Table 3

Expectations inferred from reported experience or satisfaction

Study country pub type	Recruited population	Funding appraisal tool and rating appraisal comments	Design	Outcome themes
Study country pub type	Recruited population	Funding appraisal tool and rating appraisal comments	Design	Efficient and comprehensive care	Person-centred holistic care and information provision	Sensitivity towards vulnerability	Headline message
Baraff et al 33 USA Journal—Primary	<1 year from attendance n=unknown Ambulatory and articulate patients aged >65 years.	John Hartford Foundation via SAEM MMAT—Qualitative ***** Population representation may have been limited.	Focus groups.	Tolerant of a considerable wait—satisfied with quality of care.	Written instructions would alleviate confusion over ED environment processes.	Felt abandoned, appreciated kindness. Considerable anxiety regarding illness and care. Fear of falling and of violence. Cold, noisy environment, stretchers uncomfortable. Difficult to arrange transport home.	Older adults would benefit from education about their emergency care. Staff should be sensitive to their anxieties, and explain delays.
Bridges and Nugus21 UK Journal—Primary	<1 month from discharge n=96. Patients >75 years or their carers.	Burdett Trust for Nursing MMAT—Qualitative ***** Rich evidence. Excluded cognitively impaired patients.	Discovery interview techniques. Inductive analysis.	Satisfied (relieved, grateful) with medical care but diminished self-perception related to long wait.		Power imbalance—felt controlled and ignored. Psychological and wider care needs variably met.	Ability to express needs was constrained by older people feeling they did not matter.
Considine et al 22 Australia Journal—Primary	<1 week from attendance n=27. Patients >65 years or their carers, able to give consent.	Victorian Department of Health MMAT—Qualitative ***** Modest interpretations from rich evidence.	Interviews. Dual inductive thematic construction	Frustration over waiting times, but understanding of prioritisation.		Reluctant to access the ED and attend in desperation. Confusion around ED processes (eg, triage). Financial concerns influenced access.	ED systems may need modification for the specific needs of older people.
Dresden et al 34 USA Conference abstract	<45 days from attendance n=30. Patients >65 years.	MMAT—Qualitative ** Abstract with limited reporting of evidence.	Focus groups. Constant comparative analysis.			Concerned about recovery to baseline. Feared loss of independence. Desired reassurance re impact of illness.	Evaluation of ED interventions should incorporate health-related quality of life measures.
Kihlgren et al 23 Sweden Journal—Primary	At ED arrival n=20. Patients >75 years or their carers.	Swedish Foundation for Health Sciences and Allergy Research MMAT—Qualitative ***** Integrated data supporting observations. Exc. fractures or MI patients.	Observation, interviews. Grounded theory analysis.	Long, unpleasant waits. Unnecessary delays.	Poor access to information.	Often left alone on uncomfortable bed. Cold. Lacked privacy. ED routines and process poorly understood.	The ED physical environment can be disconcerting and inhibit older patients’ understanding.
Lawlor et al 35 Ireland Conference abstract	n=20 Older patients or carers.	MMAT—Qualitative * Abstract with limited reporting of evidence.	Focus group.	Generally positive towards quality of care. Negative perceptions of the waiting times and lack of holistic approach.	Lack of information, communication difficulties.	Lack of privacy. Felt as if care was rushed.
Le Guen et al 36 France Journal—Primary	ED triage n=2115. Patients >80 years potentially needing critical care.	MMAT—Quant desc ***** Patient preference was reported by the physician (may overestimate).	Questionnaire Logistic regression.		13% patients were asked about their preference for ITU treatment.	Older people or those with cognitive impairment were less likely to be asked about their preferences.	Individuals’ wishes were rarely sought when considering admitting older people to the ITU.
Liu et al 37 Australia Journal—Primary	During ED attendance n=361. Patients >65 years (reported subgroup). Exc. cognitive deficit.	MMAT—Non-random.= **** Limited population (day-time only, excluded cognitively impaired patients).	Survey Merged Likert scales, χ² comparison.		Variability in quality of explanations.	Often unsure how the ED system worked or how to call for help. Older patients were less afraid of their illness and felt less ignored.	Older people were resilient. Staff should provide clear information about illness and treatment, and explain how to call for help.
Lyons and Paterson24 UK Journal—Primary	After attendance n=20. Patients >65 years, able to consent.	MMAT—Qualitative ***** Unclear time between attendance and recruitment.	Interviews Constant comparative analysis.	Identifying, investigating and managing problems was the priority. Confident in clinicians’ abilities. All commented on wait and appreciated updates during delays.	Important to be kept up to date.	Wanted to be treated in a caring manner. Physical comfort, hygiene and nutrition all important.	Physical, cognitive and emotional well-being of older patients should be considered in emergency care environments
McCusker et al 39 Canada Journal—Primary	<1 week from attendance n=412. Patients >75 years or relatives.	Quebec Research Fund-Health MMAT—Quant desc ***** Development and validation of experience measure.	Interviews. Multiple correspond. analysis Linear mixed model.	Overall time and time waiting for physician were perceived differently. Negative perceptions regarding pain control.	Problems and tests communicated poorly. Negative reflections of information provided at discharge.	Did not feel appropriately respected.
