Patient Satisfaction Planner

Center dedicated to patients over age 65

Staff are trained to provide geriatric care, support

The nation's first senior emergency center, opened by Holy Cross Hospital in Silver Spring, MD, is specifically tailored to meet the needs of a growing population of adults and provides care that goes beyond the typical emergency department assessment and treatment.

The Seniors Emergency Center at Holy Cross is an eight-bed, separate, enclosed area of the main emergency department and is dedicated to the care of patients over age 65, says Susan Spivock Smith, RN, CRNP, PhD, geriatric nurse practitioner at the center. The center is staffed by two nurses, an emergency center physician, a geriatric social worker, and a certified nurse assistant.

"We operate on a model similar to a pediatric emergency department. Just as children are not small adults, older adults are not the same as younger adults. Having geriatric specialists who can recognize atypical presentations in this specialized population can help speed the plan of care and treatment and result in better outcomes," adds Marcella Smith, MSW, social worker at the center.

For instance, a younger adult who is having a heart attack will have symptoms of mid-sternal crushing chest pain, sweating, and nausea. In the older adult, the atypical presentation of a heart attack may be manifested as abdominal pain, change in appetite, or altered mental status.

"In the younger adult, when you hear hooves, you think horses; but in the older adult, you must thing zebras," Spivock Smith says.

The center opened Nov. 6, 2008. In its first year, the hospital provided care to more than 12,000 seniors in the emergency center, and more than 50% of them were admitted.

Among respondents to a patient satisfaction survey sent to patients three weeks after a visit, 98% say they would recommend the center to friends and families.

"The emergency department is a frequent point of entry into the health care system for seniors. Holy Cross Hospital has always been senior-friendly, but we wanted to expand the services we provide to older adults," says Smith.

Patients over 65 who are not experiencing an acute event such as a heart attack or a stroke are triaged to the senior emergency department or Express Care, Spivock Smith says.

About 75% of seniors who present to the emergency department meet the criteria for the senior emergency center, she adds.

Spivock Smith and Smith also see senior patients in the main emergency department.

Almost half of the patients seen in the emergency department have had a fall. The most common conditions seen in the Senior Emergency Center include abdominal pain, shortness of breath, diarrhea and vomiting, dehydration, urinary tract infections, or change in mental status.

"We assess problems that older adult patients may be having beyond the reason they came to the emergency department. For instance, if someone tells us they can't pay for their blood pressure medicine or can't afford groceries, we help them access the appropriate resources that can help. As a social worker, I have the expertise to provide support, compassion, and respect to these vulnerable elders," Smith says.

When the patient arrives at the emergency center, the RN on duty conducts a comprehensive assessment that includes the patient's living conditions, support at home or in the community, mobility issues, and whether they have been in the emergency department during the last 72 hours and the last 30 days, or have been hospitalized in the past three months.

As part of the assessment, the RN records family concerns, caregiver stress, or other issues that may affect a safe discharge.

"We look at the potential for readmissions from the get-go so we can take measures to make sure they can transition safely into the community and prevent them from coming back," Spivock Smith says.

If patients are taking five or more medications, the staff alert the pharmacist, who assesses the medication to determine if there is an inappropriate drug or dose. The pharmacist communicates the information to the physician so he or she can make changes to the medication regimen.

"A lot of times, medication can contribute to falls. The patients may not be taking the right dosage or the right class of drugs. In those cases, the pharmacist makes a recommendation to the physician to prescribe a more appropriate drug," Spivock Smith says.

The Senior Emergency Center staff have access to all the resources the hospital provides.

The team of Spivock Smith and Smith team is able to help avoid unnecessary hospitalizations by identifying proactively what issues might be a roadblock to discharge.

For instance, if a patient has fallen, they can request a physical therapy evaluation in the senior emergency center. A physical therapist can assess the need for equipment and make recommendations for home care services to assist the older adult with transitioning home safely.

