Enhancing Care of Older Adults in the Emergency Department

Abstract

The findings from a recent comprehensive systematic review, in combination with a case study, are used to illustrate the importance of translational research to inform advanced practice nursing. The review article discussed in this column is a comprehensive systematic review of age-friendly nursing interventions in the management of older persons in the emergency department (ED). Two themes were synthesized from the research and texts: (1) the ED can be a foreign and challenging environment for older patients, and (2) older ED patients need specialized care to meet their complex physical and psychosocial needs. At the same time, these authors acknowledged that much more high-quality research is needed in this field. Comments by a certified geriatric nurse practitioner elaborate on these findings and provide practical suggestions for the ED advanced practice registered nurse.

THE PURPOSE OF this column is to assist advanced practice nurses (APNs) with the translation of research to practice. For each column, a topic and a paper of interest are selected. The stage is set by using a case-based scenario. A research paper or evidence review is then reviewed and critiqued, and finally, the implications for translation into practice are discussed. In this column, the following paper is reviewed: Pearce, S., Rogers-Clark, C., & Doolan, J. M. (2011). A comprehensive systematic review of age-friendly nursing interventions in the management of older people in the emergency department. The JBI Library of Systematic Reviews, 9(20), 679-726, downloaded March 8, 2012, from http://connect.jbiconnectplus.org/ViewSourceFile.aspx?0=5100. Commentary on the care of older adults in the emergency department (ED) has been provided by a board-certified geriatric nurse practitioner (C.C.).

THE CASE

It is 3:30 p.m. on a Sunday afternoon in the ED, two staff nurses have called out sick with no replacements, the hospital is full, and the average wait time for admission is 7 hrs. Three ambulances have just arrived: one with a patient in cardiac arrest; the second with a patient having altered mental status, possible spinal injury, and tibia/fibula fracture who was involved in a high-speed roll-over motor vehicle crash. "Mr. George," a 92-year-old man who was transferred from his assisted living center with a diagnosis of near-syncope and possible congestive heart failure. Patients 1 and 2 are immediately prioritized for care and placed in treatment areas. The two physicians on duty begin their evaluations assisted by all of the other nurses in the immediate treatment area. You have just finished evaluating an 87-year-old patient with an obvious wrist fracture and take report from the paramedics as they move Mr. George onto a gurney in his designated hall spot away from the critical patient rooms. The paramedics report that the patient was transferred from the nearby assisted living facility where, as they understand it, he was living independently and in his usual state of health until last evening when security personnel were called by the patient's son to conduct a welfare check after the patient failed to answer his phone for 2 days. Security personnel found the patient asleep in his chair but easily awakened. The patient sent the security personnel away, telling them he was fine and agreeing to call his son. To appease his son, Mr. George agreed to be seen at the on-site medical clinic the next morning. The physician at the clinic determined that the patient seemed lethargic and was having difficulty breathing, and an electrocardiogram (ECG) also showed nonspecific T-wave changes. After conferring with Mr. George and his son, the patient agreed to be taken to the ED to be "checked out."

You find the patient lying supine on a gurney at the end of the hall. He appears to be sleeping but arouses to a calm voice, answers questions appropriately, and is alert and oriented x 4, although he is not entirely sure why he was transferred to the ED. (He states, "Because my son told me I needed to be here.") When asked whether anything is bothering him or whether he is in any pain, he tells you, "No, not really." When you ask whether he needs anything, he replies, "No, I'm alright." The patient's vital signs are as follows: temperature, 36.2 [degrees]C (97.2 [degrees]F); heart rate, 82; respiratory rate, 20; blood pressure, 127/87 mmHg; and oxygen saturation, 92% on 2 L/min of oxygen via a nasal cannula. His general survey reveals an elderly man in soiled clothing who does not appear toxic. He is in no acute distress, but his breath sounds are audible without a stethoscope. He also appears very lethargic and moves very little during your examination. Examination of the head, eyes, ears, nose, and throat is unremarkable except for poor dentition. The physical examination reveals severe kyphosis. Heart has a regular rate and rhythm without murmurs, rubs, or gallops; peripheral pulses are 2+ and equal, and capillary refill is brisk. Respiratory excursions are symmetrical, and there are diffuse rhonchi throughout both lower lobes. The abdomen is round, with normal bowel sounds and without tenderness or organomegaly. Lower extremities have 3+ brawny edema, with some skin breakdown over the dorsal and posterior ankles. Neurological examination is grossly intact with no focal findings. Reflexes are 3+ and equal bilaterally. Muscle strength is strong and symmetrical in the upper extremities (5/5) and strong, but slightly asymmetrical, in lower extremities (4/5).

The only history available is in the clinic notes that came with the patient on transfer, indicating essential hypertension, hyperlipidemia, and a history of cervical fracture and fusion. Your differential diagnoses include stroke, transient ischemic attack, delirium secondary to urinary tract infection or pneumonia, congestive heart failure with exacerbation, and venous stasis and cellulitis of lower extremities.

