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Improving the quality of older people’s care in EDs

This paper aims to address the issue of understanding, planning and improving the quality of care for older people in emergency departments (EDs) across Europe

Consultant in Emergency Medicine &
Associate Medical Director for Clinical 
Quality & Improvement
University Hospitals of Leicester NHS Trust
The percentage of Europeans aged over 65 is projected to rise from 16.0% in 2010 to 29.3% in 2060. The European population aged over 80 is set to rise significantly. In 1960 just 1.4% of Europeans were over 80. This figure, according to Eurostat, reached 4.1% in 2010 and is projected to increase to 11.5% by 2060. This has obvious implications for the planning of future hospitals, emergency departments (EDs) and community resources from the perspective of the right structure, processes and resources to affect older people’s care. 
The ED is a crucial interface between the hospital, community and health and social care systems. It is a site where older people present with medical and social crises. EDs can be considered to be a barometer for risk management across the system and accessed by older people, their carers, families and other services. EDs are highly visible, responsive and critical frontline services that people find highly dependable. An increasing number of older people are attending EDs and they already contribute towards 15–25% of ED attendances across Europe and 30–40% of hospital admissions. 
The reasons for increasing older people’s attendance are multifactorial and with variable impact across countries and regions. Determinants of ED visits reported from previous multivariate analyses included: measures of need (perceived and evaluated health status, prior utilisation); predisposing factors (health beliefs and socio-demographic variables); enabling factors (physician availability, regular source of care, family resources, geographical access to services).1 This increase is a global phenomenon. 
However, a recent report on the Organisation for Economic Co-operation and Development (OECD) countries displayed significant variation in nomenclature and understanding of patterns of ED use including the notion of ‘inappropriate’ attendances.  Although there is a reasonable research literature describing older people’s patterns of ED use, there is much less research on ED use as a function of other health service use, which limits our understanding of the full scope of the issue and opportunities for practice and policy intervention.2
Other reasons for increased hospital use may include changing risk aversion among healthcare professionals and the public, improved ability of emergency care to treat conditions more effectively and easier access to specialist services. 
A systematic review of trends in ED attendances highlighted the contribution of ageing towards increasing presentations.3 Longitudinal population-based Australian data show acceleration in the rate of emergency health service usage by patients aged 85 years or more.4,5 This acceleration in demand by this age group is predicted to continue in the future based on population projections.5 Older people also re-attend EDs on multiple occasions per year. 
An ED visit for an older person is often a ‘sentinel’ event, associated with functional decline and adverse outcomes.6 Older patients spend longer in the ED and are more likely to be admitted during an ED visit, and have longer hospital stays. These patients are also at risk of adverse outcomes from lack of recognition of frailty syndromes, including delirium and depression, medication errors, poor communication and inadequate appreciation of disease severity. Hospitalisation also results in reduced health-related quality of life and independence. 
We do not know if outcomes for older people in ED are a consequence of acute illness and ageing or secondary to inappropriate or inadequate emergency care. EDs have traditionally operated on a ‘one person, one problem’ paradigm and non-specific presentations in older people with multiple morbidities pose a challenge to existing care models. EDs are often sub-optimally equipped, staffed, and trained to address the holistic needs of older people.
Older people present with non-specific complaints and the inability to address these is a marker of harm. A frail older person could be understood from the perspective of a complex adaptive system (CAS). Multiple health and social care needs with threatened vulnerability, combined with polypharmacy, immunosenescence and altered physiological response to illness, necessitates the need for an integrated, multidisciplinary care management within a biopsychosocial approach. These make a frail older person a stand-alone ‘complex adaptive system’.
The ED and its working can also be explained from the perspective of a CAS. The processes of triage, risk assessment, management and disposition with mechanisms for addressing communications and transitions for multiple people presenting with a wide range of undifferentiated problems makes the ED a CAS. Nugus et al.7 found the CAS approach to be “salient to analysing integrated care in the ED because the processes of categorisation, diagnosis and discharge are primarily about the linkages between services, and the communication and negotiation required to enact those linkages, however imperfectly they occur in practice”.
Management of CAS requires system and leadership rather than power. The process typically involves deconstructing the system into individual problem areas and then reconstituting with solutions for each problem that also complement the whole. So for older people this can be a list including problems around mobility, polypharmacy cognition, nutrition, hydration, continence, isolation, mood and health perception. For the ED, this list can include flow, staffing, equipment, space, adjacencies, information access. Thus the framework for understanding and managing older people and EDs are similar and require the same type of consideration. ED doctors and managers are traditionally good at understanding ED complexities but need to redesign the ‘one person, one problem’ paradigm of ED patient management to tailor to the complexity in older people.
Quality and improvement
The Institute of Medicine in their report8 defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”. The report also described clinical quality as having six dimensions. These were: patient centredness, safety, equity, efficiency, effectiveness and timeliness. There is a need to understand, measure and monitor these dimensions with a view to continuing improvement. The measures need to be a combination of process, balancing and outcome measures. 
