Elderly care in the emergency department: an integrative review

Luciana Aparecida Soares de Andrade Sulamita de Paula Santos Roselene Campos Corpolato Mariluci Hautsch Willig Maria de Fátima Mantovani Alessandra Luciana Aguilera About the authors

Abstract

Objective:

To identify the care practices of nurses for the elderly in emergency departments.

Method:

An integrative review was carried out in the CAPES database, selecting publications in English, Portuguese and Spanish published between January 2011 and October 2016. The descriptors used were: "Emergency nursing"; "Geriatric nursing"; "Health services for the elderly"; "Elderly person"; "Nursing care".

Results:

Sixteen articles were analyzed in English, the majority of which had a qualitative approach (56.2%). Australia had the largest number of publications (31.2%). After reading the studies in full, the common themes were organized and classified into three categories: Challenges/difficulties in the care of the elderly in the emergency department, Positive experiences of elderly care in the emergency department and The emergency department as a space of death and dying.

Conclusion:

The care practices of nurses are focused on identifying the main problems regarding elderly care, adaptation and the planning of their work routine. Another strategy is the implementation of instruments of evaluation specific to elderly patients and the involvement of the family in all stages of care.

Keywords:
Emergency Nursing; Geriatric Nursing; Health Services for the Aged; Elderly; Nursing Care.

Resumo

Objetivo:

Identificar as práticas de cuidado realizadas pelo enfermeiro ao idoso atendido nos serviços de emergência.

Método:

Revisão integrativa realizada na base de dados CAPES, selecionando publicações em inglês, português e espanhol do período de janeiro de 2011 a outubro de 2016. Os descritores utilizados foram: “Enfermagem em emergência”; “Enfermagem geriátrica”; “Serviços de saúde para idosos”; “Idoso”; “Cuidados de enfermagem”.

Resultados:

Foram analisados 16 artigos em inglês, sendo a maioria de abordagem qualitativa (56,2%). A Austrália se destaca como país com o maior número de publicações (31,2%). Após a leitura dos estudos na íntegra, os temas comuns foram organizados e classificados em três categorias: Desafios/dificuldades no cuidado do idoso no setor de emergência, Experiências positivas do cuidado do idoso no setor de emergência e o Setor de emergência enquanto espaço de morte e morrer.

Conclusão:

As práticas de cuidado realizadas pelos enfermeiros estão voltadas para identificação dos seus principais problemas em relação ao cuidado do idoso, adaptação e no planejamento da sua rotina de trabalho. Outra estratégia tem sido a implantação de instrumentos de avaliação específicos para o paciente idoso e o envolvimento da família em todas as etapas do cuidado.

Palavras-chave:
Enfermagem em Emergência; Enfermagem Geriátrica; Serviços de Saúde para Idosos; Idoso; Cuidados de Enfermagem.

INTRODUCTION

The need for emergency care of the elderly has gradually increased due to population aging and a changing epidemiological profile11 Berlize EM, Farias AM, Dalazen F, Oliveira KR, Pillatt AP, Fortes CK. Analysis of the functional capacity of elderly residents of communities with a rapid population aging rate. Rev Bras Geriatr Gerontol [Internet]. 2016 [acesso em 20 ago. 2017];19(4):643-52. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1809-98232016000400643&lng=en&tlng=en
http://www.scielo.br/scielo.php?script=s...
. A study carried out in emergency departments in the USA found that the elderly, especially those over 75 years old, have a higher admission rate for emergencies than other age groups, a rate that is likely to increase as the population ages22 Rosenberg M, Rosenberg L. The geriatric emergency department. Emerg Med Clin North AM [Internet]. 2016 [acesso em 21 fev. 2017];34(3):629-48. Disponível em: https://www.sciencedirect.com/science/article/pii/S0733862716300268?via%3Dihub
https://www.sciencedirect.com/science/ar...
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Increased life expectancy can result in the occurrence of problems arising from morphophysiological changes inherent to aging, leading to an increase in chronic diseases, morbidity and functional disability11 Berlize EM, Farias AM, Dalazen F, Oliveira KR, Pillatt AP, Fortes CK. Analysis of the functional capacity of elderly residents of communities with a rapid population aging rate. Rev Bras Geriatr Gerontol [Internet]. 2016 [acesso em 20 ago. 2017];19(4):643-52. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1809-98232016000400643&lng=en&tlng=en
http://www.scielo.br/scielo.php?script=s...
. The elderly are therefore more likely to seek emergency care, and are usually admitted to the hospital twice as often as younger individuals22 Rosenberg M, Rosenberg L. The geriatric emergency department. Emerg Med Clin North AM [Internet]. 2016 [acesso em 21 fev. 2017];34(3):629-48. Disponível em: https://www.sciencedirect.com/science/article/pii/S0733862716300268?via%3Dihub
https://www.sciencedirect.com/science/ar...
. As the elderly suffer from more complex health problems they need specialized care and therefore represent the most frequent users of the main health services33 Oliveira MR, Renato PV, Cordeiro HPC, Pasinato MT. A mudança de modelo assistencial de cuidado ao idoso na Saúde Suplementar: identificação de seus pontos-chave e obstáculos para implementação. Physis [Internet]. 2016 [acesso em 14 set. 2016];26(4):1383-94. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-73312016000401383&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s...
,44 Sanon M, Baumlin KM, Kaplan SS, Grudzen CR. Care and respect for elders in emergencies program: a preliminary report of a volunteer approach to enhance care in the emergency department. J Am Geriatr Soc [Internet]. 2014 [acesso em 18 set. 2016];62(2):365-70. Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/24428229
https://www.ncbi.nlm.nih.gov/pubmed/2442...
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This is due to the clinical heterogeneity of these patients, which combined with a depletion of physiological reserves and diminished cognitive capacity results in the atypical manifestation of common diseases, casting doubts over the efficacy of standard approaches and representing a challenge for the implementation of care by emergency department nurses22 Rosenberg M, Rosenberg L. The geriatric emergency department. Emerg Med Clin North AM [Internet]. 2016 [acesso em 21 fev. 2017];34(3):629-48. Disponível em: https://www.sciencedirect.com/science/article/pii/S0733862716300268?via%3Dihub
https://www.sciencedirect.com/science/ar...
. The objective of the present study was therefore to identify the care practices performed by nurses for elderly persons receiving care in emergency departments.

