Customize design, staffing for geriatric ED or wing

When you're planning a geriatric ED or looking to transform part of your department into a geriatric wing, there are several design and staffing considerations the ED manager must take into account, advises Robert Fitzgerald, MD, FACEP, an attending physician in the ED at Boswell Hospital in Sun City, AZ. Fitzgerald also lectures at Harvard University in Cambridge, MA, on the topic of designing the ED for the elderly patient.

"You've got to consider the kind of environment that would be more comfortable and more conducive to better care, given the visual and hearing limitations of the elderly," he says. "The typical ED is noisy, chaotic, and brightly lit, which does not work well for most patients — especially the oldest of the old."

These issues can be addressed by having private rooms with individual controls over lighting, temperature, and acoustics, Fitzgerald says. "In a typical ED when you're lying on a gurney and you can hear everyone else's conversation, a lot of the elderly will not understand a word you're saying," he notes.

Issues with lighting

Lighting can be a big issue in ways you might not typically think about, says Fitzgerald. "If you are a typical ED doc or nurse and are backlit, for a lot of elderly patients that really blanks out your face," he says. "In an ideal geriatric ED, you should have the ability to have indirect lighting and a rheostat to adjust it."

The elderly do not do well on the typical 2-inch gurney pad, Fitzgerald says. "After 45 minutes, they overcome capillary refill, so you are working on skin breakdown at minute 46," he explains. Fitzgerald says he uses 5½-inch mattresses "which have become more of a standard now because, frankly, the younger patients do not like the thinner mattresses, either." Beds, he adds, should be able to be lowered down to 14 inches so the older patients will not require step stools.

"I'm also a big believer in eye-to-eye contact," Fitzgerald says. "We have moving barstools with joysticks so you can look directly in the patient's eyes, rather than standing over someone and looking down on them." In addition, he shares, at South Shore Hospital in Weymouth, MA, "We designed part of the ED with nonskid linoleum, which made it easier to evaluate the gait of older patients."

In reality, says Fitzgerald, "Most of these changes are things you might want to do for your younger adult patients as well. After all, who wouldn't want private rooms with less harsh lighting?"

When it comes to staffing, he says, a geriatric ED requires that you develop a geriatric team to treat the patients. "This should include a doctor, a nurse, a social worker or case manager, and ideally a midlevel provider like a geriatric physician's assistant," Fitzgerald advises. "They will have the time to spend on things doctors or nurses may not — for example, screening patients for depression or to determine if they have an altered mental status rather than a stroke." These fine distinctions are universally missed in most EDs, Fitzgerald asserts, "and such patients often get admitted for a couple of days."