The article being reviewed is an unpublished paper downloaded from the Joanna Briggs Institute (JBI) library of systematic reviews (JBI, 2012a). The JBI, an institute within the University of Adelaide in Australia, is a collaborative group of experts from more than 40 countries who complete rigorous systematic reviews to support expeditious translation of quality evidence into improved practice and outcomes. This particular comprehensive systematic review covered published and unpublished studies, texts, and opinion pieces to identify and evaluate evidence about age-friendly nursing interventions for older patients in the ED. The review focused on interventions designed to reduce risks of pressure ulcer formation; ensure adequate hydration and nutrition; maximize comfort level; and achieve optimal pain management. Review of texts and opinion pieces focused on policies and recommendations for age-friendly interventions.

Following the strictly prescribed methods of the JBI (2012b), the authors searched nine databases, reference lists from articles chosen for the review, unpublished theses and dissertations, discussion papers, and policy documents, using numerous search terms that included references to older persons, nursing care, and the ED. Articles published in English between 1990 and 2010 were eligible for inclusion. As required by the JBI, two reviewers independently evaluated articles throughout the review process, beginning with article selection through the article critique, synthesis of the findings, and grading of evidence.

Articles were reviewed using the JBI suite of electronically supported review instruments called SUMARI (JBI, 2012c) covering the domains of feasibility, appropriateness, meaningfulness, and effectiveness. Data from quantitative studies were pooled, but no meta-analysis was conducted because of differences in the way data were collected and analyzed. Textual evidence, such as expert opinion and policy recommendations, was synthesized using JBI standard methods and aggregated into categories that summarized the texts into "a coherent whole" (Pearce, Rogers-Clark, & Doolan, p. 686).

Results, Discussion, and Conclusion

The initial search yielded 850 potentially relevant articles and papers. After reviewing titles, abstracts, and full articles for relevance and methodological quality, 16 of these 850 titles were included in the review, including two quantitative studies and 14 textual pieces, expert opinions, and policy papers.

The two quantitative studies were reviewed in detail. The first, a pilot study with hospitalized older adults, found that applying warm blankets resulted in improved comfort levels. The second was a more robust study showing that using reclining chairs in the ED rather than gurneys reduced pain in older ED patients. The meta-synthesis of the textual data identified two major findings: (1) the ED can be a foreign and challenging environment for older people, and (2) older patients in the ED need specialized care to meet their complex physical and psychosocial needs. These two findings were supported by multiple examples from the 14 papers included in the textual analysis.

The authors placed their findings in the context of the aging of the general population, with expected increases in both the numbers and percentages of older patients who will be presenting to EDs in the coming decades. They also emphasize that these older patients often have longer ED lengths of stay (LOS) due to their complex health needs and that these increases in LOS result in functional declines for the older adults. Given these two realities, the authors emphasized the need to identify evidence that supports nursing interventions addressing the needs of this especially vulnerable population. Although the authors present textual evidence covering a range of interventions to address skin integrity, nutrition, hydration, comfort, and pain management, they acknowledge finding precious little in the way of research evidence to support the recommendations. They conclude their review by clearly stating the need for more and better research to develop the evidence base for effective nursing care of older patients in the ED.

SUSAN'S COMMENTS

Two brief comments before considering Dr. Clevenger's important points. First, this evidence review was obtained from a recognized database of evidence reviews. Emergency department APNs should consult these databases, particularly the JBI, the Emergency Nurses Association's (ENA) Emergency Nursing Resources (ENRs; http://www.ena.org/IENR/ENR/Pages/Default.aspx), the Cochr-ane Library (http://www.thecochranelibrary.com/view/0/index.html), and the National Guidelines Clearinghouse (http://www.guideline.gov/) in addition to published articles when seeking information about the strength of the evidence supporting clinical practice. Second, like reviews in the Cochrane Library, the National Guidelines Clearinghouse, and the ENA ENRs, evidence reviews in the JBI library are conducted according to rigorous methodological standards. The advantages of JBI reviews for nurses include the fact that JBI uses an evidence grading scale and levels of recommendation for practice that consider more than just evidence of clinical effectiveness, that is, research evidence (Shapiro, 2010). These scales also consider the feasibility of implementing the intervention/practice change; the meaningfulness of the change to patients and health systems; the applicability in different settings or with different patient populations; and the economic impact of the intervention/practice. Finally, the JBI review process includes a rigorous framework for evaluating and synthesizing the evidence from qualitative research and other text-based evidence as well as more traditionally included quantitative/research evidence (JBI, 2011).

CAROLYN'S COMMENTS

Pearls About Older ED Patients

The patient in this case presentation, Mr. George, is typical of many older patients presenting to the ED. His complaints are vague, as is the history of events that led to the decision to transfer him to the ED. He does not appear acutely ill, and he is placed on a hallway stretcher amidst the noise and chaos of an obviously busy and short-staffed ED. Given the circumstances of his arrival, the prognosis for him emerging from this illness episode with no deterioration in his baseline physical and cognitive function is poor.

