By Meredith Cohn
The Baltimore Sun
July 5, 2015
When Phyllis Lansing’s husband, suffering from diabetes and dementia, landed in the emergency room at St. Agnes Hospital some years back, she said he was overwhelmed.
Doctors ran numerous tests as they evaluated her husband, who is now deceased, but no one told the elderly couple what they were looking for.
“It was a confusing process,” said Lansing, an 80-year-old resident of Charlestown, a Catonsville retirement community near St. Agnes. “With everyone going in every direction a person doesn’t know what’s happening to them. They need to be aware that they are dealing with an older person who needs more reassurance, better communication.”
Moving to better serve its older population, St. Agnes recently became the second Maryland hospital to open a separate emergency department for seniors. It offers an entrance next to the existing one, safer, more comfortable environs and a staff trained in elder care issues.
Dozens of hospitals across the country have adopted similar emergency accommodations to tailor care for seniors, though some question the need for separate departments. Those who study geriatric care say seniors visit the emergency room more than any other group but infants, and hospitals are under pressure by federal and state regulators to reduce rates of admission and readmission to cut costs and improve care.
St. Agnes treats about 8,000 seniors in the emergency department annually, or just under 10 percent of its more than 84,000 emergency patients in fiscal 2014. Now older patients will go to one of seven exam bays in the separate emergency room to be treated by any of the 164 emergency staff.
Patrick Mutch, interim president and CEO at St. Agnes, said he knows the emergency department can be overwhelming and disorienting for the growing number of seniors visiting them.
“That knowledge, coupled with a review of emergency department visits and admission rates among patients over the age of 65 — nearly 55 percent of visits in 2012 resulted in an admission — made it clear how important it was to transform the culture of senior care and provide a specialized experience for seniors in which they can feel calm, safe and well attended.”
Since St. Agnes opened its department in June, Amanda Rocco, an emergency staff nurse there, and others said they found the setting and protocols promoted more consistent and thorough care in a more comfortable environment — and slowed things down just enough.
“It’s usually all hustle and bustle in here, and some nurses were nervous about the extra time,” Rocco said. “But it flew by and it was nice to just focus on these folks.”‘
The senior emergency department that Holy Cross in Silver Spring opened in 2008 is considered the nation’s first. As at St. Agnes, officials there said the approach was two pronged — screen patients for a range of conditions including mental state, fall risk, nutritional deficiencies and drug interactions, and improve the physical setting.
Officials traded curtains for walls in treatment bays for privacy and quiet, employed thicker mattresses, heated blankets, softer lighting and larger signs for comfort, and installed handrails, bedside commodes and nonslip floors for safety.
Staff was trained in the new procedures and the complex health conditions of seniors. Social workers, pharmacists and nutritionists were brought in.
The number of repeat visitors began ticking down.
“The pediatric emergency room was really the genesis for senior emergency rooms,” said Dr. Judah Ronch, dean of the Erickson School at University of Maryland, Baltimore County, which specializes in aging issues. “The need was pretty evident, and places that saw success with that said OK what is the next opportunity.”
Both Holy Cross and St. Agnes turned to the Erickson School for help developing their programs.
Hospitals saw a large and growing geriatric population they may have been underserving, Ronch said.
Seniors make up about 12 percent of the 2 million visits in Maryland, data from the Maryland Hospital Association shows. Census data shows by 2050 the number of Americans age 65 and older is expected to almost double to nearly 84 million.
Ronch said his colleagues found the earliest adopters of senior-oriented care did little more than put up signs, but that’s changed. Now they focus on making the experience calmer, safer and targeted to geriatric conditions.
Screening takes time, but Ronch said standardizing procedures and training staff could reduce patients’ overall time at the hospital. Clear discharge instructions and follow-up to ensure patients fill prescriptions, for example, could avoid repeat visits.
There are about 85 emergency departments across the country doing some type of senior-focused emergency medicine, less than 2 percent of hospitals nationwide, according to John Schumacher, an assistant professor in UMBC’s Department of Sociology and Anthropology, who has been tracking the trend.
Implementation also varies, Schumacher said. About 30 percent have a separate space, while the rest designate beds within the existing emergency room, for example.
Dr. Chris Carpenter, associate professor of emergency medicine at Washington University in St. Louis, recently co-authored geriatric emergency guidelines and is pushing for their wide adoption. He also holds boot camps for providers.
For now, there is no accreditation by an outside group for elderly emergency care, like there is for pediatric or trauma medicine, signaling to patients and other professionals that a certain level of care is provided.
Carpenter’s protocols “should provide hospitals with a framework of best practices for providing care to older patients,” Schumacher said.
While many agree care can be lacking for seniors, he said some emergency physicians resist accreditation or even guidelines because they say they don’t need them or believe the marketing value would be outweighed by the burden of gaining a stamp of approval.
Carpenter said he got into geriatric emergency medicine and began researching best practices after witnessing the poor treatment given his grandparents. He said he and others will continue tracking data to prove the value.
“We can do things to make it less stressful for seniors and get better outcomes,” he said. “There is a lot of evidence coming out, like we don’t recognize delirium and cases of dementia. We’re not screening for the risk of falls, just dealing with the consequences of a current fall. There are so many opportunities to improve care.”
In deciding whether to open separate emergency departments, hospitals must consider the population they serve, how it may change, who else is providing the same services and other capital needs, said Robert Maliff, director of the applied solutions group at the ECRI Institute, an independent research and consulting firm.
A recent report from the institute found 50 such departments and about 150 in development. Hospitals were spending anywhere from $150,000 to $3.2 million on them. Some already operating anticipated a return on investment in the form of decreased admission to ICUs and readmissions and improved outcomes.
“There is a lot of interest in this,” Maliff said. “But whether patients are able to function at home any better, if there are fewer instances of confusion, if there are reduced admissions, there aren’t hard numbers if this works. It makes theoretical sense.”