Aim and objectives

This paper was part of an overall study exploring the discharge of older adults out of hours from the ED. This paper focused on the experiences of senior Health Care Professionals’ when discharging older people during OOH versus office hours from the ED.

Objectives:

• To determine the experiences of HCPs when discharging older people from the ED
• To examine the differing practices, if any, between OOH and office hours discharge of older adults from the ED
• To identify recommendations for future practice when discharging older people OOH from the ED

Study design

In this study a qualitative methodology was used consisting of semi-structured interviews. The questions for the interviews were constructed by the researchers following a review of relevant literature, taking cognisance of the Integrated Care Framework [19], the biopsychosocial aspects of health, and the Integrated Care Programmes for Older People (ICPOP). ICPOP was introduced in Ireland with an aim to improve quality of life for older people and to shift from acute hospital, episodic care to community based longitudinal, coordinated, and integrated care [20]. This links in with the aim, objectives and theoretical framework of this study. The interview schedule (S1 Appendix) was developed by the authors and reviewed by an ED expert group. A pilot study with one participant was also undertaken to ensure further rigour of the semi-structured questions. For this study, an older person was defined as 75 years and over, based on an integrative review of the literature [17], and following discussions with this same ED expert group as it was deemed that this cohort would be more likely to attend the ED. Whilst all of the researchers were academics, two members of the team had worked for many years in EDs and provided great insight into difficulties inherent for older people within the ED.

Population and recruitment

This study was undertaken in Ireland. Inclusion criteria for participants stipulated that they were required to be senior healthcare professionals working at a senior grade in the ED, either as a nurse manager, medical doctor or health care professional such as a senior physiotherapist. These participants would have the experience of working with older people in the ED and could provide rich data in the interviews. Fourteen participants in total responded which included clinical nurse managers, consultants in emergency medicine, advanced nurse practitioners, clinical nurse specialists in frailty, clinical education facilitators and physiotherapists, all of whom were directly involved in patient care and older person discharge decisions. Participants included a broad range of healthcare professionals and originated from a diversity of urban and rural geographical areas and models of hospitals which added to the rigour of the study and the generalisability of the findings. All participants completed the study.

Ethical approval

Ethical approval was obtained from Ulster University Research Ethics Filter committee (Project Number: FCNUR-22–017) as well as from the individual hospital Research Ethics Committees (RECs). No national ethics committee currently exists in Ireland; therefore, approval had to be sought from individual hospital RECs. In many of the sites, the Consultant in Emergency Medicine acted as gatekeeper for the research participants as stipulated by the hospital REC. Following confirmation of ethical approval, assistance to identify and invite participants to take part in the study was provided by members of The National Clinical Programme for Emergency Medicine and The Irish Association for Emergency Medicine. All participants were provided with a participation information sheet providing the purpose, risks, benefits of the study, the right to withdraw, and the assurance of anonymity. This was explained by one of the research team to each of the respondents and a consent form was subsequently signed by participants prior to commencement. Consent was also obtained for the possible dissemination of the study findings. Due to the small number of urban and rural EDs in Ireland, it was vital not to breach General Data Protection Regulations (GDPR) by identifying any of the hospitals and/or the participants who contributed to the study. Therefore, careful selection and reporting of the narrative exemplars was undertaken to take cognisance of and avoid the risk of this possibility.

Data collection

The recruitment period for this study was between February 17^th and November 24^th, 2023. One-to-one interviews were conducted. Written informed consent was obtained by the researcher, and consent was reconfirmed at commencement of the interviews with all the participants. The advantages and disadvantages of video conferencing, identifying cost reductions, increased accessibility, and convenience have been highlighted but a need exists to ensure data security and consider its suitability for target groups [21]. All interviews took place via video conferencing and at a time to suit the participants following individual consent to use this option. Due to the busyness of the ED environment, time constraints for participants and the distance between each site for the researcher, this method was deemed to be the most appropriate. Interviews lasted 50–60 minutes in duration and were recorded using a digital recorder and via the computer to reduce the risk of loss of the interview data. Data saturation was reached following the final interview as only consistent recurring data with no new information was evident. This was alongside the successful recruitment of an adequate sample size. Recruitment then ceased as it was felt that no further insights would be gained. The recordings were transcribed by one member of the research team and checked for accuracy prior to analysis (MD).

