Performance Improvement

Serving Older Emergency Patients with Extra TLC

A new accreditation program promotes age-friendly emergency departments

By Lola Butcher

When a college student shows up at Carroll Hospital’s emergency department with a sprained ankle, Nicole Cimino-Fiallos, M.D., treats the patient and sends him or her home.

If that ankle belongs to an older patient, the emergency physician takes a different approach. “When I see a geriatric patient who has fallen, I ask: ‘Why are you falling?’" she says. “‘Who is helping you at home? Do you need an assistive device? Do you need someone to come check on you? Are your medications making you fall?’"

She has that perspective because Carroll Hospital is among a growing number of hospitals with a “geriatric emergency department" designed to address the unique needs of frail elderly patients. The term does not necessarily mean a designated unit set aside only for older patients; but it does mean clinician training, extra resources and a big-picture approach — what’s really going on with this patient? — to improve patient care and reduce avoidable hospital stays.

Mark Rosenberg, D.O., chairman of emergency medicine and chief innovation officer, St. Joseph’s Health in Paterson, N.J., spearheaded creation of one of the country’s first geriatric emergency departments in 2009. He was inspired to do so after his mother, living in Florida when her health declined late in life, became afraid of going to the emergency department. It was too loud and too chaotic; she saw too many trauma victims; the environment increased her anxiety.

“So we created a place where I would want my mom to go," Rosenberg says.

The emergency department at St. Joseph’s University Medical Center includes a 20-bed geriatric unit that features special lighting, nonglare/nonslip floors, extra-thick mattresses, and staff who are trained to recognize and respond to the needs of seniors. A patient liaison visits each patient to offer a heated blanket, food, tea or whatever is needed for comfort. A case manager makes sure everything is in place — whether that’s a commode, home health care or a follow-up appointment with a specialist — for a safe return home before the patient leaves the emergency department.

“Most importantly, we screen everyone for risk of falls, dementia, delirium, dietary problems and depression," Rosenberg says. “If we identify any of those problems, we provide specialty care to help keep the person functionally independent at home."

Why “Senior Friendly" Is Important

St. Joseph’s, an academic tertiary care medical center, and Carroll, a community hospital serving a Baltimore suburb, were among the first hospitals in the nation to receive geriatric emergency department accreditation when the American College of Emergency Physicians began accrediting facilities in 2018.

As they seek ways to be more age-friendly, many hospitals have started promoting geriatric emergency departments in recent years, says Kevin Biese, M.D., an emergency physician at UNC Health Care in Hillsborough, N.C., and chair of the ACEP accreditation committee. But until the ACEP set standards for its accreditation program, the range of amenities and expertise associated with the term varied widely.

The term “geriatric emergency department" is not a one-size-fits-all concept, Biese says. In one hospital, the extra services might be targeted for patients 75 and older; in another, they might be extended to patients as young as 55.

The accreditation program offers three levels, from Level 3 (the lowest) to Level 1 (the highest). Carroll has Level 3 accreditation; St. Joseph’s has Level 1. Each hospital chooses the specific protocols and services right for its patients and staff. But all accredited departments have initiatives to meet these standards:

• Physicians, nurses and other staff who are trained about the special needs of older patients
• A physical environment and supplies that create a safe and comfortable environment for older patients while they are in the emergency department
• Standard protocols to address common geriatric issues, such as assessing for falls risk
• Processes to make sure patients are safely transitioned from the emergency department to other settings, whether that’s an inpatient bed, home, a rehab facility or long-term care

As of February, ACEP had accredited 40 geriatric emergency departments, and more than 160 other hospitals had initiated the accreditation process.

“Now I'm having many conversations with health care systems that want to bring many or all of their emergency departments into accreditation in a coordinated manner," Biese says.

Many geriatric emergency departments get their start because a person in a position of influence — for example, a board member or a senior hospital executive — comes to see that the standard emergency department experience is not exactly age-friendly.