METHOD

An integrative review was carried out in accordance with the six methodological steps proposed by Mendes et al.55 Mendes KDS, Silveira RCCP, Galvão MG. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto & Contexto Enferm [Internet]. 2008 [acesso em 15 dez. 2015];17(4):758-64. Disponível em: http://www.scielo.br/scielo.php?pid=S0104-07072008000400018&script=sci_arttext&tlng=pt
http://www.scielo.br/scielo.php?pid=S010...
In the first step the following guiding question was defined: what are the nursing care practices for elderly persons receiving treatment in emergency departments described in Brazilian and non-Brazilian nursing publications in the last five years?

In the second stage the following inclusion criteria were established: complete articles in English, Portuguese and Spanish available online, published from January 2011 to September 2016, which addressed nursing care for the elderly treated in emergency departments. The exclusion criteria were: systematic, integrative reviews, case studies, reports of experiences and editorials.

In the third step, it was decided that the online search platform of the Coordination for the Improvement of Higher Education Personnel (CAPES) would be used to research scientific productions, as this encompasses several Brazilian and non-Brazilian databases and is available for public access. The online search occurred in October 2016, using the following descriptors: emergency nursing, geriatric nursing, nursing care, the elderly, health services for the elderly, emergencies, geriatric hospitals. To search for articles, the following combinations of descriptors in Portuguese, English and Spanish were used: "emergency nursing" AND "elderly", "emergency nursing" AND "health services for the elderly", “emergencies” AND "elderly", “emergencies AND “geriatric nursing”, "nursing care” AND “elderly”, “health services for the elderly" AND "emergencies", "geriatric hospitals" AND "emergencies".

Firstly, two researchers independently evaluated the titles and abstracts of the publications in the database for the selection of potentially eligible studies. From these, full texts were obtained for a thorough reading. Afterwards, those that did not meet the inclusion criteria were excluded. The flowchart of the article selection process based on the PRISMA66 Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med [Internet]. 2009 [acesso em 31 jan. 2017];151(4):264-9. Disponível em: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2707599/
http://www.ncbi.nlm.nih.gov/pmc/articles...
model is shown in Figure 1.

Figure 1
Flowchart of selection of publications for integrative review, based on PRISMA model6. Curitiba, Paraná, 2017.

In the fourth stage data analysis was performed, organized by categories. In the fifth stage the discussion was developed according to the pertinent literature and in the sixth stage the synthesis of the review was elaborated.

RESULTS

The sample consisted of 16 articles in English, with eight (50.0%) qualitative, seven (43.8%) quantitative and one (6.2%) mixed approach studies. In relation to the year of publication, four (25.0%) articles were published in 2015; three (18.7%) in the years 2011, 2013 and 2014; two (12.5%) in 2012 and one (6.25%) in 2016. Australia had the largest number of publications on the subject, with 31.2%, followed by Canada with 18.8%, and the USA and Spain both with 12% each. Also included were articles from other countries such as Finland, Switzerland, Sweden and England, which accounted for 26.0%. The articles were published in 15 journals, with International Emergency Nursing publishing the most articles (12.0%) (Chart 1).

Chart 1
Results of study. Curitiba, Paraná, 2017.

The topics covered in the studies were classified into three categories: Challenges/difficulties in care for the elderly, Positive experiences of care for the elderly and the Emergency department as a place of death / dying.

