Healthcare providers’ perspectives on the care of older people in an emergency department in Hong Kong: a qualitative study

Parallels Between Efforts to Improve Geriatric and Pediatric Emergency Care

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This study identified factors associated with use of the emergency department for medical reasons among individuals with serious mental illness. A total of 200 randomly selected outpatients who were receiving community-based psychiatric care were recruited for the study and interviewed with items from the National Health Interview Survey and other national health surveys. Emergency department use (37 percent of the sample) was negatively associated with older age and positively associated with the number of co-occurring medical conditions, smoking, recent injury, and recent change in health care provider. The relatively high rate of emergency department use may be suggestive of inappropriate use or may reflect perceived barriers to care. Future work should identify specific reasons for seeking care in the emergency department and develop interventions to optimize appropriate emergency department use.

563 Objective: This study identified factors associated with use of the emergency department for medical reasons among individuals with serious mental illness. Methods: A total of 200 randomly selected outpatients who were receiving community-based psychiatric care were recruited for the study and interviewed with items from the National Health Interview Survey and other national health surveys. Results: Emergency department use (37 percent of the sample) was negatively associated with older age and positively associated with the number of co-occurring medical conditions, smoking, recent injury, and recent change in health care provider. Conclusions: The relatively high rate of emergency department use may be suggestive of inappropriate use or may reflect perceived barriers to care. Future work should identify specific reasons for seeking care in the emergency department and develop interventions to optimize appropriate emergency department use. (Psychiatric Services 57: 563–566, 2006)

Introduction: The use of emergency department (ED) services has known a significant rise in the past decade. Organizational factors, such as the models of after-hours primary medical care services, and the shortage of general practitioners (GPs) could explain this phenomena. But also demographic and societal elements combined with the problem of patient’s ‘inappropriate visits to the ED. In order to ensure continuity of care for patients, collaboration between GPs and EDs becomes increasingly essential. Not to mention the benefit of this collaboration for the healthcare system in terms of efficacy and efficiency.This papers explores positive experiences of collaboration between GPs and ED teams in Brussels and the French speaking regions of Belgium, with the objectives of 1) identifying the main concepts related to IC that are highly valued by actors; and 2) analyzing forces and opportunities of the Belgian context in terms of IC. Focusing on positive experiences is inspired from the Appreciative Inquiry (AI) philosophy which is based on the assumption that every organization has something that works well and these strengths can be the starting point to create a positive change.Methods: A series of eight focus groups (FG) with GPs and ED teams was conducted in Brussels and different French speaking regions between September 2014 and December 2015. FG lasted one and a half hours on average. Participants’ number varied between 6 and 12 per FG. They were audio recorded and transcribed verbatim. An interview guide was designed based on the first two phases of AI, “discovery and dream”. Transcripts were analyzed thematically using an inductive content analysis technique.Results: Findings showed that a positive experience of collaboration is mainly related to a high level of communication. Both GPs and EDs attach great importance to clear, timely, and accurate written reports, but also to oral communication. Phone calls are highly valued as they allow actors to interact directly, and negotiate the patient plan of care. Mutual acquaintanceship is another component of IC. Actors agree that knowing each other and being able to put a face to a name optimizes contact, enhances relationships and strengthens trust. Trust is also the result of previous experiences. It is manifested by seeking advice from each other and making joint decisions. Another finding is about power. A positive experience of power is mainly characterized by a relationship of equality without any dominance behavior. It shows in respectful and professional attitudes towards each other. Role clarification is also of particular importance. Knowing one’s own role and that of others and fulfilling that role is considered as a valuable lever for collaboration. It supposes that actors are aware of each other training, thus more confident in the competencies of the others. It also improves the referral process. The patient himself plays a major role in enhancing IC and can be the driving force in communication between actors. As for the political environment and the healthcare system in general, they don’t seem to play a significant role in promoting collaboration between GPs and EDs. With the absence of integration policies, data and information exchange system remains poorly developed; there are no incentive measures to encourage collaboration; no gatekeeping process; the out of hours GPs services are problematic for both parties; and the fee-per-service payment and the legislation on both parties financing encourage competition. Finally, actors’ priorities, in order to achieve better collaboration, include better communication and mutual acquaintanceship.Discussion: Opportunities for enhancing IC in the Belgian context include a recent report from the Belgian healthcare knowledge center addressing the organization and payment of ED services in Belgium and highlighting the necessity of increased collaboration between EDs and GPs. Although controversial, the report is definitely a starting point of negotiation toward better IC. Also the recent federal plan aiming at developing integrated and patient centered care for chronic patients by developing pilot projects which experiment and evaluate models of integration. As for the forces, they lie in the fact that mutual acquaintanceship happens informally, despite the lack of organized activities, and that actors are aware of the benefits of IC and ready to engage in a better relationship.Conclusion: In terms of cost-efficiency, the performance of the Belgian healthcare system remains poor. Several initiatives aiming at coordinating care between hospitals and primary care have been established. But until today, only rare strategies target the ED specifically. In the future, strategies to enhance collaboration should be seriously investigated if we aspire to integrating efficiently the different healthcare providers.

