3 Reasons to Tailor Emergency Departments for Seniors

Hospitals and health systems are already containing costs and improving outcomes for other patient populations with specific needs. Stratifying emergent care for seniors is another opportunity to do the same.

Hospital emergency departments are crowded, noisy places. When patients come in, either via ambulance or on their own, there is some expectation that the ED environment is going to be uncomfortably bustling. This busy, congested atmosphere could be contributing to poor patient outcomes in seniors, a growing population with multiple needs.

"Ten thousand people turn 65 every day," says Teresita Hogan, MD, director of geriatric emergency medicine, and associate professor for geriatric and palliative care medicine at the University of Chicago Medicine, the 568-bed academic medical center on the campus of the university with the same name.

Hogan, who helped write new geriatric ED guidelines that came out in 2014, is passionate about making sure that seniors in the ED get quality care.

"I became a crusader when I looked around and saw things we could fix that were so simple," says Hogan.
 
In 2013, Hogan's study on the number of geriatric EDs in the U.S. and their characteristics was published in Academic Emergency Medicine. She found 24 hospitals had an existing geriatric ED, and six were planning on building one. Most of the of the hospitals with a geriatric ED reported making the simple changes Hogan refers to, including Holy Cross Hospital, a 443-bed nonprofit hospital that is part of Holy Cross Health, which is part of Livonia, Michigan–based Trinity Health, one of the largest health systems in the country.

1. Seniors' Basic Comfort Needs are Unique
In 2008, Holy Cross opened a seven-bed Senior ED. The investment was just $150,000 because hospital executives focused on senior patients' needs, which were, and are, fairly straightforward.

"It's changing the lighting, the paint on the wall, [and] the floor color so it would be easier for seniors to navigate," says Blair Eig, chief medical officer at Holy Cross. "We put walls between bays, so that it cuts down on noise. The mattresses are much thicker. We installed a blanket warmer, simple things like that."

In Hogan's research, those were among the most common changes hospitals made to help seniors navigate their EDs. Visual aids and direct follow-up with senior patients post-discharge are also two common characteristics of existing geriatric EDs. The Holy Cross SEC uses both of those, too, and Eig says the follow-up with patients has been one of its most effective changes.

"We have a geriatric social worker in that SEC and they follow up with most of patients a day or two later… now, six and a half years later, it's been successful and it was so obvious, 'Why didn't we do this before?' "

2. An Opportunity to Reduce Readmissions
Hospitals and health systems without the space to build a new ED dedicated to seniors can still do a better job taking care of seniors that present in their existing EDs.

Last year, the American College of Emergency Physicians, the American Geriatrics Society, the Emergency Nurses Association, and the Society for Academic Emergency Medicine released its Geriatric Emergency Department Guidelines, a multi-year collaboration on senior care in the ED that laid out specific guidelines and recommendations for common issues in the ED.

From medication management to appropriate use of urinary catheters in the senior population, the guidelines are an important step in improving the care of this population, says Hogan.

The medication interactions in the senior population are a big issue. Because seniors typically have comorbidities, they may be taking five or more medications before they even get to the ED. Managing their pain from a fall becomes more complicated, and ED physicians need to realize the differences in this patient population.

"When the frail elderly woman falls down and breaks her arm, and you put her arm in a two pound cast and sling, she can't balance… And if you give her a bottle of Vicodin, she's going to fall and break a hip," says Hogan. "Geriatric ED care is very different, and the awareness level is low."
Incorporated into the guidelines for ED care for seniors is a sample dashboard, which includes measuring readmissions within 24 and 72 hours. At Holy Cross, the 72-hour readmission rate among its seniors was reduced after it built its SEC.

3. ED-CAHPS Scores are Coming
Measuring patient satisfaction via HCAHPS may be a sore point among hospital leadership because the survey isn't an accurate representation of everything a hospital does well, but it's a tool that CMS is expanding.

ED-CAHPS was supposed to begin this year, but it's been delayed and now the survey is expected to begin in 2016. Still, with a good chunk of hospital admissions originating through the ED, it's prudent to improve care now in the ED for populations that frequently use it.

"Seldom will a patient wait 12 hours in a waiting room and give a glowing report on HCAHPS," says Christina Dempsey, RN, chief nursing officer for Press Ganey, a large healthcare consultancy.

Dempsey is a former vice president for emergency and surgical services at a level 1 trauma center. She's familiar with the common bottlenecks that occur in an ED, which can leave patients who get admitted, and thus, get HCAHPS surveys to fill out, primed to complain.

Hospitals and health systems are already tailoring care for other patient populations in order to get costs down and improve outcomes. Stratifying the senior population is another opportunity to do the same.