Lucas Oliveira J. e Silva, MD

Lucas is a research fellow in the Department of Emergency at Mayo Clinic, Rochester, MN.

The number of emergency department (ED) visits by older adults continuously increases.[1] Older patients have unique needs, and strategies to optimize their individual care are have to be developed.

Since 2014, the Geriatric Emergency Department Guidelines[2] have been leading the way “geriatricizing” emergency care. The development of geriatric-friendly EDs will rely upon buy-in from administrative stakeholders who will require compelling associations between specific interventions and improved patient satisfaction and overall experience of care. Patient experience is by definition patient-centered, and is a metric of hospital reimbursement with potentially significant impact on profitability.[3]

With our team, we conducted a systematic review in order to summarize the literature on interventions that may impact on the experience of older adults in the ED as measured by patient experience instruments (e.g. satisfaction and experience surveys).

Here is the link to the article published in The American Journal of Emergency Medicine. 

DOI: 10.1016/j.ajem.2020.03.012

After an extensive literature search by a librarian, we found 992 studies from which 21 studies met eligibility criteria. Six studies were randomized controlled trials and 15 were quasi-experimental or observational. The included studies involved 3,162 older adults (age 65 or older) receiving an intervention strategy aimed at improving patient experience in the ED.

There was significant heterogeneity in the tools used to measure patient experience and although several studies claimed to use “validated” questionnaires, none of the studies provided a reference for validation in the ED setting (ie: Press Ganey®). This highlights the need for future studies to use adequately validated tools to measure ED patient experience.

Overall the quality of the evidence on the patient experience topic had several limitations such as high risk of bias and inconsistencies across the literature.

We found improved patient experience in department-wide interventions like a geriatric ED and comprehensive geratric assessment unit, for example. See table below with the main findings of the review. We separated interventions by themes related to geriatric patient experience in the ED.[4]

Theme Involved	Summary of Interventions Associated with Enhanced Experience
General Elder Care Needs	o   Department-wide interventions aimed to provide comprehensive geriatric-friendly acute care. Most effective interventions involved the following: geriatric-trained healthcare professionals, screening for common geriatric conditions, and environmental enhancements such as non-slip floors. o   Volunteers to offer social support, anxiety-reducing techniques, and cognitive stimulation interventions
Care Transitions (pre-ED discharge coordination)	o   Specialized role for conducting pre-discharge assessment and referrals. This was performed by a geriatric social worker, geriatric advanced practice nurse, nurse discharge plan coordinator, or interdisciplinary team.
Care Transitions (post-ED discharge care coordination)	o   Care coordination teams focused on promoting smooth transition following discharge. These teams involved physiotherapy, occupational therapy, speech pathology, nursing, and social work. Home visits were conducted if needed.
Role of Health Care Provider	o   Aged care pharmacist to provide patient education, medication reconciliation, and referrals.
Physical Needs in Emergency Care Setting	o   Reclining hospital chair rather than standard gurney to enhance comfort.
Barriers to Communication	o   Hearing loss screen upon arrival to the ED and assistive listening device for patients who screened positive.
Wait Times	o   "No Wait" Policy where older adults are brought to a private room or care area immediately following check-in.
Content of Communication and Patient Education	o   Patient Liaison within a Geriatric Emergency Department to address non-medical needs and communicate updates to patients.

Bottom-line for clinicians and administrative stakeholders: This systematic review highlights potential interventions that could be used to improve geriatric patient experience in the ED. Effective interventions were department-wide interventions aimed to provide comprehensive geriatric-friendly acute care.

Bottom-line for researchers: This review highlights the need for validation of patient experience questionnaires as well as the need for providing detailed descriptions of intervention strategies, with special attention to intervention fidelity.

Please read our article in The American Journal of Emergency Medicine in order to obtain more details on how to improve the care of our geriatric patients in the ED.

REFERENCES

1. Center for Health Statistics N. National Hospital Ambulatory Medical Care Survey: 2016 Emergency Department Summary Tables. https://www.cdc.gov/nchs/data/ ahcd/2016_NHAMCS_ED_PRF_Sample_Card.pdf. [accessed 29 May 2019].
2. Carpenter CR, Bromley M, Caterino JM, Chun A, Gerson LW, Greenspan J, et al. Opti- mal Older Adult Emergency Care: Introducing Multidisciplinary Geriatric Emergency Department Guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Aca- demic Emergency Me. J Am Geriatr Soc 2014;62(7):1360–3. https://doi.org/10. 1111/jgs.12883.
3. Richter JP, Muhlestein DB. Patient experience and hospital profitability: Is there a link? Health Care Manag Rev 2017;42(3):247–57. https://doi.org/10.1097/HMR. 0000000000000105.
4. Shankar KN, Bhatia BK, Schuur JD. Toward patient-centered care: A systematic re- view of older adults’ views of quality emergency care. Ann Emerg Med 2014;63 (5):529–550.e1. https://doi.org/10.1016/j.annemergmed.2013.07.509.