Kyung Menkick, 77, thought she might be dying one morning last December when she awoke and felt her heart beating dangerously hard and her intestines twisted in a tight, painful knot.
Alarmed, she called her brother, who drove her to a nearby hospital, Exempla Lutheran Medical Center in Wheat Ridge, Colo. There, triage nurses in the regular emergency room ruled out a life-threatening emergency and directed Menkick to a quiet area down the hall: the hospital’s new emergency room for seniors.
A social worker came into her room, started asking questions, and soon, Menkick was articulating her deepest concerns: the husband at home with pancreatic cancer and advanced dementia; the ongoing, sometimes unbearable strain of caregiving; days full of loneliness and despair.
“That was really comforting, to have someone take the time to talk to me like that,” says Menkick, who received a diagnosis of high blood pressure and began receiving counseling services arranged by the social worker after returning home. The symptoms she had experienced were due to stress.
This attention to a patient's life situation, not just his or her symptoms, is an essential part of the new model of emergency care for seniors that Exempla Lutheran and several other hospitals across the country have begun implementing over the past several years.
'Cold, hungry, thirsty'
Nationally, there are probably fewer than two dozen senior emergency rooms, says Sue Penoza, director of strategic planning at Trinity Health of Novi, Mich., one of the largest Catholic hospital systems in the United States. All take older patients, generally anyone 65 and older, who aren’t experiencing potentially life-threatening traumas, like heart attacks or strokes, based on findings from an initial evaluaton in the regular ER. Common conditions seen by the medical staff in these special emergency rooms include falls, hip fractures, generalized weakness, abdominal pain and non-urgent chest pain.
The impetus is a growing understanding that older adults have unique medical needs and vulnerabilities that often aren’t very well served in traditional emergency rooms.
“Loud, clattering, chaotic, confusing places are simply not good for older people,” says Dr. William Thomas, a geriatrician and professor at the University of Maryland who helped design the new model for senior emergency care that hospitals are adopting. Older patients confirm this: When asked about their experiences in emergency rooms, they report being “cold, hungry, thirsty” and distressed by poor communication and the lack of privacy, according to a July 2010 study in the Journal of Health Services Research and Policy.
The consequences can be serious, Thomas and other medical experts say. Older people can easily become dehydrated, which can lead to a precipitous drop in blood pressure, seizures and other medical problems. Lying on hard hospital mattresses, their skin can begin to break down in as little as two hours. When overstimulated or unable to hear clearly, many older adults will draw inward and become non-communicative, making it difficult for medical staff to understand what is wrong and offer appropriate help. A sense of severe disorientation can also begin to set in, creating anxiety and even panic that can lead to sudden, distressing changes in a patient’s mental status.
Less stressful environment
The model that Thomas helped design responds, in part, by making the environment of care for older patients more comfortable and less stressful. Instead of harsh lights, dimmers are used to reduce glare that can strain older patients’ eyes. Non-skid surfaces replace slippery floors that can make it easy for someone with unsteady balance to fall. Thicker mattresses reduce the pressure on seniors with sensitive skin and aching muscles. Noise from beeping monitors, intercoms and other sources is kept to a minimum.
Even seemingly small changes make a big difference, Penoza says. For example, in Trinity Health’s senior ER, older patients are given “pocket talkers” — small devices that amplify sound, used with headphones or other headsets — to ease communication between medical staff and patients. Trinity was the first provider to introduce a senior emergency room, in November 2008, at Holy Cross Hospital in Silver Spring, Md. The system has since rolled out an additional dozen senior ERs in Michigan and Iowa, with plans to introduce six more by the end of June.
The most important medical innovation consists of screening older patients for depression, dementia, delirium, functional limitations, fall risk, nutritional deficiencies and medication interactions, says Dr. Scott Miner, medical director of Exempla Lutheran General’s eight-bed senior ER, the first in Colorado.
These sorts of screenings don’t occur in traditional ERs and they have the potential to have “a huge impact” by identifying seniors who need more in-depth evaluations and referrals to specialists or social services, Thomas says.
Out of more than 2,000 senior ER patients screened at Trinity Health’s St. Mary Mercy Livonia Hospital in southeast Michigan, 11.8 percent tested positive for depression, triggering a referral to a behavioral medicine health professional, Penoza says. All older patients taking five or more medications were referred to a pharmacist, who checked for potentially harmful interactions. Nearly 16 percent of patients showed signs of dementia, sparking attempts to arrange respite care, counseling or other services for family members.
Specially trained staff
Extra training that focuses on seniors’ special needs is another part of the model. Unlike younger patients, older adults often present with different symptoms and multiple medical problems, requiring more time with the medical staff and, often, more complicated work-ups. At Exempla Lutheran General, doctors undertook four hours of online geriatric training from the Cleveland Clinic, while nurses underwent up to 10 hours of online training in geriatrics from the Emergency Nurses Association. Excluding time devoted to training, the cost of setting up the hospital’s senior emergency room was $302,000, says Bev White, director of the hospital’s emergency trauma services.
After seeing an article about this new model of care in her local newspaper in a Cleveland suburb, Emily Popik, 69, asked to be taken to a senior ER at University Hospitals Richmond Medical Center late last year. She was feeling feverish and sore, and then, suddenly, found it difficult to breathe.
“I was seen immediately, and after they took care of me medically, they asked all kinds of questions,” she says. “It’s nice to know that they care so much for seniors and want to watch out for us.”
Popik was especially grateful for the follow-up call she got from a social worker after spending six days in the hospital being treated for double pneumonia. “They asked how I was feeling, if I had made an appointment with my doctor,” she says. “I thought that was a really good personal touch.”
UH Regional Hospitals opened senior ERs at its Richmond and Bedford hospitals in November and “it’s really helped us better serve the needs of older patients,” says Laurie Delgado, president of the two hospitals.
But some medical experts are skeptical. “I think there absolutely is a need for geriatric emergency medicine, but what I don’t know is whether special geriatric ERs need to be created as opposed to conducting more training in geriatrics through general ERs,” says Dr. Howard Mell, a spokesman for the American College of Emergency Physicians and medical director of the emergency room at TriPoint Medical Center in Concord, Ohio.
“I don’t think we have enough evidence yet to know whether senior ERs produce better outcomes,” says Dr. David Ross, an emergency room physician at the Penrose-St. Francis Hospital & Health Services in Colorado Springs. “And I don’t think most resource-limited ERs will have the luxury of doing this.”
That doesn’t trouble Thomas, who says sound medical research generally supports the interventions being tried in senior emergency rooms. “This is a pioneering innovation, and we think it’s going to grow and spread."
What you can do for an older relative you take to an emergency room: Make sure you bring your relative’s glasses or hearing aids to the hospital. Once the medical staff in the general ER rule out a life-threatening medical problem, ask if there is someone trained to work with older adults, or if the hospital has a senior ER. Ask nurses and doctors attending to the person what the plan of care is. Ask the medical staff if your relative can have food and water and make sure this happens, if appropriate. Speak up if the person’s needs aren’t being met. Be alert to signs of sudden confusion or disorientation that arise in the ER — these can signal the potential onset of delirium — and let medical staff know if this occurs.
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