Methodology for Developing Quality Indicators for the Care of Older People in the Emergency Department

Melinda Martin-Khan; Ellen Burkett; Linda Schnitker; Richard N Jones; Leonard C Gray


BMC Emerg Med. 2013;13(23) 

In This Article


Currently older persons make up an important group of patients served by Emergency Departments (EDs). The elderly have higher rates of utilisation of emergency services than other patient groups; in developed countries, older people represent 12% to 21% of all ED encounters.[1] The proportion of older people aged 60 years and over is expected to rise from 19% in 2000 to 34% by 2050,[2] resulting in a commensurate increase in ED presentations by older persons. Awareness of the connection between ED use and the health of older people, has led to an increased focus on the quality of geriatric emergency medical care and patient outcomes.[3–5]

Emergency practice is characterised by high volumes of high acuity and high complexity patients. This, combined with often-incomplete information and frequent interruptions, creates an environment prone to error.[6,7] Older people have been identified as a particularly vulnerable population in ED, having substantially inferior clinical outcomes, with higher rates of missed diagnoses, and medication errors, when compared with younger, severity-matched controls.[8–12] Older persons discharged from ED are at high risk of adverse outcomes, such as functional decline, ED re-admission and hospitalisation, death, and institutionalisation.[12–17]

While the quality of care for older people is a key issue, there may also be a need to consider older people with special needs as a separate sub-group as they may have some additional significant quality of care issues. There is evidence that older ED patients with cognitive impairment, which is common in the older ED population,[18–20] have an increased risk of bad outcomes and events.[17,21,22] Along with issues associated with being older, older persons with cognitive impairment, who may experience problems with their memory, reasoning, insight, or their ability to learn, have special needs when presenting to busy ED environments. Another second significant sub-group includes people residing in long term care. Persons living in long term care are in general older, have complex medical histories and are more likely to present to the ED with cognitive impairment.[23] They experience longer waiting hours, are resource intensive, are more likely to die in hospital.[24,25] A third important sub-group includes older people at the end-of-life. The chaotic ED environment can be particularly burdensome for older patients requiring palliative care. A study by Beyon et al. found that among older people who died in ED, over half of them presented to the ED with a diagnosis that triggered palliative care.[26] However, in ED palliative care is often not provided.[27]

High quality care has been shown to be associated with improved survival and health outcomes of elderly patients.[28] The anticipated "greying" of the population, with its attendant increase in older ED patient attendances, mandates an evaluation of the capacity of EDs to deliver quality care to this vulnerable patient group. Accurate assessment of current levels of quality of care in EDs is required to enable a targeted approach to care that is identified as inadequate, to improve patient outcomes. Quality indicators allow levels of performance to be determined and, as part of a quality management system, provide opportunity for benchmarking and improved care delivery.[29] The development of a comprehensive set of quality indicators (QIs) will aid in improving delivery of care in the ED to the geriatric population. This will be timely in the context of the anticipated burgeoning in the numbers of elderly presenting to EDs. In order to be considered valid, QIs should be:[29,30]

  1. Specific & defined, with content validity in the QI definition (including a defined numerator, denominator, clinical exclusions to the denominator & covariates used for risk adjustment)

  2. Meaningful with evidence to link them to the desired outcome

  3. Structured to facilitate comparison of care delivery between facilities

  4. Amenable to improvement by each particular facility, and

  5. Efficiently measurable.

Review of the literature revealed one previous publication of a group of ED-specific QIs aimed at geriatric patients.[31] These, proposed by the Society for Academic Emergency Medicine (SAEM) indicators, pertain to 3 clinical domains (cognitive assessment, pain, and transitional care) and have a predominant focus on process of care, rather than structure or outcome. The data for the process indicators are derived from chart audit, but no field testing data is available in the scientific literature. After creating scoring rules, Schnitker et al. used the SAEM QIs for cognitive assessment, in a geriatric ED population (N = 277) and found that cognitive assessment and its documentation in medical records occurred in too few patients such that scoring the majority of the QIs was impracticable in this sample.[32]

The aim of this project is to determine predictors of quality of care of geriatric patients in EDs, and to develop a suite of QIs, including structural, process and outcome measures, that are feasible with minimal collection cost, whilst being reflective of true levels of quality delivered, for use in ED-care of the elderly. This will include the potential to propose a sub-set of QIs focused on the special needs of 1) older ED patients with cognitive impairment 2) those residing in nursing homes presenting to EDs, 3) and older ED patients with palliative care needs.