Meet the needs of aging patients with a senior-friendly ED
Geriatric EDs offer lessons on improving care for all patients
Emergency departments tend to be noisy, bright, and intensely focused on patient throughput. For the most part, the model works for young adults who are used to such hustle and bustle in their daily lives. But as the population ages, a growing number of health systems are questioning whether this kind of environment best meets the needs of their senior patients.
Mark Rosenberg, DO, MBA, FACEP, FACOEP-D, the chairman of emergency medicine, geriatrics, and palliative medicine at St. Joseph's Regional Medical Center in Paterson, NJ, and the chairman of the geriatrics emergency medicine section of the American College of Emergency Physicians, thinks the answer is pretty clear. "I know my mom very well, and she is 80 years old," he says. "She gets nervous and uncomfortable when she is in an environment that is loud with monitors going off and bright lights everywhere. She tends to clam up and not give you all the detailed information that you would really need to take care of her."
Consequently, to remove senior patients from the "organized chaos," Rosenberg opened up a senior ED that sits three floors above the main ED at his inner city medical center. "We knew there was a crisis of aging a great tsunami, with this wave of baby boomers who are turning 65. And we also knew that patients over the age of 65 tend to use the ED much more than their younger patients," he says. "We thought we needed to get ready for that and look at the special needs of seniors."
The 14-bed geriatric ED has now been in operation for two years, and evidence is mounting that there is something to the approach. "Literally, 100% of the patients who are seen in that unit are satisfied or delighted that their visit was better than their prior experience in the ED," says Rosenberg. Further, the number of senior patients who return to the ED with a similar complaint within 30 days has plunged from a high of 20% before the unit was opened to just over 1% today, he adds. (Also, see "Pay close attention to medications in older patients to prevent adverse drug reactions," below.)
The New Jersey hospital is not the first to unveil a senior ED. That distinction belongs to Holy Cross Hospital in Silver Spring, MD, which opened its senior ED in 2008 after administrators there noted the same kinds of issues that Rosenberg observed. The concept worked so well at Holy Cross that the Novi, MI-based Trinity Health, of which Holy Cross is a part, has launched an initiative to open senior EDs in all of its hospitals.
"Holy Cross innovated and piloted the program, and we took everything they started with and built upon that, creating a replicable program that we have begun to implement in Michigan," explains Eve Pidgeon, MA, the manager of corporate communications for Trinity Health. In the past year, eight hospitals within the St. Joseph Mercy Health System in eastern Michigan have implemented senior EDs.
Each senior ED has unique characteristics, depending on size, staffing, and other factors, but they share a common purpose, stresses Pidgeon. "One of the wonderful key elements of our senior EDs is we slow down a lot. We really deliver patient-centered care and focus on truly exploring everything about the patient: what got them there, how to solve the problem now, how to solve other problems, and avoid having them come back," she says
For example, if a patient comes in to the senior ED with a broken ankle, it will be taken care of, but staff will also spend time trying to find out why the ankle broke, says Pidgeon. There may be a hazard in the home, a mobility issue that needs to be addressed, or the senior patient may need some additional support at home. By identifying and resolving such issues, staff can lower the odds that the accident will be repeated, adds Pidgeon.
There is no separate point of entry for the senior EDs. Everybody still comes in through main ED, explains Sue Penoza, RN, BSN, MA, the director of growth and strategic leadership at Trinity Health. A trauma patient, or any patient with an acute condition requiring immediate care, will be kept in the main ED, but other patients aged 65 or older will be triaged to the senior ED, she says.
While most facilities have dedicated space set aside for the senior ED, some of the smaller facilities have outfitted all of their rooms with senior-friendly features. "What we have tried to do is design the ED so that it physically accommodates this patient population," says Penoza. "We are doing things like pressure-reducing mattresses, adjusted lighting, making sure we have safety rails in place, and we have looked at assistive devices for vision and hearing so that we can make sure we are communicating clearly with these patients." (Also, see "Take these steps toward a senior-friendly ED," below.)
A second key component to the concept is staff education. All of the Trinity facilities have taken advantage of modules for geriatric emergency nursing that are available through the Emergency Nurses Association, based in Des Plaines, IL. "There are eight modules, and they cover things like physical care, elder abuse, ageism, and medications," says Penoza.
