New Trend in Emergency Rooms That Cater to Seniors

Published March 15, 2011 FoxNews.com

For years, many hospitals have had specialty emergency rooms just for children, but now more and more ERs are opening their doors to seniors with facilities that promise less clamor and disorder. Although currently there are only a few hospitals catering to seniors, doctors expect the trend to rise dramatically with the U.S. population of baby boomers aging to their golden years. But many are left wondering if these ERs will provide better care. "Older people are not just wrinkly adults. They have totally different needs," says Dr. David John, who chairs the geriatric medicine division of the American College of Emergency Physicians. Modern ERs are best equipped to handle crises like gunshot wounds or car crashes, not the lengthy detective work it can take to unravel the multiple ailments that older people tend to show up with, John says.

Those older patients may not even have the same symptoms as younger people. They're less likely to report chest pain with a heart attack, for instance, complaining instead of vague symptoms such as dizziness or nausea. Urinary tract infections sometimes cause enough confusion to be mistaken for dementia. And a study published in January called delirium and dementia an "invisible hazard" for many older patients because ERs don't routinely check for not-too-obvious cognitive problems yet such patients can't accurately describe their symptoms or understand what they're supposed to do at home. Seniors already make 17 million ER visits a year, and 1 in 5 Americans will be 65 or older by 2030. St. Joseph's Regional Medical Center in Paterson, N.J., started a 14-bed Senior Emergency Center two years ago, and plans to open a larger one in the fall, said emergency medicine chairman Dr. Mark Rosenberg. "It's still hustle and bustle, but it's a couple notches down from the craziness of the main emergency department," he says. The idea behind senior ERs: Put older patients in an area that's a bit calmer for team-based care to not just treat the problem that brought them to the hospital, but to uncover underlying problems from depression to dementia to a home full of tripping hazards that might bring them back. Rosenberg has documented a big drop in the number of seniors who make return visits since his center began day-after-discharge calls to monitor how they're doing. There's no official count, but at least a dozen self-designated senior ERs have opened around the country since the first in Silver Spring, Md., in 2008. The one in Maryland and eight in Michigan are operated by Catholic health system Trinity Health of Novi, Mich., which plans to open two in Iowa later this year, followed by more in other states. How does it work? Seniors still enter through the main ER, where triage nurses decide if they have an immediately life-threatening condition. Those patients stay in the regular ER with all its bells and whistles. But other seniors get the option of heading for these new special zones. "It's a very nurturing environment," says nurse practitioner Michelle Moccia, who heads the senior ER at Trinity's St. Mary Mercy Hospital in Livonia, Mich. There, doors instead of curtains separate beds, tamping down the noise that can increase anxiety, confusion and difficulty communicating. Nurses carry "pocket talkers," small amplifiers that hook to headphones so they don't have to yell if a patient's hard of hearing.

Mattresses are thicker, and patients who don't need to lay flat can opt for cushy reclining chairs instead; Moccia says people feel better when they can stay upright. Nonskid floors guard against falls. Forms are printed in larger type, to help patients read their care instructions when it's time to go home. Pharmacists automatically check if patients' routine medications could cause dangerous interactions. A geriatric social worker is on hand to arrange for Meals on Wheels or other resources. "In the senior unit, they're just a lot more gentle," says Betty Barry, 87, of White Lake, Mich., who recently went to another of Trinity's senior ERs while suffering debilitating hip pain. But Moccia says the real change comes because nurses and doctors undergo training to dig deeper into patients' lives. While they're awaiting test results or treatments, every senior gets checked for signs of depression, dementia or delirium. An example: A diabetic was treated for low blood sugar in a regular ER. A few weeks later she was back, but the newly opened senior ER uncovered that dementia was making her mess up her insulin dose, repeatedly triggering the problem, says Dr. Bill Thomas, a geriatrician at the University of Maryland Baltimore County who is advising Trinity Health Novi's senior ER program. It doesn't take opening a separate ER to improve older patients' care, says New Jersey's Rosenberg, who calls better overall geriatric awareness and training the real key. Still, he says his center saw a 15 percent rise in patients last year. "Those hospitals that have the money and space and the luxury to do something like that are going to get a definite advantage down the road," predicts John at the American College of Emergency Physicians, who says his own Boston hospital didn't have the money to try it. The Associated Press contributed to this report.

