Participants and circumstances leading to ED attendance

In total, 40 participants were interviewed: 24 patients and 16 carers who, between them, described ED attendances for 28 patients across the three sites.

Over two-thirds of patients (68%) were female; 43% were aged 75–84 years and 57% were aged over 85 years, including three aged over 95 years. The majority were white British. Twelve had CFS scores of 5, 12 had CFS 6 and 4 had CFS 7. Table 1 shows demographic and ED attendance details for the patients whose ED experiences are described in the study.

Over a third of patients had a fall as their primary presenting conditions (‘chief complaint’); other common conditions included breathing difficulties, heart problems, stomach/back pain or confusion.

The key themes generated by the analysis of the interviews were an initial reluctance to attend ED, staff care and attitudes, information and communication, environment and comfort and waiting times. These are described in more detail in the sections below.

Reluctance to attend ED

Most participants were reluctant to be taken to ED. Reasons for this included: previous poor experiences in hospital; only recently having come out of hospital and therefore not wanting to go back in; fear of ‘never coming home again’; fear of a specific hospital; fear of ‘picking up a bug’ and the belief that it would be a ‘waste of time’:

M: I resisted it. Told them [the ambulance crew] that I’d gone through the same thing before. Anyway I went in and my treatment there exactly duplicated the previous time.

I: …So you said you resisted that.

M: Not physically.

I: But you just made it—

M: Yeah, I made it clear that I didn’t want to go…

I: …And why is it that you didn’t want to go in…?

M: Because the last time I went in, they wasted so much time.

In the face of pain, distress and anxiety initial feelings of reluctance and resistance about being taken to ED gave way to feelings of resignation in most cases. In this context, the ‘decision’ to take participants to ED cannot really be seen as a decision at all—certainly not one in which participants could engage in any meaningful way. Ultimately, most accepted the course of action recommended by paramedics who were seen as ‘knowing best’. Family members had, in several cases, played a role in persuading patients that they needed to be taken to ED:

F: So we had to convince my Mom that taking to the hospital.

I: Why did she not want to go?

F: At first she didn’t wanted to but then when she, when we mentioned that was as soon as the treatment is finished we can bring you back home.

I: Right.

F: Everything will be fine and she trusts us of course, so I went into hospital with her in the ambulance. (S2 08C)

Staff: care and attitudes

Participants generally emphasised attitudes, manner and responsiveness, rather than technical competence, when reflecting on the staff they had encountered in ED. Overall, participants were very positive about ED staff who were seen as being very caring, reassuring and pleasant in their manner:

F1: I didn’t doubt for one minute they cared.

I: Why did you not doubt it?

F1: I don’t know. They kept saying ‘You’ll be all right [name] in a little while’ and they were gently caring. They weren’t sort of saying ‘Well, right …’ and talking amongst themselves as much to say ‘Well right’ you know ‘here comes another one through the machine sort of thing’. But they weren’t. They were genuinely caring. (S1 07PC)

The importance of being treated with respect, particularly in the context of older age, was highlighted. Comments made by some indicated that they had not expected a positive experience—fearing that they would be treated negatively because of their age—but this had not been the case:

F1: I refer to older people, to my age group, normally I’d be the first to say ‘Her age. They haven’t got the patience’. But having been in the last time, well four times, I can’t fault it. (S1 07PC)

A small number of participants, however, did feel that they had been treated negatively due to their age, describing what they saw as a lack of input or intervention during their time in ED/hospital:

I: Right. Okay. It doesn’t sound like much happened whilst you were there?

F: No. It didn’t. To be quite frank with you. They don’t want to know us old ones.

I: Is that how you feel?

F: That’s how I feel…

F: Did you feel the same in every single part of the hospital that you went in?

F: Yeah. They didn’t. If you were over 80 they didn’t want to know. (S2 06P)

A key concern related to staff being unresponsive when patients called for their attention. This was a particular issue for patients who needed assistance with toileting. While highlighted by a relatively small number of patients, this issue had a significantly negative impact on their ED experience—relating as it does to personal comfort and dignity. One patient described how on requesting assistance to go to the toilet she was effectively told it was acceptable for her to soil herself as she was wearing incontinence protection:

M: You get the impression, because you were wearing counter measures

F: Oh—

M: Yeah, proper pants—

I: Incontinence—

M: It’s basically—it’s alright, we’ll sort it out later. Which isn’t very good for dignity.

I: No, it’s not—

F: And I was told 2 or 3 times, when I say I don’t like getting wet underneath—I was told 2 or 3 times oh it doesn’t matter, that’s what the nurses are for.

I: Really?

F: I was more or less told it’s quite alright if you do it in your pants. (S1 09PC)

Information and communication

The provision of information and effective communication between staff and patients were highlighted as crucial by patients and relatives during their time in ED. Being kept informed of what was happening (tests and treatment), what was likely to happen (ie, admission, transfer or discharge) and some indication of what was wrong was absolutely key. Experiences, however, varied significantly. Some patients reflected positively—staff had kept them informed, explaining pending tests and procedures using a clear and friendly communication style. On the other hand, some participants described negative experiences concerning the provision of information and communication which had caused frustration and bewilderment—as they were left with little sense of what was going on:

I: Did you feel that they were communicating with you what tests had been done and did you get any results back or—?

