Comprehensive systematic review of age-friendly nursing interventions in the management of older people in Emergency Departments.

Abstract

Review question/objective Review Objective: To identify the best available evidence on age-friendly nursing interventions used in the management of older people (over 65) during their stay in the Emergency Department. Review Questions: 1. What is the effectiveness of age-friendly nursing interventions used in the management of older people (over 65) during their stay in the Emergency Department? 2. What are the recommended policies regarding age-friendly nursing interventions for the management of older people (over 65) during their stay in the Emergency Department? Background According to Bridges, Meyer and Dethick 1, older people are high users of Emergency Department (ED) services and on presentation are often acutely ill. Generally they have higher levels of urgency, are at risk of functional decline and have higher rates of adverse outcomes post discharge compared to younger cohorts of patients in the ED 2. Life expectancy for Australian men and women is one of the highest in the developed world, with the life expectancy for men being 76.5 and for women 81.9 years 3 and there is a strong growth trend in the proportion of males and females over the age of 85 4. In view of their potenital for impaired functional status, need for assistance at home, co-morbid conditions, and physiological differences, older people present unique challenges to the health system 5. Nurses working in the ED are in the forefront of dealing with these challenges by providing care that is specifically tailored to meet the needs of the older population and reducing the risks of adverse health outcomes during their stay in the ED. Facing the health and other issues associated with an ageing population is not unique to Australia as this trend is world wide 6. In terms of health care delivery, an increasingly older population means a greater requirement for services able to manage people, who are more likely to be living with age related complex chronic conditions and disabilities requiring ongoing medical attention, such as hypertension, heart disease, osteoporosis, arthritis and diabetes 4. In 2004-2005, over 2.5 million people over the age of 65 were admitted to public and private hospitals in Australia, constituting about 35% of all hospital separations 7. In relation to the Emergency Department, it is estimated that the frail elderly will soon constitute 20% of the presentations and ED staff will require the appropriate knowledge and skills to care for this complex group 8. The hospital ED is generally the central admission point for people in need of acute and emergency care and is designed to provide first line treatment and assessment of patients. However there is some evidence that the ED environment is not always optimal for older patients, who are more susceptible to negative health outcomes and functional decline during their stay in the ED 9. Older people, particularly those over the age of 80, frequently experience multiple physiological, psychological and social needs which require additional evaluation time in the ED 10. In 2005, the most common reported conditions for people over the age of 64 were long sightedness, short sightedness, deafness (partial/complete) and arthritis 4. Alterations in sensory perception, mobility and/or cognition (either existing or newly developed), can impact on how a person reacts and interacts in the ED environment. The ED environment can be unfamiliar and overwhelming to older people particularly those experiencing cognitive or sensory impairments with extended periods of time waiting to be seen and appraised by the relevant ED personnel compounding potential problems. Older people have been found to have longer lengths of stay in the Emergency department compared to their younger counterparts 11 with typical stays being about 5-6 hours and even longer for people from Residential Aged Care Facilities 9. These lengthy stays are predictive of negative hospital outcomes 9. Negative health outcomes leading to functional decline of the older patient during a lengthy stay in the ED can occur on a number of levels. Long waiting periods in the ED, whilst sitting or lying on hospital equipment designed for short term care, the use of hard hospital beds, lack of pillows, high noise levels and long periods of separation from carers and family, can have significant negative impacts on the older patient 12. Functional decline is a common and significant complication of hospitalisation of older people and can include malnutrition, decreased functional mobility, loss of skin integrity, incontinence, falls, development of delirium, problems with medication, poor self care and depression. These complications have the potential to result in extended hospital stays, higher rates of institutionalisation and increased morbidity and mortality 13. Fundamental care needs, including basic comfort measures such as managing hydration, nutrition and elimination needs, ensuring warmth and pain management are not always adequately addressed in busy ED departments which are geared for short-term, acute care. One study evaluating the comfort and suitability of the ED environment found that over half were not comfortable during the winter months and 70% were uncomfortably warm during the summer months 14. This is an issue for nursing. Ensuring a safe and comfortable physical environment is seen as an important aspect of good nursing care 15. However the nursing