Emergency department care transition barriers: A qualitative study of care partners of older adults with cognitive impairment

Abstract

INTRODUCTION After emergency department (ED) discharge, persons living with cognitive impairment (PLWCI) and their care partners are particularly at risk for adverse outcomes. We sought to identify the barriers experienced by care partners of PLWCI during ED discharge care transitions. METHODS We conducted a qualitative study of 25 care partners of PLWCI discharged from four EDs. We used the validated 4AT and care partner‐completed AD8 screening tools, respectively, to exclude care partners of older adults with concern for delirium and include care partners of older adults with cognitive impairment. We conducted recorded, semi‐structured interviews using a standardized guide, and two team members coded and analyzed all professional transcriptions to identify emerging themes and representative quotations. RESULTS Care partners’ mean age was 56.7 years, 80% were female, and 24% identified as African American. We identified four major barriers regarding ED discharge care transitions among care partners of PLWCI: (1) unique care considerations while in the ED setting impact the perceived success of the care transition, (2) poor communication and lack of care partner engagement was a commonplace during the ED discharge process, (3) care partners experienced challenges and additional responsibilities when aiding during acute illness and recovery phases, and (4) navigating the health care system after an ED encounter was perceived as difficult by care partners. DISCUSSION Our findings demonstrate critical barriers faced during ED discharge care transitions among care partners of PLWCI. Findings from this work may inform the development of novel care partner‐reported outcome measures as well as ED discharge care transition interventions targeting care partners.

“You treat what you have to treat, and you don’t care as much if they understand or if they feel good about it”: Communication barriers and perceptions of moral distress among doctors in emergency departments

“…In accordance with the informants worry regarding making incorrect clinical judgements and assessments, previous research has found that dementia indeed is associated with decreased accuracy of the older patient presenting illness, [ 29 ] and that communication barriers pose risks for patients. [ 13 , 15 – 18 ] Specifically for PLwD, whose ED visits are associated with adverse outcomes including functional decline, hospitalization, and mortality, [ 3 , 10 , 11 , 30 , 31 ] with one of the found reasons for adverse outcomes being communication barriers. [ 11 ] Indeed, PLwD are less likely to comprehend their discharge diagnosis and instructions.…”

“…[ 13 , 15 – 18 ] Specifically for PLwD, whose ED visits are associated with adverse outcomes including functional decline, hospitalization, and mortality, [ 3 , 10 , 11 , 30 , 31 ] with one of the found reasons for adverse outcomes being communication barriers. [ 11 ] Indeed, PLwD are less likely to comprehend their discharge diagnosis and instructions. [ 29 ] ED visits for PLwD are further associated with higher mortality and higher costs compared to patients without dementia, [ 3 , 32 ] in line with the informants’ experience of PLwD requiring more resources.…”

“…[ 3 ] In fact, nearly half of all PLwD will visit the ED in any given year, and ED visits by PLwD are associated with adverse outcomes. [ 3 , 10 , 11 ] One factor that has been attributed to this is poor communication. [ 11 ]…”