Data analysis

Data analysis was undertaken using a six-step framework for Thematic Analysis (TA) [22] which included familiarisation with the data set; coding; generating initial themes; developing and reviewing themes; refining, defining, and naming themes; and writing up. TA is a highly effective method to use when looking to analyse and understand a collection of experiences, thoughts, or behaviours [23], therefore taking cognisance of the aim of this study, this framework was selected as appropriate to use in this data analysis. These six steps involved a collaborative approach with the four members of the research team (MD, AR, DG, SMcI). Several meetings took place to interpret the data, identify categories, codes, provisional themes, edit and refine themes to ensure rigour, consensus, and a richer interpretation of the data and to minimise personal bias. These collaborative meetings with the experienced research team at all stages of the study are advocated to ensure reflexive practices in qualitative research [24; 25]. Participants were informed that the researcher was an academic who had extensive nursing experience in EDs and that the study was part of her PhD studies. The researcher’s background in ED clinical practice shaped all aspects of the research study with knowledge of the contextual elements of ED practice. The Standards for Reporting Qualitative Research (SRQR) [26] checklist was also completed to ensure rigour and a transparent reporting of the research process (see S2 Appendix).

Findings

Following data analysis, several themes and sub-themes were identified. One recurrent theme highlighted the issues of risks and safety for older people being discharged from the ED OOH. In addition to this over-arching theme, several sub-themes were also identified (see Table 1). Significant differences were reported by the respondents between office hours and OOH discharge of older adults from the ED.

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Table 1. Risks and safety theme and sub-themes.

https://doi.org/10.1371/journal.pone.0313968.t001

Should they stay or should they go?

Participants reported on the risks in OOH ED discharge for the older person. The safety decision to discharge an older adult OOH from the ED or to delay discharge until reviewed by specialist older people services during office hours was influenced by several factors, including the time of discharge and distance to home. However, if there was any concern that the older person required more support following discharge OOH, it was reported that s/he would have a delayed discharge or be “boarded for review” in ED until 8am when older person specialist staff are available. This was despite staff being aware of the pressures of not having people lying on trolleys.

“It’s two or four in the morning, but they are a very vulnerable high-risk patient …. and they’re going to go home to an empty house where there is no one. There’s not a light on… we would keep them until the morning.” (Clinical Nurse Manager No. 2)

Participants reported being conscious of the need to ensure safe discharge and refer older people to the specialist supports in the ED and the community OOH. They also reported the benefits of having these specialist older person teams as a great form of support. However, participants also identified difficulties with the limited availability of these specialists OOH whilst trying to run a 24-hour service in the department and the need to make a quick decision. During OOH, it was identified that admission avoidance became a difficulty due to a lack of resources for the older person both within the ED and in the community as these specialist staff are not on duty. OOH discharge was not deemed to be as safe as office hours. Often older adults would end up having to stay in ED or be admitted due to an identified risky discharge OOH, especially at weekends.

“There is a huge differential in you coming and being seen by a Frailty Intervention Team during office hours on Monday to Friday and you coming to the emergency department at any other time.” (Consultant in Emergency Medicine No.1)

Respondents also reported a level of risk based on the variances of when assessments were undertaken, and their suitability for assessing older people attending the ED. This included triage and frailty assessments following ED presentation. Variances existed in relation to if, and when, these assessments took place, and the scales used. Some participants reported that frailty assessments were not undertaken at the initial triage assessment and not at all during OOH due to demands on and availability of specialist older person team members, and the numbers of attendees to the ED. Others reported it was the first important step and always tried to get older people assessed as quickly as possible. Again, variances occurred between office hours and OOH practice.