care required for elderly patients differs significantly to other patient groups and current models of nursing care within the Emergency Department (ED) are not always reflective of these differences16. In 2004, the Australian Health Ministers' Advisory Council (AHMAC) Care of Older Australians Working Group developed a number of age-friendly principles and practices for managing elderly people in the health care environment. In general, age friendly nursing interventions include treatment and care delivered to older people, which is based on strong evidence and focuses on maintaining, improving and preventing deterioration in their health and quality of life 17. It is envisaged that the application of age friendly principles and practices will avoid unnecessary admissions and lengthy stays in hospital for older Australians 18. In relation to the specific care of the elderly in the ED, the AHMAC recommends ‘access to specialist resources to assist them to assess and meet the needs of older people and these may include risk screening tools, specialist advice on geriatric conditions and separate areas associated to co-located with emergency departments which allow medical, allied health and nursing staff to provide safer and more comfortable management of the older person, their families and carers and to facilitate liaison with referring general practitioners service providers and carers’ 18. The need to provide an environment for older patients that is designed to meet their needs is well recognised. The ideal age-friendly ED environment is inclusive of the ‘older person's strengths and abilities, protects against harm and empowers the person or their carer to be actively involved in decision making’ 19. It is equally important to consider the patient's perception of care needs. For example, in a study by Hawley 20, participants reported feeling scared, nervous, worried or frightened on arrival to the ED. According to Hawley 20, nurse strategies that patients attending the ED find comforting included prompt and competent care physical and technical care; a positive approach, careful observation, appropriate response to physical discomfort and family centred care. The Australian and New Zealand Society for Geriatric Medicine has argued that best practice nursing care should begin on admission to the ED, which for older patients includes ‘pressure area identification and prevention, falls minimisation and provision of adequate nutrition and hydration’ 21. This notion is supported by the Australasian College of Emergency Medicine who recommend that elderly patients in the ED have a call button within reach, are able to reach or receive assistance with their meal and that systems should be in place to manage pressure area care 22. Creating and sustaining an age-friendly ED Department requires health professionals to be informed and educated about interventions and models of care that have shown to be of benefit to this patient group. Under-resourcing, poorly prepared staff and high level of activity resulting in time-poor nursing staff can lead to poor health outcomes for elderly patients 23-25. According to Kihlgreen 16, the key to good nursing care and meeting the specific needs of the elderly patient, is by having knowledgeable nursing staff who understand these needs and take responsibility to provide good nursing care. The Queensland Health's Direction for Aged Care (2004-2011) identifies patient centred care delivered by skilled staff as a fundamental cornerstone of high quality aged care. Similarly, Shanley et al 15 assert that the nurse has a crucial role in raising the bar in the provision of care for the older people in the ED by ensuring a more comprehensive approach to assessment and discharge planning, improved levels of communication with the elderly patient and attention to the basics of nursing care. Emergency nurses work under substantial time pressure, and are expected to be highly trained, skilled specialists 26. In an increasingly time-poor environment 27, emergency nurses may be challenged to find the time to concentrate on the provision of essential nursing care. Essential nursing care is about attending to the nutritional, hydration, mobility, comfort, hygiene, elimination and orientation needs of patients, which may be particularly challenging in an ED environment which is geared to speedy patient assessment and turnover with ED physical space as well as ED models of care not designed for the often complex needs of older people 28. In view of the recommendations put forward by the Australian Health Ministers' Advisory Council, it appears that a multifaceted approach is required in order to adequately meet the needs of older people in the ED. According to Bridges 1, there are still significant gaps in meeting the needs of older people and communication and involvement, cutting waiting times and meeting needs for comfort, privacy and dignity are important elements in creating a positive experience for this patient group presenting to the ED. In summary, age-friendly principles and practices for the actual ED physical environment, as well as the care provided to older people within the ED, emphasises a multifaceted and holistic approach Currently a dearth of literature exists on many of the care aspects relating to older patients in ED; for example Bridges et al 1 found that there is a lack of evidence to guide the practice development of specialists in the care of older patients in the ED. According to the Australian and New Zealand Society for Geriatric Medicine 21, older