High Impact Change Area C: Managing presentations in the Emergency Department

Setting out the challenge

Within an Emergency Department (ED) there is the pressure of juggling time, space, demand and diverse presentations, with different needs (including those of inclusion health groups). Internationally it is estimated that 21 to 42 per cent of older people attending an ED will have cognitive impairment or dementia (British Journal of Nursing, 2020).

For people with dementia, the experience of being in ED can be stressful as, in addition to being physically unwell, the person is in strange surroundings, with unfamiliar and changing staff. This is worse for people who attend alone, are in crisis and do not have an advocate to support them. Attendance at ED can also be stressful for the accompanying care partner who could be worried about how the person might react in a chaotic environment.

The person may be displaying signs of behavioural and psychological symptoms of dementia (BPSD), such as delusions, hallucinations, apathy, anxiety, depression, or disinhibition, which can be exacerbated by the hospital environment and relies on busy staff having the skills to optimise their care. The setting therefore also present challenges for department staff, who report that they are not able to give optimal care to their patients.

Voices from stakeholders

People with dementia are spending too long in A&E; we need a clear pathway out for dementia and delirium."

We need to improve the knowledge of staff in A&E in how to support people and give them the environment to do so."

Clear pathways out of A&E for people with dementia and good links between older people’s services and A&E are the key to success."

Outcomes

C1. Optimal management of people with dementia and delirium in an Emergency Department, aligned to the acute frailty pathway

This includes: 

• defining how the ED initial assessment team can indicate when people require this response (and have the relevant skills and training to do so)
• identifying who can support with common presenting issues such as: hydration, nutrition, and the ability to manage pressure areas – whilst the person awaits assessment
• identifying where this support will take place, minimising ward moves where possible
• ensuring that patients requiring urgent mental health support are getting support through CMHT/ the liaison Psychiatrist within four hours. This includes the management of BPSD in a holistic way, that does not cause further distress to the person
• proactively requesting a care plan from the person or their care partners, or retrieving this care plan from available clinical record systems, in order to gather as much information as possible on presentation to ED
• considering how decisions are made, based on the paradigm the person is in. This includes thinking carefully and holistically (i.e. what are their goals, wishes, preferences, and how that aligns with their presenting situation) informing decisions about what to do for the person based on what matters and who matters most to them (e.g. in end of life care)
• facilitating an assessment for the acute condition the person has presented with, including a clinical frailty assessment within 30 minutes of arrival, for the acute condition the person has presented with (FRAIL Strategy NHS England, 2024)
• outlining how the front door frailty response is able to connect with the next step in the frailty pathway (e.g. the acute medical unit, Home First services, virtual wards services), recognising that partnership working will enable a more effective response
• optimising the expertise of volunteers or the VCFSE care sector who may have the skills to provide support for people with dementia and their care partners. 

Supporting resources