"We've also helped facilitate admissions for patient who were not safe to go home. We are involved with discharge planning for these patients so when they do leave the hospital, it's to a safe environment," Smith says.

If patients are admitted to the hospital, Smith and Spivock Smith follow up with the case manager and social worker on the unit, alerting them of any issues they have observed.

"This means they are a step ahead in the discharge planning process because they already have the information we have gathered on their living situation, caregiver availability, and any mobility or cognitive issues," Spivock Smith says.

When patients are being discharged from the senior emergency center, Spivock Smith takes an active role in making sure they understand their discharge instructions and get an appointment with their primary care physician for a timely follow up.

"We take a holistic approach to the care the patient receives through the entire continuum of care. We found that sometimes patients come back to the emergency department because they don't understand their discharge instructions and they don't get the appropriate follow up after discharge," Spivock Smith says.

Smith calls the patients the day after they are discharged from the emergency department to make sure they have everything they need at home.

"Home may be a nursing home, a group home, an assisted living center, or the patient's own home," she says.

She asks if they've gotten their prescription filled, whether they have an appointment for follow-up care, and answers any questions.

If there are any barriers to care, Smith works with the patient and family to meet those needs.

For example, when patients tell Smith that they couldn't get an appointment with their doctor for several weeks, she asks for permission to call the doctor and see if she can get the appointment in a more timely manner.

"We know that if patients are not seen in a timely manner, symptoms may not be well controlled and they'll end up back in the hospital. We work to get them an appointment with a doctor in one or two days," she says.

The Spivock Smith-Smith team facilitates care along the continuum. They have a collaborative relationship with the doctors in the community.

"The physicians trust our judgment and are very receptive to our requests," Spivock Smith says.

Sometimes the team provides help and support for someone other than the patient and looks beyond his or her physical complaints, Smith reports.

For instance, a man who came in complaining of abdominal pain is the primary caregiver for a wife with cognitive issues and was experiencing a lot of stress related to caregiving.

"While the staff took care of the patient, I met with the daughter, who agreed that something needed to be done to relieve her father. We arranged for adult care to get relief for the father," she adds.

Kevin J. Sexton, president and CEO of the hospital, came up with the idea of the special emergency department for seniors because of the growing senior population in Montgomery County.

"Within the next 10 years, the senior population is expected to grow five times faster than everyone else. The growing number of seniors in this country presents a tremendous challenge to our health system, and it is our responsibility to respond in a way that is both sensitive and sustainable," Sexton said.

The hospital formed an advisory committee that included clinicians as well as a focus group of seniors and worked closely with Bill H. Thomas, MD, an elder care expert, and his team at The Erickson School at the University of Maryland to design the area and create a senior-friendly space.

The Holy Cross Hospital auxiliary earmarked the money from its gala in 2007 for the senior program.

Patients in the focus group said they wanted to be kept warm, kept comfortable, and kept informed during their emergency department stay.

The hospital modified what had been an overflow area for the Express Care department to include six bays, two private patient rooms, and a room for family consultations.

The environment was designed to reduce anxiety, confusion, and risk of falling.

"We focus on making the experience as pleasant as possible. The patients often are here for several hours," Spivock Smith says.

Features used throughout the senior center include soft colors; noise-abatement features; non-slip, non-glare floors; non-glare lights with dimmers; hand rails; and grab bars. The area has a blanket warmer and a nursing station designed for increased visibility.

The rooms have pressure-reducing mattresses, clocks, calendars, telephones with large buttons, a dry-erase board, a flat-screen television with a speaker that can go under the pillow for patients who are hard of hearing, and comfortable chairs for family members.

"We encourage family members to stay with the patients. We strive to keep them informed. We let them know what tests are being performed and when we expect the results back. It has been our experience that patients and family members become less anxious when they know what to expect," Smith says.

(For more information contact: Marcella Smith, MSW, social worker, Senior Emergency Center, Holy Cross Hospital, e-mail: smithmarc@holycrosshealth.org.)