DISCUSSION

Challenges/difficulties in care for the elderly

The results show that the profile of care in the emergency departments is changing as a consequence of population aging, with the number of elderly people seeking this service gradually increasing77 Santos MT, Lima MADS, Zucatti PB. Elder-friendly emergency services in Brazil: necessary conditions for care. Rev Esc Enferm USP [Internet]. 2016 [acesso em 10 ago. 2017];50(4):592-9. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342016000400594&lng=en&tlng=en
http://www.scielo.br/scielo.php?script=s...
,99 Huded JM, Dresden SM, Gravenor SJ, Rowe T, Lindquist LA. Screening for fall risks in the emergency department: a novel nursing-driven program. West J Emerg Med [Internet]. 2015 [acesso em 10 ago. 2017];16(7):1043-6. Disponível em: https://escholarship.org/uc/item/4rg7c7rh
https://escholarship.org/uc/item/4rg7c7r...
. Although these patients are treated by pre-hospital and primary care services, the hospital emergency department is the most frequently used in cases of health problems1010 Caldas CP, Veras RP, Motta LB, Guerra ACLC, Carlos MJ, Trocado CLM. Atendimento de emergência e suas interfaces: o cuidado de curta duração a idosos. J Bras Econ Saúde [Internet]. 2015 [acesso em 27 ago. 2017];7(1):62-9. Disponível em: http://files.bvs.br/upload/S/2175-2095/2015/v7n1/a4757.pdf
http://files.bvs.br/upload/S/2175-2095/2...
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A documentary study on the identification of health problems that led the elderly to seek treatment in the emergency departments of two public hospitals in Rio de Janeiro showed that most were suffering from more than one basic disease, which was the main reason for seeking care1111 Tenório DM, Camacho ACLF. Identificação dos agravos de saúde que levam os idosos ao serviço de emergência. Rev Enferm UFPE on line [Internet]. 2015 [acesso em 27 ago. 2017];9(1 Supl.):457-65. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/10359/11083
https://periodicos.ufpe.br/revistas/revi...
. An aggravating factor is that these patients are admitted with more serious health problems, as their disease is combined with several comorbidities1212 Bailey CJ, Murphyb R, Porockc D. Dying cases in emergency places: caring for the dying in emergency departments. Soc Sci Med [Internet]. 2011 [acesso em 12 nov. 2016];73(9):1371-7. Disponível em: https://www.sciencedirect.com/science/article/pii/S0277953611005132?via%3Dihub
https://www.sciencedirect.com/science/ar...
, which increases the risk of mortality, the length of stay in the emergency department and the number of hospitalizations1313 Taylor BJ, Rush KL, Robinson CA. Nurses’ experiences of caring for the older adult in the emergency department: a focused ethnography. Int Emerg Nur [Internet]. 2015 [acesso em 12 nov. 2016];23(2):185-9. Disponível em: http://www.internationalemergencynursing.com/article/S1755-599X(14)00306-1/fulltext
http://www.internationalemergencynursing...
,1414 Connel B, Hawkins M, Considine J, Au C. Referrals to hospital emergency departments from residential aged care facilities: stuck in a time warp. Contemp Nurse [Internet]. 2013 [acesso em 12 nov. 2016];45(2):228-33. Disponível em: https://www.researchgate.net/publication/259152303
https://www.researchgate.net/publication...
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This situation indicates that more and more of the work of nurses in the emergency department includes care for the elderly. Thus, care priorities must be continually rethought1313 Taylor BJ, Rush KL, Robinson CA. Nurses’ experiences of caring for the older adult in the emergency department: a focused ethnography. Int Emerg Nur [Internet]. 2015 [acesso em 12 nov. 2016];23(2):185-9. Disponível em: http://www.internationalemergencynursing.com/article/S1755-599X(14)00306-1/fulltext
http://www.internationalemergencynursing...
as admission to the emergency sector exposes these patients to the risk of functional decline and incidents arising from the care itself77 Santos MT, Lima MADS, Zucatti PB. Elder-friendly emergency services in Brazil: necessary conditions for care. Rev Esc Enferm USP [Internet]. 2016 [acesso em 10 ago. 2017];50(4):592-9. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342016000400594&lng=en&tlng=en
http://www.scielo.br/scielo.php?script=s...
,1515 Baumbusch J, Shaw M. Geriatric emergency nurses: addressing the needs of an aging population. J Emerg Nurs [Internet]. 2011 [acesso em 12 nov. 2016];37(4):321-7. Disponível em: http://www.sciencedirect.com/science/article/pii/S0099176710001868
http://www.sciencedirect.com/science/art...
. Unfavorable outcomes such as delirium and death may increase when the hospitalization of elderly patients occurs in non-specialized settings1616 Inzitari M, Gual N, Roig T, Colprim D, Bocanegra CP, José ASJ, et al. Geriatric screening tools to select older adults susceptible for direct transfer from the emergency department to subacute intermediate-care hospitalization. J Am Dir Assoc [Internet]. 2015 [acesso em 12 nov. 2016];16(10):837-41. Disponível em: https://www.sciencedirect.com/science/article/pii/S1525861015003072?via%3Dihub
https://www.sciencedirect.com/science/ar...
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Elderly care in the emergency sector is a challenge for nurses and begins with triage1717 Grossmann FF, Zumbrunn T, Ciprian S, Stephan FP, Woy N, Bingisser R, et al. Undertriage in older emergency department patients: tilting against windmills? Plos ONE [Internet] .2014 [acesso em 12 nov. 2016];9(8):1-7. Disponível em: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0106203
http://journals.plos.org/plosone/article...
. It includes difficulties in assessment and diagnosis due to atypical presentation of symptoms, the presence of multiple comorbidities, changes in mental state and communication difficulties77 Santos MT, Lima MADS, Zucatti PB. Elder-friendly emergency services in Brazil: necessary conditions for care. Rev Esc Enferm USP [Internet]. 2016 [acesso em 10 ago. 2017];50(4):592-9. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342016000400594&lng=en&tlng=en
http://www.scielo.br/scielo.php?script=s...
,1818 Misch F, Messmer AS, Nickel CH, Gujan M, Graber A, Blume K, et al. Impact of observation on disposition of elderly patients presenting to emergency departments with non-specific complaints. Plos one 2014 [acesso em 12 nov. 2016];9(5):1-7. Disponível em: https://pdfs.semanticscholar.org/7b3d/c9c1dd74ec8720be623d59d29ad47923415a.pdf
https://pdfs.semanticscholar.org/7b3d/c9...
. In this sense, health care professionals must invest in the communication process to allow effective and efficient care1919 Barros LM, Araújo TM, Neri MFS, Soares E, Caetano JA. Internação em uma unidade de emergência hospitalar: vivência. Cogitare Enferm [Internet]. 2013 [acesso em 14 ago. 2017];18(2):336-43. Disponível em: http://revistas.ufpr.br/cogitare/article/view/32583.