“We do the clinical frailty scale…. The triage nurses are overwhelmed…. They can’t keep up with the tsunami of patients coming through, so that would be done post triage.” (Consultant in Emergency Medicine No. 1)

Several respondents reported strategies to reduce risk and ensure safety for older people when being discharged home OOH from the ED. These included arranging transport, providing a staff escort for support and to ensure safety, and using a discharge lounge which was only available during office hours. Practices varied between hospitals. Many hospitals witnessed changing variances in staff profiles and skill mix with staff turnover being significant in some areas. This change in personnel following the employment of many international nurses to Ireland was reported to be a difficulty for the older adult in the ED, with cultural and language differences evident. This was identified as a specific issue OOH when no specialist frailty team support was available to support these new international staff members who may be unfamiliar with the specific needs of older people on discharge from the ED. Thus, adding to a potential risk on OOH discharge. Other challenges identified included the increasing numbers of international older adults with growing health care needs living in inappropriate places such as hotels, and associated difficulties in accessing support on discharge from the ED.

“There are issues with new staff from outside of Ireland, and the biggest problem is communication particularly for the elderly patient. Language is a big thing, same with the doctor. They just have a different culture. They just presume that there is going to be somebody at home to look after that patient, because that’s what they would do.” (Clinical Education Facilitator No. 4)

Bright lights and noise

Many EDs in Ireland have a Frailty Intervention Team who would assess those over 75 years of age and are usually available from 8am to 5 pm during weekdays. If patients are being discharged out of hours but are not deemed safe to go home at this time, then they would often wait OOH in the ED to see the Frailty Intervention Team. Participants identified several risks for the older adults who were delayed in the ED OOH whilst awaiting discharge, often because of an overstimulated environment resulting in adverse consequences. These included significant biological and psychological effects such as sleep deprivation, anxiety, delirium, and medication and mobility issues. Older people also faced challenges within the ED environment, including being exposed to frightening incidents, and the risks of acquiring infections and pressure ulcers. A drop in the level of supervision and care from HCPs was also a concern once an older person was deemed fit for discharge but awaiting review by the specialist team.

“Older people staying in an ED can…. get sicker, pressure sores and anxiety.…. you have to weigh up the pros and cons and what is safest in the long run and having to keep them in to be seen by the team the next morning.” (Clinical Nurse Specialist in Frailty, No. 2)

Keeping an older person in ED OOH for follow-up by the older person services although medically discharged was reported to result in an increase in patient experience times and a reduction in patient flow within the ED. This was identified as a cause of stress for staff and an increase in workload, due to overcrowding within the ED but also due to a reflection of poor ED performance because of prolonged patient experience times for those over 75 years of age. In the Irish health system, patient experience times (PETs) are a metric used by health services, quantifying the length of time patients wait in ED before they are either discharged or admitted to hospital [27].

“Out of hours, where our colleagues notice an issue with a patient that would benefit from the multi-disciplinary team input, is when we would see that knock-on effect on time.” (Consultant in Emergency Medicine No.2)

It was reported that older people also faced challenges within the ED environment OOH, as often no specific older person area was available within the ED due to the volume of attendances, overcrowding and a lack of space. Respondents reported that this could lead to increased adverse outcomes for the older person because of difficulties in meeting fundamental needs, from having to stay overnight on a chair or trolley and often on a busy corridor.

“…. for a patient who has poly morbidities, their risks of having a negative outcome are much higher. There is also the risk of them not getting appropriate medications, and meals as well as not getting the toilet ….” (Consultant in Emergency Medicine No.2)

New ways of working

Participants interviewed recognised the difficulties in providing a 24-hour service in the ED, when their counterparts in other areas of the hospital and community services were not available. They were very forthcoming in providing recommendations for future practice to improve services for older people whilst being discharged from the ED OOH (Fig 1). This included various aspects of discharge and care within the department and extending services to have specialist older person HCPs working 24/7 to ensure safe older person discharge from the ED OOH.

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Fig 1. New ways of working- recommendations for practice.

https://doi.org/10.1371/journal.pone.0313968.g001

Many respondents identified the need to improve experiences OOH. This included ED staffing OOH, and the need for more older person specialist health care professionals 24/7 in the ED including physicians in older person emergency medicine and employment of a nurse to ensure any required follow-up is organised for older people following ED discharge. Respondents also highlighted the need for upskilling of all ED staff. With the increasing older person demographics, it was identified that a need existed to ensure that ED staff had the knowledge and skills to be able to provide a 24/7 service safely and effectively for this specialist cohort. This could be in the form of a national education programme.