‘Quality improvement’ has been defined as “better patient experience and outcomes achieved through changing provider behaviour and organisation through using a systematic change method and strategies.”9
There is no evidence that improving quality saves money in all situations although some make care better for patients but the research evidence is weak and lacks information to predict local savings and effect.9
There are many tools for improving quality. These range from Lean and Toyota Production System, Six Sigma, Total Quality Management, Model for Improvement, Business Process Reengineering etc. These are all evidence-based methods of improving patient outcomes through incremental changes in adaptive design and have seen many applications in the healthcare industry. It is important to adopt the right improvement methodology to the aims for improvement.
Improving outcomes in older people
Over the years recommendations have been published in few countries to improve older people’s care. McCusker and Parke10 developed consensus-based recommendations to address care and service delivery problems faced by EDs providing care for older people. These covered seven categories of policy recommendations including education, integration and coordination of care, resources, ED physical environment, evidence-based practice, research and evaluation, and advocacy. Recently there have been best practice recommendations and policy reports from the UK11 and USA12 on improving care for older people in EDs.  These, combined with several pieces of research over a period of time, represent a series of attempts to influence policy makers, regulators and providers to improve older people’s care in EDs. 
However in the absence of a suite of quality indicators including patient-centred outcomes, it is difficult to say what has been truly improved. There is, as yet, no evidence-based set of outcomes in older people from a clinical, service or patient-centred perspective although there is one in development.
The best evidence-based tool to improve outcomes in individual older people is the process of Comprehensive Geriatric Assessment (CGA). This can be delivered in the ED13 and is well supported in the empirical literature.14 Hospitals and EDs need to develop processes that deliver CGA and link such services with the community to address the whole systems care continuum. CGA improves outcomes and reduces mortality. 
Staff need to be supported in EDs to provide optimal care to older people. Access to information on health and social care is crucial to understanding the unique needs of frail older people vulnerable to decompensation.  Access to appropriate medication, such as those for Parkinson’s Disease, may easily avoid worsening of stiffness while waiting in the ED. Education and training to improve staff attitudes towards older people and competency in delivering aspects of CGA is also required. 
Processes within EDs need to be developed for people with dementia and at risk of delirium and falls. These frailty syndromes will need special screening with use of the right evidence-based tools. Delirium is missed nearly two-thirds of the time in the ED and adds to length of stay and worsens morbidity and mortality.
Falls and fragility fractures are one of the commonest ED presentations and EDs need access to falls services for improving outcomes. Older people also present with other frailty syndromes including immobility, incontinence and issues at the end of life. 
The last one is increasingly common and EDs need to develop pathways for improving care at the end of life. The ED building is also an important factor that can improve older peoples care.
Noise reduction, good ambient lighting, reminiscence products, improved signage, low beds and padded floors can all contribute towards building a frailty-friendly environment that can add to the quality of care and improve outcomes. 
A dementia friendly environment is of growing importance and the Health Building Notes from the UK are evidence-based recommendations for this purpose.15
Increasing numbers of older people with complex frailty syndromes are attending emergency departments. EDs are complex adaptive systems and a critical interface where older people present with medical and social crises. EDs need to be supported with competent staff, robust processes, structure and resources to improve care of older people through a biopsychosocial approach. Improvement methodologies need to be applied to deliver enhanced outcomes across the system and in a systematic and reliable manner.
  1. McCusker J et al. Determinants of emergency department visits by older adults: A systematic review. Academic Emerg Med 2003;10(12):1362–70. 
  2. Gruneir A, Silver M, Rochon A. Emergency Department Use by Older Adults: A Literature Review on Trends, Appropriateness, and Consequences of Unmet Health Care Needs. Med Care Res Rev 2011;68(2):131–55. 
  3. Lowthian JA et al. Systematic review of trends in emergency department attendances: an Australian perspective. Emerg Med J 2010;28(5):373–8.
  4. Lowthian JA et al. The challenges of population ageing: accelerating demand for emergency ambulance services by older patients, 1995-2015. Med J Aust 2011;194(11):574–8.
  5. Lowthian JA et al. Demand at the emergency department front door: 10-year trends in presentations. MJA 2012;196:128–32.
  6. Schnitker L et al. Negative health outcomes and adverse events in older people attending emergency departments:  A systematic review. Australasian Emerg Nurs J 2011;14:141–62.
  7. Nugus P et al.  Integrated care in the emergency department: A complex adaptive systems perspective. Soc Sci Med 2010;71:1997–2004.
  8. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington DC: National Academy Press 1990:244.
  9. Øvretveit J. Does improving quality save money? A review of the evidence of which improvements to quality reduce costs to health service providers. London: Health Foundation 2009.
  10. Parke B, McCusker J. Consensus-based policy recommendations for geriatric emergency care. Int J Health Care Qual Assur 2008;21(4):385–95
  11. Banerjee J, Conroy S, Cooke MW. Quality care for older people with urgent and emergency care needs in UK emergency departments. Emerg Med J 2013;30(9):699–700.
  12. Carpenter CR et al. Optimal 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 Academic Emergency Medicine. Acad Emerg Med 2014;21(7):806–9.
  13. Conroy SP et al. A controlled evaluation of comprehensive geriatric assessment in the emergency department: the ‘Emergency Frailty Unit’. Age Ageing 2014;43(1):109–14.
  14. Ellis G et al. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ 2011;343:d6553 
  15. Department of Health. Health Building Note 08-02 Dementia-friendly Health and Social Care Environments. 2015. Available at: Last accessed April 2016.