The establishment of satisfactory communication begins in the patient's first contact with the nurse, usually when the patient undergoes triage. Inadequate triage can increase the risk of deterioration of the health status of the patient while they wait for care. In this aspect the elderly represent a vulnerable group and are more susceptible to undertriage due to the atypical manifestation of diseases and difficulties in interpreting the vital signs, which may appear normal even in cases of severe disease1717 Grossmann FF, Zumbrunn T, Ciprian S, Stephan FP, Woy N, Bingisser R, et al. Undertriage in older emergency department patients: tilting against windmills? Plos ONE [Internet] .2014 [acesso em 12 nov. 2016];9(8):1-7. Disponível em: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0106203
http://journals.plos.org/plosone/article...
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Although training and skills in emergency care allow nurses to quickly recognize a critical illness, they may have difficulty detecting a problem in elderly patients because of the complexity of some chronic conditions88 Deasey D, Kable A, Jeong S. Results of a national survey of australian nurses’ practice caring for older people in an emergency department. J Clin Nurs [Internet]. 2016 [acesso em 10 ago. 2017];25(19-20):3049-57. Disponível em: https://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.13365
https://onlinelibrary.wiley.com/doi/abs/...
,1212 Bailey CJ, Murphyb R, Porockc D. Dying cases in emergency places: caring for the dying in emergency departments. Soc Sci Med [Internet]. 2011 [acesso em 12 nov. 2016];73(9):1371-7. Disponível em: https://www.sciencedirect.com/science/article/pii/S0277953611005132?via%3Dihub
https://www.sciencedirect.com/science/ar...
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An integral approach to older patients requires critical thinking skills to minimize adverse events and prolonged hospitalization, as well as planning and organizing skills for care. While nurses are competent at providing emergency care, they may exhibit limitations when addressing the complex needs of the elderly88 Deasey D, Kable A, Jeong S. Results of a national survey of australian nurses’ practice caring for older people in an emergency department. J Clin Nurs [Internet]. 2016 [acesso em 10 ago. 2017];25(19-20):3049-57. Disponível em: https://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.13365
https://onlinelibrary.wiley.com/doi/abs/...
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Additionally, a study carried out in Spain in 2014 revealed that the characteristics of the environment, such as excess numbers of patients awaiting care, a shortage of health professionals and a lack of physical space can influence the decision making of professionals and, consequently, the care offered, which can compromise the physical integrity of the patient1717 Grossmann FF, Zumbrunn T, Ciprian S, Stephan FP, Woy N, Bingisser R, et al. Undertriage in older emergency department patients: tilting against windmills? Plos ONE [Internet] .2014 [acesso em 12 nov. 2016];9(8):1-7. Disponível em: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0106203
http://journals.plos.org/plosone/article...
.

