During and beyond the triage encounter: Chronically ill elderly patients’ experiences throughout their emergency department attendances

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Abstract

Background

Chronically ill elderly patients are frequent users of care in emergency departments (EDs). Due to their presenting symptoms, these patients are often assessed on a low urgency level of priority by the triage nurse.

Aim

The aim of the study was to explore and describe the experiences of a group of chronically ill elderly patients’ during their triage encounter and subsequent ED stay.

Method

The data consisted of 14 open-ended interviews with chronically ill patients aged between 71 and 90 years. A lifeworld approach was used in order to describe the essence of patient experiences. The study was carried out with a descriptive phenomenological research perspective.

Conclusion

The visit to the ED was experienced as contradictory. The triage encounter fostered confidence and set promising expectations, but during the rest of the visit, the patient felt abandoned and considered the staff to be uncommitted and reluctant. These ambiguous experiences of their ED visits indicate a need for exploring possible ways of improving the situation for the chronically ill older person in ED.

Introduction

Emergency departments (EDs) in Western Sweden have implemented the Manchester Triage System (MTS) (Manchester Triage Group, 2006) as a common standard. Nurses have been trained in the technique in order to identify and prioritise incoming patients. Structured triage models such as the MTS are evidently effective in identifying critically ill patients requiring immediate care. The model is also expected to give the less critically ill a lower prioritisation in order to optimise the resources for those who need them most (Beveridge et al., 1998, Beveridge et al., 1999, Fernandes et al., 2005, Olofsson et al., 2009). Therefore, less critically ill patients form queues in EDs, waiting for their turn for diagnosis or treatment. One effect of this is overcrowded EDs and long waiting times (Rogers et al., 2004, Larsson-Kilgren et al., 2004, Larsson-Kilgren et al., 2005, Coughlan and Corry, 2007). A long wait can be especially difficult for elderly patients with non-emergency conditions (Richardson et al., 2007, Shanley et al., 2008, Olofsson et al., 2009). These circumstances raise the question of whether MTS and other ED routines are appropriate for the older and chronically ill person. The aim of this study is to describe and understand chronically ill elderly patients’ experiences during their ED stay.

Section snippets

Background

In Swedish EDs, nurses assess the incoming patient by means of observations, interviews and registration of physiological parameters. Prioritisation times in MTS are classified by colour. The model has five triage categories corresponding to time intervals specified in minutes. The estimated time is the longest recommended waiting time based on clinical indicators. Patients triaged in the red category are in need of immediate care. The next two categories, orange and yellow, have longer

Method

Patients who satisfied the study’s inclusion criteria were: Swedish speaking; older than 70 years of age; diagnosed with at least three different clinical conditions; had visited the ED three times or more during the past 12 months; and were prioritised as yellow (60 min) or green (120 min) (Polit and Beck, 2004). Fourteen participants that fulfilled these criteria accepted the invitation to participate in this study; (male n = 5, female n = 9; aged 71–90 years). These participants had a diagnosis of

Ethical aspects

The study complied rigorously with all ethical procedures, in accordance with Swedish law (SFS 2003:460) and the Declaration of Helsinki II (World Medical Association, 2009). The study contained an introductory letter in which the aim of the study was described; detailed instructions were provided, together with information clearly stating that participation was entirely voluntary, confidentiality was guaranteed and participants were free to withdraw from the project at any time without any

Results

Overall, the participants perceived the visit to the ED as a somewhat contradictory event. Initially, confidence was achieved by means of prompt and competent care. Sincere interest from the nurse during the triage encounter contributed to a feeling of being ‘at the centre of attention’. Attentive listening also contributed to a respectful relationship between nurse and patient.

However, during the rest of the visit, the nurses’ attitudes, indifference and inattentive behaviour caused a feeling

Discussion

A caring relationship between the triage nurse and the patient was clearly established during the triage encounter. This relationship was established by the nurse’s direct attention and communication and the nurse’s evident skills and competence. These two capabilities – the communicative and medical abilities – are in accordance with Mishler’s (1984) concept of using ‘two voices’ – the medical voice and the voice of the lifeworld in the nurse–patient encounter. According to Mishler (1984),

Conclusion

This study demonstrates that their visits to the ED were contradictory experiences from the perspectives of these chronically ill elderly patients. The initial triage encounter established confidence and set a promising expectation for the rest of the visit; however, the patients felt abandoned and neglected during their subsequent long waiting times. These conflicting perceptions flag the need to explore possible ways of improving the situation for the elderly and chronically ill person

Funding/sponsorship

This study was funded by a grant from the Department of Research and Development in the NU-Hospital Group, which is gratefully acknowledged.

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