Hospitals are finding that EDs designated specifically for geriatric patients can improve quality of care and patient satisfaction for an aging population, but it also is possible to make existing EDs more geriatric-friendly and reap the same benefits.
The unique needs of an elderly population can affect quality of care in the ED, going far beyond mere comfort and patient satisfaction, says Catherine Gow, AIA, principal with health facilities planning at the architecture and design firm Francis Cauffman in Philadelphia. She has worked with several hospitals to design geriatric EDs or retrofit existing EDs to make them more accommodating to the needs of the elderly. EDs that treat the elderly more effectively can expect to see improved outcomes and reduced readmissions, Gow says.
Elderly patients have health conditions that are not common in the general population, and their limitations or sensitivities can interfere with effective treatment, she says.
“Some of the design issues involve the prevalence of disorientation, light and sound sensitivity, stability concerns, many factors that can affect the level of care they receive and their outcomes,” Gow says. “There also is the need to make them feel relaxed, which is very difficult for the elderly and can interfere with the effectiveness of the care you provide. They tend to come in with multiple issues and polypharmy, which is not what you usually see with other ED patients.”
Gow notes that much of the theories on geriatric EDs are driven by the work of Mark Rosenberg, DO, MBA, FACEP, FACOEP-D, chairman of the Department of Emergency Medicine and chief of Geriatrics and Palliative Medicine at St Joseph’s Healthcare System in Paterson, NJ. Rosenberg has advocated for more geriatric-oriented EDs for years and many of his strategies are used in current designs. Gow and her firm helped design the geriatric ED at St. Joseph’s. (See the story in this issue for more on Rosenberg’s ideas.)
In designing or redesigning an ED, the goal with elderly patients is to create a calm and soothing environment so the patient can relax, Gow says. A typical ED can be loud, crowded, and frenetic, with bright lights and furniture that is not ideal for the elderly, all of which can make an already ill elderly patient more nervous and uncomfortable, she notes. When the environment allows the elderly patient to relax, he or she will more accurately convey their symptoms and concerns, and better understand the information provided, she says.
Gow notes that hospitals do not have to establish a separate geriatric ED to meet these needs, though that can be ideal if the budget allows. St. Joseph’s was able to create a separate geriatric ED to maximize the effect of the strategies, but the same design changes can be applied to existing EDs either in total or in a designated portion of the ED, Gow says. (See the story in this issue for more examples of how hospitals are accommodating the needs of the elderly in their EDs.)
Simple Strategies, Big Effect
Some of the strategies are simple but can have a significant effect on the elderly. St. Joseph’s uses exam beds with thick mattresses for the elderly, which makes them much more comfortable than the usual thin mattresses found in EDs. Some hospitals even choose to use hospital beds in a geriatric ED. The environment is designed to be quieter and less busy than a typical ED, minimizing the use of alarms, intercoms, radios, and bright lights.
Non-slip floors are important, but the floors also must be non-glare, Gow points out. Corridors should be free of hazards, with no equipment, and there should be hand rails also. The design should allow for soundproofing between rooms, so that noise in one area does not intrude into others. LED lights on the ceiling can provide adequate light without overwhelming elderly patients sensitive to light. A good idea is “cove lighting,” in which small areas of a room are illuminated instead of the entire area.
“These are features that you might find more commonly in an inpatient unit, but not necessarily in an ED. For the older patient, these features are very important in the ED,” Gow says.
Another concern is having enough room for family members. The elderly patient is more likely to arrive in the ED with family in tow, at least one or two and sometimes more, so it is important to have room and seating for them, Gow says. The ED also should have blankets available and easily accessible because the elderly patient is more likely to be cold while waiting.
The path to the bathroom is especially important, she notes. The path from the waiting area or exam room to the bathroom should be especially safe, with handrails, proper lighting, safe floors, and no obstacles.
