Experiences of family members of elderly patients in the emergency department: A qualitative study

BackgroundElderly patients are more frequent users of emergency department (ED). An elderly patient entering the ED is often accompanied by a family member who has an important role in the patient’s life. Current literature does not adequately address the question of the experiences of family members accompanying elderly patient in ED, although they could give us valuable and interesting knowledge and information about nursing practices.AimThe aim of this study was to describe the experiences of family members of elderly patients aged over 65 in the ED for internal medicine.MethodThis interview study based on the experiences of family members (n = 9) of elderly patients being cared for in the ED. The interview material was analyzed using inductive content analysis.ResultsFamily members of elderly patients perceived themselves as satisfied participants, invisible participants, or disappointed outsiders in the ED. Family members accompanying an elderly patient wanted to be active participants not being excluded, but this was possible only because of their own active attitude.ConclusionsBroader educational initiative for ED staff about the family presence and involvement in care in the ED is needed, because the family members’ experiences showed that they were left as outsiders. Family members are well aware of the elderly patient’s previous level of functional capacity and their medication, which is decisive information when planning further care and thinking patients coping at home.     

Unplanned postdischarge healthcare utilisation,discharge readiness,and perceived quality of teaching in mothers of neonates hospitalized in a neonatal intensive care unit: A descriptive and correlational study

BackgroundDischarge teaching has been positively associated with discharge readiness in various care settings and patient types. Association of discharge readiness with unplanned use of health services has not received as much attention in the neonatal intensive care unit (NICU) population, but has been negatively associated in parents of older children.ObjectivesThe objective of the study was to describe and assess relationships between maternal readiness for neonates' discharge, discharge teaching, and unplanned use of health services after discharge from an NICU.MethodsMothers from an NICU of a tertiary referral hospital in Switzerland completed the “Readiness for Hospital Discharge Scale” and the “Quality of Discharge Teaching Scale parental forms” in the 24 h preceding discharge. Telephone interviews evaluating the unplanned use of health services were conducted 28 days after discharge. Simple linear regressions and multiple regressions were used to explore the links between the readiness, perceived quality of discharge, and unplanned use of health services.ResultsOf the 71 participants, 75% (n = 53%) felt ready for discharge when asked directly, and for 60% (n = 42) of them, the amount of discharge teaching received was equal to or higher than that needed, but with high heterogeneity in scores. For 38% of mothers (n = 27), the expected support from the medical care of their child after discharge was deemed insufficient. In the month after discharge, unplanned use of health services occurred in 46% of the participants (n = 32). Perceived quality of teaching positively predicted readiness for discharge (R² = 0.24, p = 0.0004). Unplanned use of health services correlated neither with readiness nor with perceived teaching quality.ConclusionsAt discharge, mothers felt mostly ready and well prepared to go home. In the month after discharge, almost half used health services in an unplanned manner. Further exploration of reasons leading to this high rate of postdischarge healthcare utilisation is warranted.     

Discharge education delivered to general surgical patients in their management of recovery post discharge: A systematic mixed studies review

BackgroundDischarge education is essential for postoperative general surgery patients for their self-management of care at home post discharge. The first 30 days’ post-surgery is pivotal to the post-operative recovery process as this is when most post-operative complications occur. Insufficient discharge education can compromise patients’ recovery process causing postoperative complications and unplanned hospital readmissions.ObjectivesTo identify the discharge education provided to general surgery patients.DesignSystematic mixed studies review.Data sourcesLiterature data sources were searched from December 2017 to January 2018 using the four databases: EBSCO CINAHL Plus, EBSCO MEDLINE, Ovid EMBASE and COCHRANE Library. Searches were supplemented with hand searching of reference lists.Review methodsThe relevance of the articles was reviewed using the inclusion and exclusion criteria; included data were extracted and presented in a summary table. Two reviewers appraised the methodological quality of the articles using the Mixed Methods Appraisal Tool. Discussions were held to examine emergent themes, quality scores of the studies, and agreement reached by consensus. Themes were derived through inductive analysis.ResultsA total of 468 records were screened for titles and abstracts and 7 studies met the inclusion criteria. There was a mix of qualitative and quantitative studies. The majority of the included sample were patients with one quantitative study including patients’ family and nurses. Discharge education was delivered at various timing and at different doses during the surgical process. Education delivered was mostly standardised and some of the discharge interventions were tailored and included a checklist for stoma care and a discharge warning tool. Four themes were identified: quality of discharge education influences its uptake, health care professionals’ perceptions of their role in the delivery of discharge education to patients, patients’ preferences for education delivery and patients’ participation in their self-care.ConclusionsThe quality of discharge education has an influence on patient participation in their management of care post discharge. Assessing patients’ preparedness for discharge is an essential component of discharge planning process. The presentation, timing and frequency of discharge education was important in the delivery of information. Tailored education reflecting the learning needs of patients using multiple media delivered in varying doses enhanced patients’ overall knowledge for successful management of recovery post discharge. The scarcity of recent literature in discharge education indicates that the quantity of evidence regarding discharge education intervention in general surgery patients is low and further work in this area needs to be undertaken.     

