This study produced three main themes which represented the older adults experience of the ED during the COVID-19 pandemic (1) Complexity of decision making regarding the ED attendance (2) Quality and timeliness of care in the ED and (3) Communication with and empathy towards healthcare staff in the ED.
This qualitative descriptive study explored older adults’ experience of the ED during COVID-19. Our findings show that the complexity of decision-making regarding ED attendance was heightened due to COVID-19 transmission concerns. Our research indicates that some of the participants were referred to the ED following a virtual consultation by their GP’s. Virtual assessments were done as a response to the COVID-19 pandemic and involved GP’s conducting telephone or video consultations to review and triage patients remotely [20]. This new method of assessment had positive and negative views from both patient’s and GP’s. Patients acknowledged the importance of virtual health assessments for non-urgent matters and managing chronic illnesses, especially when regular follow ups were necessary, and their GP was familiar with their condition [21]. However, when it came to acute issues, some patients found virtual health assessments challenging. They had to describe their symptoms over the phone to their GP and felt uncertain about receiving an accurate assessment without a physical examination [21]. In a Canadian study older adults expressed worry about not seeing clinicians face to face and had reservations about the quality of virtual healthcare for their complex conditions [22] Similar views of concern were noted by some GP’s in particular for older adults, it was observed that they felt that the inability to perform physical examinations during virtual consultations was a disadvantage for some older people as they may have had sensory difficulties such as hearing difficulties and also some did not know how to use digital technology, therefore older adults were at risk of misdiagnosis, incorrect treatment or inappropriate referrals during the COVID-19 pandemic [23]. In our findings, some participants reported that if they had received a physical assessment from their GP, they may have been able to avoid going to the ED. A study carried out in Italy, which examined non-urgent admissions to the ED, revealed an increase in the access of non-urgent patients during the pandemic [24]. The researchers noted that this rise could be attributed to a decrease in visits to GP’s, leading patients to choose to visit the ED instead of opting for a virtual consultation [24]. Furthermore a study conducted in Spain, which investigated the effects of COVID-19 on the inappropriate use of the ED, they identified that the inappropriate use of the ED was a result of delays in patient care in the primary care settings and a growing lack of trust in the primary care [25]. Interestingly, these factors were like those seen in the period before the pandemic. Additionally, the study highlighted that younger patients and those classified as less severe were the primary users of the ED for inappropriate use [25]. In our research, the choice to visit the ED involved a complex decision-making process. Most of our participants were deemed appropriate referrals considering the complexity of their health conditions. Interestingly, older adults were not categorized as inappropriate users of the ED in these studies [24, 25]. The Virtual assessments were noted to be very beneficial going forward monitoring patients with chronic conditions such as diabetes, therefore following on from the COVID-19 pandemic virtual health assessments may be the norm in managing certain chronic conditions but not for acute illnesses [26].
The participants in this study expressed hesitancy and anxiety about going to the ED during the COVID-19 pandemic, this may have been due to isolating, cocooning and fear of contracting the virus. However, in our study participants were shown to place trust in advice from their GP in terms of the need to attend the ED as they felt that this was necessary for their well-being. This initial reluctance and fear surrounding COVID-19 contributed to a decrease in older adults seeking unscheduled care at the ED during the pandemic as evidenced in a study in Ireland looking at trends of ED use by older adults during the first lockdown [14]. In a qualitative study, it was found that the majority of patients visiting the ED had concerns about contracting the virus [27]. However this study also reported that where patients were informed about the safety measures being implemented at the hospital to mitigate the risk of COVID-19, anxieties about going to the ED were alleviated [27]. This was also shown in our study, where participants who initially had some concerns about visiting the ED felt reassured once they were able to learn about the cleaning precautions, mask wearing and screening protocols being employed in the ED.
