01/02/12

Emergency care targeted to seniors could eventually become standard practice in emergency departments across the nation, a shift prompted by the growth of the aging population. The rapid triage and diagnosis system now used in emergency departments (EDs) may not be suitable for older adults, who have unique needs resulting from multiple comorbidities, poly-pharmacy, cognitive impairment, and atypical presentation of disease.

So a handful of hospitals have established senior emergency centers (also called senior ERs or geriatric EDs), and although some experts say it’s too soon to tell whether such centers are part of a growing trend, others say that this is just the beginning of a movement that will spread to most EDs.

Despite the financial or institutional barriers to senior EDs, advocates say that the increase in the aging population, health reform incentives, and early success will propel the concept forward.

HOLY CROSS HOSPITAL With a patient at Holy Cross Hospital, the Senior Care Team includes (from left) Merry Adler, coordinator; Susan Spivock Smith, geriatric nurse practitioner; Bonnie Mahon, senior director; and Marcy Smith, geriatric social worker.

“It’s definitely an emerging area of research,” said Dr. Ula Y. Hwang, of the department of emergency medicine and geriatrics at Mount Sinai School of Medicine in New York. “Every time I do a search for [senior emergency centers], there are more and more."

Dr. Hwang and her colleagues wrote about the idea of senior EDs in 2007 (J. Am. Geriatr. Soc. 2007;55:1873-6). They proposed geriatric emergency department interventions (GEDIs), which would include “better clinical staff education in geriatric emergency medicine and nursing care, evidence-based protocols for common geriatric syndromes, and ideally, appropriate structural modifications.

“Emergency medicine recognizes the special needs of children and psychiatric patients. Perhaps it is time to also address the specialized needs of older adults within the ED setting,” they said. In a soon-to-be-released study on improving ED outcomes for geriatric patients, Mark S. Rosenberg, MD, and colleagues found that the senior read- mission rate dropped from 20% to as low as 1% per month after a geriatric ED was established at St. Joseph’s Healthcare System in Paterson, N.J. (www.ncbi. nlm.nih.gov/pubmed/2181651).

Since the geriatric ED was established in 2009, it has had dozens of groups visit from U.S. and foreign hospitals.

“It’s an international phenomenon” because the population in many countries is aging, said Dr. Rosenberg, chairman of the department of emergency medicine at St. Joseph’s. He predicted that as many as 50 senior emergency centers could open within the next year alone.

The current ED design is for rapid patient assessment, ending in discharge or hospital admission. However, evaluating elderly patients isn’t the same as assessing younger adults.

“Their work-up takes longer, and they utilize more resources,” said Dr. David P. John, the current chair of the geriatric emergency medicine section of the American College of Emergency Physicians. “But ED beds need to be turned over quickly, so you need a specialized approach” to taking care of the elderly.

This need could become more apparent as more baby boomers turn 65. Elderly patients “deserve to be heard and treated at their own pace,” said Dr. Michael Mikhail, regional director of emergency medicine for Saint Joseph Mercy Health System in Ann Arbor, Mich. Dr. Mikhail has been involved in establishing senior EDs in most of the health system’s hospitals in Michigan, which is part of Trinity Health, a national network of nonprofit community hospitals.

Trinity Health lays claim to being the first hospital system to establish senior EDs, starting with Holy Cross Hospital in Silver Spring, Md., which opened its Senior Emergency Center in 2008. After Holy Cross’s Emergency Center pilot, Trinity Health created a model for replication, and has so far implemented it in 13 of its hospitals.

The plan was initiated by the hospital’s CEO after he received a telephone call from his distraught elderly mother in a New Jersey ED. The hospital began forming focus groups and researching the available models for senior emergency care. Hospital administrators also consulted with Dr. Bill Thomas, of the Erickson School at the University of Maryland, Baltimore County, and founder of changingaging.org.

“We did a literature review, and we found several studies that said some changes had to be made, but there was no ED that had implemented the idea,” Dr. Thomas said.

The team began by modifying a section of the ED with the goals of eliminating chaos and reducing anxiety, confusion, and the risk of falling for seniors who arrived at the ED with non– life-threatening emergencies.