Family functioning evaluated by family members of older patients and nurses in emergency departments

The functioning of families in emergency departments (ED s) encompasses the level at which the families of older patients perform as a whole during the ED stay. Currently, little is known about how the families of older patients function in EDs. In this study, family functioning included the subareas of family strengths, structural factors and relationships both inside and outside the family. The study aimed to describe family functioning in EDs as evaluated by both the family members (n  = 111) of older patients and nurses (n  = 93). The data were collected from four Estonian hospitals, and the scale used was the Family Functioning, Health and Social Support scale. The results showed that both the family members and nurses evaluated family functioning and all its subareas as being moderate. Family structural factors were found to be associated with the family members’ social status. The scores in the subareas were higher when older patients had received help from family members before the ED visit. The family members and nurses differed significantly in the scores they gave for family functioning in general and for all the subareas. No association was found between family functioning as rated by nurses and the families’ demographic characteristics. These results suggest that nurses should pay more attention to family functioning in general and to the structural factors within the family, including internal relationships, while older patients are in the ED . Comprehensive knowledge about how families function during an ED stay may help nurses to better meet the needs of older patients and their families and help them to prepare families to provide aftercare at home. Our findings support the idea that healthcare organisation and delivery should be more family centred.     

Assessing the discharge instructing in the emergency department: Patient perspective

ObjectiveThe objective of the study is to assess how well the emergency department (ED) personnel succeed in instructing the patient at discharge.MethodsIn November and December 2016 at Peijas Hospital ED, Finland, a structured questionnaire was conducted during a phone interview on patients the day after discharge.ResultsA total of 132 patients interviewed. Ninety percent had received discharge instructions from the ED staff, most of them (75%) about medication. Almost half of the patients (45%) were satisfied with the communication at discharge, those not satisfied (47%) felt that the staff did not know enough of their background to give discharge instructions. Of the patients, 20% thought that they did not have the opportunity to ask questions during the guidance session, and 41% thought that the session was too short and restricted. Some patients (20%) felt that the instructions were ambiguous, but 63% (83/132) felt they were able to follow them well or very well.ConclusionThe pace of care in the ED is fast and duration of the stay is short. The patients must be able to take responsibility of their self-care. Failure to follow medical discharge instructions could lead to non-compliance. Attention should be paid to enhancing the quality of discharge instructing and the instructions provided by the ED personnel, as recurring visits and inquiry calls add to the ED workload.     

A family caregiver-oriented discharge planning program for older stroke patients and their family caregivers