patients require care that is based on the best available scientific information and best evidence nursing care practices, which is the focus of the proposed review. This proposed systematic review aims to identify any age-friendly nursing interventions that have shown improvements in the management of the older people presenting to the Emergency Department. It is envisaged that by conducting this comprehensive systematic review, best practice nursing models for the care of the elderly in the ED can be identified. Inclusion criteria Types of participants This review will consider men and women over the age of 65 presenting to the Emergency Department. Types of intervention(s)/phenomena of interest The review will consider any age-friendly nursing interventions in the management of older patients during their stay in the Emergency Department. These may include nursing interventions to enhance comfort, nutrition, hydration, pressure area care, pain management and communication. The opinion part of the review will consider the policies and recommendations related to age-friendly nursing interventions. Types of outcomes Outcomes of interest for the quantitative part of the review are: pressure area status, hydration status, nutritional status and pain status measured during their stay in the emergency department. The text and opinion part of the review will focus on the recommended policies for age-friendly nursing interventions. Types of studies The quantitative part of the review will consider randomised controlled trials (RCT's), quasi-experimental studies and observational studies. The opinion part of the review will consider expert opinion papers, discussion papers and policy documents. Search strategy The search strategy is designed to access published and unpublished material in the English language, including unpublished texts found within research theses and conference proceedings. Articles published between 1999 and 2010 in English and indexed in the selected databases will be searched in order to ensure currency of any recommendations found from the search. The search will be conducted via a number of steps which include: 1) An initial search of CINAHL and Medline to identify any relevant keywords contained in the title, abstract and subject descriptors, including MeSH terms. The following terms are proposed as suitable descriptors to initiate the search and will be adapted to suit the requirements of each database: *Emergency department *Elderly *Aged *Geriatric *Senior* *Old* *Models of care *Patient satisfaction *Comfort *Nursing care *Assessment *Length of stay *Patient experience *Hydration *Nutrition *Elimination *Pain *Pressure area care *Quality care *Falls *Risk management *Pain management 2) Terms identified and the synonyms used by respective databases will be used in a second extensive search of the literature including the following databases: CINAHL Medline Cochrane Library Health Business Fulltext Elite Informit PsycINFO Emerald Embase Dissertation Abstracts ERIC 3) Reference lists and bibliographies of the articles collected from those identified in stage two will also be searched. 4) Any unpublished texts will be searched using Mednar Dissertation Abstracts International. 5) For the opinion part of the review selected databases and grey literarture sources (for example, health policy websites etc.) will be searched in order to identify opinion papers, discussion papers and policy documents. Full copies of articles identified by the search, and considered to meet the inclusion criteria, based on their title, abstract and subject descriptors, will be obtained for data synthesis/analysis. Articles identified through reference lists and bibliographic searches will also be considered for data collection based on their title. Two reviewers will independently select articles against the inclusion criteria. Discrepancies in reviewer selections will be resolved at a meeting between reviewers prior to selected articles being retrieved. Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardised critical appraisal instruments from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information package (JBI-SUMARI). Quantitative studies will be assessed for validity using the tools from JBI - Meta Analysis of Statistics Assessment and Review Instrument (MAStARI) (Appendix I). Textual papers will be assessed using the JBI Narrative, Opinion and Text Assessment and Review Instrument (NOTARI) (Appendix I). Disagreements between reviewers will be resolved through discussion and with the assistance of a third reviewer where required. Data collection Data extraction tools developed by JBI will be used to extract all required and relevant information from the papers (Appendix II). The data extraction will be performed independently by two reviewers. Data synthesis Data from quantitative studies will be pooled, where possible, in statistical meta-analysis using the JBI-MAStARI. All results will be double entered to minimise the risk of data entry error. Narrative from will be used to present findings if statistical pooling is not possible. Where meta-synthesis is possible, conclusion of opinion and other text will be pooled using the NOTARI. This involves the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, on the basis of similarity in meaning. These categories should then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings. Where textual pooling is not possible the conclusions will be presented in narrative form. Conflicts of interest No conflict of interest has been identified