by Nancy Vessell
As the first baby boomers turn 65 this year, emergency departments across the country may be forced to see a new reality. “People will start to recognize that geriatric [patients] are not just wrinkly adults,” says David John, MD, chair of geriatric emergency medicine for the American College of Emergency Physicians (ACEP).
Just as hospitals began developing pediatric EDs 30 years ago upon recognizing that children were not just small adults, so too must they adapt their emergency services to meet the unique needs of the over-65 population, John and others say.
Emergency departments rooted in fast, chaotic, M.A.S.H.-style emergency treatment are not suited to elderly patients who often have multiple health issues, as well as mental and social concerns.
“The really, really good emergency departments are in no way optimized to care for frail, elderly people. Emergency departments were conceived and staffed to provide care for well, injured people. And they work pretty darn well for that. But they don’t work well for frail, older people with multiple morbidities,” says William Thomas, MD, who founded the Eden Alternative to improve quality of life for elderly residents of long-term care facilities. Thomas, a geriatrician, is now turning his attention to acute care and consults with Trinity Health in developing senior emergency departments in the system’s hospitals in eastern Michigan.
John and Thomas explain what’s wrong with conventional emergency departments. To begin with, they are noisy and chaotic, which can cause confusion in elderly patients. The glare from artificial lighting can lead to falls. ED mattresses are too thin for frail bodies. Patient rooms or bays are too cramped for visits from extended family members. In addition, the quick pace that expedites necessary ED turnover often fails to identify the complex issues of aging.
“Frequently, staff members are kind and compassionate, but have little patience with elderly problems,” Thomas says. “The culture of the emergency department is built on fast medicine. The needs of frail older people are founded on the virtues of slow medicine.”
John, who is director of emergency medicine at Caritas Carney Hospital in Boston, says that the typical ED is simply “not a nice place for an old person.” But he adds, “Less than a handful” of hospitals so far have adapted to the new reality.
The transformation begins
Holy Cross Hospital in Silver Spring, MD, part of the Trinity Health system, was the first hospital in the country to develop a senior emergency department. The initiative was launched in 2008, after the CEO recognized that his hospital’s ED was not well suited to care for his elderly mother.
The transformation at Holy Cross served as a pilot for other Trinity hospitals, says Sue Penoza, the system’s director of planning. The numbers helped fuel the momentum. Nearly 19 percent of Trinity’s ED patients were 65 and older, compared with the national average of 15 percent, Penoza reports. That portion will grow nationwide as the baby boomer generation ages.
In 2010, Trinity hospitals in eastern Michigan – known regionally as Saint Joseph Mercy Health System – developed seven senior EDs. They have adopted various models of operation based on size, Penoza explains. Larger hospitals built separate EDs with dedicated staff for senior patients, while smaller hospitals with lower patient volumes carved out sections of existing EDs for elderly patients.
Penoza says that basic standards apply across all models. A typical senior ED has fewer units, natural lighting, non-skid flooring, soothing colors, and amenities such as warm blankets and fresh flowers to create a homier feel. Communication pieces, such as wall posters and pain scales, have larger print, and reading glasses are available.
“When you walk into the senior ED, it’s almost a sensory experience. You feel the calmness, the quiet, the slower pace,” Penoza says.
Another big part of the care for older patients is a thorough medication review by a pharmacist. “One of the major problems older people contend with is overuse and misuse of prescription medications,” Thomas points out. “A trip to the emergency department is the ideal opportunity to look at the medications the person is taking and think about how they might be contributing to the problems. We place premium value on revisiting a person’s medication list and streamlining it.”
St. Joseph Regional Medical Center in Paterson, NJ, was another pioneer in geriatric emergency services. Mark Rosenberg, DO, chair of emergency medicine, introduced the concept there as a way to improve the health of elderly patients to prevent their need to return to the ED.
He cites a Canadian study showing that 40 percent of ED patients older than 65 returned to EDs with their conditions worsened. He feels that’s partly due to incomplete assessments in the ED, which fail to address psychosocial and physical needs of elderly patients.
St. Joseph solicited input from area geriatricians to develop a separate, 14-bed geriatric ED, which opened in 2009. In addition to a calmer environment, the dedicated ED has full access to hearing, vision, and balance testing.