Meyer et al, Spilsbury et al 25 26 UK Journal—Primary	<1 month from attendance n=12. Patients >75 years (purposive sample).	Local (Trust-commissioned) MMAT—Qualitative **** Recruitment and interview methods not clearly described.	Observation, interviews Framework.	Low expectations of care. Understood staffing constraints. Aim for comprehensive assessment on arrival.	Would appreciate information at time of arrival. Overall lacking information.	Disorientating waiting time – would value explanation and acknowledgement. Consider safety, privacy and comfort.	‘Little gaps’ in staff actions. If related to attitudes towards ageing, these need to be uncovered.
Morphet et al 27 Australia Journa—Primary	1–4 years after attendance n=24. Relatives of older patients.	Nurses Board of Victoria Legacy Grant MMAT—Qualitative **** Long time period—possible recall bias.	Semi-structured interviews. Inductive coding.	ED staff and environment resources perceived to be inadequate to provide specialised care for older people.	Relatives represent a valuable information source but often excluded from decision-making.	Older people felt invisible. Attitudes towards them were perceived as indifferent.
Nerney et al 38 USA Journal—Primary	During attendance n=778. Patients >65 years or their proxies	Chicago Community Trust, Retirement Research Foundation MMAT—Quant desc ***** Validation of experience measure, timely recruitment.	Questionnaire and follow-up survey. Logistic regression.	70% rated care as excellent or very good. Pain control improved satisfaction.	More satisfied when questions answered clearly and investigations explained. Appreciated involvement in care decisions.	Appreciated time spent with staff and prompt assistance.	Satisfaction often influenced by ED staff factors (and not just predetermined factors).
Nikki et al 28 Finland Journal—Primary	During attendance n=9. Relatives of medical patients >65 years.	MMAT—Qualitative ***** Small sample size. Restricted to medical patients (justified—prolonged stays).	Interviews. Inductive analysis.		Relatives satisfied when giving information and feeling actively involved. Unhappy when excluded or unable to access information.	Stressful environment, lacking support.	Lack of understanding regarding holistic care. Need for broader involvement of family members in ED care.
Nyden et al 29 Sweden Journal—Primary	n=7 Patients >65 years (selected sample)	MMAT—Qualitative ***** Small sample size, selected by nurse manager. Duration since attendance not reported.	Interviews. Framework analysis.	Little or no attention paid to patients with non-urgent health problems.	Wanted to be well-informed. No patients discussed active decision-making.	Long waits on hard trolleys, without attention or food. Needed affection and belongingness, but perceived staff as too busy to attend to existential needs. Felt safer waiting in corridor than alone.	Basic needs, including safety, must be supported in the ED to assist older people to take an active role in health processes.
Olofsson et al 30 Sweden Journal—Primary	During attendance n=14. Patients >70 years, at least 3 ED visits /1 year.	NU-Hospital Group MMAT—Qualitative ***** Small sample. Integrated supportive data.	Interviews. Inductive analysis.	Triage: prompt and competent, short wait. After triage: long delays, inattention to pain.		Triage: personal touch, attentive listening. After triage: perception of indifference and disinterest.	Contradictory experiences between positive triage encounters and subsequent neglected, long wait
Padrez et al 31 USA Conference abstract	At hospital discharge n=21. Patients >55 years or carers	MMAT—Qualitative ** Abstract with limited reporting of evidence.	Interviews. Modified grounded-theory analysis.	Returning to preinjury baseline and management of chronic illness perceived as important.	Education and advocacy important.	Supported care transitions and arranging access to services at home.	Identified themes of care for injured older people. Care transitions was an area for improvement.
Richardson et al 40 New Zealand Journal—Primary	During attendance n=95. Patients >80 years exc. cognitively impaired.	MMAT—Mixed methods ** Limited purposive sample for the qualitative element.	Patient flow audit. Interviews. Deductive framework.	Nurses caring for many other patients and frequently reallocated. Transfer times often prompt.	Generally patients received very little information.	Patients felt as though they relinquished control to the system.	Important to understand older peoples’ ED experiences to enable effective and efficient patient-friendly service.
Watson et al 32 USA Journal—Primary	<72 hours from attendance n=12. Sampling not specified.	MMAT—Qualitative **** Small sample. Recruitment and eligibility not reported. Unclear description of data analysis methods.	Interviews. Content analysis.	Waiting time was always noticed, and explanations for delays appreciated. Sensitive to the needs of other patients.		Wanted to understand care processes and what could be expected. Importance of humour and courtesy—avoiding patronising. Uncomfortable beds. Departments difficult to access.	Suggested a number of innovations to improve the care of older patients.