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A new trend for seniors

Geriatric EDs practice preventive care

Monday February 27, 2012
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Ramazan Bahar, RN-BC, MSW, LSW, was treating a 75-year-old woman who came to the emergency room because her nose would not stop bleeding. The bleeding stopped in the ED, and she was discharged with instructions to skip her next dose of Coumadin and then restart with a lower dose. Luckily the woman had walked into a hospital that recently had opened a new geriatric ED. Part of the protocol for all patients 65 and older is to make a follow-up phone call within 72 hours.

“When we called her back to review the discharge instructions, we realized she was getting ready to double-dose herself because she was confused,” said Bahar, program coordinator of the geriatric ED at St. Joseph’s Regional Medical Center in Paterson, New Jersey. “She could have bled out.”

In the past, this patient’s potentially fatal misunderstanding could have gone unnoticed until it was too late, but a growing number of hospitals are experimenting with a concept aimed at minimizing that possibility. The new geriatric EDs typically include not only environmental improvements such as non-slip floors and thicker mattresses, but also nurses who are trained to do assessments and follow-ups geared to this patient population. “When geriatric patients reach a stage of life when they start using the emergency department more frequently, they typically start on a spiral of decline, but a lot of these things are preventable,” Bahar said. “We opened a geriatric emergency department to make sure these people will remain functional in the community as long as possible.”

How it works

Hospitals like St. Joseph’s recognize the demographics of aging in this country are expected to shift dramatically in the next 20 years. By 2030, the number of people 65 and older is projected to double when compared to the number in 2000, according to a 2010 report by the Federal Interagency Forum on Aging-Related Statistics. Almost 20% of the population will be 65 and older by 2030, according to the report.

Research also suggests a more troubling trend for this growing sector of the population: Based on data from more than 11 million patients nationwide, nearly 20% of Medicare beneficiaries who had been discharged were rehospitalized within 30 days. Two-thirds who were discharged with medical conditions such as heart failure, pneumonia, chronic obstructive pulmonary disease, psychoses or gastrointestinal problems were readmitted or died within one year of the initial hospitalization. These findings were published in 2009 in the New England Journal of Medicine.

In an effort to buck this trend, Holy Cross Hospital in Silver Spring, Md., opened the first geriatric ED in 2008, and more hospitals are following suit. St. Joseph’s Regional Medical Center opened its 14-bed geriatric ED in January 2010; beds are reserved for highly functional seniors who do not require stabilization. The nurses in the ED are trained to use the Identification of Seniors at Risk screening tool for patients 65 and older. The tool includes questions such as:

• Are you taking more than five medications?
• Have you been hospitalized in the last 30 days?
• Have you experienced changes in your functional status?
• Have you experienced any change in vision?
• Before coming to the ED, did you need someone to help you at home on a regular basis?

If patients answer yes to two or more of the questions, they are referred to Bahar. He performs a more comprehensive assessment to determine the patient’s functional and psychosocial status, family support situation and reason why he or she may be declining.

“If, for example, you have an 85-year-old female who lives alone and is functional, but is in the ED for a fractured wrist, I would find out why she fell,” Bahar said. “Has her vision declined or medication changed? Does she need home health, visiting nurse services or support from a church group?”

Traditionally, this type of patient would come to the ED, be seen by a physician and then discharged, but perhaps nobody would find out why she fell. If she returns home with a cast on her fractured wrist, she may struggle to cook for herself and may be at risk for dehydration, which could create a host of new problems, Bahar said.

Once Bahar identifies the patients’ needs, he forms a plan to help them stay healthy after they return home. He often calls community organizations that can assist with rides to appointments, meals or more direct medical care at home. After the patient is discharged, a nurse makes a phone call to follow up with the patient. The nurse asks about the patient’s visit to the ED, whether he or she understands discharge instructions and, if the patient was prescribed medication, whether he or she was able to obtain the medication and understands how to use it.

ED patients who are admitted to St. Joseph’s are cared for on a Nurses Improving Care for Healthsystem Elders unit designed to meet the complex needs of this population, according to Bahar.

Statistics confirm the geriatric ED is making a difference. Mark Rosenberg, DO, MBA, chairman of the department of emergency medicine at St. Joseph’s, reported unscheduled returns of ED patients ages 65 and older dropped from 20% to just more than 1% since the dedicated ED opened.

Environmental differences

St. Mary Mercy Hospital in Livonia, Mich., opened a geriatric ED in July 2010, and the benefits became clear almost immediately. “Within hours after opening, we knew we had done the right thing because of everything we discovered from the assessments,” said Michelle Moccia, RN, MSN, ANP-BC, CCRN, program director of the senior ED at St. Mary Mercy Hospital. “It is about delivering relationship-based care rather than just focusing on their medical chief complaint.”

Nurses use several assessment tools to screen for dementia, delirium, geriatric depression or other barriers to living independently. Based on these assessments, nurses will alert the ED social workers, who then connect the patients with community resources to ensure they will have support at home. Moccia said pain, shortness of breath, change in the level of consciousness, falls, dehydration and electrolyte imbalance are common problems seen in the ED, as well as medication adherence and adverse drug events.

The unit also is designed to be more senior-friendly with pressure-reducing mattresses, hand rails along the walls and devices such as a “pocket talker,” which uses headphones connected to an amplifier to help seniors who are hearing impaired.

ED RNs at St. Mary Mercy completed the Geriatric Emergency Nursing Education through the Emergency Nurses Association and ongoing education. The inpatient RNs also completed the Geriatric Resource Nurse Module through NICHE.

Eight hospitals in the St. Joseph Mercy Hospital System in Michigan have opened geriatric EDs in the past two years, and since then, there has been a more than 10% increase in the number of seniors who visit the ED. Moccia suggests this increase is directly correlated to the fact the elderly are drawn to an ED that is designed to meet their specific needs.

The emotions of aging

Many seniors who come to the geriatric EDs want to stay independent as long as possible. One important way to help them achieve this is knowing how to detect when they are struggling with daily life, said Kimberly DiSanto, RN, assistant vice president of emergency services at Newark (N.J.) Beth Israel Medical Center, which opened a geriatric ED in November 2011.

This was one of the important concepts covered in the training for nurses staffing the unit. “A lot of these individuals want to continue to be independent, so they are hesitant to reach out and ask for services,” DiSanto said. “You have to develop a relationship with them so they trust you. Then you can help them understand the services that are available to help them stay independent in the community.”

Although it may take extra time to tease out the needs of the elderly, this time is well-deserved by the people who have laid the foundation for our modern way of life, said Bahar.

“They are the pillars of society, and we are what they built, so they deserve quality care and respect,” he said. “We can’t stop aging, but we can slow down the complications of aging, and the geriatric ED is our way of making sure they get the best healthcare possible.”

Heather Stringer is a freelance writer. Post a comment below or email specialty@Nurse.com.