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St. Joseph’s Regional Medical Center pioneered a new Geriatric Emergency Department, and now they’re helping other facilities do the same.  

Ms. V is an 86-year-old widow who presented to the St. Joseph’s Regional Medical Center (SJRMC) ED after falling while getting out of bed. She had a previous history of a hip fracture and declining functional status.  The comprehensive assessment provided by the ED physician and geriatric RN coordinator resulted in a discharge directly to a sub-acute rehab from the ED. Ms. V and her family’s needs were met without an unnecessary admission to the hospital; the discharge plan was safe, medically appropriate, and cost effective.

What makes this case unique is that all of the care took place within St. Joseph’s specially-designed geriatric emergency department, an innovation that lowered the SJRMC return rate for the geriatric population from 20% to less than one percent.

How it Started
Although the need for a geriatric-specific ED was identified in 2002, it wasn’t until 2009 that the administration at St. Joseph’s supported the concept, resulting in a 14-bed department. The Geriatric ED is open 18 hours per day (8 a.m. to 2 a.m.) with 30 hours of physician coverage and 48 hours of nursing coverage. They serve up to 60 patients per day.
Multiple meetings with staff and community geriatricians aided in designing an ED that specifically addressed the complex medical issues faced by elderly patients. They often present with vague complaints, comorbid conditions, coexisting chronic medical issues and polypharmacy, which results in longer lengths of stay in the ED. Elderly patients also have skin that is more sensitive to pressure that can result in skin breakdown and damage in as little as two hours. Thicker mattresses are more comfortable and lessen the possibility of skin breakdown during periods of extended workups. The stark harshly lighted ED is very unsettling to anyone forced to remain on an ED stretcher during a prolonged workup, so the geriatric ED uses softer, natural light.

Overcoming Hurdles
As pioneers in geriatric ED design, there was no model to follow, so floor staff and administrators did not readily buy in. The geriatric population was not viewed as distinct.  Doctors and nurses thought they already possessed the skill set to address their needs. The staff’s interest grew when they realized that “geriatric” included active, independent older people instead of the stereotypical nursing home patient. This redirected the focus to understanding the complexities and specific needs of geriatric emergency care, and the vision and commitment of the staff become synergistic. The entire staff was educated and procedures put in place to address the specific needs of this population. Each RN completed 16 hours of geriatric-specific training and each physician completed six hours of training. The key physicians in this program are double boarded in emergency medicine and internal medicine. All policies and procedures were developed in house based on literature review.
 
How it Works
Between the hours of 11 a.m. and 11 p.m., physician triage identifies eligible patients (based on age, disability criteria, functional capacity) for the Geriatric ED. The Geriatric ED team consists of assigned physicians, advanced practice nurses, registered nurses, a clinical pharmacist, case managers and patient liaison personnel. This core team is also supported by a toxicologist. We know that polypharmacy is a major problem with geriatrics and that frequently seniors share their medications with others. A toxicologist is consulted to review potential interactions since the literature shows that seven or more medications have a significant risk of drug-drug interactions. In our program, the pharmacist performs initial screenings for five or more drugs and consults with the toxicologist on each case when seven or more drugs are used.

All patients seen in the Geriatric ED receive a call from the patient liaison within 24 to 48 hours after discharge. The patient liaison follows a script of five follow-up questions. If a problem is identified, the RN coordinator of the Geriatric Care Team provides further follow-up ranging from reassurance/clarification, to appointments with their Primary Care Physician (PCP). All PCP are notified that their patient was seen in the Geriatric ED and any follow-up that was recommended. If a return to the ED is necessary, the Advanced Practice Nurse or Geriatric Program Coordinator meets them on arrival to the ED and they are taken to a bed without having to wait.  The follow-up phone call in the life of Mrs. B, a 76-year-old female who lived alone, made the difference between life and death. Seen in the Geriatric ED for a complaint of dizziness, she was discharged after a complete work-up, including electrocardiogram (EKG) revealed no abnormal findings. The next day, because of the phone call from the patient liaison, Mrs. B returned to the ED.  The patient liaison initiated the return visit because Mrs. B just wasn’t feeling right. The repeat electrocardiogram revealed increased ischemia and she was admitted.  

