CLINICIAN’S CAPSULE
What is known about the topic?
While EDs serve a critical role in the care of older adults, about 25% of visits made by older adults are classified as “non-urgent”.
What did this study ask?
What are older adults’ reasons for seeking non-urgent care in EDs?
What did this study find?
Comprehensiveness and convenience of diagnostic and treatment services in a single location were the primary motivations for older adults to seek treatment in the ED.
Why does this study matter to clinicians?
Novel partnerships between EDs, primary and community care are needed to better address the non-urgent care needs of older adults.
INTRODUCTION
As a system already burdened by overcrowding and long wait times, the emergency department (ED) serves a critical role for the growing population of older adults seeking treatment. The proportion of older patients who use ED services has increased over time, reflecting the demographic shift in the Canadian population and creating a growing demand for ED services.Reference Xu, Nelson and Berk 1 A recent analysis of administrative and clinical records for 35,000 visits by older adults found that 25% of these were classified as non-urgent.Reference Latham and Ackroyd-Stolarz 2
While there has been significant effort expended to profile the medical characteristics of older adults seeking care in the ED using administrative data, there are gaps in our understanding of the self-reported reasons for older adults who seek non-urgent treatment in the ED. Few studies have allowed older adults to describe in their words how they decided to visit the ED, as noted in a qualitative review of literature by Langer et al.Reference Langer, Chew-Graham, Hunter, Guthrie and Salmon 3 In particular, there has been an absence of an investigation of the contextual forces that constrain or shape the use of unscheduled care such as EDs.
The overall aim of this qualitative study was to explore how and why older adults who present with non-urgent (Canadian Triage and Acuity Scale [CTAS] 4 and 5) conditions to the ED decided to seek treatment in this setting. Our specific objective was to describe older adults’ understandings, expectations of, and self-reported reasons for seeking care and treatment provided in the ED.
METHODS
Design
A qualitative, descriptive design was used to address our aim and objective. This approach afforded the opportunity to gain an in-depth understanding of the patient perspective.Reference Barker 4 A thematic analysis was used to identify key themes in the data.Reference Braun and Clarke 5
Setting
This project was conducted in the three EDs located within the city of Saskatoon. The latest available administrative data (2014–2015) indicated that 3,672 adults aged 65 years and older who were classified as CTAS 4 or 5 and attended the Saskatoon EDs during this reporting period. Of these, one-third were aged 85 years and older, with direct referrals from their general practitioner for consultation in the ED, constituting the largest reason for attendance (20%). More than one-third (36%) arrived by ambulance. Between 33% (patients aged 65–74 years) and 53% (patients aged 85 years and older) of this cohort was admitted to the hospital.
Study population/ethics
Eligibility criteria for this study were: 1) aged 65 years and older; 2) triaged as non-urgent (CTAS 4–5); 3) spoke English; and 4) had sufficient cognitive capacity to answer the interview questions. A formal cognitive evaluation was not conducted, but the extensive professional experience of the research associate who was a retired geriatric social worker allowed for discernment of those patients who were able to respond to the questions meaningfully. If family members accompanied eligible patients, they were also invited to contribute to the interview, with the consent of the older adult participant.
Ethical approval for this project was granted by the University of Saskatchewan Behavioural Research Ethics Board (BEH 16-181).
Data collection/study procedures
Using the sampling technique successfully adopted in an ED setting by Stevens, study enrolment was conducted during 30 four-hour blocks randomly selected to begin at 0900, 1300, or 1800 and scheduled over 15 weeks.Reference Stevens, Richmond, Pereira, Shenvi and Platts-Mills 6 Random selection of times and sites was performed using a simple computer algorithm.
The research associate was notified by the triage nurse or registration clerks of patients who met the eligibility criteria. The research associate provided a verbal explanation of the project to eligible patients, a written information sheet, and requested verbal consent to proceed. The most private space available in the ED at that time (e.g., a quiet room) was used for the interviews.
