Inappropriate--the patient or the service?

Caring for older people in acute settings: Lessons learned from an action research study in accident and emergency

The health and social care of older people has never been so high on the political agenda. In particular, there has been growing concern about the care of older people in acute settings. This paper reports the findings of an action research study which explored the organisation of care for older people in an accident and emergency (A&E) setting. Although the findings cannot be generalised directly to all acute settings, the action research methodology generated unique exploratory data, which suggest older patients arrive at hospital with low expectations of care and appear to understand many of the constraints under which staff are working. However, while patients appear to be able to identify small ways in which care could be improved easily, staff instead appear to blame the wider organisation for poor care and give the impression of being disempowered to care. This is despite findings which suggest nurses could make changes in the priorities they give to different aspects of care. The lessons learned from this action research study suggest that nurses may need to work more closely together to foster the much-needed improvements in care of older people. With the National Service Framework for Older People on the horizon, nurses cannot afford to ignore the needs of such a significant group of patients under their care.

Needs and fears of young people presenting at accident and emergency department following an act of self-harm: secondary analysis of qualitative data

BACKGROUND

Presentation at an accident and emergency (A&E) department is a key opportunity to engage with a young person who self-harms. The needs of this vulnerable group and their fears about presenting to healthcare services, including A&E, are poorly understood.

AIMS

To examine young people's perceptions of A&E treatment following self-harm and their views on what constitutes a positive clinical encounter.

METHOD

Secondary analysis of qualitative data from an experimental online discussion forum. Threads selected for secondary analysis represent the views of 31 young people aged 16-25 with experience of self-harm.

RESULTS

Participants reported avoiding A&E whenever possible, based on their own and others' previous poor experiences. When forced to seek emergency care, they did so with feelings of shame and unworthiness. These feelings were reinforced when they received what they perceived as punitive treatment from A&E staff, perpetuating a cycle of shame, avoidance and further self-harm. Positive encounters were those in which they received 'treatment as usual', i.e. non-discriminatory care, delivered with kindness, which had the potential to challenge negative self-evaluation and break the cycle.

CONCLUSIONS

The clinical needs of young people who self-harm continue to demand urgent attention. Further hypothesis testing and trials of different models of care delivery for this vulnerable group are warranted.

A profile of older emergency department attendees: findings from an Irish study

AIMS

  This paper is a report of a study of older emergency department attendees' demographic, health and social profiles.

BACKGROUND

  Relative to the general population, older people are higher users of hospital emergency departments. Attendance is most often associated with medical need, including a chronic condition and related morbidities.

METHOD

  A series of standardized health and social profiling questionnaires was administered to a non-probability sample of 307 older emergency department attendees. The sample was recruited during the spring-summer and autumn-winter periods in 2008 and 2009 at two hospitals in the city of Dublin. Subjects who met the inclusion criteria were recruited as they presented to the emergency department during the hours 8 am to midnight. The sample was stratified into those admitted and those discharged, with the aim of equally representing each stratum. Data were collected at the time of the index visit or shortly following hospital admission.

FINDINGS

  Medical conditions accounted for almost half of all reasons for attendance and the health profile of the sample was characteristic of a population of chronically ill older people. Relative to the national picture for older people's social networks in Ireland, a proportion of the sample was at risk of social isolation.

CONCLUSIONS

  In the absence of other avenues to treatment and based on health profile and diagnostic category, older people's attendance at the emergency department was appropriate. The hospital emergency department remains a major arm of the Irish health service in dealing with the morbidity associated with enduring illness.

Factors associated with inappropriate utilisation of emergency department services

This study was carried out to determine the associated factors and the reasons for inappropriate utilisation of Emergency Department (ED) services at Universiti Sains Malaysia Hospital. A case-control study was conducted with 170 cases from ED and 170 controls from the Outpatient Department (OPD). A self-administered questionnaire was designed and used to obtain sociodemographic data, knowledge on the functions of ED and OPD, health seeking attitude and behaviour, and reasons for seeking treatment at ED. The study found that gender, marital status, family size, shift work, perceived illness, and knowledge on the role and functions of ED and OPD were significant associated factors. The three most common reasons for inappropriate utilisation of ED were as follows: "due to severity of illness" (85%), "can't go to OPD during office hours" (42%), and "ED near my house" (27%).

