Hospitals Revamping EDs to Serve Elderly

Mt. Sinai Hospital in New York City opened its geriatric ED in 2012 after realizing the growing elderly patient population needed more directed attention than they could receive in the normal ED. Mt. Sinai had already responded with an expanded volunteer program aimed at assisting the elderly, says Denise Nassisi, MD, director of the geriatric ED.

“We tried to give them more of the human touch, someone to advocate for the patient and keep them engaged with activities. We also had someone donate reading glasses and hearing devices in case patients forgot theirs at home,” Nassisi says. “These changes helped and we started looking at the possibility of making physical changes as well. We ended up deciding to create a separate physical space for our elderly patients.”

Part of the impetus for the separate geriatric space was to keep elderly patients from being admitted unless absolutely necessary, Nassisi explains. Elderly patients don’t want to be admitted and a hospital stay often is risky for them, so ED services that best meet their needs could improve the chances of them going home afterward, she says.

The project involved a wide range of hospital departments and services and a year of planning, she says. A space adjacent to the existing ED was scheduled for renovation already, so Mt. Sinai incorporated the geriatric ED into that plan, making the financial investment lower than it would have been if starting an entirely new construction project, Nassisi says. The hospital also received a federal grant that helped with hiring additional staff.

The geriatric ED has yielded positive results, she says. Elderly patients consistently report that they prefer it to the regular ED, she says. Social services has a particularly robust presence in the geriatric ED, focused on helping patients go home rather than being admitted and helping them with discharge and aftercare. Avoiding admission sometimes means keeping patients in the ED longer than they would be in the regular ED, Nassisi says.

“We try to avoid just admitting patients who have a lot going on, and instead we take the time to sort out what’s going on so that we can send the patient home if that is at all possible to do in a safe way,” she says.

Coordination with other available services is important in making the geriatric ED effective, Nassisi says, so it is important to get the buy-in of social services, pharmacy, case management and many other departments in the planning process. Staff also must be trained in the special concerns with elderly patients.

ED Affects Elderly More

MedStar Good Samaritan Hospital in Baltimore has long-term plans to put a geriatric-designated area in its ED, says Director of Geriatrics George Hennawi, MD, CMD, FACP. The hospital established a center for aging in response to the growing need, and now it plans to set aside part of its ED as well.

“It’s not that traditional EDs don’t serve the elderly well, but the experience for them is not what it could be. The reality is that the fast pace, the noise, the uncomfortable seats, the traditional approach in an ED is not usually soothing or comforting for older folks,” Hennawi says. “People over 65 already account for a large proportion of ED visits and that number is only going to grow.”

Elderly patients often fare poorly in a traditional ED because they have a poor reserve for dealing with stress. An experience that may be unpleasant for a younger person can trigger real problems in the older patient, he says. With patients already susceptible to delirium, the onslaught of noise, lights, strangers touching them and asking questions or giving instructions, can result in the elderly patient being overwhelmed and sliding into a state of delirium, Hennawi notes. That complicates their care and can reduce the quality of the outcome.

“That can begin a trajectory of decline,” he says. “Hopefully a geriatric ED will reduce the confusion and delirium, which will reduce the other complications that come from that and lead to greater quality for older folks. We will treat them without making them confused, which will lead to better results.”

The plan is to give elderly ED patients an area that is quieter and more comfortable, which Hennawi says is about patient satisfaction — but more. The Good Samaritan ED has about 50 beds, so Hennawi is thinking of setting aside an area with about eight beds, which roughly matches the percentage of elderly patients seen in EDs. Even though it will be small in comparison to the rest of the ED, Hennawi estimates that the project will cost about $2 million because of the extent of the redesign for that area — everything from new flooring to soundproofing and all new furniture.

An Outpatient Feel

The geriatric ED may be ready in 2018, Hennawi says. The area will be physically separated to avoid the noise and bustle of the regular ED.

Hennawi says Good Samaritan is aiming more for the feel of an outpatient clinic, so it won’t have the high-efficiency but low-comfort amenities of a normal ED. Rather than exam beds with thin mattresses, it will have reclining chairs. A volunteer will roam around to check on people and provide assistance. Even the curtains have been chosen carefully, with plastic rings and supports to avoid the typical noise of curtains being pulled open or closed.

Colors are chosen to be more pleasing to an elderly generation, avoiding overly bright or high-contrast colors. Artwork will be chosen similarly, perhaps depicting traditional scenes from Baltimore history.

Some of the changes, such as a quieter environment and more comfortable beds, would appeal to all ED patients and not just the elderly. But Hennawi says it would be impractical to implement them across the entire ED, which has to deal with high-acuity patients rapidly.

“You can’t take someone who comes in with a heart attack and needs rapid IVs, needs to be laid flat on the bed for a central catheter, and treat them in this more comfortable ED,” he says. “EDs are designed to take care of people like that in the most effective and efficient way, but we’re carving out a segment of the ED population that doesn’t always need that aspect.”

Other Patients Could Benefit

Elderly patients are most negatively affected by the typical ED environment because they have poor reserves to begin with. However, Hennawi notes that the elderly are not the only ED patients who don’t always require that high-speed, high-acuity care. He suggests that hospital EDs should work toward providing this more patient-centered approach to as many segments of the ED population as possible.

“This is critical for any hospital because in addition to the statistics, patient satisfaction scores are a big part of how hospitals are going to be reimbursed, and this type of ED has a shown a great satisfaction score right off the bat,” he says. “I think it’s a great strategic move for our hospital.”

Good Samaritan also is hoping to reduce readmissions from the ED, which is increasingly viewed as a bad metric that penalizes hospitals, he says. The hospital plans to study the level of delirium among ED patients, readmissions, outcomes, and other factors to assess the effectiveness of the geriatric ED.

“It’s a win-win situation, with the patient getting better patient-centered care and the hospital improving patient satisfaction scores, reducing complications, and reducing readmission,” he says.

SOURCES

• George Hennawi, MD, CMD, FACP, Director of Geriatrics, Medstar Good Samaritan Hospital, Baltimore.
• Denise Nassisi, MD, Director Geriatric Emergency Department, Mt. Sinai Hospital, New York City.