“The ED staff don’t tend to think about these things,” Gow says. “They’re busy saving lives. It’s life or death and they’re in a rush. You have to educate the ED teams, and you can retrofit any existing ED to make it more friendly to these patients.”
Change Clinical Practices
The need for geriatric-friendly EDs is driven in part by the aging baby boom population, notes Marcus Escobedo, MPA, senior program officer with The John A. Hartford Foundation, a nonprofit in New York City dedicated to improving the care of older adults. Hospitals are responding more to the trend since the idea of geriatric EDs first emerged in 2008, he says. There are now more than 100 geriatric EDs in the United States, and still more EDs that are not solely geriatric but are catering more to the needs of the elderly, he says.
“We’re seeing a lot of attention to emergency care in general that is important in terms of quality and cost outcomes in hospitals,” Escobedo says. “Part of that is paying more attention to the needs of the geriatric population, trying to make them more accommodating and more able to effectively treat this population.”
Escobedo points out that the physical design is not the only concern when making an ED geriatric-friendly. This population also is more likely to have certain illnesses and complications, such as delirium, so the ED staff must be on alert for those conditions and ready to respond appropriately.
“We know that when older adults receive age-appropriate care, we can see better quality outcomes and improve the experience of those patients,” Escobedo says. “We don’t advocate necessarily separate and distinct ED structures be set up for elderly adults. There are things you can do in terms of retrofitting and learning from best practices in terms of modifications, as well as training your work force.”
Escobedo also advises hospitals to seek resources from the John A. Hartford Foundation, the American College of Emergency Physicians, and the Geriatric Society.
“This is vitally important now. Twenty million of the annual 60 million ED visits are older adults. More than half of elderly adults can expect to visit the ED in a year,” Escobedo says. “Those older adults are consistently at risk for poorer outcomes and higher costs when their needs aren’t met.”
SOURCES
- Marcus Escobedo, Senior Program Officer, The John A. Hartford Foundation, New York City. Telephone: (212) 832-7788. Email: [email protected].
- Catherine Gow, AIA, Principal, Health Facilities Planning, Francis Cauffman, Philadelphia. Telephone: (215) 255-7229. Email: [email protected].
Stats Show Need for Geriatric EDs
Much of the early research and advocacy for geriatric EDs comes from Mark Rosenberg, DO, MBA, FACEP, FACOEP-D, chairman of the Department of Emergency Medicine and chief of Geriatrics and Palliative Medicine at St Joseph’s Healthcare System in Paterson, NJ.
In a study published in 2011, Rosenberg notes that the elderly make up 15-20% of all ED patients and use seven times more ED services than other patients. They account for 43% of all admissions and have a 20% longer length of stay. They also require 50% more lab work and radiology, and the rate of social service interventions is an astounding 400% higher.
When it comes to clinical care and outcomes, elderly patients are more likely to suffer delays in diagnosis and treatment, Rosenberg reports. The incidence of certain illnesses is significantly greater, including acute myocardial infarction, sepsis, appendicitis, an ischemic bowel. Some conditions are more likely to be overlooked in the elderly, including delirium, depression, cognitive impairment, drug and alcohol abuse, and elder abuse.
Rosenberg also cautions that without proper protocols and staff education, elderly patients can be harmed by overuse of sedation and Foley catheters. Adverse drug events also are more likely if staff do not adequately understand the patient’s medication usage.
Physicians and staff in a geriatric-friendly ED also should keep in mind that they must interact differently with these patients, Rosenberg advises. They are more likely to have vague complaints such as, “I just don’t feel well” that, if explored more in depth, can lead to serious symptoms. Their vital signs are likely to be normal and the elderly patient may seem to have no serious illness, Rosenberg cautions, but further investigation is always a good idea. He urges physicians to press for more information and pursue potential diagnoses more aggressively with elderly patients than with the typical ED patient.
A summary of Rosenberg’s research and advice is available online at http://bit.ly/2fWH8kH.