“….. that the ED staff themselves need a greater skills set which could be provided by a 2-day course with online learning …. we wouldn’t contemplate having staff in the emergency department if they didn’t have ACLS or ATLS training and yet, there isn’t much of our work which is now cardiac arrest. There’s far more of our work that is older adult now.” (Consultant in Emergency Medicine No.1)

Participants in this study recommended a greater and earlier focus on frailty on a 24/7 basis, not just at triage in the ED, but also pre-attendance by ambulance personnel and at primary care centres. This was identified as being very important considering the growth in older people demographics internationally and the associated risk of an increased incidence of frailty [28,29,30]

“Ideally frailty should be scored in triage from the minute the person presents to the door. I think everybody should be thinking frailty.…… to start scoring them coming through the door from triage. And even before that, the ambulance staff, the GP surgery.” (Clinical Nurse Specialist in Frailty No. 1)

Recommendations from participants also included a need to focus on specific documentation which could identify and highlight the risk of frailty for the older person presenting to the ED. It was suggested that a national discharge checklist could help to ensure that there is uniformity in discharging the older person from the ED. A focus on written instructions and patient education for older people in the ED was also suggested to have a record of treatment provided and further care required. Improvements to the ED environment were also suggested. These included specific frailty units and separate treatment areas for older people as seen internationally. It was suggested that these could help reduce the risk of adverse reactions for older adults presenting to the ED by the avoidance of frightening experiences in a busy, highly stimulated ED.

“What I would say needs to happen is to have an older person’s unit, like a frailty unit part of the ED. In America some of the hospitals are just older people EDs because that’s the population they’re getting. Their whole focus in the 24 hours is older people. And that’s the way it’s going to be. It’s not going to go away.” (Clinical Nurse Specialist in Frailty, No. 1)

Strengths and weaknesses

This study had several strengths and weaknesses. Firstly, whilst considerable research has been undertaken on ED matters in recent years, a dearth still exists in relation to out of hours ED discharge experiences. This study is the first of its kind to explore this important topic and has addressed the gap in research which existed. It is likely that the practices, experiences, and concerns regarding out of hours discharge seen in this study also pertain to EDs globally although there is a need for further international research. Secondly, participants included HCPs from a variety of backgrounds and from a wide geographical spread which enhanced the rigour of the study. This study identified diverse practices in healthcare, taking cognisance of the availability of resources and follow-up care, the geographical landscape, demographics, and cultural aspects in caring for older family members. However, additional participants such as occupational therapists and social workers may have generated additional insightful experiences. Similarly, the authors are cognisant that as there may be differences in health care delivery nationally, this is also an international phenomenon which has been difficult to identify in the paucity of literature available. Not all health care systems are delivered in the same manner as what is happening in the ROI, which may have an impact on the generalisability of the study findings and recommendations. The researcher’s identity and positionality from years of experience of working in this field of emergency care added valuable insights into the workings within the ED. These were of benefit in all aspects of the research including: the development of the research question, the study design and questionnaires; in communication with ED staff during the interviews and data collection; being cognisant of an ED workload and time available to partake in an interview; and during data analysis in understanding the data and terminology used. However, care was taken to reduce any researcher bias throughout the stages of the study by having regular meetings and input from the full research team, along with the use of the SRQR [26] checklist.

The use of technology including video conferencing for conducting the interviews had also some identified strengths and weaknesses. Strengths of this format discussed earlier included an increased ease of selecting a time schedule to suit the participants in a busy ED environment, less time constraints for participants and the reduction in travel between each site for the researcher. Other benefits included the opportunity to include all EDs nationally whilst covering a wide geographical area without the need to travel, with less financial and time costs for the researcher. When selecting this format, the research team did recognise that there could be the risk of Information Technology connection difficulties in some sites as well as some staff being unfamiliar with the forum recommended. Use of this technology also loses the in-person advantage particularly if a participant were to become distressed during the interview.