A key to the program, Rosenberg believes, is a nurse coordinator who calls every elderly patient the day after discharge. The coordinator makes sure the patient is improving, is taking prescribed medications, and has made follow-up appointments.
Rosenberg, who is chair-elect of ACEP’s geriatric emergency medicine section, reports the successful outcomes of St. Joseph’s senior ED. Unscheduled returns of ED patients age 65 and older dropped from 20 percent to just over 1 percent since the dedicated ED opened. In the same time, the volume of ED patients age 65 and older increased by 11 percent, and surveys show “virtually 100 percent are satisfied,” he says.
A culture change
The new, senior-friendly EDs at St. Joseph and the Trinity hospitals required special staff training. Trinity nurses went through an eight-hour course in geriatric care through the Emergency Nurses Association, while non-nursing staff members were trained in the hospital, Penoza says. ED physicians were encouraged to pursue online training in geriatric emergency care.Realizing that physicians lack geriatric training, John is developing a course that will be offered to emergency physicians through ACEP.
“Part of it is just awareness that people are different,” he says. “You don’t send an elderly person home after 9 p.m. to an empty apartment. It’s not safe. You keep them overnight. An elderly person with a trip-and-fall is not the same as a young person with trip-and-fall. You don’t just fix the bruising and send [the elderly] on. You ask them why they tripped today, if they’ve been walking over that same rug for over 30 years. If we do the work-up, 99.9 percent of the time we find something that might have caused them to trip.”
The shift to a geriatric ED is “an enormous culture change” for staff, says Eve Pidgeon, manager of corporate communications and public relations for Trinity Health. “You have to get involved with each patient to deliver individualized care and find out, for example, [patients’] level of depression and whether they have resources for help at home after they’re discharged. You really have to slow it down. It’s a different mindset. The people who want to work in senior emergency centers are people who feel called to that space for personalized service.”
The culture change can be difficult. Rosenberg expected an easy launch at St. Joseph, but was surprised to find that doctors and nurses initially did not want to work in a separate ED for elderly patients. “They really had the perception that it was a bedpan unit. It’s anything but.”
So the transformation was started slowly by first incorporating a geriatric pathway in the general emergency department. Staff members realized they were dealing largely with functional seniors, so they were more eager to work in a separate ED, Rosenberg explains. “Once the program was established, nobody minded taking care of the whole continuum of aging,” he says.
So far, marketing of senior EDs has been minimal. Most of the attention has come from stories in the news media about the novel programs. St. Joseph focused its early communication efforts on area geriatricians, and only recently did it begin public relations activities.
Trinity hospitals have been sending staff to speak to community groups interested in learning more. A more formal marketing campaign will soon be underway in eastern Michigan with billboards, direct mail, newspaper ads, and public relations efforts promoting the patient-centered experience, Penoza says.
Other hospitals are expected to develop dedicated geriatric EDs, but financial constraints may slow the trend. “Nobody has any money,” John points out. “Whenever there’s a disconnect between what should be and what is [happening] in medicine, it’s always about money.”
Trinity’s hospitals in eastern Michigan spent $1.4 million on facility renovation and staff training to launch seven senior EDs – not including ongoing operational costs. Penoza says administrators recognized the value. “They saw some of the positive response they got at Holy Cross Hospital and were looking at the demographics going forward with the aging population and health care reform,” she says.
Under health care reform, hospitals are encouraged to improve the health outcomes of senior patients, because they are subject to reduced reimbursements for excessive readmissions of discharged Medicare patients.
It could be argued that the same quiet, slow, warm-blanket approach would be good for emergency patients of all ages. Thomas agrees. “If you create a system that really works for vigorous and sick younger people, it won’t work for older people. But a patient-centered system for older people will serve younger people very well,” he says. “It’s an irony of our time. Taking care of the frail is really the key to transforming acute care into person-centered care. An important message for health care strategy is to stop and ask the question: How well do we serve the frailest people among us? It’s the best way to begin a conversation about patient-centered care in your health system as a whole.”
Nancy Vessell is a freelance writer and editor specializing in the health care field. She can be contacted at firstname.lastname@example.org.