An Emergency Room Designed for Older Patients

The emergency room was packed one night a couple of years ago when Marilyn Riffkin visited Holy Cross Hospital, in Silver Spring, Md., suffering from diverticulitis. She expected to wait for hours. But five minutes later, Riffkin was taken to an ER designed for non-trauma patients ages 65 and older.

Riffkin, 71, was the only patient. The nurse gave her a hot water bottle to ease the pain and hooked her up to an intravenous antibiotic. After Riffkin returned home, the ER called to see how she was doing. “They treated me like a gem,” she says.

Older adults account for 15% of all ER visits, and that share is sure to grow as the population ages. A study at one hospital found its geriatric ER reduced admissions of older persons, who federal data show are much more likely than younger patients to be admitted.

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Holy Cross Hospital’s senior emergency room opened in 2009, the first of about 90 hospitals to build a geriatric ER. During a recent tour, Dr. James Del Vecchio, medical director and chairman of emergency services for Holy Cross Health, showed off the ER’s features.

The eight treatment bays are separated by walls rather than curtains, to provide quiet and privacy. Mattresses are thick, and the phones have large numbers. The walls are painted a calming cream and soft brown—Del Vecchio says he learned the pale blue he originally wanted tends to look dirty to aging retinas.

Del Vecchio pointed to the floor, made of a non-slick wood alternative. “Hospital floors are usually white and shiny,” he says. “But shiny looks wet, and when patients think the floor is wet, they’re more likely to fall.”

For design help, Holy Cross and other hospitals turned to the Erickson School, which offers programs in aging services at the University of Maryland, Baltimore. Using the latest research in geriatrics, Erickson focused in part on fostering communication between the staff, who are trained in geriatric care, and patients, who are often disoriented, says Judah Ronch, Erickson’s dean. The soothing environment helps reduce anxiety. “Stress can impair memory, and anything that promotes comfort improves rapport and the accuracy of information,” such as a patient remembering when she last took medication, Ronch says.

Targeting the Health Needs of Seniors

All patients are screened for cognitive impairment and abuse. They’re also tested for fall risk: Broken bones or a poor gait could be signs of an undiagnosed physical condition or obstacles at home. And if someone is taking many medications, the hospital pharmacist will check for harmful interactions.

Del Vecchio recalls one female patient whose daughter was about to place her mother in a nursing home because she was always groggy. The ER ruled out a stroke and sepsis when the pharmacist found the woman’s physician had increased a medication for nerve pain. The hospital cut back the dosage. “The great news was that she woke up,” Del Vecchio says, though her pain notched up a bit.

The medical staff recognizes that older patients often show different symptoms than younger patients for the same disease. For example, a person older than age 80 who is having a heart attack may not have chest pains but instead appear weak or fatigued. “Ill-defined symptoms could represent a more serious issue,” says Del Vecchio.

Over the years, Holy Cross’s geriatric ER has reduced the number of older patients who return within 72 hours. Del Vecchio says a big reason is the discharge process. Marcy Smith, the ER’s geriatric social worker, calls each patient the day after discharge to make sure prescriptions have been filled and an appointment with a doctor scheduled. If not, Smith will arrange to have the medication delivered or call the doctor herself.

Smith will also coordinate home care, the delivery of supplies to the patient or admission to a nursing facility. And for patients who have fallen at home, Smith may call on an expert to check for loose extension cords or other hazards. “We can set up whatever services that are appropriate, even before they are out of the ER,” Smith says.

Acute Care Units for Seniors

Here’s a sobering statistic: One-third to one-half of patients older than age 70 who land in the hospital with an acute illness or injury leave more disabled than when they arrived. This is true even if they recover from the medical condition that sent them there, research shows. Many patients who may have been independent before will need help with walking, dressing and other activities when they go home.

Older patients are less likely than younger ones to bounce back from a stint in the hospital, in part because they may suffer from several chronic conditions. To help prevent the functional decline of geriatric patients, between 100 and 200 hospitals nationwide have opened Acute Care for Elders (ACE) units.

The ACE unit at the University of Alabama at Birmingham’s hospital is typical. Patients are treated by an interdisciplinary team that includes a geriatrician, nurse, social worker, dietitian, physical therapist, pharmacist and psychologist.

All new patients are tested for physical function and cognitive impairment. Even a mild cognition issue can lead to confusion and agitation after the addition of new medications, interrupted sleep, poor eating habits and days in bed. The delirium that may follow can result in permanent decline, says Dr. Kellie Flood, a geriatrician who directed the establishment of the 26-bed ACE unit at UAB in 2008.

At UAB’s unit, all the rooms are private, promoting a peaceful environment. The staff monitors medications for debilitating interactions. Patients who are able eat their meals in a chair, not in bed. Volunteers help with range-of-motion exercises. A “move and groove” music program, as well as card games and Sudoku, keep patients physically and mentally active.

Patients also do a lot of walking. “If a person was walking before coming in, the patient needs to be walking as much as possible in the hospital,” says Flood, director of clinical programs of the UAB’s Division of Gerontology, Geriatrics and Palliative Care.

A 2010 study found that patients who stayed in the Birmingham hospital’s ACE unit had lower 30-day readmission rates than older patients treated in the hospital’s regular acute-care unit. A study of another hospital’s ACE unit showed that its patients had shorter hospital stays than other older patients.