M: Erm…no, I think it’s just that waiting thing that kills it. So my wife and daughter went off and then at eleven o'clock, two ambulance guys turn up ‘can you get your kit, we’re off to [name of another hospital]’.

I: At what point did you know you were going to be admitted, taken to the [name of other hospital], was that decided quite quickly or did that take quite a while?

M: I think the system knew but I didn’t really…the information really doesn’t go to the patient until it’s happening I think, you know, […] the system seems to know what’s happening, but sometimes the patient doesn’t. (S2 01P)

Linked to the provision of information, some patients commented on the extent to which they had been involved in discussions and decision making about their care. Again, experiences were rather mixed. Some patients reported that they felt listened to and had participated in decision-making; others, however, had not felt involved in important decisions about their care:

I: When did you know that you were going to be moved on to a ward?

F: Not till the stretcher come. I said, ‘Where am I going?’ They said, ‘You’re going on a ward’. I said, ‘What for?’ ‘Oh, we don’t know whether you broke your leg or not’. Well if they didn’t know if I broke my leg or not who did know?

I: So you had had an x ray?

F: Yeah. But nobody ever says, ‘Oh your x ray is fine’ or this that and the other. No. Very badly done.

I: So nobody asked you whether or not you wanted to go onto a ward?

F: No.

I: It was just kind of done without asking you?

F: Without asking me. As though I’m an idiot. I know I’m 82 years but I’ve still got it all up here. (S2 06P)

Together with the provision of information, the manner in which ED staff communicated and the language they used were important to patients and relatives while in ED. Some patients had been impressed by the way in which staff had introduced themselves and explained what they did. Others, however, were not always clear on these details and this was seen as an impediment to communication—patients were often unclear as to whom they had seen and should speak to with queries. A few patients commented that the various different coloured uniforms on display in ED (with no explanation as to what these represented) added to the confusion:

I: Yeah. So you’re in the A&E bit. How many different doctors did you see, do you know?

F: I think I saw two different ones. And some nurses, you don’t know who’s who, to be honest, even when I was in hospital, I said to my husband ‘do you know, there’s so many different colours, you know—

I: Uniforms you mean?

M: Yeah.

F: —one’s got green, one’s got blue and one’s got light blue, one’s got white, one’s got pink’ and so in the end I never knew who really was the Sister and who wasn’t, you know. (S3 05PC)

A few participants commented on the language and communication style used by ED staff—again, painting a rather mixed picture. Some had appreciated the clear, candid and honest language employed by staff when discussing their cases. Others, in contrast, stated that they could not always hear or understand what they were being told, or that things were not always explained properly. Staff, they found, did not always take time to speak slowly and clearly to ensure that information was received and understood.

Environment and personal comfort

The ED environment created a significant impression on participants’ experiences of emergency care. Several patients at one site in particular drew attention to what they described as an overcrowded, noisy and sometimes rather ‘chaotic’ ED environment:

F: Yeah. And it was, you know, chaotic I thought.

I: Just because of the number of people there or—?

F: Yes, it was a huge amount of people there, seemed to be, you know, and there was somebody calling out ‘I want some biscuits, can you get me some biscuits I want some biscuits!’ and then she turned round and started to sing! And I thought I’ve landed in a mental home! [Laughs]…You know, it sort of went on like that for quite a while. And there was no music, nothing to listen to, except these chaotic things that were happening around me and I thought for crying out loud, you know, it would be nice if somebody turned on some music or if you could watch a screen and, you know—

I: But there was nothing at all.

F: No. (S1 08P)

In contrast, patients at another site, which had recently been refurbished and used glass, rather than curtained cubicles, generally talked about the ED environment in overwhelmingly positive terms. The resulting modern, calm and quieter atmosphere had in turn made them feel calmer as they experienced less rushed and ‘smoother’ care:

F: Well that’s something else, I don’t know—well you know the old A&E—they’re always, in the old A&E was this rustling and bustling about, now there’s a quiet sort of everything’s done equally as quickly but there’s no noise, it’s so quiet and you don’t get this trolleys rushing about and that and handovers and that, they seem to be so easy now, you know, from your ambulance stretcher onto your sort of bed sort of thing, yeah, no, as I say, the handover as I say is good. Everything I found was, it’s done, I don’t know, much smoother—everybody is hurrying about but they don’t seem to be rushing about, you know.

I: So it feels, is it calmer?

F: Oh calmer, definitely. (S2 12P)

Comments regarding privacy while in ED were, on the whole, quite positive. Several patients who had experienced the new glass cubicles in the refurbished site felt that these had resulted in improved privacy. Interestingly, even those patients who described care in very busy and overcrowded conditions in other EDs did not raise privacy as a concern even though the systems employed by staff to maintain privacy appeared to be far from ideal:

F: No, no. But it was funny because, as I said before, if you needed to be examined privately, if a doctor wanted to, they’d yank somebody out of this cubicle, push them in, shut the curtain, the doctor would do what he’d got to do, the curtain would come out again and then somebody had gone in! And it was funny I suppose but—

I: How did you feel in terms of kind of privacy and dignity and things like that in this ridiculous situation?!