Another difficulty faced by nurses relates to the transfer of care of the elderly, which involves a set of actions aimed at allowing the safe and timely passage of users between different health sectors and services. As they can suffer from several chronic diseases with different treatments, elderly patients are often treated by many health services.

However, the transfer of patient care information between services usually fails to happen, resulting in the elderly person being returned to emergency departments and leading to further hospitalizations and the occurrence of adverse events77 Santos MT, Lima MADS, Zucatti PB. Elder-friendly emergency services in Brazil: necessary conditions for care. Rev Esc Enferm USP [Internet]. 2016 [acesso em 10 ago. 2017];50(4):592-9. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342016000400594&lng=en&tlng=en
http://www.scielo.br/scielo.php?script=s...
,1515 Baumbusch J, Shaw M. Geriatric emergency nurses: addressing the needs of an aging population. J Emerg Nurs [Internet]. 2011 [acesso em 12 nov. 2016];37(4):321-7. Disponível em: http://www.sciencedirect.com/science/article/pii/S0099176710001868
http://www.sciencedirect.com/science/art...
,2020 Dalawari P, Duggan J, Vangimalla V, Paniagua M, Armbrecht Patient transfer forms enhance key information between nursing homes and emergency department. Geriatr Nurs [Internet]. 2011 [acesso em 26 out. 2016];32(4):270-5. Disponível em: http://www.gnjournal.com/article/S0197-4572(11)00266-7/fulltext
http://www.gnjournal.com/article/S0197-4...
. The implementation of instruments that enable the transfer of patient information is of great importance if continuity of care is to be ensured.

The emergency department is a dynamic environment in which there is pressure for tasks to be executed in a timely manner due to the severity of cases and the number of patients waiting for treatment1313 Taylor BJ, Rush KL, Robinson CA. Nurses’ experiences of caring for the older adult in the emergency department: a focused ethnography. Int Emerg Nur [Internet]. 2015 [acesso em 12 nov. 2016];23(2):185-9. Disponível em: http://www.internationalemergencynursing.com/article/S1755-599X(14)00306-1/fulltext
http://www.internationalemergencynursing...
. In this environment, in which new patients are continuously admitted, elderly persons waiting for a hospital bed are no longer a priority for nurses, who direct their attention to those in life-threatening situations1313 Taylor BJ, Rush KL, Robinson CA. Nurses’ experiences of caring for the older adult in the emergency department: a focused ethnography. Int Emerg Nur [Internet]. 2015 [acesso em 12 nov. 2016];23(2):185-9. Disponível em: http://www.internationalemergencynursing.com/article/S1755-599X(14)00306-1/fulltext
http://www.internationalemergencynursing...
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As a consequence, elderly persons undergo a contradictory experience in the emergency department, as they are initially the focus of the nurse's attention, before being left to one side and having their care needs, such as assistance to get up and go to the bathroom, ignored1313 Taylor BJ, Rush KL, Robinson CA. Nurses’ experiences of caring for the older adult in the emergency department: a focused ethnography. Int Emerg Nur [Internet]. 2015 [acesso em 12 nov. 2016];23(2):185-9. Disponível em: http://www.internationalemergencynursing.com/article/S1755-599X(14)00306-1/fulltext
http://www.internationalemergencynursing...
,2121 Olofsson P, carlstrom ED, Pettersson SB. During and beyond the triage encounter: chronically ill elderly patients’ experiences throughout their emergency department attendances. Int Emerg Nurs [Internet]. 2012 [acesso em 26 out. 2016];20(4):207-13. Disponível em: http://www.internationalemergencynursing.com/article/S1755-599X(12)00051-1/fulltext
http://www.internationalemergencynursing...
. In this way, the environment can result in stress for the elderly and cause episodes of confusion due to its fast pace88 Deasey D, Kable A, Jeong S. Results of a national survey of australian nurses’ practice caring for older people in an emergency department. J Clin Nurs [Internet]. 2016 [acesso em 10 ago. 2017];25(19-20):3049-57. Disponível em: https://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.13365
https://onlinelibrary.wiley.com/doi/abs/...
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These findings indicate the need to restructure the working processes of the emergency department to ensure care that meets the needs of the elderly.

