Recent news reports of seniors being inappropriately discharged from a hospital emergency ward to their homes in the middle of the night outrage the public and frighten any family member with an older relative who lives alone. This month Elder Voice has three articles which focus on Seniors in the emergency ward. Our first article describes what happens in emergency. The second article covers the family member’s role. Our third article talks about the family and decision making in emergencies.
When someone arrives by ambulance at the emergency ward they are usually brought directly into a treatment area. Otherwise they will first be seen by a triage nurse who assesses the immediacy of the need for treatment and may take some vital signs. The triage nurse will assign a level of urgency. Naturally, people with the highest level of urgency are seen first and if necessary are brought directly into the treatment area. The triage nurse may also assign a stream or pathway which indicates the medical problem such as heart attack or stroke The stream may trigger alerts in the treatment area so that staff know what to being to look for or treat right away and even what area of the treatment area they should be treated in.
If the patient is not brought directly into the treatment area, they will be referred to admitting where an admitting clerk will take basic information such as name, address, insurance, next of kin, etc.
As most people know these days, emergency wards are often very, very busy.The wait to be brought into the treatment area can be quite long. It can be a further wait in the treatment area before a patient is seen by a nurse or doctor. The waiting time is sometimes longer than it should be because people use the emergency ward in place of a family doctor or clinic.
In the treatment area the patient is put on a bed in an area that can closed or curtained off. In times where the unit is over capacity, a patient can be on a stretcher in the hallway. Wherever they are, as soon as possible the patient is seen by a nurse who takes vital signs and gathers initial or more detailed information about what brought the person to the emergency room. This information will follow the patient during their stay and may be the base upon which further treatment, investigations and decisions are made. It is essential that it be accurate.The nurse will often start a monitoring machine which tracks blood pressure, heart rate,and oxygen levels and alerts the staff if there is an emergency.
In the event that someone arrives with critical injuries, a stroke, or heart attack, they will be seen immediately by a doctor and treatment started. Often, resources and personnel may be diverted from other patients to attend to this emergency.
Initial information from nursing and the triage nurse goes to a doctor who then makes preliminary diagnoses and decisions about initial treatment and investigations. Treatments may include intravenous fluids or antibiotics and investigations may include x rays or other scans, blood or urine tests. (In some hospitals these decisions may also at times be made by a nurse.)The physician also decides whether someone needs to be seen by a specialist such as a cardiologist or neurologist. As can be seen, during the course of treatment many people may be involved and a patient may be asked several times to give or repeat information and history.
The nurse who takes the vital signs is generally the nurse who is responsible for the patient while he or she is on shift. Find out who that person is and what time their shift ends. Try to be there at the first shift change, or call to let the new nurse know you are involved, your contact details and ensure that you ask them to call you before the person will be discharged. Be aware also that nurses have either an eight or a twelve hour shift and they will have several breaks and at least one meal break during that time. When the primary nurse is on a break there is usually what is called a “float” nurse, who will take over his or her patients.
As test results come in and your relative is seen by specialists the preliminary diagnosis/diagnoses will be reviewed and perhaps refined and this will lead to further treatment plans and decisions about whether someone should be admitted or treated and discharged. This process also can take many hours. At times no decision is made right away and the doctor will want the patient to be monitored.
Decisions about discharge and admission are based not only on each patient’s life situation, abilities and care needs but they can also be influenced by the limited resources that are available. There are often very few beds unoccupied in the hospital and many people in the emergency ward who need one.This means that a decision has to be made about whether someone is well enough to function at home or whether they should be kept in the emergency ward in a partitioned cubicle or even the hallway if there are no cubicles available until a bed is open.
Once all tests have come back, and treatment has started, the doctors and nurses may wait until they see the results of treatment before they make a decision. If the issue seems to be resolved, or does not call for admission, the patient will be discharged. If not, they may wait longer and do additional tests or treatment, and monitor the patient until they feel there is some resolution or there should be an admission to an inpatient unit. Should the patient be discharged, there may not be a Social Worker available to do emergency discharge planning.
At Diamond Geriatrics in our role as Advocate and Care Managers, we have accompanied many clients to most of the hospitals in Greater Vancouver when family has not been available or when they have had no family. Our experience has been that the doctors, nurses, social workers, and other personnel in emergency wards have been extremely kind, patient, and caring. Considering how busy they are and the length of shifts they may be doing, we would like to take this opportunity to acknowledge them and the work they do and the manner in which they do it.
The Family Member’s Role in the Emergency Ward
As a starting point, in the event of an emergency it is critical that seniors have up to date information on their medical status, medications, allergies, and treatments easily available to be brought to hospital. (To make this easy, download and fill out the Diamond Geriatrics Emergency Form in the Eldercare Advice section of our website.) If an ambulance is called, this package of information should be given to the paramedics. It should be kept in an easily visible and accessed spot such as on the outside of the refrigerator door in case there is no one to tell the paramedics where the information is.
