Geriatric ERs Provide Better Care for Older Patients
A more suitable environment and risk assessments make the difference
Suffering from frail health in her 70s, Dr. Mark Rosenberg’s mother had to make repeated trips to the emergency room of a South Florida hospital. It was loud and chaotic, and seeing trauma victims and people with drug overdoses added to her distress.
“One day she got so upset she left the emergency department against medical advice because she was so afraid to be there,” Mark Rosenberg says. “She called me up and said, ‘You need to build an emergency department for people like me.’”
It was no idle comment. Rosenberg, chair of emergency medicine at St. Joseph’s Health in Paterson, N.J., heads one of the nation’s busiest ERs, and he knew his mom’s complaint was justified.
He got together with his mother, her sisters and her bridge partners to discuss what the ideal ER for older and frail individuals would look like. Using their advice, St. Joseph’s University Medical Center in 2009 opened the nation's first geriatric emergency department.
Since then, the concept of ERs designed with older patients in mind has spread across the country. Dr. Kevin Biese, an emergency medicine physician at UNC Health Care in North Carolina, says geriatric emergency departments are distinguished by four features:
- Nurses and doctors trained to work with older adults
- Age-friendly design elements, such as thick mattresses, dimmed lights and non-skid floors
- Risk assessments for older adults to identify factors that could exacerbate health problems
- Ability to connect patients with community resources they need to stay healthy
In most cases, the term “geriatric emergency department” doesn't mean a separate emergency room. Rather, it refers to a special type of care for older patients. “If you're an older adult, you can know that the care team has an awareness of your unique needs and vulnerabilities,” Biese says.
Hospitals Can Get Geriatric ER Accreditation
Last spring, St. Joseph’s became one of the first geriatric emergency departments in the country to earn accreditation from the American College of Emergency Physicians (ACEP). The accreditation program, developed with support from the Gary and Mary West Health Institute and The John A. Hartford Foundation, seeks to improve care for older patients when they are in the ER and when they get back home.
About two-thirds of the older patients who seek emergency care are discharged to their homes rather than admitted into the hospital. That’s why Aurora Health Care, a large health system based in Milwaukee, started developing geriatric ERs in 2014.
“Those patients that are being admitted, of course, are going to get a lot of resources and focus,” says Aaron Malsch, Aurora’s senior services program coordinator. “But the patients who come into the emergency department, are treated and then discharged back to their home or their assisted living facility — we wanted to focus on them.”
Five ERs in the Aurora system earned geriatric accreditation from ACEP last spring. Older patients who arrive at one of these ERs are asked six questions as part of the risk assessment, including “Do you take more than three different medications every day?” and “Before the illness or injury that brought you here, did you need someone to help you on a regular basis?”
A patient’s responses quickly help the doctors and nurses know whether the patient may need additional support to be able to recover safely at home. “This is really getting to the root cause of what the issues are with that particular individual,” Malsch says.
If a patient takes several medicines, for example, a pharmacist can review the list to make sure the drugs are safe to be taken together. If a patient needs help at home, a home health aide can be arranged. Or maybe the patient just needs someone to set up an appointment with a primary care physician — the hospital can do that as well.
At St. Joseph’s huge ER, a 20-bed wing is dedicated to making sure older patients get special TLC. A patient liaison offers a warm blanket and a cup of tea, and a case manager ensures patients have what they need arranged — such as a commode to be delivered to the home or an appointment with a specialist — before leaving the emergency department.
Most important, Rosenberg says, is the risk assessment to screen for risk of falling, dementia, delirium, dietary problems and depression. “And if we identify any of those problems, we provide specialty care to help keep the person functionally independent at home,” he says.
If a patient is at risk of falling, for example, that means a referral for physical therapy, tips on how to avoid falling and, if necessary, a home assessment to make sure throw rugs and other hazards are removed.
How to Find Geriatric Emergency Care
More than 125 hospitals in the U.S. claim to have geriatric ERs, although patients and caregivers should be aware that some of those merely amount to marketing ploys to attract older people. ACEP created standards that hospitals must meet to earn geriatric emergency department accreditation.
Currently, there are just 23 accredited ERs in 10 states, but more than 100 have started the application process, says Biese, who chairs the accreditation program.
“It is spreading rapidly, and my personal goal is that in 10 years, none of this will seem unique,” he says. “Of course you would treat older adults this way. All of this should be common sense and raise the standard of practice.”
He encourages older adults and their caregivers to check their local hospitals, or the ACEP website, to see if there’s one with an accredited geriatric ER. “And if there is none in your neighborhood, ask your hospital why,” and ask the hospital to start working toward accreditation, he says.