This study found that most older adults had a positive experience during their time in the ED, reporting feeling reassured and safe due to the implementation of COVID-19 measures. Most participants were not intimidated by COVID-19 PPE and adapted well to mask wearing seeing it as a necessity to beat the virus. This ease of adaptation to the COVID-19 measures could have been drawn from lived experiences. A Canadian study that explored the experiences of older adults during the COVID-19 pandemic found that these individuals drew upon their past experiences of hardship, trauma, plague and times of economic recession to navigate and cope with the challenges brought about by the pandemic [22]. They found perspective enabled them to accept the current circumstances of COVID-19 and acquire new skills, foster personal growth, engage in self-reflection, and exhibit creativity [22]. Furthermore, in a qualitative study examining the resilience in older adults who have chronic health issues, it revealed that their early life experiences and witnessing the difficulties faced by their parents played a significant role. It provided older adults with a valuable perspective, as they observed their parents working hard during challenging times, such as using a horse for transporting milk on the farm [28]. This perspective proved beneficial in developing strategies to cope with future challenges faced in life such as COVID-19.
Findings from this study also identified a high satisfaction rating with the shorter triage time, noting that waiting times were longer before the pandemic. This high satisfaction in the older adults experience could be due to the positive effect that COVID-19 had on a reduction in footfall into the ED and also the COVID-19 measures meant patients needed to be separated therefore avoiding overcrowding [29]. The initial triage was quick in this study, however the delays seemed to be predominantly around diagnostics and review by the medical team which some participants were not pleased with. It has been observed [8] that older adults tend to tolerate and expect long waiting times in the ED, however if they are not provided with regular updates about their status, it can negatively affect their satisfaction in care as patients. The positive experience noted from our study, aligns with previous studies that have shown older patients are more likely to report a positive experience in the ED and overall hospital experience compared to younger patients [3, 30]. The positive experience of older adults in the ED may be attributed to their tendency to downplay their own needs and avoid burdening others by seeking help or expressing complaints [4, 31].
The participants were also noted to be reluctant in expressing any dissatisfaction or complaints regarding the care they received. This corresponds to a qualitative study conducted in New Zealand where older adults’ were hesitant to provide feedback that could be perceived as a complaint [32]. According to a report by the Health Service Ombudsman in the UK [33], it was found that although older adults make up a large proportion of NHS users, only 25% of all healthcare complaints received were from older adults over the age of 65. In focus groups conducted, half of the participants expressed that they refrained from complaining due to concern about the potential impact it may have on their future treatment [33]. Our study also found that there was a vast amount of empathy shown towards the healthcare workers from participants, acknowledging the busy work environment, this supports findings from previous studies where older adults were empathetic to the busy and challenging conditions faced day to day in the ED [3]. This empathy was further intensified during the COVID-19 pandemic, as seen by some participants who were hesitant to express any dissatisfaction considering the stressful months the staff had to endure. According to a study in Switzerland [34] on older adults who were hospitalised during the pandemic they expressed their admiration for healthcare staff. They acknowledged the challenges faced daily during the COVID-19 pandemic and recognised the strength it takes for them to show up for work every day, putting their own lives at risk. While older adults in this study and previous studies have been noted to show positive feedback towards healthcare staff and a reluctance to complain, it has been highlighted, that some older adults provide limited information about their journey in the ED department and their involvement in the decision-making process. This could be attributed to their acute illness, which may result in impaired recollection of events or limited awareness of their surroundings and circumstances due to their presenting complaint [32]. It would be interesting to note what families’ experiences of the ED would have been if they were allowed to be present with the older adult in the ED during the COVID-19 pandemic.