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A new trend for the aging

Geriatric EDs practice their own brand of preventive care By Heather Stringer Monday February 20, 2012 Ramazan Bahar, RN-BC, MSW, LSW, was treating a 75-year-old woman who came to the emergency room because her nose would not stop bleeding. The bleeding stopped in the ED, and she was discharged with instructions to skip her next dose of Coumadin and then restart with a lower dose. Luckily the woman had walked into a hospital that recently had opened a new geriatric ED. Part of the protocol for all patients 65 and older is to make a follow-up phone call within 72 hours. When we called her back to review the discharge instructions, we realized she was getting ready to double-dose herself because she was confused, said Bahar, program coordinator of the geriatric ED at St. Josephs Regional Medical Center in Paterson, New Jersey. She could have bled out. In the past, this patients potentially fatal misunderstanding could have gone unnoticed until it was too late, but a growing number of hospitals are experimenting with a concept aimed at minimizing that possibility. The new geriatric EDs typically include not only environmental improvements such as nonslip floors and thicker mattresses, but also nurses who are trained to do assessments and follow-ups geared to this patient population. When geriatric patients reach a stage of life when they start using the emergency department more frequently, they typically start on a spiral of decline, but a lot of these things are preventable, Bahar said. We opened a geriatric emergency department to make sure these people will remain functional in the community as long as possible. How it works Hospitals like St. Josephs recognize the demographics of aging in this country are expected to shift dramatically in the next 20 years. By 2030, the number of people 65 and older is projected to double when compared to the number in 2000, according to a 2010 report by the Federal Interagency Forum on Aging-Related Statistics. Almost 20% of the population will be 65 and older by 2030, according to the report. Research also suggests a more troubling trend for this growing sector of the population: Based on data from more than 11 million patients nationwide, nearly 20% of Medicare beneficiaries who had been discharged were rehospitalized within 30 days. Two-thirds who were discharged with medical conditions such as heart failure, pneumonia, chronic obstructive pulmonary disease, psychoses or gastrointestinal problems were readmitted or died within one year of the initial hospitalization. These findings were published in 2009 in the New England Journal of Medicine. In an effort to buck this trend, Holy Cross Hospital in Silver Spring, Md., opened the first geriatric ED in 2008, and more hospitals are following suit. St. Josephs Regional Medical Center opened its 14-bed geriatric ED in January 2010; beds are reserved for highly functional seniors who do not require

stabilization. The nurses in the ED are trained to use the Identification of Seniors at Risk screening tool for patients 65 and older. The tool includes questions such as: Are you taking more than five medications? Have you been hospitalized in the last 30 days? Have you experienced changes in your functional status? Have you experienced any change in vision? Before coming to the ED, did you need someone to help you at home on a regular basis? If patients answer yes to two or more of the questions, they are referred to Bahar. He performs a more comprehensive assessment to determine the patients functional and psychosocial status, family support situation and reason why he or she may be declining. If, for example, you have an 85-year-old female who lives alone and is functional, but is in the ED for a fractured wrist, I would find out why she fell, Bahar said. Has her vision declined or medication changed? Does she need home health, visiting nurse services or support from a church group? Traditionally, this type of patient would come to the ED, be seen by a physician and then discharged, but perhaps nobody would find out why she fell. If she returns home with a cast on her fractured wrist, she may struggle to cook for herself and may be at risk for dehydration, which could create a host of new problems, Bahar said. Once Bahar identifies the patients needs, he forms a plan to help them stay healthy after they return home. He often calls community organizations that can assist with rides to appointments, meals or more direct medical care at home. After the patient is discharged, a nurse makes a phone call to follow up with the patient. The nurse asks about the patients visit to the ED, whether he or she understands discharge instructions and, if the patient was prescribed medication, whether he or she was able to obtain the medication and understands how to use it. ED patients who are admitted to St. Josephs are cared for on a Nurses Improving Care for Healthsystem Elders unit designed to meet the complex needs of this population, according to Bahar. Statistics confirm the geriatric ED is making a difference. Mark Rosenberg, DO, MBA, chairman of the department of emergency medicine at St. Josephs, reported unscheduled returns of ED patients ages 65 and older dropped from 20% to just more than 1% since the dedicated ED opened. Environmental differences St. Mary Mercy Hospital in Livonia, Mich., opened a geriatric ED in July 2010, and the benefits became clear almost immediately. Within hours after opening, we knew we had done the right thing because of everything we discovered from the assessments, said Michelle Moccia, RN, MSN, ANP-BC, CCRN, program director of the senior ED at St. Mary Mercy Hospital. It is about delivering relationship-based care rather than just focusing on their medical chief complaint.

