It takes a special skill set to meet the needs of elderly patients in any treatment scenario. In the ED, caring for seniors means treating emergent conditions, while remaining sensitive to physiological differences and cognitive or sensory deficits that come with age and that can make ED visits trying at best. As the population ages, more ED nurses are educating themselves on geriatric care and more hospitals are striving to make their EDs more comfortable for seniors.

Elderly -— Not Helpless
A study published in the American College of Emergency Physicians’ 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.

To effectively care for these patients, nurses first need to realize seniors need special care and dismiss any preconceived notions they have about the elderly, says Joan Somes, RN, PhD, CEN, FAEN, a staff nurse at the ED of St. Joseph Hospital in St. Paul, Minn.

“You have to remind yourself that seniors’ bodies are different, therefore they have different needs,” she says. “At the same time, you also have to rid yourself of stereotypes. [Some nurses] assume that just because someone is old, they are helpless. They can be independent and often try to demonstrate that to their families by wanting to go home [quickly from the hospital] to take care of themselves. But sometimes they need more help than they think.”

In 2003, Somes, who has worked as an ED nurse for 35 years, became a member of the Geriatric Emergency Nurse Education committee at the Emergency Nurses Association. The committee’s purpose was to create a GENE course on geriatric care that was first presented live in October 2004 at an ENA Scientific Assembly. The course addresses the physiological differences of elderly patients and how they should be incorporated into the assessment process, medication, and discharge, as well as how to help patients make end-of-life decisions. It also emphasizes demonstrating respect toward patients and keeping them informed.

Since its premier in 2004, the course has been offered live to more than 400 nurses at numerous conferences, presented in several webinars, and made into an eight-hour interactive program available on the ENA Web site.

The course also addresses preventing bed sores, which can plague patients even in the relatively short period of time they spend in the ED. “Besides turning the patient, we are very careful with backboards. Geriatric patients often fall and arrive on backboards, but the board can break down their skin very quickly,” Somes says. “Therefore, we immediately get a physician to determine if we can remove the patient from the backboard.”

Building Serenity
While Somes helped create the GENE course, she also was advocating change in her own hospital at St. Joseph, which recently began tailoring its ED to be more aesthetically pleasing and comfortable for seniors.

Somes and others made recommendations that included soundproofing, handrails, taller toilets that seniors can easily sit on, lighting that can be dimmed, and floor coverings with non-reflective carpeting instead of shiny and slippery linoleum.

“Our patients had a difficult time sitting on the low toilets in our existing ED,” Somes says. “Two years ago, we got new toilets and new lighting, and the shiny linoleum disappeared.”

Somes recommends that even if an institution does not make these changes, nurses can rearrange the environment, remove distractions, and pay extra attention to the comfort of the patient.

“A visit to the ED can be confusing and scary even for a regular adult, but it is especially difficult for someone who can’t hear or see very well,” Somes says. “Keeping them informed as much as possible puts them at ease. Nurses also should be careful of using seemingly innocent words like ‘grandma’ or ‘honey’ because they can be derogatory.”

A handful of hospitals around the country have created separate geriatric EDs and made modifications to their existing units to cater to the special needs of the elderly. Holy Cross Hospital in Silver Spring, Md., was able to overhaul ED to create an ED specifically for geriatric patients.

Judith Ann Rogers, RNC, MSN, PhD, chief nurse executive/patient care services at the hospital, says Holy Cross’ ED was the first specialized unit for adults age 65 and over in the country when it opened in November 2008.

“When we were planning to create this unit, we looked around to find blueprints on how to do it,” she says. “We could not find one. We decided to get it done because with the graying of America, the elderly is the group that needs us the most and deserves our attention. There also is a national agenda to reduce the readmission rate.”

The hospital’s administration partnered with Erickson School, a Maryland agency dedicated to advancing the life of seniors. Their geriatric care experts gave recommendations on the design of the unit. The hospital also sought out the input of the community by creating several focus groups of seniors who voiced their needs and talked about negative experiences in EDs.

“Our unit is very patient friendly,” says Maureen Garcia, RN, MSN, ED nurse educator and geriatric unit nurse. “There are six beds and two rooms, and they are arranged so the nurse can see all beds from her station. We only place patients here with non-critical conditions.”

Rooms are equipped with special speakers at the head of the beds, telephones with bigger buttons, clocks with larger numbers, and mattresses that are 4 inches thick — double the thickness of an ordinary hospital bed mattress.

“It is all about making the patients comfortable,” Garcia says. “We limit the number of patients, while in the regular ED we often have patients even in the hallways.”

All of the hospital’s ED nurses work in both the regular ED and in the geriatric unit and completed the GENE course.

Nurses, including a geriatric nurse practitioner dedicated to the unit, work closely with social workers. Discharge also is a very important part of the process and great care is taken to make sure the family is included and patients are thoroughly prepared, which helps improve readmission rates.

“It is time well spent, and it does not take that much longer either,” Rogers says. “Just using the right words can make a big difference.”

Patients are called within 24 hours of discharge to make sure they are following discharge instructions, having their prescriptions filled, and setting up appointments with referrals.

Geriatric care patients’ nutrition also is scrutinized, as they often arrive in the ED dehydrated or malnourished. They often comment that it is difficult to cook for one person or that their sense of taste has changed so they don’t enjoy food anymore.

Garcia says she also thinks having a quiet place for the elderly is good idea.

“It is a much more controlled environment,” she says. “It’s less chaotic, which is good for the patients but also for the staff. I wish the whole ER was like this.”

The hospital’s next step is to introduce a senior ambulatory and surgery department, which opens soon.

“We are very happy with the results of the geriatric unit,” Rogers says. “We hope to bring the same approach to the pre- and post-procedure care.”

Tamas Horvath is a freelance writer.