Positive experiences of care for the elderly

Emergency departments follow a curative model aimed at quick treatment and short stays. However, this model is inconsistent with the management of care for elderly persons with chronic and complex conditions, which requires health services based on health care models that encompass their biopsychosocial needs88 Deasey D, Kable A, Jeong S. Results of a national survey of australian nurses’ practice caring for older people in an emergency department. J Clin Nurs [Internet]. 2016 [acesso em 10 ago. 2017];25(19-20):3049-57. Disponível em: https://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.13365
https://onlinelibrary.wiley.com/doi/abs/...
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Changing this model is a long process which begins when professionals first become aware of its problems. A study of nurses from an emergency department in Australia in 2016 revealed that, even though there was no specific evaluation of elderly persons, such professionals identified their main care-related problems as being adequate pain control, hygiene, psychosocial care and the maintenance of the patient’s independence88 Deasey D, Kable A, Jeong S. Results of a national survey of australian nurses’ practice caring for older people in an emergency department. J Clin Nurs [Internet]. 2016 [acesso em 10 ago. 2017];25(19-20):3049-57. Disponível em: https://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.13365
https://onlinelibrary.wiley.com/doi/abs/...
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Becoming aware of the problems they faced led nurses to seek new practices such as using appropriate language when talking to the elderly without labeling them, promoting patient independence, and performing close observation88 Deasey D, Kable A, Jeong S. Results of a national survey of australian nurses’ practice caring for older people in an emergency department. J Clin Nurs [Internet]. 2016 [acesso em 10 ago. 2017];25(19-20):3049-57. Disponível em: https://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.13365
https://onlinelibrary.wiley.com/doi/abs/...
. Another key element is confidence and self-efficacy, which need to be strengthened by nurses in the emergency department to ensure appropriate, timely and compassionate care1212 Bailey CJ, Murphyb R, Porockc D. Dying cases in emergency places: caring for the dying in emergency departments. Soc Sci Med [Internet]. 2011 [acesso em 12 nov. 2016];73(9):1371-7. Disponível em: https://www.sciencedirect.com/science/article/pii/S0277953611005132?via%3Dihub
https://www.sciencedirect.com/science/ar...
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Respectful actions, honest and understandable information and allowing patients to express their opinions and anxieties are fundamental actions in the emergency department. It is essential that nurses approach family members, as when an elderly person cannot provide accurate information about their health status and participate in the decision-making process, the family must assume this role88 Deasey D, Kable A, Jeong S. Results of a national survey of australian nurses’ practice caring for older people in an emergency department. J Clin Nurs [Internet]. 2016 [acesso em 10 ago. 2017];25(19-20):3049-57. Disponível em: https://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.13365
https://onlinelibrary.wiley.com/doi/abs/...
,1515 Baumbusch J, Shaw M. Geriatric emergency nurses: addressing the needs of an aging population. J Emerg Nurs [Internet]. 2011 [acesso em 12 nov. 2016];37(4):321-7. Disponível em: http://www.sciencedirect.com/science/article/pii/S0099176710001868
http://www.sciencedirect.com/science/art...
.

Two-thirds of patients admitted to the emergency department suffer cognitive impairment and are unable to describe their personal history and the medications they use or provide information about allergies and the dates and reasons for recent hospitalizations. The use of forms, such as discharge summaries that contain records of the history of hospital visits by the elderly, improves the transmission of essential information to the nurses who admit the patients to the emergency department2020 Dalawari P, Duggan J, Vangimalla V, Paniagua M, Armbrecht Patient transfer forms enhance key information between nursing homes and emergency department. Geriatr Nurs [Internet]. 2011 [acesso em 26 out. 2016];32(4):270-5. Disponível em: http://www.gnjournal.com/article/S0197-4572(11)00266-7/fulltext
http://www.gnjournal.com/article/S0197-4...
.

Access to accurate patient information can help nurses identify their limitations and plan care with an emphasis on promoting autonomy. Although it takes up time, the benefits of this practice are vital to prevent the patient from becoming dependent on intensive care2121 Olofsson P, carlstrom ED, Pettersson SB. During and beyond the triage encounter: chronically ill elderly patients’ experiences throughout their emergency department attendances. Int Emerg Nurs [Internet]. 2012 [acesso em 26 out. 2016];20(4):207-13. Disponível em: http://www.internationalemergencynursing.com/article/S1755-599X(12)00051-1/fulltext
http://www.internationalemergencynursing...
.

In this process the elderly and their families can be considered as active agents in the construction of care, with the family assuming the role of supervising health status, making decisions and accompanying their loved one2222 Reis CCA, Sena ELS, Menezes TMO. Vivências de familiares cuidadores de pessoas idosas hospitalizadas e a experiência de intercorporeidade. Escola Anna Nery on line [Internet]. 2016 [acesso em 16 maio 2017];20(3):1-6. Disponível em: http://www.eean.edu.br/detalhe_artigo.asp?id=1429
http://www.eean.edu.br/detalhe_artigo.as...
,2323 Nogueira IS, Previato GF, Scolari GAS, Gomes ACO, Carreira L, Baldissera VDA. Intervenção domiciliar como ferramenta para o cuidado de enfermagem: avaliação da satisfação de idosos. Rev Gaúcha Enferm [Internet]. 2016 [acesso em 16 maio 2017];37(esp):1-7. Disponível em: http://seer.ufrgs.br/index.php/RevistaGauchadeEnfermagem/article/view/68351/40827
http://seer.ufrgs.br/index.php/RevistaGa...
. Therefore, the elderly and their family require special attention from the nurse, which contributes to the development of a relation of trust and respect and to quality and humanized care2424 Santos SC, Tonhom SFR, Komatsu RS. Saúde do idoso: reflexões acerca da integralidade do cuidado. Rev Bras Promoç Saúde [Internet]. 2016 [acesso em 16 maio 2017];29(Supl):118-27. Disponível em: http://periodicos.unifor.br/RBPS/article/view/6413
http://periodicos.unifor.br/RBPS/article...
.

