title: Facilitators and barriers to safe emergency department transitions for community dwelling older people with dementia and their caregivers: a social ecological study.
abstract: BACKGROUND
  Internationally, older adults visit the ED at a rate higher than other age groups. Little attention has been given to ED care for older people with dementia, although concern for such care is growing with the increasing number of individuals worldwide affected by this significant disabling problem. It is critical to understand ED transitional processes and consequences because the complexity of dementia care poses multiple challenges to optimizing safety, effectiveness and quality of care during admission, assessment, and treatment in this setting.
  
  
  METHODS
  Using an interpretive, descriptive exploratory design with three iterative, interrelated phases, we conducted interviews, created a photographic narrative journal (PNJ), and finally held photo elicitation focus groups to identify factors that facilitate or impede safe transitional care for community dwelling older adults with dementia in two Canadian emergency departments, and to identify practice solutions for nurses. We purposively sampled to recruit ten older adult-family caregiver dyads, ten ED RNs, and four Nurse Practitioners. Data were analyzed using constant comparative analysis.
  
  
  RESULTS
  Four interconnected reinforcing consequences emerged from our analysis: being under-triaged; waiting and worrying about what was wrong; time pressure with lack of attention to basic needs; and, relationships and interactions leading to feeling ignored, forgotten and unimportant. Together these consequences stem from a triage system that does not recognize atypical presentation of disease and illness. This potentiated a cascade of vulnerability in older people with dementia and their caregivers. Nurses experienced time pressure challenges that impeded their ability to be responsive to basic care needs.
  
  
  CONCLUSIONS
  In an aging population where dementia is becoming more prevalent, the unit of care in the ED must include both the older person and their family caregiver. Negative reinforcing consequences can be interrupted when nurses communicate and engage more regularly with the older adult-caregiver dyad to build trust. System changes are also needed to support the ability of nurses to carry out best practices.
authors.affiliation: Edmonton Clinic Health Academy, 11405 87 Avenue, University of Alberta, Edmonton, Alberta, Canada T6G 1C9. belinda.parke@ualberta.ca
authors.forename: Belinda
authors.initials: B
authors.lastname: Parke
authors.forename: Kathleen F
authors.initials: KF
authors.lastname: Hunter
authors.forename: Laurel A
authors.initials: LA
authors.lastname: Strain
authors.forename: Patricia Beryl
authors.initials: PB
authors.lastname: Marck
authors.forename: Earle H
authors.initials: EH
authors.lastname: Waugh
authors.forename: Ashley J
authors.initials: AJ
authors.lastname: McClelland
mesh_terms: D000368:Aged; D002170:Canada; D017028:Caregivers; D003704:Dementia / Q000451:nursing*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D006801:Humans; D061214:Patient Safety