Charged with transforming geriatric emergency care by applying palliative care principles, a process improvement team at New York City's Mount Sinai Medical Center developed the GEDI WISE (Geriatric Emergency Department Innovations in Care through Workforce, Informatics, and Structural Enhancements) model. The model introduced workforce enhancements for emergency department (ED) and adjunct staff, including role redefinition, retraining, and education in palliative care principles. Existing ED triage nurses screened patients ages sixty-five and older to identify those at high risk of ED revisit and hospital readmission. Once fully trained, these nurses screened all but 6percent of ED visitors meeting the screening criteria. Newly hired ED nurse practitioners identified high-risk patients suitable for and desiring palliative and hospice care, then expedited referrals. Between January2011 and May2013 the percentage of geriatric ED admissions to the intensive care unit fell significantly, from 2.3percent to 0.9percent, generating an estimated savings of more than $3million to Medicare. The decline in these admissions cannot be confidently attributed to the GEDI WISE program because other geriatric care innovations were implemented during the study period. GEDI WISE programs are now running at Mount Sinai and two partner sites, and their potential to affect the quality and value of geriatric emergency care continues to be examined.

PC-FACS

With the growing senior population in Canada, geriatric emergency care becomes an emerging field of importance in medicine. This article will provide an overview to the current state of geriatric care in the emergency department (ED) in Canada by reviewing recent peer-reviewed literature. Although emergency medicine (EM) physicians have a series of sophisticated triage tools and algorithms, Canadian EM residents report feelings of ill-preparedness to treat geriatric patients in ED. High levels of burnout and frustration have been reported by EM staff including physicians and nurses regarding their attitudes towards elderly patients in the ED. The article concludes with several areas to focus on in order to improve geriatric EM in Canada, such as more efficient resource allocation, geriatric exposure in EM resident training, and room for respectful mutual decision-making between EM physicians and the elderly patient and their families.

Measuring the Value of a Senior Emergency Department: Making Sense of Health Outcomes and Health Costs

Achieving innovation requires knowing history.

To examine factors that affect the performance of oral health care (OHC) for older people receiving nursing care at home. Oral health is often neglected by health care providers caring for older people. Research shows that health care providers' provision of OHC may be influenced by various factors (barriers and facilitators). When this research was conducted, health care providers from home healthcare services (HHCS) and nursing homes were grouped together despite setting differences; therefore, this study focuses on the performance of OHC by home health care providers (HHCPs) as a single group. Explorative design with a qualitative approach. The managers of four HHCS units recruited 17 HHCPs to participate in focus group interviews. One interview was conducted per unit, and there were four to five participants in each interview. The analysis of interviews was based on theoretical thematic analysis and the PRECEDE constructs in the PRECEDE-PROCEED model. Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines were used in reporting this study. The analysis resulted in two themes with predisposing factors (HHCPs' professional responsibilities, older people's attitude), five themes with enabling factors (knowledge and skills, older people/carer trust, available time, available equipment and collaboration with public dental service (PDS)), and two themes with reinforcing factors (routines and OHC focus on the workplace) that affect the provision of OHC. The factors were categorised as individual, organisational and collaboration factors. In addition to individual factors found in previous studies, factors related to the organisation of services and communication between HHCPs and PDS seem to affect HHCPs' provision of OHC for adults receiving HHCS. This study provides in-depth knowledge that can contribute to increasing HHCPs' provision of OHC and thereby prevent oral and dental disease among older people receiving HHCS.

