An ethnographic study of frail, older patients’ health care journeys through, and experiences of, an Emergency Multidisciplinary Unit
The background to the research There is a growing body of research which indicates that increased age is associated with increased Emergency Department (ED) attendance and emergency hospital admissions. However, while frail, older people may be heavy users of health care services there are concerns that those services may not recognise and meet their needs and that the acute hospital environment is not well suited to the older person.
The acute care pathway at the Emergency Multidisciplinary Units (EMUs) and the Acute Ambulatory Care Unit (AAU) in Oxfordshire, UK, is aimed in particular at older, frail patients and was designed as an alternative to emergency admission to an acute hospital, treating patients closer to their homes. This study aimed to explore the health care journeys of frail, older patients when they were assessed and treated in these settings. The main research aims were:
- To investigate frail, older people’s experiences of visiting the EMU and the AAU and their journeys through care within those settings.
- To explore the main events and transitions in their care and how these impacted upon the patients and their carers.
- To identify how patients’ experience of ambulatory care provision fitted with their expectations, needs and priorities.
Conclusions drawn from the research
From our findings, it became apparent that going to hospital was a possibility that older people living with frailty prefer to avoid, even at times when they knew they were unwell. Attendance at an ambulatory care setting was regarded as more acceptable alternative and many of our participants were surprised and delighted at what could be done for them there. Overall patients’ and carers’ responses showed that they viewed this type of ambulatory care as a model of service provision, which was especially suited to the needs and priorities of older people living with frailty. This was largely due to the fact, that dependent on the reason for referral, patients were able go home between visits (a number of patients were themselves caring for frail, older people), food and drink were provided during their stay and patients received support in maintaining independence and functioning through the involvement of the multi-disciplinary team present at these sites. Our research demonstrated that key to patients’ and carers’ positive view of ambulatory care was the size of the settings. The small size of the EMU, where up to around 10 patients could be cared for at one time, was greatly valued and substantially contributed to patients’ and carers’ perception of it as a comfortable, friendly place, with a more relaxed atmosphere particularly suited to the needs of frail, older people. It also contributed to the feeling that the care they received was more ‘personalised’, which was a hugely significant feature for the patients and carers. Although bigger, and able to treat more patients at any given time, the AAU was still perceived as a pleasant, relaxed environment. The importance of communication with heath care professionals for patients and their carers was emphasised across the ambulatory care settings. The many opportunities for communication and interaction between patients and staff appeared to be a factor in making EMU and the AAU settings which patients viewed positively. Although journeys could involve long days and repeat visits, at each stage of their care staff made efforts to keep patients and their carers informed about what was happening and what the next steps were, and to involve them in discussions about delivering the care that fitted the patient. Many of the patients were able to be part of the decision-making process around the treatment they received, and this sometimes meant them rejecting suggestions of help offered. Some patients, especially when they were acutely unwell, did not always expect to participate in decision-making. These patients were content to rely upon the decision-making of the professionals to do what was best for them in an environment where they felt cared for.
Recommendations for the future
Our research is an indication of the feasibility of conducting research in acute care settings and that participating in ethnographic research, even during periods of acute illness, can be acceptable to patients. This offers the possibility of designing other studies where the experiences and perspectives of patients can contribute to an understanding of whether, and how, acute services work for them. This study also shows ethnography as a means of drawing older people living with frailty, including cognitive frailty into research. Thus future research around care provision and new platforms of care for older people with frailty should consider building in a qualitative, ethnographic component.