Aims. To test the effectiveness of a discharge planning program for dyads of older stroke survivors and their family caregivers in Taiwan. Background. Family caregivers of stroke survivors often feel inadequately prepared to deal with the physical, cognitive and emotional needs of the stroke survivors. However, little information could be found on discharge planning programs for caregivers of stroke survivors in Asian families. Design. A randomised experimental design was used to explore the effects of a discharge planning program for 158 dyads of older stroke patients and their family caregivers. Methods. The control group (n = 86 dyads) received only routine hospital discharge planning services and the experimental group (n = 72 dyads) received routine hospital discharge planning services plus the caregiver‐oriented discharge planning program. Outcome variables were measured at baseline, before discharge and one month after hospital discharge. Variables were measured by the Nurse Evaluation of Caregiver Preparation Scale, Preparedness for Caregiving Scale, Caregiver Discharge Needs Satisfaction Scale and Perception of Balance between Competing Needs Scale. Results. Caregivers in the experimental group had significantly better nurse evaluation and self‐evaluation of preparation after the program than before, and greater satisfaction of discharge needs one month after discharge than before discharge. Caregivers in the experimental group had significantly better nurse evaluations and self‐evaluations of preparation and better satisfaction of discharge needs after the program compared with the control group. However, no significant difference was found between caregiver groups in perceived balance of competing needs. Conclusions. This discharge planning program benefited family caregivers of older stroke patients during the transition from hospitalisation to one month after discharge. Relevance to clinical practice. This caregiver‐oriented discharge planning program, with its emphasis on individualised health education and home visits following discharge may improve caregivers’ preparation and the satisfaction of their needs during the discharge transition.     

Emergency Nurses’ Perception of Geriatric Readiness in the ED Setting: A Mixed-Methods Study

IntroductionThe Centers for Disease Control and Prevention (CDC) reports 136.9 million ED visits in 2015, of which 21.4 million (15.6%) were by patients who were 65 or older. This US population demographic is expected to grow by 112% over the next 40 years, becoming just below 25% of the total US population. Emergency nurses will play an increasingly important part in the development of nursing care for geriatric patients. The purpose of this study was to explore emergency nurses’ perception of their ability to care for geriatric patients in the emergency setting.MethodsThis was a mixed-methods sequential design using quantitative survey data and qualitative focus group data, which were analyzed separately and then given equal priority during the data-interpretation phase.ResultsLess than 50% of survey respondents (N = 1,610) reported geriatric-specific screenings, accommodations, and communication with outside agencies as “always available” in their care settings. Qualitative analysis (N = 23) yielded the categories of Triage/Assessment, Care in the Emergency Environment, Discharge Planning, and Facilitators and Barriers, which generally reflected the trajectory of care for the older patient. The overarching concern was keeping patients safe in both the community and in the emergency department.DiscussionEmergency departments should develop integrated systems to facilitate appropriate care of older patients. Identified barriers to improved care include a lack of integration between emergency care and community care, deficits in geriatric-specific education, inconsistent use of early screening for frailty, and lack of resources in the emergency care environment to intervene appropriately.     

Nurses’ experiences and expectations of family and carers of older patients in the emergency department

BackgroundOlder people are often accompanied by family/carers to the emergency department (ED). Few studies investigate nurses’ experiences of interacting with these family/carers.AimThis study was an exploration of the experiences and expectations that ED nurses have of family and carers accompanying the older adult patient.MethodFocus group interviews (four, n = 27) were conducted and interviews were audio-taped, transcribed and then thematically analysed.ResultsThree themes emerged relating to the way nurses judged family/carers of the older person, with the main theme the importance of time. Family/carers were evaluated as supportive and helpful when they saved nurses time and demanding and obstructive when they cost nurses time. A second theme was the family/carer as a knowledge resource. Nurses evaluated family/carers according to whether they could provide timely and useful information on the older patient. The third theme centred on nurses’ evaluations of family/carers getting in the way of assessing or treating the patient, by their physical presence and demands and by limiting open communication with the patient.ConclusionEmergency nurses have clear expectations of older patients’ families and/or carers. Future research must determine how nursing roles can sustain positive interactions with older patients’ families and/or carers in the ED.     