BackgroundAs emergency department (ED) leaders started integrating geriatric emergency guidelines on a facultative basis, important variations have emerged between EDs in care for older patients. The aim of this study was to establish a consensus on minimum operational standards for Geriatric ED care in Belgium.MethodsA two-stage modified Delphi study was conducted. Twenty panellists were recruited from Dutch and French speaking regions in Belgium to join an interdisciplinary expert panel. In the first stage, an online survey was conducted to identify and define all possible elements of geriatric emergency care. In the second stage, an online survey and online expert panel meeting were organized consecutively to determine which elements should be recognized as minimum operational standards.ResultsBetween March 2020 and February 2021, the expert panel developed a broad consensus including ten statements focusing on the target population, specific goals, availability of geriatric practitioners and quality assurance. Additionally, the expert panel also determined which protocols, materials and accommodation criteria should be available in conventional EDs (39 standards) and in observational EDs (57 standards).ConclusionsThis study presents a consensus on minimum operational standards for geriatric emergency care in two ED types: the conventional ED and the observational ED. These findings may serve as a starting point towards broadly supported minimum standards of care stipulated by legislation in Belgium or other countries.

To describe the role of geriatric emergency management nurses as a catalyst for culture change in emergency department processes with the goal to improve care and outcomes of older people. The changing context and literature has called for a culture change within emergency department care to integrate principles of older people care into care delivery. There is a paucity of reports describing how geriatric emergency care models bring about a broader change in culture within the entire emergency department. The Ontario Ministry of Health and Long-term Care in Canada established a programme to place geriatric emergency management nurses into emergency departments with the goal to improve delivery of care through development of unique, site-appropriate solutions. Geriatric emergency management nurses incorporate capacity building into their role to develop and strengthen the skills, instincts, abilities, process and resources of the emergency department. Care processes focus on areas of staffing, mobilization, comfort, medication, hygiene, nutrition/hydration, cognition, environment, equipment and stimulation. Multi-modal educational strategies and advocacy promote appropriate person-centred care. Improved communication among care providers at key patient transition points remains a priority system-level improvement. Geriatric emergency management nurses work collaboratively with the emergency department team to facilitate change in the way that emergency department care is provided to the older person experiencing health emergencies. Known strategies that have been effective in improving outcomes for older people within the hospital and residential care setting can be generalized into emergency department care. Further research into the effectiveness of these strategies in this environment is recommended.

The global population is ageing, and healthcare systems continue to adopt outdated social models of ageing that do not respond to older people's needs. The aim of this study was to explore the experiences of participants in the implementation of the Transcultural social-ethical-care (TEC-MED) model for integrated community care. A qualitative descriptive research study was conducted. Qualitative data were collected through individual interviews and focus groups with purposive sampling. We gathered experiences from five older people, five informal caregivers, two training agents (nurses), six healthcare professionals and eight stakeholders (senior management of businesses, public administrators, researchers and educators). Four themes were extracted: TEC-MED as a new model of home care, TEC-MED model outcome, key role of training agent and platform and resources. Overall, all the participants were satisfied with the model and various positive outcomes were found. The TEC-MED model of care was inclusive and personalised and bridged the communication and integration gaps between different services for the care of dependent older people and their caregivers in the community. Recommendations were made for improvements to the model. New models of care that are inclusive, personalised and integrated are necessary to respond to the multiple needs of the older people. A model that integrates the multiple skills of healthcare professionals is an optimum solution in the care of the older people and their caregivers in Mediterranean countries. Similar research is imperative for other healthcare systems to help them prepare adequately to respond effectively to the needs of present and new generations of older people. The TEC-MED model presents a promising approach to addressing the complex care needs of older people and their caregivers by fostering inclusivity, personalisation and integration across services. For nursing practice, this model emphasizes the importance of multidisciplinary collaboration and the role of nurses in facilitating the adoption of new care strategies. Implementing such models in everyday practice could improve the quality of care provided to older adults, enhancing communication between healthcare providers and ensuring that care is more aligned with the individual needs of patients. Furthermore, integrating digital platforms and targeted resources, as highlighted in the TEC-MED model, can aid in overcoming existing barriers in healthcare systems, improving the coordination of care at the community level.

The prevalence of advanced dementia (AD) is expected to increase dramatically over the next few decades. Patients with AD suffer from recurrent episodic illnesses that frequently result in transfers to acute care hospitals. The default pathway followed by some emergency physicians, internists and intensivists who see those patients is to prioritize disease-directed therapies over attention to the larger picture of AD. While this strategy is desired by many families, some families prefer a different approach. This essay examines the reason why there can be a failure to focus on the over-arching issue of AD and offers suggestions for improvement. Gaps in information and physician workload are important factors, but we argue that until physicians who see patients in emergency departments learn to pause first and ask “Why are we doing this?” they will revert to their comfort zone of ordering tests and therapies that may be unwanted. A separate emergency palliative care pathway may be one solution. Shifting the focus back to the larger picture of AD and away from the physiologic disturbance of the moment may alter the trajectory of care in ways that truly respect the wishes of some patients and their families.