Starting with the physical environment, they painted the walls in a warm golden color, replaced the shiny floors with nonglare, slip-proof faux wood, and added handrails, large-face clocks, calendars, and televisions in each room. They replaced the regular mattresses with thicker ones and included heated blankets in the bays. They installed noise-absorbing ceiling tiles and softer lighting. The center is staffed with an emergency physician, geriatric nurse practitioners, registered nurses trained in geriatrics, a geriatric social worker, certified nursing assistants, and volunteers who keep the elderly company and help them remain calm and oriented.

The hospital also focused on staff education and training. “We actively and openly address the issue of ageism...We confront ageism and help the staff to have a forward-looking attitude about older people,” Dr. Thomas said.

(St. Joseph’s geriatric ED has a similar model with slight variations, and like St. Joseph’s, Holy Cross has had dozens of visits from interested hospitals.)

An interdisciplinary approach and a focus on continuity of care to make sure patients receive appropriate care following discharge are especially important for elderly patients. At Holy Cross, patients’ discharge planning begins upon admission when a nurse completes a high-risk screening tool and polypharmacy referral. Patients receive calls from the social worker after discharge; high-risk patients are referred to fall prevention programs or are recommended to have a home safety evaluation. (St. Joseph’s calls all patients the day after they’re discharged.)

Holy Cross Hospital’s preliminary 12-month data for 2010 showed that revisits within the first 72 hours dropped from 4.9% to 2.0%, 30-day revisits fell from 16.5% to 11.8%, and 30-day revisits with hospital admission dropped from 10.9% to 5.2%.

But whether having a separate senior ED is feasible for all hospitals and whether it is the best model of emergency care for the elderly are not yet clear.

“At this point, [there are] no criteria or standards on what a geriatric emergency center should or should not be,” said Dr. Hwang of Mount Sinai.

Some researchers argue that an integrated approach is best.

“I don’t believe it’s useful to have stand-alone seniors’ EDs,” said Belinda Parke, PhD, of the University of Alberta, Edmonton, and past president of the Canadian Gerontological Nursing Association. “I believe that with an aging population, more and more older adults will be visiting the ED. With this growth, I don’t know who will come to the nonsenior ED. More importantly, if we have 8 or 10 designated beds in an area designed for older people, how will decisions be made about who gets the ‘senior-friendly’ beds when there are 12 or 15 older people at triage? This sets up an unnecessary moral dilemma in my view. If we can have better care for older people, why not apply it to all?”

Dr. Parke, who has been researching elder-friendly hospitals and EDs in Canada added, “We need a multi-pronged approach. One solution, one problem doesn’t give us a sustainable gain. Socially and economically, we have to begin to tangle ageism and the cultural implications. And we have to begin to appreciate the value of old people, and see them as [people with] abilities instead of a population of [people with] disabilities that is a burden on society. We need to push against that.”

Others say that when the establishment of a geriatric unit isn’t feasible, promoting a senior-friendly culture in the ED can be as effective.

“If you don’t have the space, make your entire ED geriatric,” said ACEP’s Dr. John. “If it’s friendly to the most frail and vulnerable, it’ll be friendly to all.”

The 65-and-older population will increase to 55 million in 2020, according to national projections. By 2030, there will be more than 72 million older persons, making up nearly 19% of the population.

“My opinion is that because the population is aging, a majority of our patients are going to be older adults, so by default many of our EDs will need to provide geriatric care,” Dr. Hwang said. “As a community [of physicians], we need to embrace care for older adults.”

Although it is too soon to tell whether senior EDs will follow the paths of pediatric and psychiatric care in EDs, advocates say that the move can only benefit the population, elderly or not.

As the incoming chair of the geriatric emergency medicine section of ACEP, Dr. Rosenberg said, “I hope we will focus on developing standards or guidelines of geriatric emergency medicine practice in emergency departments, and that this becomes standard of practice, and that geriatric core curriculum becomes a major aspect of emergency training.

“This is a huge wave. I think we’re going to see many centers opening up and, in the following 5 years, this becoming standard,” he said.

For a video of the Senior Emergency Center at Holy Cross Hospital and more information on this topic, go to acepnews.com.


Naseem S. Miller is a senior writer with Elsevier Global Medical News.

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