In addition, William Thomas, MD, a national authority on geriatric medicine and a professor at the University of Maryland Baltimore County, who is working as a consultant to Trinity, has helped to educate staff on how to best meet the needs of senior patients. "One thing we really emphasize in the senior ED model is helping the staff to really recognize that when older people present to the ED, very often they are in crisis," says Thomas, noting that this is the case even when a person's physical need may not be catastrophic. "I think the first and most important thing that both patients and family members really benefit from is that when they come through those doors, the people who are meeting them understand that this episode could very likely change the course of that older person's life."
Thomas also stresses the importance of using screening tools to identify underlying issues in the geriatric population. "A shiny machine that costs a million dollars always gets respect in medicine, but what we have found in the senior ED is that these low-tech screening tools give us a lot of information," he says.
For example, Trinity uses the following readily-available tools in its senior EDs:
- Geriatric Depression Scale (GDS), a brief 30-item screening tool for depression;
- Triage Risk Screening Tool (TRST), a six-item screen that is used to track functional status in older patients who have been discharged from the ED;
- Katz index of independence in activities of daily living (Katz ADL), a tool that assesses the ability to function in six key ADLs;
- Mini-Mental State Examination (MMSE), a screening tool for dementia; and
- Confusion Assessment Method (CAM), a screening tool for delirium.
Consider the financial case
Similar to the senior EDs in the Trinity Health System, Rosenberg explains that everyone still enters the main ED at St. Joseph's to begin with. Then the triage nurse will determine whether the patient should be transported to the senior unit. Trauma cases, or very sick senior patients, are likely to be kept in the main ED, says Rosenberg, but older patients complaining of abdominal pain or similar problems are likely to be triaged to the third floor, where the lighting has been dimmed and where there is a core group of physicians and nurses who want to work with the senior population.
While the ratio of staff to patients is no different in the geriatric unit, the physicians who work there are all double-boarded in emergency medicine and internal medicine, says Rosenberg. He states that the hospital is in the process of hiring two fellowship-trained emergency medicine geriatricians to work there.
The biggest difference between the main ED and the senior unit is the feel of the place, adds Rosenberg. "If you walked into the main ED, it would really feel chaotic to you. There would be stretchers and monitors beeping and that sort of thing," he says. "Then if I took you up to the geriatric unit, you would have a sigh of relief. There is natural lighting that comes in on three sides, it is a bright, open-feeling room, but when you are lying in bed, the lights are dimmed a little bit more and you feel comfortable laying there."
Rosenberg acknowledges that many of the features of the senior ED would actually work well for everybody not just seniors. In fact, he has taken steps to make sure that the main ED becomes more senior friendly as well. This has involved installing thicker mattresses throughout both units and providing all physicians and nurses with training in how to take care of senior patients. "The difference now is that just like with pediatrics, the geriatric ED is a unique environment where we are able to segregate a unique group of people away from the craziness of the normal ED," he says.
Further, Rosenberg stresses that there is a financial case to be made for the senior ED concept. "Quality care is absolutely the most cost-effective way of managing anybody because if you are not having any errors, then patients do better," he stresses. "Our returns [to the ED within 30 days] have decreased and outcomes have improved. And better emergency care translates into cost savings."
Thomas agrees, pointing out that efforts to meet the needs of seniors in the ED are actually a step ahead of where policy makers are in the move toward health reform. "What we recognize is this notion that when it comes to integrated care for older people, the ED is the tip of the arrow," he says. "The ED is actually key to any strategy in integrating care and moving away from episodic care because the ED is where older people come when they are in crisis."
- Sue Penoza, RN, BSN, MA, Director of Growth and Strategic Leadership, Trinity Health, Novi, MI. E-mail: firstname.lastname@example.org.
- Eve Pidgeon, MA, Manager of Corporate Communications, Trinity Health, Novi, MI. E-mail: email@example.com.
- Mark Rosenberg, DO, DO, MBA, FACEP, FACOEP-D, Chairman of Emergency Medicine, Geriatrics, and Palliative Medicine, St. Joseph's Regional Medical Center, in Paterson, NJ. E-mail: firstname.lastname@example.org.