Closing the Gap: The Role of Discharge Nurses in an Emergency Department

IntroductionPatients discharged from the emergency department may require a follow-up appointment with an outpatient specialty clinic. Referral processes vary by clinic, some requiring faxed referrals, some providing appointments immediately, and others contacting the patients directly. The frequency with which patients are successfully connected with outpatient follow-up services is largely unknown.MethodsThe ED discharge nurse role was developed to facilitate the navigation of patient follow-up and confirm that patients successfully connect with specialty outpatient clinics. Eight emergency nurses were recruited into this position to study the problem using a quality improvement approach. The ED discharge nurses reviewed referrals, contacted clinics and patients discharged from the emergency department, and intervened when barriers to transition occurred.ResultsThe ED discharge nurses were able to determine specific causes and themes of missed appointments experienced by patients. Systemic problems identified include lost faxes, illegible contact information, incomplete referrals, and referral refusals by the clinics without patient notification. Considering the variability of clinic processes outside the emergency department’s control, the ED discharge nurse role became crucial in minimizing the risk of lost/unsuccessful follow-up for patients discharged from the emergency department.DiscussionImplementing the ED discharge nurse role created a contact for outpatient clinic referrals, patient inquiry, and a process to track errors and data to better understand the frequency of missed follow-up. In this quality improvement initiative, the role of the ED discharge nurse addressed the risk of patients falling through the cracks of a complex system.     

Personalized Care Plans: Are They Effective in Decreasing ED Visits and Health Care Expenditure Among Adult Super-Utilizers?

ProblemSuper-utilizers comprise 4.5% to 8% of all ED patients, but account for 21% to 28% of all ED visits. Excessive use of the emergency department contributes to increased health care costs, recurrent and unnecessary ED workup, decreased emergency readiness, and reduced staff morale.MethodsThe impact of personalized care plan implementation was evaluated using a within-subjects pre-post design. The number of ED visits for each enrolled patient (N = 65) were analyzed before and after personalized care plan enrollment at 90, 180, and 365 days. A post-hoc analysis was completed for each ED visit that resulted in a disposition of discharge. Total and average charges from the ED visits were analyzed to determine the intervention’s effect on health care expenditure. Staff was anonymously surveyed to assess perceived efficacy and level of satisfaction with the intervention before completion of data collection.ResultsMedian ED visits had a statistically significant decrease over 90, 180, and 365 days. There was also a decrease in median, average, and total ED charges for all time points. ED staff perceived the personalized care plans to be an effective intervention and were satisfied with their implementation.DiscussionPersonalized care plans effectively decreased the number of ED visits, reduced health care expenditure, and were well-received by the staff.     

A Picture Is Worth a Thousand Words: Pictographs to Improve Understanding of Discharge Instructions

IntroductionPoor comprehension of ED discharge instructions has been reported. Discharge instructions often include written information. Identification of home-care practices that were different from recommended discharge instructions among multiple clients led nurses at a community emergency department to evaluate health literacy among specific clients.MethodsA bilingual translator administered the Newest Vital Sign—a 6-item validated scale that assesses health care literacy—to 150 English and Spanish-speaking parents of pediatric patients admitted to the fast-track area.ResultsAlthough mean scores for both groups indicated participants were, on average, “at risk” for health literacy problems, English speakers had a significantly higher mean total score (3.82, standard deviation [SD] = 1.60) than did Spanish speakers (2.61, SD = 1.71), indicating better literacy.DiscussionStudy findings of low levels of health literacy in many parents led to a practice change of using nurse-developed pictographs, along with discharge instructions, for specific common ED diagnoses. Postdischarge calls to parents or patients receiving the pictographs documented positive postdischarge client feedback. The pictograph strategy is transferable to other institutions.     

Interventions to improve older adults' Emergency Department patient experience: A systematic review

Study objectiveTo summarize interventions that impact the experience of older adults in the emergency department (ED) as measured by patient experience instruments.MethodsThis is a systematic review to evaluate interventions aimed to improve geriatric patient experience in the ED. We searched Ovid CENTRAL, Ovid EMBASE, Ovid MEDLINE and PsycINFO from inception to January 2019. The main outcome was patient experience measured through instruments to assess patient experience or satisfaction. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the confidence in the evidence available.ResultsThe search strategy identified 992 studies through comprehensive literature search and hand-search of reference lists. A total of 21 studies and 3163 older adults receiving an intervention strategy aimed at improve patient experience in the ED were included. Department-wide interventions, including geriatric ED and comprehensive geriatric assessment unit, focused care coordination with discharge planning and referral for community services, were associated with improved patient experience. Providing an assistive listening device to those with hearing loss and having a pharmacist reviewing the medication list showed an improved patient perception of quality of care provided. The confidence in the evidence available for the outcome of patient experience was deemed to be very low.ConclusionWhile all studies reported an outcome of patient experience, there was significant heterogeneity in the tools used to measure it. The very low certainty in the evidence available highlights the need for more reliable tools to measure patient experience and studies designed to measure the effect of the interventions.     

