EXECUTIVE SUMMARY

At St. Mary Mercy Hospital in Livonia, MI, patients 65 or older are treated in an ED staffed by clinicians with geriatric training, and equipped with non-skid floors, pressure-reducing mattresses, and tools to help with impaired hearing and low vision.

• All patients 65 or older are evaluated with a unique assessment designed for older adults.

• Information from the assessment is shared with patients’ primary care physicians.

• Social workers call patients within 48 hours after discharge and can arrange interventions if the patients experience problems.


When senior citizens present to the ED at St. Mary Mercy Hospital in Livonia, MI, it’s not unusual for them to tell the registration staff that they chose the hospital because of its senior ED.

The 304-bed acute care hospital treats patients who are 65 or older in a special 14-bed unit geared to the needs of the senior population. When the senior ED opened in July 2010 with six beds, it was the first of its kind in Michigan. Now, all five hospitals in the Saint Joseph Mercy Health System in Michigan have opened similar departments.

A team from the hospital visited the first senior ED in the nation at Holy Cross Hospital in Silver Spring, MD, to gather ideas for their unit. Like Saint Joseph Mercy Health System, Holy Cross is part of Trinity Health.

“Everything about the senior unit was designed to improve the hospital experience and the quality of care for older patients,” says Michelle Moccia, RN, MSN, ANP-BC, Senior ER Center program director.

The unit has safety rails, non-skid floors, extra-thick pressure-reducing mattresses, and a reclining chair in each room. The nurses can provide hearing amplified earphones for hearing-impaired patients, magnifiers and reading glasses for those with vision problems, and warm blankets. The whiteboard in the room is extra large with room for staff to write in large letters. The pain chart, clocks, and phones all have large figures.

The staff dedicated to the Senior ER Center all have received geriatric clinical training and the nursing staff have completed a 17-module course on geriatric emergency nursing offered by the Emergency Nurses Association.

Patients who are 65 years or older are evaluated when they enter the hospital, and are triaged to the senior unit when there is a bed available. Regardless of where the patient’s bed is, the nurses conduct a unique assessment designed for older adults.

“If the senior emergency department beds are full, patients over 65 will be placed in the main emergency department and the emergency department nurse completes the same assessment,” Moccia says.

The assessment covers activities of daily living, medication issues, availability of transportation, and recent hospitalizations and ED visits. The nurse completes a depression screen and assesses for cognitive issues.

“One of the most important questions is whether the patients live alone, and if they do, whether they have a willing caregiver,” Moccia says.

The nurse asks what the patient would do in case of an emergency, whether they have an alert bracelet, and if someone checks on them daily.

“We want to make sure that they understand they could be at risk if they need help and have no way to contact anyone,” Moccia says.

When the nurse enters the assessment information in the electronic medical record, the system immediately sends an alert to any department that must interact with the patient. For instance, the social worker is alerted if the patient has psychosocial issues. If there may be problems with medication, the pharmacist receives an alert.

“Pharmacists are an important part of our team,” Moccia says. If a patient comes in following a fall and doesn’t know why it happened, the pharmacist reviews his or her medication to determine if that could have been the cause. If the patient’s mental status is altered and there hasn’t been a change in his or her normal situation, it also could be due to medication, she adds.

The assessment often turns up information on senior patients that the team shares with other healthcare providers. For example, some primary care physicians do not regularly screen for cognitive issues or depression.

“The emergency room is the front porch of the healthcare system. We often discover some of a patient’s needs that the primary care physician was not aware of, and we are supplementing the information needed to care for patients in the community,” Moccia says.

Sometimes, the family doesn’t know things that the assessment reveals, she adds. “When patients exhibit memory issues, the assessment often validates what family members suspected all along,” Moccia says.

A social worker is dedicated to the senior ED from 8 a.m. to 5 p.m. Case managers cover the entire ED 24 hours a day, seven days a week, and assist with patients in the senior ED when needed.

When patients cannot be safely discharged, the social worker or case manager collaborates with the rest of the team to arrange the best discharge destination.

Whenever possible, the ED team arranges a follow-up visit with patients’ primary care physicians and the hospital pharmacy fills any prescriptions before the patients are discharged.

All patients discharged from the ED receive a follow-up telephone call within 48 hours after discharge. A social worker calls senior patients, asks how they are feeling, and checks on whether they’ve filled their prescriptions and arranged a follow-up appointment.

“Based on the call, we may do more interventions to ensure that the patient adheres to the discharge plan,” Moccia says.

If patients say they haven’t received their medications, the social worker calls the prescriptions in to their normal pharmacies or, if necessary, a pharmacy that will deliver. If patients don’t have a follow-up appointment with their primary care physician, the social worker sets up the appointment.

If there is a question with the discharge instructions, the social worker can call on the nurse practitioner or physician to review it again.

“Patient satisfaction scores for the Senior ER are very high. We know our population is aging, and we are responding to their needs,” Moccia says.