• geriatrics
• quality
• emergency department management
• care systems

It will not be news to readers that the emergency department (ED) population is ageing. Nor will it be surprising to know that, for the most part, we have done relatively little to accommodate the changing demographic profile of our patients. A systematic review of older patients’ experiences published in the EMJ in 2019 found that older patients felt vulnerable in the ED, and they wanted holistic care, support with decision-making, prompt waiting times and clear communication.1 A little over a year ago, EMJ published a qualitative study relating the experiences of older patients in the ED. Although the participants were understanding of the pressures staff were facing, they described poor experiences with information delivery, participation in decisions about their own care and lack of attention to simple comfort measures. ED patients of all ages likely have similar concerns and issues about their ED experiences, and expectations (or at least hopes) for their care.2 However, younger patients are often more physically capable of finding solutions, such as hopping off the trolley to find the bathroom or walking up to the nursing station to ask how long the wait will be.

Given what we have learnt from prior studies, why do we need a tool that can measure the experience of older patients in our EDs? Perhaps it is because we think research, no matter how well done, occurs for the most part somewhere else. A different country, a different ED. ‘My ED is not like that.’ ‘ I do not practice that way.’ What may better shake us out of this self-delusion is hearing from our own patients after they have been in our own ED. Yes, the National Health Service has mandated the use of ‘patient satisfaction surveys’ since 2013, but these are quite generic and the response rate is poor.3 Or your ED may have decided to write its own survey, but these kinds of home-grown surveys are often lacking the extensive psychometric testing that is needed to be sure the questionnaire is valid (does the participant understand the question and answer it how you intended it?) or reliable (would they answer it the same way next week?) Those of you who have or intend to use a survey or questionnaire for an upcoming study would do well to realise that while it is easy to write a series of questions, it is not easy to write a good questionnaire.

The study reported in the EMJ by Graham et al is a master class on how to create a questionnaire.4 Graham and colleagues had previously devised an 82-item patient-reported experience measure (PREM) to understand the experiences of older patients in the ED. In the study reported currently, they asked English-speaking patients aged 65 and older to complete the survey on discharge from the ED and then answer the same 82 questions 7–10 days later. From this work, they were able to determine which questions, essentially, were most pertinent, avoided repetition or had so much variation as to be useless, and whether participants answered the questions similarly on the day of discharge and a week or so after the visit. Using this information, they whittled the 82 items down to 25, a much more reasonable size for a questionnaire to be given routinely to patients. It is important to note that this survey has been developed with the extensive input of patients, starting with the Sheffield Emergency Forum and then subsequent patient interviews for content, prioritisation and readability.

While the PREM-ED 65 is available to readers now (see supplement 6)4 it needs further evaluation including among those older adults hospitalised from the ED. We do not know how it will perform among UK populations with greater ethnic diversity, or among those where English is not their primary language. Can it be used in other countries or, will it need cultural adaptation, even where English is the dominant language? (The USA, for instance, has never used the term A&E, and while emergency physicians prefer ‘ED’, this questionnaire uses the term more familiar to patients, ‘ER’.) These adaptations might require a repetition of the formal techniques used by Graham and colleagues, but more practical alternatives, such as that described by Roberts and colleagues, would likely suffice.5 Nevertheless, this current version is a very important start to methodically understanding the experiences of older patients in our own EDs.

Based on prior studies of the experiences of older patients in the ED, I suspect we will not, at the beginning, like some of the responses to the PREM-65. As you consider sending out this questionnaire in your ED, early engagement with your hospital executive team is key. We anticipate that the shortcomings that are revealed will provide a clear roadmap for to create a more satisfactory and fulfilling experience for older, and indeed all, patients—as well as ourselves.