Danish emergency nurses' attitudes towards self-harm – a cross-sectional study

AimThe aim of this study was to examine Danish emergency nurses' attitudes toward people hospitalized after an acetaminophen poisoning. Furthermore, the study examined the relationship between attitudes and factors such as age, gender, and education on self-harm.MethodsA cross-sectional design was applied. Nurses from seven emergency departments (EDs) in a region in Denmark were asked to complete the Danish version of Attitudes towards Deliberate Self-Harm Questionnaire (ADSHQ).ResultsOf the 254 eligible nurses working in the ED, 122 returned the questionnaires, leaving the response rate at 48%. Results show that the emergency nurses generally held positive attitudes toward patients with acetaminophen poisoning. Nurses with longer ED experience held more positive attitudes, and women scored significantly higher than men on the whole scale. Only 19% of the respondents had received education on self-harm, and this education seems to produce more positive attitudes and a greater self-efficacy in relation to managing the patient group.ConclusionNurses working in the ED generally hold positive attitudes toward patients with acetaminophen poisoning. It is suggested that education on self-harm is a worthwhile endeavor with the potential to strengthen and improve attitudes, for the benefit of both the nurses and the patients.     

Characteristics of intentional fall injuries in the ED

Introduction

This study was conducted to examine the characteristics of intentional fall injuries and the factors associated with their prognosis.

Methods

The study included 8992 patients with unintentional falls from a height (nonintentional group) and 144 patients with intentional falls from a height (intentional group). General and clinical characteristics were compared between the 2 groups. Intentional fall cases were divided into severe and nonsevere groups, and the factors associated with severe injury were evaluated by comparing these groups.

Results

The most common age group was younger than 14 years in the nonintentional group and between 30 and 44 years old in the intentional group. For the nonintentional group, 65% of the patients were male, and 48% were male in the intentional group. Fall heights of more than 4 m were most common in the intentional group. Discharge was the most common result in the nonintentional group; however, death before arrival at the emergency department (ED) or during ED treatment occurred in 54.9% of patients in the intentional group. In the severe injury group within the intentional group, patients were older, and the height of the fall was higher. Factors associated with severe injury in the intentional group included being a high school graduate rather than a college graduate and greater fall height.

Conclusion

The risk of severe injury increased with fall height in the intentional group, and a high school level of education rather than a college level of education was associated with more severe injury.     

Social determinants and emergency department utilization: Findings from the Veterans Health Administration

BackgroundSocial determinants of health (SDH) are strong predictors of morbidity and mortality but health care systems struggle to integrate documentation of SDH into health records in ways that can be used for health services research. Given the impact of social factors on health, it is important to examine the relationship with emergency department (ED) utilization.ObjectiveTo examine the association between seven indicators of SDH and ED utilization using electronic health record (EHR) data from the Veterans Health Administration (VHA).MethodsThis cross-sectional analysis included data from all patients who had at least one health care visit in the Veterans Integrated Service Network region 4 from October 1, 2015 through September 30, 2016 (n = 293,872). Seven categories of adverse SDH included violence, housing instability, employment or financial problems, legal problems, social or family problems, lack of access to care or transportation, and non-specific psychosocial needs identified through structured coding in EHR. Negative binomial regression was used to examine the association of the count of adverse SDH (0–7) with the count of ED visits, adjusting for socio-demographic and health-related factors.ResultsApproximately 18% of patients visited the ED during the observation period. After adjusting for covariates, adverse SDH were positively associated with VHA ED utilization. Each of the SDH indicators, other than legal issues, was positively associated with increased ED utilization.ConclusionEven after accounting for several demographic and health-related factors, adverse SDH demonstrated strong positive associations with VHA ED utilization.