“In many cases, it starts with a personal story in which an individual or a loved one has been to an emergency department," says Jon Zifferblatt, M.D., vice president for strategy and successful aging at the Gary and Mary West Health Institute. (The Institute and The John A. Hartford Foundation provided financial support for the ACEP geriatric emergency department accreditation program.)

Weighing Costs and Benefits

While major construction is not required for accreditation, making an emergency department age-friendly does require a commitment of resources. To earn Level 3 accreditation, the department must have both a nurse and a physician who are designated champions for the initiative, leading continuous improvement efforts and making sure staff are trained on a regular basis; food and beverages available for older patients around the clock; and devices, such as walkers, to assist patients with mobility. The higher accreditation levels require greater investment.

The return on investment for geriatric emergency departments can be measured in both dollars and improved patient care, Zifferblatt says.

For hospitals in value-based contracts, a geriatric emergency department can reduce avoidable hospitalizations when case managers connect patients with the resources they need to be safe at home. “This reduces what we call ‘social admits’ where a patient may be admitted because the ED docs just feel there is not a good alternative for them," he says.

Meanwhile, hospitals in fee-for-service contracts benefit by being able to manage their inpatient census better. If an elderly patient can recover from, say, a urinary tract infection with the right support at home, that frees an inpatient bed for a patient who needs surgery or is more acutely ill.

Beyond that, patients avoid the hefty copay associated with a hospital admission — and most importantly, they are better served if they can avoid an unnecessary hospitalization. “We feel good about helping patients go home, with the additional supports they need, because we know that's often for the better for the patient," Biese says.

An Age-friendly Front Door

Helen W. Whitehead, an executive and individual coach in Mount Airy, Md., is a member of Carroll Hospital’s board of directors. The hospital made a commitment to older patients in 2012, when it earned certification from Nurses Improving Care for Healthsystem Elders (NICHE), documenting that all nurses had received special training about working with older patients.

The decision to invest in a geriatric emergency department was a logical next step, she says.

“Carroll County has an older population — demographically speaking, we're just slightly older than the average county in America," Whitehead says. “We are very aware of our elderly population’s needs because, as a community hospital, they are our neighbors, friends and family members."

Carroll Hospital opened its Frank and Ellen Hull Senior Care Suite — four rooms equipped with full-size hospital beds, special lighting and a host of amenities — in 2016. But four rooms is not always sufficient to accommodate all the patients age 65 years and older.

“Over the past year we have made the entire emergency department more geriatric-friendly, almost like a virtual geriatric emergency department," Cimino-Fiallos says. “No matter what room you're in, you're still getting all the same geriatric care that you would if you were in those designated rooms."

That means all emergency department patients 65 and older are assessed for mobility and have access to a case manager to help arrange home care and physical or occupational therapy. All rooms have white boards that use large-font letters to keep patients apprised of the date, time and members of their care team.

Perhaps the most important feature is monthly training for physicians and nurses. Cimino-Fiallos coaches nurses on the use of tests to screen older patients for depression, falls risk, elder abuse and delirium.

“I really want nurses to be aware of specific issues that face geriatric patients that aren't always immediately apparent when they come to the emergency department," she says.

For physicians, Cimino-Fiallos focuses on how medical complaints — and treatment protocols — in the geriatric population are different from those of younger patients. The 30-year-old who presents with pneumonia is simply different from the 85-year-old with the same diagnosis. “It's different bacteria that are responsible, different medications that are appropriate," she says. “For the 30 year old, you may not think twice about sending them home to follow up with their outpatient doctor; but the 85 year old may need to be admitted to the hospital, even though it seems like a simple pneumonia."

That’s good care for an elderly patient with an added bonus for the hospital. Age-friendly care in the emergency department is an opportunity to make a good impression on an entire family, Whitehead says. A healthy 35-year-old woman may have never needed inpatient care; but if she has to zoom her mom to the emergency department, she will evaluate the entire hospital based on that experience.

“It's an entry point to a family's relationship with you," Whitehead says. “Making sure that someone's parent is taken care of appropriately — what better impression can you give?"

Lola Butcher is a contributing writer to Trustee Insights.