Getting ready for emergency care for the elderly

This article was originally published in The Sacramento Bee.

There is no dispute here – the elderly are coming and in unprecedented numbers.

Their arrival promises to have a lasting impact on California’s health system.

The state’s Department of Aging estimates that the 60-plus population is on course to have doubled between 1990 and 2020. The most frail of our residents – those 85 and older – will have tripled in 26 of the state’s 58 counties.

At some levels, state health officials and professionals are making ready.

California boasts fine medical schools and first-rate hospitals, departments of gerontology at major universities, and county and state agencies for the aging.

But at the typical entry point for the elderly into the medical system – the emergency room – there’s evidence that preparations are lagging.

We’re familiar with pediatric ERs – places made more comfortable for the children they serve. For example, Stanford Children’s Health ER advertises on its website that there are “play activities, movies and games to reduce a child’s anxiety and fear.” It has big-screen TVs showing cartoons and exam rooms equipped with “computers with children’s games, music, movies and Internet access.”

At the other end of the life spectrum, the particular needs of seniors seem to have gone unnoticed.

Despite high interest in creating what are called “geriatric ERs” by emergency physicians and otherhealth professionals elsewhere, a California Hospital Association spokesperson says it knows of no such units among its member hospitals, and no plans for any. UCSF’s emergency medicine experts say it’s a very new concept currently in place only at some East Coast hospitals. A Department of Aging spokesperson says the agency is not aware of any sort of program in California with a geriatric ER.

Clearly, it’s new. But the American College of Emergency Physicians has thought long and hard about this for more than two years, giving final approval in January to new “geriatric emergency department guidelines.” The Emergency Nurses Association announced this month that it has joined the ER doctors in support of this concept. And there are dozens of them up and running, with more in the planning phase – but not in California.

According to experts like Dr. David John, a member of the guidelines task force, geriatric ERs offer significant benefits to the elderly while saving time and money for ERs.

First, John checks off some sobering statistics:

• The oldest of the old represent 42 percent of all intensive care unit visits.

• If you are over 65, you have a 54 percent chance of being admitted to a hospital from an ER.

• Even if not admitted, seniors spend a longer time in the ER and utilize many more resources than the general population.

“Older adults are not just pale, wrinkly adults,” says John, co-chair of emergency medicine at Johnson Memorial Medical Center in Stafford Springs, Conn., which plans to open a geriatric “Emergency Department” this spring. “ED docs know a lot about trauma and pediatrics but were never trained for geriatrics, and their needs are very different than the general population.”

Physically, a geriatric ER starts with some important little things, like providing softer mattresses to prevent bedsores, or installing alarms to help seniors deal with falls that too often keep them in the hospital for weeks.

There are color scheme changes and markers on floors and clear, large-font signage to help with navigation for those with vision or memory-loss problems. There are certain kinds of handles on doors that make them easier to see and use.

Staffing is also different, with specialized nurses, pharmacists and social workers who understand the infirmities of age and the psycho-social problems that often ensue.

The primary job of these health professionals is to try to steer elderly patients away from unnecessary hospital admissions, which, studies show, too often lead to delirium, infection and overall functional decline. And that means that the geriatric ER must extend treatment beyond its doors.

“Even if we do a really good job of taking care of those in the ED and admitted,” says John, “the half that we send home we don’t do a good job with.”

A geriatric ER program is aware that seniors’ homes may not be a refuge, but a danger. The home may have steps or levels and the person is ill, injured or immobile or can’t see or hear well.

As part of the geriatric ER concept, health professionals assign nurses to visit the home to conduct a safety assessment, provide prescription assistance and education, and make sure seniors’ transportation needs are met.

John tries to convince seniors to allow such services to become part of their home routine. “We call them back the next day. A lot of people won’t accept services in their own home. They say they want privacy. Sometimes we appeal to them that they’re helping their family. Sometimes we appeal (directly) to the family.”

John says he works with this credo: “I’m not going to let any older person go home without being safe and without services.”

Could such a concept work in California? It should.

“Make every ED geriatric-friendly and everyone will benefit,” John says.

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