Some older adults in our study felt that having a discharge pathway or communication with someone post discharge was beneficial. While others reported that they were not aware of their discharge plan and relied heavily on their GP for this information. An evidence synthesis examining the experience of older adults transitioning to the community from the ED highlighted the prevalence of fragmented care from the ED to the community. Specifically there were issues with both informational continuity and management continuity in the transition process [9]. To enhance outcomes for the older adult, it has been recommended that ED’s offer supplementary care transition support to older adults upon discharge from the ED [35]. Some of our participants received support for transition care when they were connected to a specialised service like a cancer service or fracture clinic. After being discharged, they were referred to these services by the ED team and received follow-up care, for example a phone call. Participants appreciated this because it gave them reassurance upon discharge. A similar finding was observed in another qualitative study where older adults with a cancer diagnosis who attended the ED felt that the discharge process was less stressful because they had already scheduled follow-up care or had access to nurse specialist [36]. However, for some of the older adults, this was not the case and some presumed their GP was aware of what was to happen next. Several participants noted that the GP was to be informed about investigation results or future tests. This left uncertainty in what to do next for these older adults. This was echoed in a qualitative study which older adults where participants voiced, they were not sure if the GP would be following up or if a specialist was to [36].
The older adult’s experience of the ED revealed a fragmentation of discharge care from the ED as there was a lack of discharge communication such as what they were to do next, and who to contact or if they required follow up tests. Additionally, the way discharge information was provided was found to be ineffective. A systematic review found that verbal guidance alone may not be enough for patients, and incorporating written or video information into discharge instructions yielded positive outcomes [37]. Furthermore, a recent study has found that the safe transition of care for older adults is greatly influenced by their comprehension of discharge instructions [35]. Healthcare professionals should not assume that all individuals attending the ED have literacy skills, and it has been highlighted by a national report by NALA that health literacy poeses a challenge with the public and written instructions should be in plain English and simple easy to use terms [38]. An evidence synthesis emphasises the importance of providing older adults with written discharge instructions that address their specific needs [9]. These needs include challenges such as not having the opportunity to ask follow-up questions or seek clarification, not understanding medical terminology, receiving conflicting instructions or advice from healthcare professionals, and not having their sensory deficits accommodated for.
Strengths and Limitations:
One strength with this study was that it was carried out across five hospitals in Ireland and has viewpoints from participants in both urban and rural hospitals. In response to the COVID-19 pandemic, the research team adhered to COVID-19 guidelines and conducted interviews over the phone. However, this method of conducting interviews may have implications for the findings as the research team was unable to establish a rapport with patients, which could have provided further insight into the experiences of the older adult if the interviews were conducted in person. Furthermore, the views of family members’ experience of their loved one attending the ED and the fact that they were not able to be present with the participant were not represented here and may have added a further dimension to the findings. Another limitation in this study was the demographics of the participants, as all participants were exclusively white Irish. Consequently, the experience of older adults from other ethnic minority groups were not represented in this study.
Clinical and Policy Implications
These data were collected in 2021 and since then there has been an introduction to a new Integrated Care Programme for Older Person’s (ICPOP) throughout Ireland [39]. This programme aims to benefit older adults by providing a person- centered approach to their care. It will also develop and implement multidisciplinary pathways for older adults with complex and social needs from the ED which will aid transitioning of care ensuring the needs for the older adults are met and effective follow-up from the ED is implemented [39].
Given the circumstances of COVID-19 in the ED it appeared to create a positive experience for the older adult as the environment was not overcrowded and the triage times were quicker. Therefore, it may be necessary for policy makers to look at the COVID-19 protocols in place and see how they can be continued long after the COVID-19 pandemic is over. It may also be worth noting that for future health pandemics, educating and advising the public on the importance of attending the ED if they are unwell and creating awareness of the infection control precautions that are in place in the hospital may relieve public anxiety about attending the ED.
Areas for future research.
This study emphasised the positive experiences of older adults in the ED amid the COVID-19 pandemic. Subsequent studies could focus on the experiences of carers or family members of older adults who attended the ED during this period. The study also pointed out that follow-up care and discharge information were disjointed upon discharge from the ED. Therefore, future research could explore effective discharge methods, care integration, and the sharing of information about older adults from the ED to the community.