New Service Combines Clinical And High-Touch Techniques To Better Serve The Patient Age 65+
Only children under age six go to the emergency department (ED) as often as adults over age 65, according to the Centers for Disease Control’s National Center for Health Statisitics (1). In fact, nearly one in four adults 65 years and older visits the emergency department one or more times in a 12 month period (2).
For years, many hospitals have had separate emergency departments for kids. Now, based on some of the newer thinking in geriatric medicine (3), Des Peres Hospital is the first in the St. Louis area with special emergency rooms for the older adult patient.
“Older adults can have complicated health histories, may take multiple medications and may have functional and cognitive impairments that add a layer of complexity to the ED situation,” said Raana Ponstingl, MD, Des Peres Hospital’s emergency department medical director.
Indeed, according to a study in the Journal of the American Geriatrics Society (3), the rapid triage and diagnosis model and physical set up of most emergency departments may not meet the needs of the older patient – for example, stretchers with thin mattresses increase the risk of pressure ulcers, and noise from monitors, clinical staff and other patients might contribute to communication difficulties for those with hearing impairments.
Des Peres Hospital’s geriatric emergency rooms are designed for the comfort and safety of the older patient – pressure reduction mattresses, foam heel pressure pads and elbow protection may be used for wound prevention; lighting can be adjusted when appropriate; designated rooms are located in lower traffic areas to keep noise to a minimum and create a more calming atmosphere, and warm blankets are provided as a way to make the patient comfortable.
“Our goal is to minimize the anxiety that our older patients might feel while being particularly attentive to the special care considerations that come with age,” said Deborah Wilke, RN, emergency department director.
All Des Peres Hospital emergency department nurses have been certified in geriatric emergency nursing education to ensure that they understand the normal physical and psychological effects of aging and the impact these can make on their clinical assessment of the patient.
For example, older patients may be reluctant to report pain or may not experience pain in the same way as younger adults, so the nurses assess for changes in behavior, changes in activity level, sleeping problems or agitation. Another example, older adult bodies metabolize medications differently than younger adults, so the ED team pays particular attention to dosages of certain medications.
If family caregivers accompany the patient, they are embraced and included in care as much as possible. “Family members often are great resources for the health history of the patient,” said Wilke. “They can tell us if behaviors or issues are new or ongoing and that can help us with our assessment.”
The holistic approach to care goes beyond the ED stay: 24 – 48 hours after discharge, Des Peres Hospital emergency department nurses follow up with the patient’s physician, nursing home and/or the patient directly to determine how they are feeling and if there are any questions about their follow-up care.
The geriatric emergency rooms build on the expertise developed in Des Peres Hospital’s Acute Care for the Elderly (ACE) Unit, which opened in 2003. The goal of the ACE unit is to minimize the adverse consequences of procedures, tests and medications on older patients, and to maintain patient function levels so that they can return home or to the same level of care as they were before they got sick.
In the ACE unit, older patients are cared for by a multidisciplinary team of nurses, physicians, including geriatricians, physical therapists, occupational therapists, pharmacists, case managers, dietitians and pastoral care staff. Together, they conduct daily medical, behavioral, cognitive and emotional reviews of each patient to help avoid complications and assist the patient in regaining and maintaining good function.
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1. Health, United States 2008, tables 91 and 92 (updates)
2. Health, United States 2008, table 92 (update)
3. “The Geriatric Emergency Department,” Ula Hwang, MD, MPH; R. Sean Morrison, MD, Journal of the American Geriatrics Society, 12/4/2007.