Area PCPs who have been unable to meet the demand for urgent cases have welcomed the initiative. The care team proactively reaches out to these providers, notifying PCPs when their patient has visited the ED and updating them on their patient’s health status. As such, SJRMC has seen an overall increase in ED utilization and geriatric admissions.  The geriatric ED care team has accomplished this with minimal financial outlay from the hospital. Reimbursement rates are determined by normal Medicare rates and the ED does not benefit from special coding, yet expenses have been kept to a minimum.  The care team staff was not newly hired additional staff but rather redirected from the main ED to the geriatric ED.

Through the vision and commitment of the department chairman the Geriatric ED has not only had a significant impact on the quality and specialization of care provided to SJRMC geriatric population, but  has reduced return visits 70-80% by providing an ongoing collaborative effort that does not end when they walk out the door.


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The Transition
This innovative program was initiated gradually with existing staff and infrastructure. The hospital leadership believed there was a need but there was confusion as to how to define success. The focus of the department was on active independent seniors not nursing home residents. This was a new concept and resulted in low expectations. However, each case provided insight into the potential benefits of such a program: clinical results of more appropriate admissions; increasing number of seniors who came to the ED from outside our catchment area; our return rate dropped; and patient satisfaction scores increased. As a result, administration recognized the need of this approach to caring for seniors, resulting in the current geriatric ED.

At the time of implementation it was not clear whether this program would be sustainable or of substantial benefit to the community. The ED executive leadership and St. Joseph’s CEO believed in the success of this program from the beginning; however, this past year has provided the data for a retrospective analysis currently underway to document all the program’s benefits and success.

End-of-Life Issues
No geriatric program would be complete without addressing palliative care and end-of-life issues. Patients of all ages and more so the elderly population have medical problems and diagnoses that will ultimately cause their demise.  This can be a terminal illness or organ failure or frailty.  To meet these needs, a program was developed and initiated in January 2010 called LSMA (Life-Sustaining Management and Alternatives). The goal of this program is to identify those patients with terminal illness, organ failure or frailty earlier in their disease. In other words, catch them when they start becoming frequent fliers in the ED and identify them before there is an end-of-life (EOL) issue. Under LSMA, when a patient is identified by a member of the nursing or physician staff to possibly benefit from these services, a consult is ordered. A physician and nurse coordinator are available 24/7.  A bedside consult provides the patient and family with necessary information on their disease, prognosis and disease trajectory.  The program is designed to give the patient choice, comfort and control of their future.  It is designed to help patients live with their illness and at the extreme helps patient and family deal with end-of-life issues earlier in the disease. For those patients identified with EOL issues, counseling is provided and facilitated decisions are made to transition from the construct of curing to caring.  Since January, more than 60 patients have been touched by this program. In emergency medicine we are frequently too rushed or not comfortable with this issue, but the need remains for this patient population. LSMA has provided the necessary resources for this complex issue.

Developing Your Own Geriatric ED
Thus far SJRMC has helped 7 other programs begin the process of developing their own Geriatric ED, and we’d be more than willing to assist others. Not ready to develop a Geriatric ED? There are still some steps you can take that will make your ED more geriatric friendly, meeting your patient’s needs and improving the care you provide. The first is to identify nursing and physician champions to further this cause. Second, educate your staff about geriatric-specific issues and modify practice styles to better meet the needs of our older patients. From a quality of care perspective, implementing gerio-specific protocols helps to ensure that best practices are incorporated into practice. Even seemingly small changes, like using a larger font in discharge instructions, improves the patient encounter. Finally, comfort issues unique to the geriatric patient can be easily implemented.  Such measures include lighting and sound adjustments, thicker mattresses, non-glare flooring and placing hand rails on the walls.

 

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