Hand-written notes of participant responses were kept as a less intrusive means of data collection than audio recording would have been in this stressful environment. The training for the research associate to use field notes as a data collection strategy focused on the importance of accurate and contemporaneous documentation of data and recording the exact phrases of the participants, whenever possible, in keeping with accepted practices for using field notes as data.Reference Emerson, Fretz and Shaw 7
Data analysis
Demographic and health data were entered into SPSS (v. 24). Chi-square analyses were conducted to compare the distributions of sex, self-rated health, independence in self-care, arrival by ambulance, fall-related visits, the presence of family, and independence of decision to visit the ED among three age groups of older adults (65–75, 76–85, and older than 85 years). Notes were transcribed by a second research assistant and reviewed and revised for accuracy by the RA conducting the interviews. Transcripts of the qualitative data were reviewed, annotated, and coded by two team members using the approach of Braun and Clarke for thematic analysis.Reference Braun and Clarke 5 The codes identified features of the data relevant to the research question, with the collated codes then sorted according to over-arching themes by discussion and consensus. Themes with insufficient data were discarded. Data were refined at two levels: 1) ensuring coded data formed a coherent pattern; and 2) considering the coherent patterns in relation to the dataset as a whole.Reference Braun and Clarke 5 Further coding took place to ensure no codes were missed. The final stage involved choosing representative examples of data to illustrate important elements of the themes.
Sample size
Determination of the sample size of 115 was guided by the principle that the number of participants should be sufficiently large and varied to elucidate the aims of the study in a manner that allows for responsible analysis.Reference Mason 8 , Reference Patton 9 The concept of “information power,” which incorporates considerations of sample specificity and quality of dialogue for determining the sample size of qualitative research, underscored the importance of collecting sufficient qualitative data to adequately reflect the experiences of a diverse group of individuals in a dynamic and busy environment.Reference Malterud, Siersma and Guassora 10
RESULTS
In total, 140 patients met the eligibility criteria during the data collection periods. One hundred fifteen patients aged 65–98 years (mean age 79.1 years) were interviewed, along with 72 family members who were accompanying the patients. Data from family members were captured as a component of the older adult’s interview. Interviews lasted between 10 and 40 minutes. Table 1 provides a profile of participants stratified by age group (65–75, 76–85, and older than 85 years). The most common reasons for ED use by this group were: fall-related injuries (19.1%), pain (17.4%), and non-fall-related acute injuries (14.8%). More than three-quarters (78.3%) of the participants had attempted to manage the symptoms on their own through rest, comfort measures such as heat or ice, or previously prescribed medications. Only three patients indicated that they chose to visit the ED because their general practitioner was not available.
Profile of participants (N=115)
ED=emergency department; GP=general practitioner.
Older adults’ understanding and expectations of care and treatment provided in the ED
Table 2 elaborated on the four key themes (accessibility, availability, quality of care, and previous experience) identified in our analysis and provides exemplar quotes illustrating each theme. The most commonly cited reason for older adults to seek non-urgent care in the ED was ease of access to comprehensive medical, diagnostic, and multidisciplinary services available in a single location. This was especially important for older adults in poor health, without family supports or with functional limitations, personal mobility, and/or transportation challenges. Five respondents who had attended the ED for scheduled procedures such as dressing changes indicated their family general practitioner did not provide this type of treatment.
Exemplar quotes of key themes
ED=emergency department.
The older adults in this study clearly understood that the ED was not the most appropriate setting in which to seek care for non-urgent concerns, but none felt there were satisfactory alternatives. Most participants felt that they had exhausted their own repertoire of possible solutions to their health issue and now needed additional help. The availability of after-hours care in the ED was critically important to the older adults interviewed, who frequently felt there was no real decision to be made about where to seek care outside of regular business hours. The majority of respondents believed that the quality of care and expertise offered in the ED were superior to the primary care setting and offered better continuity of care if they had a complex medical history involving previous surgeries, diagnostic tests, or hospital admissions. Familiarity with the ED was a component of the trust expressed by some participants as a factor in deciding to visit the ED. Past experiences of attending primary care and inevitably being sent to the ED also influenced many older adults’ decisions. If asked to describe alternative settings in which the care the respondents were seeking could be provided, very few respondents felt there were other options. Respondents were generally prepared to exercise patience during a wait in the ED, with only a few negative comments made about wait times.
Several family member participants of patients with dementia, however, expressed concerns about the appropriateness of the environment and willingness of ED staff to recognize their unique concerns. For those patients with dementia or confusion, family members typically felt the range of services required to manage these conditions effectively were only available in an ED setting that had access to both community and hospital resources. Three family members of patients with dementia indicated that having a physician in the community who did house calls would have prevented their visit to the ED.
DISCUSSION
Accessibility, availability, perceived quality of care, and satisfactory past experiences with ED care were key considerations shaping the decision of older adults to seek non-urgent treatment in the ED. Participants cited comprehensiveness and convenience of diagnostic and treatment services in a single location as the primary motivation for seeking treatment in the ED. Older adults experiencing health, functional, or social challenges found it particularly burdensome to coordinate services that were geographically dispersed across the city. Given that after-hours care was typically not available, many older adults perceived the ED as the only option. Perceptions that care in the ED was superior in quality to primary care were supported by the participants’ previous experience of care in the ED setting. Almost one-third (31.6%) of these non-urgent patients had been referred to the ED by either their family physician or a specialist, although the majority of patients (62.6%) did not seek advice from others on whether to attend the ED.