Geriatrics is a subspecialty of primary care focused on the specialized needs of older adults. The hallmarks of geriatric care are atypical presentations of common illnesses, and complex patients with high comorbidity burden whose physical and psychosocial issues are often comingled and lead to precipitous decline and disability. Examples of atypical presentations include presence of infection presenting as recurrent falls rather than with fever and elevated white blood cell count; major depressive disorder presenting with lack of appetite and sleep pattern changes rather than sad mood; and myocardial infarction presenting as altered mental status rather than chest pain. In addition to atypical presentations of significant illnesses and multiple comorbidities, older adults generally have high emotional stability, resulting in a tendency to minimize symptom severity; if you are used to living with the pain and limitations of chronic arthritis, new pains and limitations may fail to elicit alarm or be interpreted as a need for care. These challenges may be compounded yet again by the presence of mild cognitive impairment or early-stage dementia (an often unrecognized problem in community-dwelling older adults), in which affected persons minimize acute symptoms or simply do not recall the details of onset, course, and self-treatments. This combination of factors may result in an older ED patient who does not appear acutely ill, but who, in reality, may be in a life-threatening situation.

The aforementioned challenges are compounded by increased risks of adverse drug events (ADEs) in older adults. We know that ADEs account for a significant number of hospitalizations for older persons, and this is a particular issue for older patients (Budnitz, Lovegrove, Shehab, & Richards, 2011). There is a tendency to consider ADEs in conjunction with the addition of new medications, but with older patients, declining renal and hepatic functioning-a normal part of aging-increases the potential for gradual toxicity from "usual medication." In addition, unrecognized cognitive changes may result in inadvertent overdoses from dangerous medications such as anticoagulants or oral hypoglycemic agents.

The Diagnostic Workup of Older ED Patients

Atypical presentations necessitate atypical diagnostic workups. When working with older patients, the ED APN should focus on two critical areas: obtaining an accurate history of the complaint and establishing the patient's "usual" level of physical and cognitive function, both of which may present time-consuming challenges, especially if no close family member or friend is available. Alternative sources of history include caregivers-whether paid or unpaid-and/or pharmacies. Given the influence of medications on utilization of the ED by older persons, medication reconciliation is critical, and the best source for accurate information in this regard may be the individual's pharmacy. My personal experience is that ED clinicians are loath to call residential care facilities and pharmacies, mostly because of the time it takes to locate someone who can actually help, despite the fact that needed information about the patient or the presenting complaint is lacking. This results in an inconclusive, and at times unnecessarily expensive, diagnostic workup. In reality, this just delays the inevitable because those contacts will need to be made, even if it is just to communicate the patient disposition. Those ED APNs who work in areas that use a standardized transfer checklist for all affiliated residential care facilities are indeed fortunate. Standard forms such as those from the INTERACT collaboration (Ouslander et al., 2011; available at: http://www.interact2.net) have been created with input from all types of facilities that regularly transfer older adults to EDs, including nursing homes, assisted living facilities, continuing care retirement communities, and personal care homes. As a result, they contain information vital to both the sending and receiving facilities. In a similar way, it is critically important for the ED to communicate vital information back to the sending facility should the patient not be admitted. These forms, however, are no substitute for verbal handoff communications during care transitions, at which time the receiver can ask any necessary clarifying questions.

The APN working up an older ED patient should focus on the patient's functional status as well as obtaining accurate information about the patient's usual-or baseline-level of function. Any functional impairment may be ascertained by the addition of three key questions to the diagnostic process: (1) Who accompanied the patient to the ED? (2) Where had the patient been residing? and (3) How did they arrive at the ED? (Birrer, Singh, & Kumar, 1999) Finally, remember that the vulnerable elder may present with a wide range of physical and psychological symptoms due to factors arising from elder abuse, whether that abuse is physical, financial, or neglectful in nature.

The APN's Role in Nursing Care of Elder ED Patients

The review of Pearce et al. (2011) focuses on enhancing basic nursing care for older ED patients rather than on diagnosing and treating their presenting complaint, and there are important reasons why ED APNs need to attend to these recommendations. For example, older adults are at high risk for pressure ulcers originating from backboards or other restrictive immobilization devices, not to mention the common ED gurney, which was never designed for prolonged stays. Emergency departments often serve as the entry point for acute care hospitalization, so pressure ulcers that initiate in the ED will be considered as hospital acquired. Delirium is another geriatric syndrome that may begin during a prolonged ED stay. Delirium, common among older persons with preexisting dementia, may easily develop secondary to dehydration, uncontrolled pain, and/or the acute illness itself. Delirium has a particularly ominous quality: its resolution is not guaranteed as was once thought, and its presence is associated with higher death rates, prolonged hospitalization, increased health care costs, and accelerated long-term functional and cognitive impairment (Han et al, 2009). Emphasizing enhanced nursing care focused on nutrition (meal trays), mobility (patient turning and ambulation with assistance to the bathroom), hydration (fluids by mouth in specific quantities if not actively contraindicated), and pain control/comfort as part of the ED order set is one of the most important things the ED APN can do for older patients.