For the Elderly, a New Kind of ER

April 16, 2012— -- "It wasn't chaotic like I'm used to in past experiences in emergency rooms," says Denis J. Mulligan, 65, of his recent trip to the new Seniors Emergency Center at Holy Cross Hospital in Silver Spring, Md.

Monitors beeping, loud voices, and people scurrying about are just a few of the things people associate with a busy emergency department. Many people may consider these factors a nuisance, but for older patients, these are things that may be downright frightening and could even affect their health. A new trend in emergency department design is seeking to optimize the environment in which older patients are treated.

Referred to as "geriatric" or "senior" emergency departments, these facilities have been popping up across the country since the first one was opened at Holy Cross Hospital in Silver Spring, Md. in 2008. They are usually small areas, away from the hustle and bustle of the main emergency department. Private rooms, simple layouts, natural lighting, more volunteers, and soothing music are among the many features Holy Cross and other hospitals across the country are adding, all aimed at creating a calm and comforting environment.

Beyond making older patients more comfortable, the focus is really on keeping them safe. Dr. James Del Vecchio, medical director and pioneer in the creation of Holy Cross Hospital's senior emergency center, thinks their follow-up service is one of the most important safety features of the care provided. Social workers are instrumental in this process. They not only set up home nursing services, but they make follow-up calls to every patient within 48 hours of being seen.

"They are checking to make sure the patient was able to get all the prescriptions or doctor appointments that they needed," Del Vecchio said.

Managing medications is another area where these senior facilities hope to intervene. At the Holy Cross Hospital, any senior who comes in on five or more medications has their prescription list reviewed by a pharmacist before leaving. According to Bonnie Mahon, director of senior services, "We've had some real saves from this. One woman kept falling until our pharmacist realized that the dose of one of her medications might be causing this."

Bed sores, one of the most common complications of hospitalization, are associated with higher costs and longer hospital stays. Research shows that these wounds can occur in as little as 4-6 hours, suggesting they may be starting to form while the patient is still in the emergency department. But the Geriatric ERs are addressing that problem as well.

Instead of the traditional thin layer of foam covered in plastic, thicker mattresses, such as the four-inch Tempur-pedic ones at Holy Cross, are being used in hopes of reducing the occurrence of these wounds.

Del Vecchio also points out that every senior who comes through the door is asked 8 to 10 simple questions which help screen for problems that seniors are more prone to, ranging from memory impairment to risk for falls at home.

And to combat falls in the hospital, Holy Cross has modified the flooring and lighting. Mahon explains that some types of lights can create shiny spots on the floor. This interferes with depth perception and can lead to falls, especially in the elderly.

These changes in emergency care have been well received by the senior population. DelVecchio and Mahon say their patient satisfaction scores are over 95 percent positive.

Mulligan is once such satisfied patient. "Usually when I enter a hospital, even as a visitor, my anxiety triples. This was different, it did help relax me.

"I felt like an individual rather than just a chart or a number. They always told me what was going to happen, as well as when and why."

Bringing Specialization to the Emergency Room

Dividing emergency departments into specialized treatment areas is not a new concept. There are "fast track" ERs for minor medical problems and pediatric emergency departments to care for kids.

As the population grows older, geriatric ERs may be the next natural step in improving emergency department efficiency. Many experts see this as important progress in identifying and accommodating the needs of the aging baby boomer population.

"It does shed more light on geriatric care, which is sometimes an overlooked part of the way we practice medicine," says Dr. Nafis Ahmed of the University of Pennsylvania.

The inspiration to create emergency treatment areas for the elderly comes from a large body of research that finds older patients have different patterns of emergency department use and thus different needs than their younger counterparts. As a while, this group incure a higher number of visits, more urgent visits, longer visits, more frequent return to the ER and higher rates of complications.

But will the specialized treatment areas solve these problems? Not all emergency physicians are so sure. They question if patients are having better outcomes as a result of these changes.

"People think 'I am in a specialty area, I must be getting better care.' But that is not necessarily true," said Dr. Alfred Sacchetti of Our Lady of Lourdes Medical Center Camden, N.J. He explains that this is just one way of making the emergency department visit more pleasant for a certain group of patients and that there are other ways to keep patients comfortable, happy, and healthy.

"Seeing them quickly, treating them quickly, and getting them admitted to the hospital or back to their own home also makes for a good -- maybe even better -- experience."

Sachetti said he sees geriatric emergency departments as perhaps best suited for hospitals that have the longest emergency department wait times. If you spend more time in the ER, you might find the services offered by the geriatric ER comforting. But if you will be in and out in an hour or two these features may have less of an impact.

Plus, he said, research has yet to show exactly what benefits, if any, these new units offer. "Here's the problem with specialty emergency departments, there's no data that you have any different outcome," Sacchetti said.

Many hospitals track return visits to the emergency department within 30 days of a visit as a measure of providing effective care. Mahon admits that so far Holy Cross has not seen an improvement in the number of return hospital visits that they hoped for, citing about a 1-2 percent reduction.

"We're not where we want to be yet," Mahon said.

Geriatric ERs Still Face Questions

Cost is also a concern. New facilities, new equipment, and additional staffing are all things that cost money. Most emergency departments operate on very limited budgets, so there is fear that hospitals will invest in these geriatric areas at the expense of other aspects of emergency care.

"I am concerned it may take away resources from other critically ill patients," said Dr. Juan March, professor in the Department of Emergency Medicine at Brody School of Medicine, East Carolina University.

And most importantly, is this what patients really want? Hospitals may find it challenging to offer these services to those who need and appreciate them while maintaining respect for the 'younger' more independent seniors who may find their assignment to these areas offensive.

While most physicians would agree that new design features being implemented in geriatric emergency departments are positive changes, some argue that the efforts are being misdirected. Rather than target the older population, the changes might be more effective if applied to emergency care in general.

"Why not add these benefits to our already existing ED's and improve patient care for all ages?" Ahmed said.

Dr. Gabe Wilson, associate medical director in the Department of Emergency Medicine at St. Luke's-Roosevelt Hospital Center agreed that these changes may apply to a bigger group than just seniors. He said he sees the new safety measures as particularly important.

"It is not just older patients that are at higher risk of fall; in fact, many younger patients may be seeking care for a condition that temporarily places them at higher risk of fall," Wilson said.

Mahon feels fortunate that her hospital was able to create this option for their patients, but admits that it may not feasible for all hospitals. Her advice to other facilities? "People don't have to do things identical. A smaller hospital might not be able to have a separate senior area, but look at what resources you do have and get creative."

Will geriatric emergency treatment areas be standard design in hospitals of the future? The jury may still be out on this issue, but the concept draws much needed attention to the challenges that emergency physicians face every day in providing care to the growing geriatric population.

"The number of older patients seeking care in the emergency departments in the U.S. will continue to substantially increase over the next decade, making this a very important topic that needs to be addressed," Wilson said.