F: Well, er, you have a blanket over you so…and they don’t do anything, they only take your blood pressure in view of everybody else, you know, everybody, they take you into one of these little cubicles— (S1 06P)

Being comfortable and having basic physical needs met were highlighted as having an important impact on participants’ ED experience. There were two main aspects to this: the availability of food and drink; and the comfort of hospital trolleys/beds. Having access to food and drink while waiting in ED (often for considerable periods of time) was an important element of patients’ and relatives’ well-being and personal comfort. Some patients reported very positive experiences in this regard, with ED staff proactively offering some kind of drinks and/or light refreshments which were very much appreciated:

I: Right. And you hadn’t…had anybody got you up and moved you or asked you if you needed the toilet or anything like that?

F: Oh yes they came and did…they gave me a buzzer, so said if you need the toilet or anything, just buzz. They did make me a drink and brought me a sandwich, because I hadn't had anything since breakfast. (S2 04P)

Other participants, however, including several with diabetes, reported that staff had not enquired as to whether they would like something to eat or drink and did not offer anything. Some participants said that they had been given refreshments when they asked for them, but one relative had to make their own arrangements:

F: Not this time, but the time before, I actually went up to one of the nurses and said, ‘Is there any possibility of organising something for my husband to eat, he’s dia-’. ‘Oh we don’t usually’. I said, ‘Well he’s diabetic and he’s not ate for’, whatever it was, six hours or whatever. She said ‘well there’s a café’, is it Costa, whatever it is.

I: Oh right, OK. So they, as a matter of course, no matter how long someone’s in the Emergency Department they won’t give them anything to eat?

F: Well I don’t—

I: That was the message that you received?

F: Yeah. (S3 06PC)

Several participants described very uncomfortable and even painful hours lying on hospital trolleys or beds unable to sleep or rest because of the discomfort. The problem was exacerbated by the fact that patients often had to wait in ED for many hours. Trolleys and beds were described as being too hard, too small and very uncomfortable:

M: See this is the concern I’ve got about it, is that there’s this target of you know, once you get into A&E you’ll be in a bed in four hours. Well, I suppose technically they meet that when they put you into a cubicle. But that’s certainly not a bed, and I wouldn’t recommend it. There’s no way I slept in that. I mean I’m only five feet ten, I’m not huge. There’s no way I can lie in that bed comfortably, no matter what they do. I would imagine that if I’m five feet ten, there’s only about five feet six of that bed.

I: So it’s uncomfortable.

M: It’s uncomfortable. (S1 10PC)

The importance of having family members present during an ED attendance was highlighted by interviewees. Just over half of patients had someone with them in ED—typically spouses or children—while approximately one-third reported that they were alone during this time (information was missing in the remaining cases). Family members provided a source of practical and emotional support during what could otherwise be a quite daunting experience. In contrast, some of those on their own in ED described the experience as frightening, lonely or simply boring:

I: Did you feel safe?

F: Yes, I felt safe, yes. I wasn’t upset or anything.

I: No, you weren’t frightened or worried or anxious?

F: No, I don’t think I was because [name of grand-daughter] was with me, if she hadn’t have been I probably would have been.

I: Right, OK, yeah. So it was important to have somebody with you.

F: That’s the way I felt, yes. (S1 05P)

Time waiting in ED

The issue of waiting times in ED emerged as a prominent theme during interviews. Just over a quarter of patients had waited 4 hours or less in ED before being admitted, transferred or discharged. These participants expressed satisfaction and sometimes surprise at such ‘swift’ treatment. In contrast, another quarter reported they had waited in ED approximately 12 hours or longer before being admitted to a ward. Such long waits were difficult to endure, especially when combined with having to lie on uncomfortable trolleys/beds and going without food and drink for extended periods of time:

F: Oh yes. The first time I ever went in there, oh boy, I’ve never got over it, my bum is still suffering from that first time.

I: Really.

F: Yeah.

I: Were you on like one of those narrow trolley things?

F Yeah.

I: Oh dear. And were you on there for a long time?

F: Oh I was, fifteen hours before they put me into a bed…

The first time I went and I were there for fifteen hours before they found me a bed but, apart from that, I have no complaints. (S1 04P)

Comments made by some relatives during interviews provided insight into the impact long waits in ED could have on them as well as their loved ones. They were often older people themselves and had also experienced discomfort, difficulties obtaining refreshments and lack of sleep:

F: Well I’ve been very well but I think visiting [name of husband] for five weeks and the first two days I spent 60 hours without going to bed—

I: Oh my goodness.

F: —simply because he went in as an emergency— … and I sat all night with him while they were waiting for the consultant to have a look at him and then we went to the [name of another hospital] for the next night and I sat all night there as well. (S2 09C)