and interview data.40 Sample sizes ranged from 729 to 2115,36 with a total sample of 5116 participants.
Quality appraisal of included studies
No studies were excluded based on quality assessment. Star ratings (tables 2 and 3) indicate whether MMAT criteria were reported; emphasis during synthesis reflected the rationale behind studies’ quality ratings and whether they directly reported preferred healthcare outcomes. Quality appraisal was limited by some studies’ availability only as conference abstracts.20 31 34 35
In five of six studies which directly explored preferred outcomes, data collection was carried out within 1 month of the ED attendance. Arendts et al 19 surveyed the expectations of care home residents who had not necessarily received emergency care, potentially reducing the recall bias introduced by subsequent experiences. Of these studies, those graded as stronger presented justifying evidence for their thematic construction,15 17 18 whereas weaker gradings were assigned to studies with limited reporting of their methods, qualitative framework, or outcomes and implications.16 20 Most of these studies excluded patients with significant cognitive impairment,15–19 limiting generalisability to many older people with frailty.
Of 20 papers where expectations were derived from context, 6 ensured representation of people with impaired capacity by including consultees,23 28 35 38 39 while 4 studies excluded patients with cognitive impairment.21 33 37 40 The stronger studies in this group again integrated data supporting the researchers’ observations,21–23 while others had small or restricted samples25 26 28 29 36 or significant lead-time following ED attendance.27 33
Synthesis: older people’s preferred outcomes for emergency care
The frequency of themes among included studies (table 4) shows that older people did not report one single dominant set of preferred outcomes. Rather, various expectations were found by researchers in different study populations in different settings. Perceived expectations for care may vary with people’s health context and the urgency of their condition. The heterogeneity in our results reiterates the need to treat older people as individuals rather than as a uniform group.
Efficient and comprehensive care
Older people and their carers wanted a comprehensive and easily accessible ED service.15 18 They reported negative perspectives when care was rushed or lacked a holistic approach.30 35 While people often accepted long waiting times15 and made concessions for busy staff,18 they wanted regular updates and explanations for delays.17 32 If the reasons for longer waits were not explained, subsequent satisfaction was reduced.19 38 Two studies reported that older people expected to be fully assessed, investigated and to receive an accurate diagnosis.16 18
Older people attending with trauma valued a holistic approach to care, prioritising the management of their chronic conditions and transitions between care providers in addition to being able to return to their preinjury baseline.31
Sensitivity towards vulnerability
Those older people who were likely to have had frailty were afraid of being alone in the ED.19 They were afraid of their illness15 and of losing independence,34 and felt that they had nowhere else to seek care.15 Older people wanted ED staff to take time to explain the likely trajectory of illness, and to use reassurance, courtesy and humour during interactions.17 18 32 They expected their clinician to be aware of their advance directives and preferences for end of life care, and wanted to discuss these in the ED.20
Older people and their carers expected a suitable physical environment for care during their attendance.27 28 They noted the importance of providing for physical needs17 18 32 37 39 such as comfortable trolleys or beds, dimming lights, toileting, access to food and drink, and orientation around the department. Carers were clear that EDs should provide adequate staffing and an optimised environment for basic nursing care, specifically suggesting treating older people in a separate space away from the noisy and busy general ED.27
Person- (and family-) centred holistic care and information provision
Older people generally wished to take an active role in decision-making but may have lacked the necessary information or understanding.17 18 Insufficient or poorly-understood explanations about diagnosis or discharge were associated with older people feeling less satisfied with their care.39 One study suggested that older people experienced different treatment in healthcare discussions because of their age or frailty: individuals with indications for intensive care transfer were rarely asked for their opinions about admission, and were less likely to be asked if they had cognitive impairment.36 Patients can only be involved in decision-making if professionals consider their views38; this may require common communication barriers to be overcome, which include visual or hearing problems, cognitive impairment and language.1
Carers also wanted to receive more information and be actively involved in healthcare discussions.18 27 28 Familiar caregivers’ or relatives’ presence in the ED was important to both older patients and their carers alike.28 Encouraging family presence can improve interaction,33 as they may act as patient advocates18 40 or help to overcome some of a person’s communication barriers.
