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Make your waiting room safe for elderly patients
(Editor's Note: This is the second of a two-part series on geriatrics. This issue, we cover elder stroke patients and ways to make long waits safer. Last month, we covered care of elders with seizures, traumatic brain injuries and psychiatric complaints, and we gave strategies to reduce risks of medication interactions and handoffs.)
There is a small but growing trend toward creating designated EDs for geriatric patients, but the reality is that in many EDs, elders often wait for hours in general waiting areas due to overcrowding. Here are some low-cost, simple solutions:
Make your external signage, internal signage, and printed materials easy to read, including large lettering.
Two especially important types of signs are directional and informational, says Steven Glow, MSN, FNP, RN, associate clinical professor at Montana State University College of Nursing in Missoula. Directional signs allow elder patients to know where to go first. Informational signs tell patients to inform nurses immediately if they experience chest pain or shortness of breath.
Make elders visible.
"Design waiting areas so that patients can be seen and heard by the triage nurse," recommends Glow. "Designate an elder's seating area closest to the triage nurse, and put comfortable chairs there."
Use comfortable, well-padded furniture, such as lounge style chairs.
"This decreases the risk of pressure ulcers and promotes rest during long waits," says Glow. (See related stories on triage practices to protect elders during long ED waits, below, and remote monitoring of vital signs, p. 119.)
5 triage practices that help elders
More elderly patients are waiting in the lobby of the ED at St. Joseph's Hospital in St. Paul, MN, says Joan Somes, PhD, MSN, RN, CEN, FAEN, ED educator. This situation is due to a bed shortage due to a temporary move from a 15-bed ED to an area with only 10 beds.
"Our current lobby area is not very large. The triage nurse is responsible for the patients in that area, thus is aware of who each patient is and why they are there," says Somes.
Here are four changes the ED has made to keep waiting elders safe:
1. A greeter obtains the patient's name, birth date, and reason for visit.
"They type only that information in the computer," says Somes. "The confidential information is collected later in the patient's room. Thus, this admitting clerk is freed up to watch the waiting room."
In addition to the triage nurse and the admitting clerk/greeter that watches the waiting area, the lobby also has a security guard. "They were initially placed there to increase safety of all patients, but the geriatric patient has benefited most from this," says Somes.
Security alerts the ED staff immediately if they see older persons who look as if they need help. "They have also learned that if they do need to control an older person, how to do that more carefully to avoid broken bones and skin," says Somes.
2. Several wheelchairs are kept at the ED entrance.
"Patients make frequent use of them. The greeter tends to put them in wheelchairs as well," says Somes. "It is easier to identify someone is a patient if they are in a wheelchair."
3. More frequent reassessment is done.
Level 2 patients are monitored constantly, and ED nurses check Level 3 patients every 30 to 60 minutes. "Charts are kept in a nursing section of the lobby area, so charting of assessments done in the lobby by the triage nurse are facilitated," says Somes.
4. Older patients are typically triaged at higher levels than younger patients, which gets them back sooner.
"Our staff is well-versed in the pathophysiogic changes associated with the older adult that makes them harder to assess and triage," says Somes. "They look for the subtle clues that indicate life-threatening problems."
She gives the example of a 90-year-old woman who denies chest pain and presents with mild shortness of breath for several days. That situation would be enough to trigger the triage nurse to be concerned about a myocardial infarction or congestive heart failure, versus a simple pneumonia. "With back or abdominal pain, our triage area is suspicious for an abdominal aortic aneurysm if the patient is older," says Somes.
5. Make hourly rounds.
Because older patients are typically triaged at Level 3 or higher, says Somes, they are "rounded on" at least every hour, if not more often.
The frequent checks mean that if an elder's condition changes, their triage level is upgraded right away. "Our staff recognizes that older people have difficulty hearing and moving about. Staff move about the waiting room, if necessary, looking for the patient if they do not answer," says Somes.
Monitor waiting elders remotely
During long wait times, consider the use of wireless pulse oximetry as one possibility to more closely monitor the vital signs of elders in your ED.
"We certainly use remote pulse oximetry as an early warning system for inpatients," says Steven Glow, MSN, FNP, RN, associate clinical professor at Montana State University College of Nursing in Missoula. "It would help identify someone who is decompensating as manifested by decreased saturation or perfusion."