Studies have also reported the use of tools for evaluating the elderly as an element that can contribute to the improvement of care in the emergency department and the targeting of the interventions to which the elderly should be submitted. One of the tools identified in the studies is the Timed Up and Go test, which evaluates the gait and balance of the elderly, which are predictive elements for the risk of falls. The author states that approximately one third of individuals over 65 years old will fall at least once a year, with such incidents resulting in fractures, surgeries, hospital admissions, prolonged rehabilitation and death99 Huded JM, Dresden SM, Gravenor SJ, Rowe T, Lindquist LA. Screening for fall risks in the emergency department: a novel nursing-driven program. West J Emerg Med [Internet]. 2015 [acesso em 10 ago. 2017];16(7):1043-6. Disponível em: https://escholarship.org/uc/item/4rg7c7rh
https://escholarship.org/uc/item/4rg7c7r...
.

Falls are common events among the elderly population and progressively increase with age, due to reduced muscle strength, changes in gait and maintenance of posture, resulting in a greater chance of stumbling and falling. They represent a public health problem, as they can result in fractures and injuries, which results in a need for emergency department care and even hospitalization2525 Alves RLT, Silva CFM, Pimentel LN, Costa I A, Souza ACS, Coelho LAF. Avaliação dos fatores de risco que contribuem para queda em idosos. Rev Bras Geriatr Gerontol [Internet]. 2017 [acesso em 21 jun. 2017]; 20(1):59-69. Disponível em: http://www.scielo.br/pdf/rbgg/v20n1/pt_1809-9823-rbgg-20-01-00056.pdf
http://www.scielo.br/pdf/rbgg/v20n1/pt_1...
.

A study carried out in the municipality of Barbacena (Minas Gerais) in 2015 found that 31.08% of patients who had fallen in the previous year were hospitalized. In addition to the psychosocial consequences, after a fall the elderly experience feelings of fear, frailty and a lack of confidence, which represent the beginning of the degeneration of their overall health2525 Alves RLT, Silva CFM, Pimentel LN, Costa I A, Souza ACS, Coelho LAF. Avaliação dos fatores de risco que contribuem para queda em idosos. Rev Bras Geriatr Gerontol [Internet]. 2017 [acesso em 21 jun. 2017]; 20(1):59-69. Disponível em: http://www.scielo.br/pdf/rbgg/v20n1/pt_1809-9823-rbgg-20-01-00056.pdf
http://www.scielo.br/pdf/rbgg/v20n1/pt_1...
.

The emergency sector can act in the prevention of these falls and alter the trajectory of the functional decline of the elderly, identifying individuals with a high risk of falls when they seek care. The application of the Timed Up and Go Test (TUGT) test is feasible and inexpensive as it can be performed by nurses, and its results allow the creation of a mobility care plan to change the trajectory of functional decline among the elderly99 Huded JM, Dresden SM, Gravenor SJ, Rowe T, Lindquist LA. Screening for fall risks in the emergency department: a novel nursing-driven program. West J Emerg Med [Internet]. 2015 [acesso em 10 ago. 2017];16(7):1043-6. Disponível em: https://escholarship.org/uc/item/4rg7c7rh
https://escholarship.org/uc/item/4rg7c7r...
.

The emergency department as a space of death/dying

In contemporary society, death has been transferred to the hospital, which in turn has become legitimized as a place to die2626 Teixeira AL. Gestões de vida e morte: um olhar sobre o morrer no contemporâneo. Ayvu Rev Psicol [Internet]. 2016 [acesso em 21 jun. 2017];2(2):150-71. Disponível em: http://www.ayvu.uff.br/index.php/AYVU/article/view/69/58
http://www.ayvu.uff.br/index.php/AYVU/ar...
. Thus, caring for the end-of-life patient in the emergency department has become more frequent. A study performed in the emergency department of a São Paulo hospital showed that the higher the level of care required by the patient, the higher the percentage of death2727 Paixão TCR, Campanharo CRV, Lopes MCBT, Okumo MFP, Batista REA. Dimensionamento de enfermagem em sala de emergência de um hospital-escola. Rev Esc Enferm USP [Internet]. 2015 [acesso em 27 ago. 2017];49(3):486-93. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342015000300481&lng=en&nrm=iso&tlng=pt
http://www.scielo.br/scielo.php?script=s...
.

