The Elder-Friendly Emergency Care Experience

The prestigious AHRQ has taken notice of the work Holy Cross hospital has done to improve emergency care for elders.

This is an important issue because…

* The population of seniors in the U.S. is growing rapidly, with growth expected to continue in coming decades, especially among those over 80. In Montgomery County, MD, for example, 70 percent of the anticipated population growth over the next 2 decades will be among people older than 65,1 and the number of residents age 65 and older not living in nursing homes is expected to double over a 30-year period, from roughly 92,000 in 2000 to 187,000 in 2030.2 Many seniors have chronic illnesses (e.g., diabetes, heart failure, osteoporosis, chronic obstructive pulmonary disease, dementia) that result in frequent ED visits.

* Stressful ED experience: Seniors often find the ED to be overwhelming due to factors such as loud noise, a lack of privacy, and the fast pace of interactions with staff. Poor hearing and neurological limitations often make it hard for seniors to understand what is occurring in the ED.

* Little followup, leading to return visits: ED care traditionally focuses on treating patients’ immediate health concerns and discharging them as quickly as possible so that additional patients can be seen. Given the emphasis on speed, older patients often do not receive or understand instructions on what they should do to address their health issues once they return home. In addition, factors such as limited transportation, unfamiliarity with technology, and difficulty dealing with bureaucracy may prevent them from going to followup doctor’s appointments and/or obtaining needed medications in a timely manner. As a result, seniors have a high rate of return visits to the ED, leading to high costs.3

What they did…

* Location and set-up: The center adjoins the main ED, in space formerly used as a patient overflow area. It contains a nursing station, eight patient rooms, and one large room for private family consultations.
* Environmental enhancements: The center includes a number of physical features designed to reduce patients’ anxiety and discomfort and enhance safety:

o Larger, private rooms: Unlike a typical ED with cubicles separated by curtains, the senior center has rooms divided by thick walls that are large enough for a comfortable chair for a family member or visitor. Patients can converse with staff and guests with reduced noise distraction from other staff-patient interactions. To further minimize noise, staff communicate via wireless phones to limit the use of the intercom system.
o Comfortable beds and appealing environment: Beds have mattresses twice as thick as those in the standard ED that are specially designed to prevent skin breakdown and pressure ulcers. Walls have been painted a warm gold with contrasting white space, which appeals to the aging eye and reduces stress. Patients can control the overhead lighting with a dimmer switch. Each room has a television, allowing patients to watch programs or nature images or listen to soothing music. Each room also has a large clock and a phone with larger than normal buttons. Patients can request coffee, tea, bouillon, or juice, and can use blankets directly from a blanket warmer.
o Additional safety features: Other safety features include a floor made of nonreflecting faux wood rather than the typical linoleum (which produces glare that can cause missteps and falls) and hand rails that line the center’s walls to further reduce the risk of falls. Staff rely on digital handheld cardiac monitoring devices to monitor patients instead of large machines that can make it hard for patients to move around.

* Staff trained in geriatric care: All emergency physicians and nurses receive specialized training on common health problems facing seniors and on strategies for providing compassionate care to them. Two staff members with additional expertise in geriatric care—a nurse practitioner and social worker—work exclusively with patients in the senior center. The social worker serves as a general problem solver who gets to know patients as much possible, makes sure they are comfortable and not left alone for long periods, tries to find underlying causes to the problem(s) that led to the ED visit, and answers questions about care (e.g., what will happen next and when this will occur).

* Screening for polypharmacy: When a senior patient is noted to be on 5 or more medications (including prescription and over-the-counter drugs, as well as herbal remedies), nurses are trained to initiate a “Senior Polypharmacy” referral. This information is automatically transmitted to the pharmacist, who reviews the medication profile and identifies drugs or doses of medications that are not appropriate for older adult patients. If an inappropriate drug or dose is detected, the pharmacist contacts the physician providing care for the patient to alert him/her and recommends alternative medications or doses.

* Assessments and followup care: Once the patient is stable, nurses screen for cognitive loss, depression, and alcohol and drug use. They also perform risk assessments for falls, neglect, or abuse; assess physical function and risk of followup problems; and refer patients to the appropriate level of care. Within 24 hours of discharge, a geriatric social worker calls each high-risk patient to check on his or her status and answer any questions. All patients receive a followup phone call from an administrative assistant within a few days of discharge (typically 2-3 days and no more than 1 week) to help them address any challenges they may be facing, such as obtaining medications, reducing household safety hazards, setting up home visits from nurses, or arranging for hospice care.

Does it make a difference?

* High patient satisfaction: A survey of 1,047 patients treated in the senior emergency center between November 2008 and October 2009 found that 98 percent of respondents rated their ED experience as excellent (selecting the top option). Additionally the following percentage of respondents selected the top response to the listed question: 98 percent when asked if senior emergency center staff listened to them; 96.7 percent when asked if staff kept them well informed; 97.3 percent when asked if staff were caring and compassionate; 98.4 percent when asked about the noise level in and around their room; 87.2 percent when asked about the waiting time for tests or treatment; and 99 percent when asked about the likelihood of recommending the senior center to others.

* Improved screening for inappropriate medications: The center averages 450 patient visits each month, 50 percent of whom are prescribed 5 or more medications. Of these 450 patients, the “Senior Polypharmacy” referral has identified approximately 20 percent who were taking an inappropriate medication or medication dose that was subsequently corrected.

* Increased patient volume: The volume of patients treated in the senior emergency center increased 16 percent from 2008 to 2009, compared to a 10 percent increase in the hospital’s volume of nonsenior patients treated in the main ED.

* Few return visits: Since the center opened in November 2008, approximately 3 percent of patients return to the ED within 72 hours, while 15 percent return within 30 days. Comparison data specific to seniors are not available.

Here’s a video from the ribbon-cutting of the ED in November 2008: