Perceptions and expectations of health-related quality of life among geriatric patients seeking emergency care: a qualitative study.

BACKGROUND: Health-related quality of life (HRQoL), encompassing social, emotional, and physical wellbeing is an important clinical outcome of medical care, especially among geriatric patients. It is unclear which domains of HRQoL are most important to geriatric patients and which domains they hope to address when using the Emergency Department (ED). The objective of this study was to understand which aspects of HRQoL are most valued by geriatric patients in the ED and what expectations patients have for addressing or improving HRQoL during an ED visit. METHODS: This was a qualitative focus group study of geriatric ED patients from an urban, academic ED in the United States with > 16,500 annual geriatric visits. Patients were eligible if they were age > =65 years and discharged from the ED within 45 days of recruitment. Semi-structured pilot interviews and focus groups were conducted several weeks after the ED visit. Participants shared their ED experiences and to discuss their perceptions of the subsequent impact on their quality of life, focusing on the domains of physical, mental, and social health. Latent content and constant comparative methods were used to code focus group transcripts and analyze for emergent themes. RESULTS: Three individuals participated in pilot interviews and 31 participated in six focus groups. Twelve codes across five main themes relating to HRQoL were identified. Patients recalled: (1) A strong desire to regain physical function, and (2) anxiety elicited by the emotional experience of seeking care in the emergency department, due to uncertainty in diagnosis, treatment, and prognosis. In addition, patients noted both (3) interpersonal impacts of health on quality of life, primarily mediated primarily by social interaction, and (4) an individual experience of health and quality of life mediated primarily by mental health. Finally, (5) patients questioned if the ED was the right place to attempt to address HRQoL. CONCLUSIONS: Patients expressed anxiety around the time of their ED visit related to uncertainty, they desired functional recovery, and identified both interpersonal effects of health on quality of life mediated by social health, and an individual experience of health and quality of life mediated by mental health.

Emergency Palliative Care: Early Assessment of an Older Adult With a Fall and Hip Fracture.

In this segment of the emergency department (ED) palliative care case series, we present a patient who arrives to the ED after a fall resulting in a hip fracture. He is also found to have hypernatremia and an acute kidney injury and develops delirium while in the ED awaiting an inpatient bed. The ED-based integrated geriatric palliative care program is consulted and performs a multidimensional assessment. The geriatric palliative care clinician facilitates discussion with his daughter about surgical intervention based on the patient's goals and values, diagnoses delirium, and worsening depression, creates a plan for delirium and pain management, and accelerates postdischarge planning.

Developing a novel integrated geriatric palliative care consultation program for the emergency department.

With the aging of our population, older adults are living longer with multiple chronic conditions, frailty, and life-limiting illnesses, which creates specific challenges for emergency departments (EDs). Older adults and those with serious illnesses have high rates of ED use and hospitalization, and the emergency care they receive may be discordant with their goals and values. In response, new models of care delivery have begun to emerge to address both geriatric and palliative care needs in the ED. However, these programs are typically siloed from one another despite significant overlap. To develop a new combined model, we assembled stakeholders and thought leaders at the intersection of emergency medicine, palliative care, and geriatrics and used a consensus process to define elements of an ideal model of a combined palliative care and geriatric intervention in the ED. This article provides a brief history of geriatric and palliative care integration in EDs and presents the integrated geriatric and palliative care model developed.

Examining emergency department communication through a staff-based participatory research method: identifying barriers and solutions to meaningful change.

STUDY OBJECTIVE: We test an initiative with the staff-based participatory research (SBPR) method to elicit communication barriers and engage staff in identifying strategies to improve communication within our emergency department (ED). METHODS: ED staff at an urban hospital with 85,000 ED visits per year participated in a 3.5-hour multidisciplinary workshop. The workshop was offered 6 times and involved: (1) large group discussion to review the importance of communication within the ED and discuss findings from a recent survey of patient perceptions of ED-team communication; (2) small group discussions eliciting staff perceptions of communication barriers and best practices/strategies to address these challenges; and (3) large group discussions sharing and refining emergent themes and suggested strategies. Three coders analyzed summaries from group discussions by using latent content and constant comparative analysis to identify focal themes. RESULTS: A total of 127 staff members, including attending physicians, residents, nurses, ED assistants, and secretaries, participated in the workshop (overall participation rate 59.6%; range 46.7% to 73.3% by staff type). Coders identified a framework of 4 themes describing barriers and proposed interventions: (1) greeting and initial interaction, (2) setting realistic expectations, (3) team communication and respect, and (4) information provision and delivery. The majority of participants (81.4%) reported that their participation would cause them to make changes in their clinical practice. CONCLUSION: Involving staff in discussing barriers and facilitators to communication within the ED can result in a meaningful process of empowerment, as well as the identification of feasible strategies and solutions at both the individual and system levels.

Understanding patient-provider conversations: what are we talking about?

OBJECTIVES: Effective patient-provider communication is a critical aspect of the delivery of high-quality patient care; however, research regarding the conversational dynamics of an overall emergency department (ED) visit remains unexplored. Identifying both patterns and relative frequency of utterances within these interactions will help guide future efforts to improve the communication between patients and providers within the ED setting. The objective of this study was to analyze complete audio recordings of ED visits to characterize these conversations and to determine the proportion of the conversation spent on different functional categories of communication. METHODS: Patients at an urban academic ED with four diagnoses (ankle sprain, back pain, head injury, and laceration) were recruited to have their ED visits audio recorded from the time of room placement until discharge. Patients were excluded if they were age < 18 years, were non-English-speaking, had significant history of psychiatric disease or cognitive impairment, or were medically unstable. Audio editing was performed to remove all silent downtime and non-patient-provider conversations. Audiotapes were analyzed using the Roter Interaction Analysis System (RIAS). RIAS is the most widely used medical interaction analysis system; coders assign each "utterance" (or complete thought) spoken by the patient or provider to one of 41 mutually exclusive and exhaustive categories. Descriptive statistics were calculated for all 41 categories and then grouped according to RIAS standards for "functional groupings." The percentage of total utterances in each functional grouping is reported. RESULTS: Twenty-six audio recordings were analyzed. Patient participants had a mean (±SD) age of 38.8 (±16.0) years, and 30.8% were male. Intercoder reliability was good, with mean intercoder correlations of 0.76 and 0.67 for all categories of provider and patient talk, respectively. Providers accounted for the majority of the conversation in the tapes (median = 239 utterances, interquartile range [IQR] = 168 to 308) compared to patients (median = 145 utterances, IQR = 80 to 198). Providers' utterances focused most on patient education and counseling (34%), followed by patient facilitation and activation (e.g., orienting the patient to the next steps in the ED or asking if the patient understood; 30%). Approximately 15% of the provider talk was spent on data gathering, with the majority (86%) focusing on biomedical topics rather than psychosocial topics (14%). Building a relationship with the patient (e.g., social talk, jokes/laughter, showing approval, or empathetic statements) constituted 22% of providers' talk. Patients' conversation was mainly focused in two areas: information giving (47% of patient utterances: 83% biomedical, 17% psychosocial) and building a relationship (45% of patient utterances). Only 5% of patients' utterances were devoted to question asking. Patient-centeredness scores were low. CONCLUSIONS: In this sample, both providers and patients spent a significant portion of their talk time providing information to one another, as might be expected in the fast-paced ED setting. Less expected was the result that a large percentage of both provider and patient utterances focused on relationship building, despite the lack of traditional, longitudinal provider-patient relationships.