A research study identified the key concerns of older people with frailty in the emergency department, revealing these differ from the NHS’s standard metrics
A study interviewed older people with frailty about their priorities in emergency department care. Autonomy and functioning were their key concerns. Participants wanted to be well-informed and in control. They sought relief from symptoms and wanted to be able to return home safely. Some interviewees wanted full independence in decision making; others wanted help from family members. The study’s results challenge the metrics typically used by the NHS to assess quality of care, urging a focus on patients’ individual needs. As a result, the researchers advocate for shared decision making and personalised care.
Citation: van Oppen J et al (2024) Emergency department care for older people with frailty. Nursing Times [online]; 120: 2.
Author: James van Oppen is National Institute for Health and Care Research (NIHR) doctoral research fellow and higher specialty trainee in emergency medicine, University of Leicester; Emma Wilkinson is freelance journalist; Helen Saul is editor in chief, NIHR Evidence.
Frailty becomes more common with ageing; people living with frailty have accumulated physical, social or mental problems that make them vulnerable to poorer outcomes when a health crisis occurs (Young, 2013). Around one in ten people who attend emergency departments have frailty (Singler et al, 2011).
Yet little is known about what matters to this group when they are receiving acute care in hospital. Waiting times are a key measure of the quality of care provided by emergency departments; an NHS ambition is for patients to be seen more quickly (NHS England, 2023).
However, this measure may not appropriately assess whether people with frailty are receiving good care. A better understanding of what matters to this group could help:
- Health professionals support them in a meaningful way;
- Researchers develop improved ways to measure the quality of care that they receive.
This article discusses a study by van Oppen et al (2022), who interviewed older people with frailty who had attended an emergency department. This work is part of a larger project exploring how to best measure person-centred acute healthcare for people with frailty. More information about frailty is available in Young’s (2013) blog on NHS England’s website.
Researchers recruited people with frailty who had attended an emergency department in Leicester, conducting in-depth interviews with 22 people. Their average age was 85 years, and one in four were living with dementia. A group of public contributors (volunteers), who were either caring for someone with frailty or living with frailty themselves, worked with the researchers at every stage. They helped ensure the study:
- Was relevant to patients;
- Involved a diverse group, including patients with communication difficulties due to cognitive impairment, or those needing translators.
The researchers asked participants about their worries at the time they went to hospital, and what they had wanted from their visit. They found that most already knew the outcomes they wanted when they went to the emergency department. Their concerns were mostly about maintaining their autonomy and function; these are discussed below.
Interviewees described autonomy as being well-informed, in control and secure.
They wanted to understand their condition and treatment plan. They wanted health professionals’ full attention during discussions, to feel heard and have their life experience acknowledged. They generally accepted long waits, understanding that healthcare systems are under pressure.
Some participants wanted to be fully informed and to make decisions independently; others did not wish to know the clinical details. Some preferred family members to make decisions, while others did not want their relatives to be ‘bothered’. Many interviewees were concerned about changes to their medication.
Almost all participants had delayed attending hospital in the hope of avoiding unfamiliar processes or burdening the NHS. They reported wanting to feel safe going home and managing their health issues. One interviewee reported making changes to their routines in order to feel safe at home:
“My fear is that I can’t get there quick enough when things go wrong because I can’t move, and that frightens me. I fry my bacon now – I don’t grill it, because, well, I don’t want to set that on fire again. Fire frightens me more than anything else.”
Participants wanted to ensure that physical problems did not prevent them:
- Looking after themselves;
- Getting around their environment;
- Continuing enjoyable activities.
They also discussed emotional and social problems. Interviewees with mild frailty were concerned about caring for loved ones; people who had more severe frailty did not want to be a burden on others.
Participants also described wanting relief from illness, injury or low mood. An interviewee living with severe frailty described this:
“Even though I walked slowly, at least I was able to do things for myself. Whatever little that is, at least it gives me a little bit of independence. Now I cannot stand up or do anything for myself. [I’ve] not been able to shower, not been able to go to the loo. So I want to get back on my feet. I want that to return to normal at least.”
The researchers observed that the public contributors’ involvement in designing and carrying out the study allowed them to assess what really mattered to interviewees. Previously, partnering with people with frailty has typically been seen as too challenging, and relatives or health professionals have been relied upon instead (Hansen et al, 2021). The researchers feel this work demonstrates that successful engagement with people with different levels of frailty is possible.
The researchers were able to explore what older people with frailty think are important and meaningful outcomes when they are in the emergency department. The study identified that these are different from the quality metrics typically used by the NHS (survival rates and waiting times).
Instead, the main concerns of the people in this study were losing their autonomy and feeling unsafe. They wanted relief from distressing symptoms, a feeling of control, and support to manage as independently as possible. They wanted to return home, but only if they felt safe doing so. Participants reported wanting varying levels of:
- Detail about their clinical condition;
- Involvement in decision making.
Improving their understanding of what is most important to people with frailty could help healthcare staff focus on meaningful outcomes. Health professionals and people with frailty need to work together to explore possibilities and preferences. The researchers call for shared decision making to tailor care to each person. This holistic care needs to include consideration of how they will manage at home.
Although this study included diverse participants, using translators where needed, it was conducted at a single hospital. Further research could explore whether the views of people with frailty differ in other areas.
“The main concerns of the people in this study were losing their autonomy and feeling unsafe when they go home”
Many healthcare settings already use risk scores to identify people with frailty, but more work is needed to ensure that these patients receive the aspects of care they consider to be important. This study’s results suggest that emergency department staff and policy makers may need to rethink how they measure quality of care.
The results could help develop person-reported outcome measures for patients with frailty. Such measures are unlikely to replace waiting time targets and mortality rates, however, they could be used alongside these to assess whether hospitals are providing care in a way that really matters to the patient.
The research team, in collaboration with the public contributors, has now developed a questionnaire with nine questions to measure person-centred care for frail people in emergency departments. This is being trialled with approximately 300 patients and is expected to be rolled out soon.
- The NHS typically measures care quality in emergency departments based on waiting times and survival rates
- Older people with frailty were interviewed about the health outcomes that were most important to them
- Interviewees reported autonomy and functioning as their priorities
- Participants varied in the level of independence and clinical information they wanted
- These findings can help health professionals support frail patients in a meaningful, person-centred way
Hansen TK et al (2021) Involving frail older patients in identifying outcome measures for transitional care – a feasibility study. Research Involvement and Engagement; 7: 1, 36.
NHS England (2023) Delivery Plan for Recovering Urgent and Emergency Care Services. NHS England.
Singler K et al (2011) Geriatrische Patienten in Notaufnahme und Intensivmedizin. Der Internist; 52: 8, 934-938.
van Oppen JD et al (2022) What matters most in acute care: an interview study with older people living with frailty. BMC Geriatrics; 22: 156.
Young J (2013) Frailty – what it means and how to keep well over the winter months. england.nhs.uk, 20 December (accessed 29 November 2023).
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