Advances in technology and the improvement of health knowledge have enabled people with multiple comorbidities to live for a long time, leading to an increase in life expectancy, as well as an increased need for care in the latter stages of life1212 Bailey CJ, Murphyb R, Porockc D. Dying cases in emergency places: caring for the dying in emergency departments. Soc Sci Med [Internet]. 2011 [acesso em 12 nov. 2016];73(9):1371-7. Disponível em: https://www.sciencedirect.com/science/article/pii/S0277953611005132?via%3Dihub
https://www.sciencedirect.com/science/ar...
.

Emergency departments, as the gateway to hospital care, have become an environment of palliative care. In this way, professionals and patients experience the experience of caring for and being cared for in spaces that were originally designed to save lives1212 Bailey CJ, Murphyb R, Porockc D. Dying cases in emergency places: caring for the dying in emergency departments. Soc Sci Med [Internet]. 2011 [acesso em 12 nov. 2016];73(9):1371-7. Disponível em: https://www.sciencedirect.com/science/article/pii/S0277953611005132?via%3Dihub
https://www.sciencedirect.com/science/ar...
.

Death is seen as dirty and inconvenient by society2626 Teixeira AL. Gestões de vida e morte: um olhar sobre o morrer no contemporâneo. Ayvu Rev Psicol [Internet]. 2016 [acesso em 21 jun. 2017];2(2):150-71. Disponível em: http://www.ayvu.uff.br/index.php/AYVU/article/view/69/58
http://www.ayvu.uff.br/index.php/AYVU/ar...
. This connotation contradicts the idealization of the emergency sector as a clean location where the fight for life is carried out on a daily basis. Consequently, the approach taken to caring for the elderly at the end of life often falls short of the expectations of the dying patient and their relatives1212 Bailey CJ, Murphyb R, Porockc D. Dying cases in emergency places: caring for the dying in emergency departments. Soc Sci Med [Internet]. 2011 [acesso em 12 nov. 2016];73(9):1371-7. Disponível em: https://www.sciencedirect.com/science/article/pii/S0277953611005132?via%3Dihub
https://www.sciencedirect.com/science/ar...
.

Even if the death/dying process is solitary, it must be experienced by the patient with care, comfort and comfort offered by prepared professionals who are aware of the pain and suffering that surrounds them, so that the dignity of the patient is preserved, regardless of where they are receiving care2828 Silva CRL, Abraão FMS, Oliveira RC, Louro TQ, Moura LF, Silva RCL. Representações sociais de enfermeiros sobre o processo de morte e morrer em UTI. Cienc Cuid Saúde [Internet]. 2016 [acesso em 21 jun. 2017];15(3):474-81. Disponível em: http://www.periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/32345.
http://www.periodicos.uem.br/ojs/index.p...
. Although nurses believe that the emergency sector is an unsuitable place to care for terminally ill elderly persons,88 Deasey D, Kable A, Jeong S. Results of a national survey of australian nurses’ practice caring for older people in an emergency department. J Clin Nurs [Internet]. 2016 [acesso em 10 ago. 2017];25(19-20):3049-57. Disponível em: https://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.13365
https://onlinelibrary.wiley.com/doi/abs/...
they have a role in challenging existing practices and improving quality of end-of-life care1212 Bailey CJ, Murphyb R, Porockc D. Dying cases in emergency places: caring for the dying in emergency departments. Soc Sci Med [Internet]. 2011 [acesso em 12 nov. 2016];73(9):1371-7. Disponível em: https://www.sciencedirect.com/science/article/pii/S0277953611005132?via%3Dihub
https://www.sciencedirect.com/science/ar...
.

One of the limitations of the present study is that only the search platform of the Coordination for the Improvement of Higher Level Personnel (CAPES) was used to seek scientific productions. The survey included publications from different countries, however, diversifying the sample in relation to cultural, political and social aspects, which directly or indirectly influence the care actions performed by nurses.

CONCLUSION

The emergency department has become the main point of access of the growing elderly population with multiple comorbidities and chronic diseases, evidencing the need to change the paradigm of care. Nursing care practices carried out by nurses in such departments are aimed at adapting their routine and work structure to meet the needs of these patients.

Nurses face a number of difficulties in this process, however. These include the physiological changes of aging, which interfere with how diseases manifest themselves, and a lack of knowledge about how to interpret these manifestations; communication barriers, especially in relation to elderly persons suffering cognitive decline; a lack of adequate physical structures; and the increased time spent evaluating patients and performing care, especially as the dynamics of emergency work rarely allow them to devote more time to the elderly.

These difficulties have challenged nurses to rethink the care they provide. The starting point has been the identification of the main problems related to caring for the elderly, the implementation of specific instruments of evaluation and the involvement of the family in care. Communication is the principal means of achieving these goals.

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Publication Dates

  • Publication in this collection
    Mar-Apr 2018

History

  • Received
    14 Sept 2017
  • Reviewed
    27 Feb 2018
  • Accepted
    03 Mar 2018
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