Nurses use several assessment tools to screen for dementia, delirium, geriatric depression or other barriers to living independently. Based on these assessments, nurses will alert the ED social workers, who then connect the patients with community resources to ensure they will have support at home. Moccia said pain, shortness of breath, change in the level of consciousness, falls, dehydration and electrolyte imbalance are common problems seen in the ED, as well as medication adherence and adverse drug events. The unit also is designed to be more senior-friendly with pressure-reducing mattresses, hand rails along the walls and devices such as a pocket talker, which uses headphones connected to an amplifier to help seniors who are hearing impaired. ED RNs at St. Mary Mercy completed the Geriatric Emergency Nursing Education through the Emergency Nurses Association and ongoing education. The inpatient RNs also completed the Geriatric Resource Nurse Module through NICHE. Eight hospitals in the St. Joseph Mercy Hospital System in Michigan have opened geriatric EDs in the past two years, and since then, there has been a more than 10% increase in the number of seniors who visit the ED. Moccia suggests this increase is directly correlated to the fact the elderly are drawn to an ED that is designed to meet their specific needs. The emotions of aging Many seniors who come to the geriatric EDs want to stay independent as long as possible. One important way to help them achieve this is knowing how to detect when they are struggling with daily life, said Kimberly DiSanto, RN, assistant vice president of emergency services at Newark (N.J.) Beth Israel Medical Center, which opened a geriatric ED in November 2011. This was one of the important concepts covered in the training for nurses staffing the unit. A lot of these individuals want to continue to be independent, so they are hesitant to reach out and ask for services, DiSanto said. You have to develop a relationship with them so they trust you. Then you can help them understand the services that are available to help them stay independent in the community. Although it may take extra time to tease out the needs of the elderly, this time is well-deserved by the people who have laid the foundation for our modern way of life, said Bahar. They are the pillars of society, and we are what they built, so they deserve quality care and respect, he said. We cant stop aging, but we can slow down the complications of aging, and the geriatric ED is our way of making sure they get the best healthcare possible. http://news.nurse.com/article/20120220/ED01/120222001

REACTION and IMPLICATION:

Emergency departments serve as a door to health care for seniors. On average, seniors represent 50% of emergency department presentations. Once there, they are seen to have multiple medical conditions, have more diagnostic tests, and are admitted to hospital more often than younger patients. This isnt because seniors are without family physicians or misuse the system. When they present in emergency, they are more likely to be triaged as urgent and have more emergent illness. Presently, if not admitted, seniors are more likely to return to the emergency department within two weeks of discharge. Unless we manage seniors in emergency departments differently, the demographic imperatives will cause this pattern of presentation to dramatically increase.

Seniors still enter through the main ER, where triage nurses decide if they have an immediately life-threatening condition. Those patients stay in the regular ER with all its bells and whistles. But other seniors get the option of heading for these new special zones. There, doors instead of curtains separate beds, tamping down the noise that can increase anxiety, confusion and difficulty communicating. Seniors are so sensitive that they need a quiet environment and they need a lot of patience from health care providers. To avoid conflict and barriers in geriatric care these are some suggestions:
Case finding of high-risk elderly; Conducting comprehensive geriatric assessments; Assisting emergency staff with admission decisions; Acting as the liaison between the emergency department and acute care and between the department and community services/agencies; Collaborating with the Emergency Social Worker to facilitate crisis placement for highrisk geriatric patients; Following-up with discharged patients; and Educating staff, patients and caregivers with respect to geriatric issues and services available.

Partnerships between geriatric medicine, emergency medicine and general and family practice whereby geriatricians working with emergency department staff and family physicians help to enhance their awareness of the unique needs of the elderly patient population and influence their attitudes and approach towards meeting those needs;