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Geriatric NP Supplements Senior Citizen ED Care

Monday June 15, 2009
Jon Sugarman, RN
Jon Sugarman, RN
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Jon Sugarman, APN, BSN, MSN, GNP, a geriatric nurse practitioner in the ED at Overlook Hospital in Summit, N.J., recalls handing a towel to a restless 98-year-old emergency patient and asking her to fold it. The simple task kept her busy for nearly an hour and calmed her down, averting the need for a sedative that someone less familiar with the care of elderly patients might have used to achieve the same result.

Another day, Sugarman noticed that the wife of an elderly ED patient with Alzheimer’s and Parkinson’s diseases looked exhausted. Sugarman worked with a caseworker to find a respite-care facility that would allow the wife a few days off to regain her strength and continue caring for her husband.

“She was enormously appreciative of that,” he recalls. “And then this 98-year-old woman, I’d like to think I saved her from getting a shot of drugs that really aren’t good for old people.”

Sugarman was hired in March to give special attention to geriatric patients coming through Overlook’s ED. The newly created position shows how one hospital is trying to meet the special needs of a rapidly growing demographic expected to stretch the capacities of the nation’s EDs in the years to come.

“My role is to be an advocate for older patients,” Sugarman says. “I want to make sure these patients are being treated the same way I’d want my own family to be treated.”

People age 65 and older are the fastest growing segment of the U.S. population. They also use the most resources in the ED and are the most likely to be admitted to the hospital of all emergency patients, according to the American College of Emergency Physicians. A study published in the college’s Annals of Emergency Medicine in December 2007 found the ED visit rate by people age 65 and older increased faster than any other age group over the 11-year period of the study. The report concluded that ED visits by patients ages 65 to 74 could nearly double from 6.4 million in 2003 to 11.7 million by 2013.

A separate survey published in August 2008 by the Centers for Disease Control and Prevention’s National Center for Health Statistics reported that patients 75 years and older visited the ED at a rate of 60.2 visits per 100 people, second only to infants in their per capita ED visit rate.

In Summit, longtime resident Amy Liss believed Overlook could do a better job of dealing with its elderly patients. “They were not as involved with geriatric issues as I would have hoped,” she says. “I felt it was an opportunity for the hospital to work even more closely with other groups servicing geriatric patients.”

The widow of a prominent neurosurgeon who had worked at Overlook, Liss contacted Jeffrey Brensilver, MD, chairman of Overlook’s department of medicine, and Michele Elkins, MD, PhD, CMD, the hospital’s medical director of geriatric services, to talk about ways geriatric care could be improved. Liss ultimately agreed to fund the nurse practitioner position for a three-year period.

Elkins, who helped design the position, says the emergency department was one place that sorely needed someone who would be a “connection” for elderly patients.

“There is always an issue with communication and things that fall through the cracks,” she says. A geriatric NP would have expertise in geriatric syndromes and an ability to bridge the communication gap between other emergency caregivers and nursing homes and patients’ families, she says.

Brensilver admits Overlook’s ED had not been meeting the needs of its geriatric patients, as evidenced by hospital board member comments and patient satisfaction scores. “You have someone coming in who has a long list of medications, a long list of problems, and even the primary assessment can be quite challenging,” he says. “The ED doctor will not have a half hour extra to talk to the patient’s family, or call the nursing home and find out more about what’s going on, and for many of these patients who can’t give you a great story because they’re either too sick or have a cognitive disability, getting that information is very important.”

That’s where Sugarman comes in. He has made visits to local nursing homes so when a patient arrives at the ED, he knows whom to call to get a better sense of their medical history. He does a census of geriatric patients each day. He examines patients and looks for common geriatric problems, such as delirium, risk of falling, urinary tract infections, or adverse effects from medication interactions. (He says he recently saw a patient who was on 28 medications.)

He also works with social workers to help patients who might need referral services once they leave the ED, and he follows patients’ progress if they are admitted to the hospital.

Whether it’s providing a thicker mattress to an elderly patient or knowing that someone with apparent delirium might be suffering from a urinary tract infection, Sugarman’s job is to make sure problems unique to the geriatric population are not overlooked.

Brensilver says a nurse practitioner is the perfect candidate for this job. “I think the nurse practitioner has the ideal set of skills in the sense that the expertise in clinical geriatrics is important, but in a package of the sort of person who is willing to provide care on the spectrum, whether that means making a complicated, sophisticated medical assessment or getting someone a cup of water or taking someone’s socks off because their feet are painful,” he says.

While a handful of hospitals around the country have created separate geriatric EDs to cater to the special needs of the elderly, not many have the space or capital to overhaul their physical space. In the meantime, programs such as Overlook Hospital’s might become more prevalent because they can improve the quality of care of geriatric patients and save money, says Barbara Resnick, PhD, CRNP, FAAN, FAANP, a professor in the department of organizational systems and adult health at the University of Maryland’s School of Nursing. Geriatric patients might complain of constipation and actually have acute appendicitis, or they might say they have a little trouble walking and have a bone fracture. Diagnosis is more accurate when a geriatrics expert is on hand, she says.

“With somebody who doesn’t know geriatrics, it might take a week,” she says. “The patient at that point is deconditioned and may have been in a hospital bed for a week. You haven’t solved the problem, and you’ve lost a lot of money.”

Brensilver is hopeful that Sugarman’s work will prove itself from both a quality and cost standpoint long before the three years of funding end. “We expect to show this is a valuable resource,” he says. “We hope we look back and say how could we have done without it.”


Barbara Kirchheimer is a freelance writer. To comment, e-mail editorNJ@nursingspectrum.com.