Perceptions of service quality and sacrifice in patients with minor medical conditions using emergency care

This study investigated the role of perceptions of service quality and sacrifice in patients attending the accident and emergency (A&E) departments with minor medical conditions that can be treated by their general practitioner (GP). Perceptions of service quality were measured using modified service quality performance indicators. Perceptions of monetary and non-monetary sacrifice were also captured. Questionnaire-based data were gathered prospectively through a random sample of adult patients who exhibited minor medical conditions at a UK teaching hospital A&E department. Service quality perceptions played a major part in the decision to attend A&E, whereas sacrifice perceptions did not. Perceptions of competence and credibility were the most important quality determinants and were rated higher for A&E than GP. Given that there were some misconceptions about the quality and nature of services each setting provides, recent reforms bringing about an ever-expanding range of healthcare service options may cause further confusion in patient decision-making.

The handover process and triage of ambulance-borne patients: the experiences of emergency nurses

One of the most important tasks that a nurse faces in the emergency room, when receiving a patient, is handover and the triage function. The aim of the study was to explore the experiences of nurses receiving patients who were brought into hospital as emergencies by ambulance crews through an analysis of the handover and triage process. A qualitative descriptive interview study inspired by the phenomenological method was used with six emergency nurses. There are three elements to a handover: a verbal report, handing over documented accounts and the final symbolic handover when a patient is transferred from the ambulance stretcher onto the hospital stretcher. The study identified that the verbal communication between ambulance and emergency nurses was often very structured. The ideal handovers often involved patients with very distinct medical problems. The difficult handover or the 'non-ideal' one was characterized by a significantly more complicated care situation. The handover function was pivotal in ensuring that the patient received the correct care and that care was provided at the appropriate level. The most seriously afflicted patients arrived by ambulance; therefore, the interplay between pre-hospital and hospital personnel was vital in conveying this important information. To some extent, this functioned well, but this research has identified areas where this care can be improved.

A review of health professional attitudes and patient perceptions on 'inappropriate' accident and emergency attendances. The implications for current minor injury service provision in England and Wales

Increasing attendances in accident and emergency (A and E) departments in the United Kingdom have been attributed to a greater number of patients presenting with minor injuries. A and E staff believe this type of patient is suitable for primary care, and is 'inappropriate' for A and E management. Thus, A and E staff find 'inappropriate' attenders time-consuming and unrewarding, and are less motivated to help them, whilst 'inappropriate' patients believe they have attended the appropriate service for their medical needs and expectations. This review examines research into health professional and patient attitudes towards 'inappropriate' attendances in accident and emergency. It identifies a discrepancy between health professional and patient perspectives regarding 'inappropriate' attendances. However, the change in accident and emergency services with the development of minor injury units and nurse practitioners within A and E to treat minor injury patients away from the mainstream A and E service, appears to be based on the professional attitude of what constitutes an appropriate A and E attendance, and not on the patients' perspective. As negative attitude formation towards 'inappropriate' A and E attendances has occurred, there is concern that such attitudes could remain or develop again in the new units. Patients are generally not medically trained and may experience difficulty in ascertaining the severity of their own condition and attending the 'appropriate' service, as defined by trained professionals. This is exacerbated by the unclear boundaries and roles of minor injury units, nurse practitioners and general practitioners in minor injury care. Therefore research is required into current attendances in minor injury units, A and E departments and general practice, in order to develop clear roles and boundaries for these services. More importantly, research is warranted into the attitudes of all minor injury care providers towards attending patients, and into patient perceptions of the services offered.

First stop A & E: a New Zealand perspective

This article will review the literature studies on the various aspects of inappropriate attenders at Accident and Emergency (A & E) departments. Included in the review is a discussion questioning whether A & E attendance is indeed inappropriate from the perspective of both the patient and the health care professionals. Primary health care providers in the community are discussed, concluding with recommendations to improve the health care needs of the patients and the community.

Inappropriate attendance in accident and emergency

Patients who attend Accident and Emergency (A & E) departments with problems that could be dealt with by their general practitioners (GPs) use time and resources of the department that could be otherwise used for patients with more appropriate needs. Definitions used for inappropriate attendance are drawn from the literature, and the usefulness of the term is discussed in the light of evidence that these patients have logical reasons for attending. Methods of improving the service offered to these patients are discussed, including emergency nurse practitioners, minor injuries units and GPs in the A & E department. The reluctance of GPs to treat minor injuries in their surgeries is noted. The implications of changing the service provided in A & E to accommodate or deter patients with primary care problems are discussed.