Every family member who might be called upon to respond to the hospital or go down to the emergency ward should also have a copy of the information. You do not want to lose time or be unable to answer a doctor’s questions during a critical care period because you are gathering the information or have to go to your family member’s home to find documentation or pill bottles. You should not assume that the hospital has accurate or complete information from past admissions or online provincial medical systems that track care or prescriptions.
If a person arrives at the emergency unit unaccompanied by a caregiver or family member and without an information package, the treatment team will have to depend on ambulance drivers or the patient themselves for basic information. If the person is suffering from dementia or is delirious they are very likely to give inaccurate or incomplete information or in some cases may not be able to give any information. They may become more disoriented as their situation progresses. If someone is hearing impaired there is a risk that they will give wrong information because they do not hear what they are being asked. Wrong or inaccurate information may also be given if there are language barriers.
Staff may not realize the degree to which someone is impaired and may take the information your loved one gives them at face value. The treatment team needs someone who can give them an accurate and complete picture of how your loved one has been functioning and what their abilities are.
The emergency ward can be a frightening place for anyone, and even more so for seniors who may have cognitive or sensory deficits or language barriers. You may need to explain to them what is happening or repeat questions that the nurse or doctor is asking.The familiar voice or warm hand of someone they know can make a huge difference in making them feel safe and lowering their anxiety level. You might be able to help your loved one feel more comfortable by finding them an extra blanket, a glass of water (with the staff permission in case tests need to be done), or obtain a pain reliever.
All of a person’s relevant information–history, capabilities, past tests, risk factors, etc.–needs to be available to the treatment personnel as early in the process as possible so it can be relayed to the doctor who considers the global situation when deciding about the best course of action, including admission or discharge. It may need to be repeated to several different doctors and nurses during the stay. Even with the emergency document, family members are helpful to confirm, explain, or expand on what is written there. This is why you need to arrive as soon as possible, and stay as long as possible.
As tests are being done, track what the results were. Let the nurse or doctor know if the results are similar to other tests that have been done in the past or even whether these or similar tests have been done and when and where.
As a decision approaches regarding admission or discharge, the staff also should be given a clear picture of the potential risks of sending a patient home. For example, family members should ensure staff knows if there is no one there to look after the patient, if there are stairs that they cannot manage, if they are too confused to manage on their own, if they have had multiple falls, if there is an abusive living situation, if they are unable to take their medications, go to the toilet on their own, or prepare food, etc.
Many major hospitals have a Geriatric Nurse Specialist whose role is to do a further assessment with an elderly patient and or their family. As a specialist in geriatrics, this nurse will understand that what may be normal or acceptable in a younger person could be problematic in an older one or is a clue that something might be occurring that would otherwise be missed. Ask whether your relative has been seen by the Geriatric Nurse Specialist, if there is one. If they have been seen, ask to speak to that Nurse and review with him/her the situation and plans. If the Geriatric Nurse Specialist has not become involved, request that he/she do so. Similarly, you can ask if a Social Worker is involved and available; if so you can ask to see that person to discuss discharge and also the situation at home which might need additional resources.
You need to keep on top of treatment and decisions until your relative is finally admitted or discharged. If you are unable to stay, try to find other family or friends who can stay in your place. Families have often hired Diamond Geriatrics as back up or even primary responders if they are not in town. If your loved one presents as well enough and also as being competent to make decisions and care for themselves, they can be discharged home without your knowing about it. Never assume that someone will be admitted to an inpatient treatment ward no matter what you are told until it actually happens. If no one can be there, write out on a large piece of paper and leave on the bedside table “DO NOT DISCHARGE WITHOUT CONTACTING (–)” and your phone number.
You are an advocate and support for your loved one while they are in the emergency ward. At the same time you are a crucial part of the treatment and decision making team.
Do Not Resuscitate and Other Questions: When Family Members Have to Make the Decisions
If your relative is not able to answer questions or make decisions the staff may ask you whether you are the power of attorney or legally entitled to make decisions on their behalf. If you have a copy of a Representation Agreement/Medical Power of Attorney or similar document, bring it with you. Staff may also may ask you about a “do not resuscitate (DNR)” order. This is the documentation which directs the treatment team’s actions if your relative has a stroke or goes into cardiac arrest. If your relative’s wishes in this regard are not in the Representation Agreement or medical power of attorney, it is up to you to relay what you know to be the wishes of your relative (not what you would like to occur).
These are very painful decisions to make at the best of times. They can be even more stressful and emotional when your loved one is in the emergency ward. You and other family members may also not agree on the best course of action. This is why you should have an open conversation with your relative about what they would like in an emergency or when they are no longer able to make decisions or care for themselves. Their wishes should be known by the whole family and documented.
For more on Representation Agreements, Power of Attorney and more, see Elder Voice’s issue of July, 2010. For updated information please also see the Nidus Registry and also Representation Agreements from Heritage Law.