Previous work by Durand and colleagues that assessed non-urgent ED patients of all ages also found that convenience and barriers to primary care were important factors affecting the “rational choice” to seek care in the ED.Reference Durand, Palazzolo and Tanti-Hardouin 11 The importance of the perceived expertise in ED settings, as compared with primary care, as a consideration for seeking care, was identified as a reason that individuals with long-term conditions sought care in the ED.Reference Hunter, Chew-Graham and Langer 12 Our finding that positive previous experiences were a key factor for older adults deciding to attend the ED for non-urgent concerns is supported by some studies,Reference Victoor, Delnoij, Friele and Rademakers 13 , Reference Kolstad and Chernew 14 although others have found that older patients frequently leave the ED dissatisfied.Reference Gruneir, Silver and Rochon 15 ,16 Given the higher rates of chronic disease and multimorbidity,Reference Fisher and McCabe 17 , Reference Fisher and McCabe 18 as well as the greater likelihood of functional impairment 19 among older adults, Gruneir and colleagues suggested that disproportionate ED use by older adults is most reflective of the greater need for ED care of older adults, as compared with younger patients.Reference Gruneir, Silver and Rochon 15
LIMITATIONS AND MITIGATING FACTORS
While collecting real-time data during participants’ ED visits lessened the risks of recall bias inherent in interviews conducted following these visits, this strategy also imposed a number of constraints. The use of field notes, rather than an audio-taped recording of the interviews, was deliberately chosen as a strategy most likely to be acceptable to participants, given that note-taking is common practice in health care encounters. The use of field notes may have resulted in some loss of data or inaccuracies in recording, although this risk was mitigated by the careful review of transcribed field notes by the RA. Additional information on the final disposition of patients after their ED visit would have been helpful.
Clinical implications
In a statement endorsed by Canadian Association of Emergency Physicians (CAEP), 20 the ED is recognized to be uniquely positioned to play a pivotal role in improving care for geriatric populations. Older adults trust and appreciate the unique contribution of EDs to their health care, despite the well-recognized challenges in implementing truly “age-friendly” care in this setting.Reference Sinha, Bessman, Flomenbaum and Leff 21 The fact that almost one-third of the participants in this study reported being referred to the ED by a general practitioner or a specialist suggests gaps in the range of community care available for non-urgent concerns that require practice and policy solutions to bridge these gaps.Reference Gruneir, Silver and Rochon 15 Hwang et al. suggested that the ED should evolve as a partner in care coordination while retaining its role as a critical care provider.Reference Hwang, Shah and Han 22
Research implications
The need to better address the requirements of older adults figured prominently in the research priority setting conducted by the Royal College of Emergency Medicine, in collaboration with clinicians, patients, family members, and the public.Reference Smith, Keating and Flowerdew 23 To support the development of innovative care strategies that better address the non-urgent care needs of older adults, future research should incorporate a system-wide approach to understanding older adults’ utilization of the ED for non-urgent concerns. Such an approach should include primary and community care providers, rather than examining the ED in isolation. Research comparing the reasons for attending the ED for non-urgent care among different age cohorts would help to understand if, how, and why the motivations of older adults differ from those of other age groups. Finally, examining patient and system outcomes for dedicated geriatric EDs is needed.
CONCLUSIONS
As the population ages and demands for patient-centred health care grows, it becomes increasingly imperative to understand the patient experience. By eliciting the perspectives of older adults seeking non-urgent treatment in the ED, this study contributes a much-needed window into patient understandings, expectations of, and self-reported reasons for these visits. Accessibility to and availability of comprehensive care, perceptions of higher quality of care than was available in primary care settings, and positive past experiences were key considerations for older adults seeking treatment for non-urgent concerns. Older adults will likely continue to use EDs for non-urgent medical care until trusted, “one-stop” settings that better addresses the needs of this population are more widely available.
Acknowledgements
We express our appreciation to the seniors and caregivers who took part in this project; the ED staff who facilitated data collection; Ms. Jennifer Heal-Salahub for data entry; and Ms. Elliot Paus-Jenssen, our research assistant from the Saskatoon Council on Aging, for conducting the interviews.
Competing interests
This work was supported through a grant from the College of Medicine, University of Saskatchewan. None declared.