- William Thomas, MD, Geriatrician and Professor, University of Maryland Baltimore County. E-mail: email@example.com.
Pay close attention to medications in older patients to prevent adverse drug reactions
One area of heightened focus in the senior ED at St. Joseph's Regional Medical Center in Paterson, NJ, is pharmacology. Why? Because older patients react differently to medications than younger patients, and proper dosages often need to be adjusted. "We have a pharmacist who is here 16 hours a day, assisting with choosing the correct medications for seniors and helping to adjust the dosages correctly," explains Mark Rosenberg, DO, MBA, FACEP, FACOEP-D, the chairman of emergency medicine, geriatrics, and palliative medicine at St. Joseph's Regional Medical Center in Paterson, NJ, and the chairman of the geriatric emergency medicine section of the American College of Emergency Physicians. "We also have a computer where all the medications a patient is taking and all the medications we are prescribing in the ED are screened to see if there are any potential drug-drug interactions."
In addition, Rosenberg explains that he has two toxicologists on call around the clock to immediately review any complex drug interactions. The issue is particularly important in the geriatric population because most older patients are taking several medications. "If patients are on more than five medications, they have a very significant likelihood of having a drug-drug interaction. If they are on seven medications, they have a 100% chance of a drug-drug interaction," he says. "These reactions may be severe or they may not be, but we are very sensitive to using particular drugs."
Rosenberg says St. Joseph's uses "Beers List," a list of medications originally developed by geriatrician Mark Beers, as a guide in determining what drugs should not be used in senior patients and what drugs should be used at very low or adjust ed dosages. The list was updated in 2003.1
Take these steps toward a senior-friendly ED
Before implementing a senior-focused unit, ED managers should first make sure they have a high level of support from the health system's administrative leadership, stresses Sue Penoza, RN, BSN, MA, the director of growth and strategic leadership at Trinity Health, a Novi, MI-based network that includes 46 acute-care hospitals in nine states. "This isn't on the scale of other initiatives where you are purchasing lots of equipment, but some investments are required in terms of your physical facility and education of staff," she says. "Senior leaders need to understand what you are doing and why you are doing it because even though it is an ED initiative, it does involve other areas of the hospital."
For example, if you are doing any remodeling or construction in the ED, that will impact maintenance staff, as well as other hospital employees, says Penoza. In addition, departments that work closely with the ED, such as radiology, may require some geriatric training as well because they will be interacting with patients from the senior ED.
Penoza also recommends that ED managers identify a champion who is passionate about the initiative and who can actively promote the advantages that a senior ED can bring to the facility and its patients. "We have found that there is a certain number of people who understand the concept and become engaged immediately ... but then there are others who are hesitant," she says. "It helps a lot to have a champion on board."
Once you have a base of support for a senior ED, figure out what changes you want to make for the care of this population and what you want to accomplish, adds Penoza. It's important to establish policies and goals that can be clearly communicated to staff. And as the initiative progresses, be prepared to take advantage of lessons learned and opportunities for improvement that may become apparent in other aspects of patient care.
"The emphasis on the needs of older people actually has the potential of making care better for people of all ages, and I think this is one of the things that the adopters of this model will tell you," explains William Thomas, MD, a national authority on geriatric medicine and a professor at the University of Maryland Baltimore County. "The things we learn when we do the senior ED model can be applied to the care of people of all ages."
Mark Rosenberg, DO, MBA, FACEP, FACOEP-D, the chairman of emergency medicine, geriatrics, and palliative medicine at St. Joseph's Regional Medical Center in Paterson, NJ, and the chairman of the geriatric emergency medicine section of the American College of Emergency Physicians, agrees with Thomas, stressing that you don't have to create a separate unit to improve emergency care for seniors. "Every ED in the country can make their unit more geriatric-friendly by using a bigger font on their instruction sheets, improving the training of geriatric-sensitive medical issues to the staff, using thicker mattresses to cut down on skin ulceration, and [by strengthening pharmacological reviews to eliminate dangerous] drug-drug interactions," he says. "If you create a system for the most frail and weak, that system will work for the strong and the healthy, so creating a geriatric-friendly ED will work for all to improve care."