Older people’s healthcare preferences included efficiency, information provision and environmental comfort; these concepts feature as National Patient Survey Programme domains and would appear valid among older people. Clear communication and explanation were also expected.3 The included studies did not, however, report an expectation for plain language. This is in contrast with research in younger populations,9 perhaps reflecting older people’s familiarity with medical conditions. Older people wanted short waiting times, but also appeared resilient and tolerated (and perhaps expected) longer waits—particularly if delays were explained.32 33
Older people had some unique healthcare expectations. These were more common in studies that included people with stereotypical markers of frailty, although the available evidence did not specifically stratify frail populations. Older people who were more likely to be frail had health outcome goals of symptom relief and return to premorbid baseline. They felt vulnerable, anxious and wanted reassurance in the ED. They were afraid of the uncertain trajectory of their illness, and of symptoms such as pain. They also feared being ignored by healthcare professionals, and needed supporting as active participants in care. To our knowledge, studies in younger populations have not identified these themes.
Strengths and limitations
We used a qualitative systematic review approach to integrate patients’ views and perceptions into communicable themes. The risk of neglecting primary literature articles was minimised by searching multiple databases. Although three-quarters of citations were initially screened by only one reviewer, there was strong inter-rater agreement for the double-screened sample and full-texts.
We assigned greater focus to those studies which directly evaluated preferred healthcare outcomes. Findings are limited by the different objectives and methods of different research groups, and are limited to those perceptions which have been captured in literature reports. Extrapolation of expectations from patients’ experiences should be interpreted cautiously.
None of the studies of older people’s expectations for emergency care used a validated frailty assessment method as a recruitment inclusion criterion or to stratify outcomes. We therefore deviated from our protocol and included study populations based on age alone. Some studies included participants who had attributes stereotypically associated with frailty, including multiple comorbidities, residence in a care home, or frequent use of emergency care. Most excluded individuals who had cognitive impairment, so our findings may not be generalisable to that significant proportion of older people. Prospective investigation of the views of people living with frailty, and comparison of healthcare expectations between older and younger people is warranted to confirm our findings.
Summary and implications for practice
Few studies have investigated expectations of treatment and concerns among older people receiving emergency care. There is no evidence about whether the presence or degree of frailty alters older people’s expectations for emergency care. There was substantial heterogeneity in the approaches employed. Research was predominantly qualitative, and of limited methodological quality. There was no single dominant set of expectations apparent from our analysis. Recurring themes gave some indication that older people receiving emergency care had health outcome goals of symptom-relief and return to premorbid baseline. Healthcare preferences included active communication, involvement in decision-making, inclusion of familiar caregivers and holistic approaches that minimise their sense of vulnerability.
Systems developing geriatric emergency medicine services will wish to support better person-centred care. Partnered healthcare (the involvement of consumers in shared decision-making) includes understanding and planning delivery of patients’ preferred healthcare outcomes. Patient-reported outcomes measures (PROMs) can capture these outcomes of interest and can be a powerful mechanism to change practice and focus care on that which is most important to patients. At the individual patient level, PROMs can drive improvements in diagnosis, communication and prioritisation of needs.41 At the population level, PROMs can be used for research, benchmarking and fed-back to providers to inform service improvements. There is no existing evidence-based outcome measure for older people with urgent care needs. Our review confirms the importance of establishing the needs of individual people rather than the ‘older patients’ group.
The authors thank Dr Mary Edmunds Otter (University of Leicester) and Dr Louise Preston (University of Sheffield) for methodological advice.
Contributors JDvO and SPC planned the review. JDvO, LK and AM extracted and analysed data. All authors contributed to the narrative synthesis and manuscript drafting.
Funding JDvO was supported by an NIHR Academic Clinical Fellowship. LK and AM were Geriatric Emergency Medicine Fellows at University Hospitals of Leicester NHS Trust.
Disclaimer The funders had no role in this review.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.