Identifying improvements in an emergency department elder friendly area based on patient experience “ED_EFA their voice project”

The Emergency Departments (EDs) classically focus on the identification of patients' acute disorders, their diagnosis, treatment and early discharge. However, in older people, urgent care must have particular features to ensure quality [1]. First, it frequently requires simultaneous treatment of several medical, social and functional problems. In addition, the priorities are symptom control, maximizing quality of life, and ensuring the continuum of care. For all these reasons, experts and scientific societies recommend developing strategies in EDs that combine: 1) comprehensive geriatric assessment (CGA); 2) structural customization; and 3) training of professionals in geriatric care [2-5].


Introduction
The Emergency Departments (EDs) classically focus on the identification of patients' acute disorders, their diagnosis, treatment and early discharge. However, in older people, urgent care must have particular features to ensure quality [1]. First, it frequently requires simultaneous treatment of several medical, social and functional problems. In addition, the priorities are symptom control, maximizing quality of life, and ensuring the continuum of care. For all these reasons, experts and scientific societies recommend developing strategies in EDs that combine: 1) comprehensive geriatric assessment (CGA); 2) structural customization; and 3) training of professionals in geriatric care [2][3][4][5].
In this regard, Hospital de la Santa Creu i Sant Pau ED has developed a Program of Care for frailty (PCF) over the last 10 years, which includes nursing care and proceedings focused on older people, and a territorial network with other healthcare providers [6]. In November 2017, the program's implementation process was completed with the creation of an Elderly Friendly Area (ED_EFA). All this has led us to obtain in May 2019, the first GEDA (Geriatric Emergency Department Accreditation) that the ACEP (American College on Emergency Physicians) has delivered to an ED outside the United States or Canada [7].
One of PCF's major objectives is the prevention and proper management of delirium, which is a geriatric syndrome that frequently appears in elderly patients in the ED and has been associated with a poor prognosis (increased stays, higher admission rate and mortality) [8]. In this way, the nursing care plan and the structural elements of the area can bring benefits. For this reason, the new EFA was built, with adjustable natural and artificial light, soundproofing, light-absorbing colours that prevent reflections that may precipitate hallucinations in patients with age-related visual defects, adequate furniture that maximizes the comfort, comfortable armchairs, furniture and adequate space for the companion, circadian rhythms in the procedures that allow night's rest, individual boxes with an autonomous buzzer to warn the unit's professionals. It is therefore an observation area integrated into the Emergency Department where the old people wait between 12-24 hours until the diagnostic process has been completed or there has been clinical improvement and they can be transferred to the best destination for discharge (home, hospitalization at home, nursing home, or socio-sanitary centers) [6,8].
Our Program of Care for Frailty has proved its worth in organizational and operational terms [6]. However, we aimed to carefully evaluate patients' experience in the new EFA. According to the Beryl Institute's definition, the patient experience is the sum of all interactions, shaped by an organization's culture, that influence patient perceptions throughout the continuum of care [9].
This project aims to analyse the quality of patients experiences in ED_EFA and identify areas for improvement and feasible solutions. The project uses the creative problem-solving methodology called Design Thinking.
Design Thinking is a creativity and innovation methodology that compiles tools for problem solving based on design principles. It is characterized by its ability to mix convergent and divergent thinking, reconciling rational and intuitive thinking. This methodology consists of four phases: Mapping (process mapping), Exploration (revision of the process), Construction (creation of new proposals) and Testing (implementation of these). In every step, techniques help to observe, get involved and immerse ourselves in the ecosystem of the patient, with the aim of designing a solution with the user and not just for him [10,11].
During the project, an assessment questionnaire was designed and distributed among ED professionals, EFA users and their caregivers. A high level of satisfaction was observed. Despite this, it was found that there were opportunities for improvement in patient information about their process and also about the peculiarities of the area. In a very special way, it was proposed to facilitate a greater involvement of the families in patient care. A co-creation workshop was held with professionals, patients and families, which resulted in the production of two prototypes. The first one refers to a leaflet or Engagement Card, which provides information to patients and relatives about the EFA peculiarities. In addition, it includes a set of proposals through which the relative may volunteer to take part in the care (meals, entertainment and hygiene). The second prototype is a customized board containing details of ED team and clinical process. At this moment the project is in a revision phase after the implantation of the two prototypes, and we hope to observe an improved experience of our users.
In summary, EDs must adapt to care for the older and more vulnerable population, which is subject to increasing risks during its stay and suffers particularly negative experiences in this setting. Adaptation requires the integration of comprehensive geriatric assessment and multidisciplinary care provided by emergency professionals with specific skills. It also requires guaranteeing quality transitions. The main objective of the ED organization is to achieve an efficient, safe and high-quality care process. In this sense, the patient's experience is an added dimension. The organization's knowledge of this aspect and including the patient's point of view can create more ergonomic processes, tailored to the patients' needs and lead to higher quality experiences.