Under old protocol

More elderly patients are presenting in emergency departments, presenting new challenges for staff. 

Emergency departments throughout the world are experiencing increased presentations of elderly patients, sparking concerns that procedures, along with physical design, may need to be rethought.

In response to the changing demands of the ageing population, a team of international researchers has conducted a survey that explored the characteristics and outcomes of 2282 patients are aged 75 and over at EDs.

In total, 13 EDs were involved in the study, from seven countries: Australia, Belgium, Canada, Germany, Iceland, India and Sweden.

Patients were initially assessed on cognition and physical function, mood, comprehension, falls history, nutritional status and presence of pain or dyspnea.

Researchers then tracked the progress of patients by interviewing them, examining medical records and speaking with hospital staff.

“Older patients have complex problems before they arrive at EDs and even more complicated needs when they get there,” lead researcher professor Len Gray, of the University of Queensland, said. “[They] require specialised care to avoid missed diagnoses, to prevent complications associated with frailty, and to ensure best care and appropriate discharge planning.

“Our study highlights to all those who haven’t taken an interest in this that there is a substantial issue that needs some sort of thought.”

Elderly patients were found to have some common complaints; a significant number had geriatric illnesses – including cognitive impairment and mobility problems – and most were largely dependent on others.

Overall, 48 per cent already had geriatric syndromes before becoming unwell, a figure that increased to 78 per cent in the ED.

Gray said there was growing concern that elderly patients presenting to the ED were “not really getting the customised care they probably deserve”.

Liz Cloughessy, executive director at the Australian College of Emergency Nursing, said the ED was probably “not the most appropriate place for the elderly patients, especially high-risk delirium and falls patients”.

“It is difficult to create an appropriate environment in the ED where these patients can be observed,” she said, explaining that it’s preferable for them to have less stimuli but that’s difficult to arrange within an ED and this often makes their confusion worse.

Gray said quite a number of hospitals around the world were combating this by incorporating sections in the ED to cater specifically for older people.

“In larger departments, there is an argument for segregating patients to some extent, so people with like problems can have the staff assess and treat them,” Gray explained. “You can’t put all people in one general ward and expect to get the best outcome, so certainly bigger departments could look at streaming frail older people into a section where the staff are familiar.”

Smaller hospitals with limited resources were encouraged to further educate generalist staff so they could handle multiple kinds of problems.

Researchers hoped that results from the study could provide a “thorough understanding of the clinical and psychological needs of older patients in the ED”, in order to redevelop protocols and services.

Concerns were also raised over ED staff perceptions that their role was to assess and manage severe illness and injuries and that geriatric care was inappropriate.

The report stated, “If this view is maintained, the case for introducing specialist teams and even specialised environments becomes more justified, so that such high-risk patients can benefit from comprehensive geriatric care.”

In Australia, a growing number of hospitals are already developing specialist aged-care teams to work within the ED, identifying and treating older people.

Aged-care nurses, who specialise in delirium, challenging behaviours, dementia and other issues, can also act as a valuable recourse to all ED staff, Cloughessy said.

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