A passel of senior citizens visited the Holy Cross Hospital emergency department (ED) in Silver Spring, MD, in late 2007. They sat in chairs. They lay on mattresses. They answered questions. The one thing they did not do was receive medical treatment of any kind.
The outreach effort by physicians and administrators came as the hospital began to design its new senior emergency center, which it bills as the country's first ED designed specifically for seniors. The senior center, which opened in November 2008, features simple comforts such as thicker mattresses as well as telephones with larger buttons. In addition to the creature comfort changes, patients also undergo a more rigorous screening to identify conditions often associated with seniors, such as polypharmacy.
“For years our profession has supported the concept of pediatric emergency medicine,” said James Del Vecchio, MD, Medical Director of the Holy Cross Emergency Center. “At our hospital we have a pediatric emergency department. We've done a lot of things right in pediatrics, like having a specially trained staff and more in-depth screenings. Really, what it came down to is asking ourselves, ‘Why aren't we doing the same thing for the other extreme of life?'”
The effort marks a recognition that like most of the US, Maryland faces a growing senior population, and that the medical community needs to find better, more efficient ways to treat them.
Retooling for Aging Population
Additionally, an Institute of Medicine report released last year, “Retooling for an Aging America: Building the Health Care Workforce,” describes a shortage of health care workers for geriatric patients. The report found that, since the year 2000, the number of certified geriatricians in the US has actually declined by 22% to about 7,000 even as the nation's population aged. Less than 1% of nurses, pharmacists, and physician assistants, the report found, were specialists in geriatrics. That report's lead author, Columbia University physician John W. Rowe, MD, said at the report's release, “In the state of California, there are higher training standards for dog groomers, crossing guards, and cosmetologists than there are for nurse aides taking care of older individuals.”
In Montgomery County, MD, where Holy Cross Hospital is located, only one of every 8 people is now over the age of 65, but within a decade the senior population is expected to grow 5 times faster than all other groups.2 Seniors are Holy Cross' fastest growing segment of patients.
The hospital's president and chief executive officer, Kevin J. Sexton, says he was driven to make the changes after visiting an ED with his mom, and the noise, chaos and confusion at the hospital led him to the recognition that such facilities were not designed for senior patients. He began to wonder, then, what a facility built for seniors might look like.
“What we hope to do is create a better model of care delivery, a unique and enhanced environment that will support and contribute to the optimum seniors emergency department experience,” Sexton said. “We realize how great the need is and that we all must continue to learn and then implement ways to better serve the health needs of our community as a whole and our seniors who need us most.”
When Sexton decided in 2007 to make the change to his ED, which sees about 87,000 patients a year, one of the first things he did was contact Bill Thomas, MD, a professor at The Erickson School at the University of Maryland, Baltimore County, and an international authority on geriatric medicine and elder care.
Dr. Thomas, who trained as an emergency physician, jumped at the opportunity to change the care seniors receive in the typical ED.
“Emergency departments are almost textbook cases for how you should not deal with seniors,” said Dr. Thomas, who suggested both physical changes to the hospital as well as staffing modifications.
First came the changes in the emergency center's physical space to make it more welcoming and accommodating to elderly patients. Within the 8-bed unit walls are painted a warm golden hue, the floors are faux wood rather than linoleum, patients have extra blankets and nurses use wireless technology rather than a noisy overhead paging system. Visitors have comfortable chairs. There are private rooms for family consultations when a patient may not be able to make decisions for him- or herself. By converting existing space and using in-house contractors, the hospital made the modifications in less than one year for about $150,000, administrators say.
Dr. Thomas said there's not specific evidence in the geriatric medical literature about the effects of such changes on seniors in the ED, but he said there's a fair amount of scholarship about what kinds of environments are deleterious for patients with dementia: a lot of strange sounds, a a lot of unknown people hurrying about and a high degree of uncertainty.
“That sounds like an emergency department to me, and it's a terrible environment for patients with dementia,” Dr. Thomas said. While not contending that even most senior patients have dementia, he said emergency medicine can benefit from dementia research to optimize their environments for geriatric patients.
The second major change came in educating the staff to better communicate with senior patients; to conduct more thorough screens for issues such as depression and cognitive loss; and perform risk assessments for falls and other concerns with seniors. A social worker or geriatric nurse practitioner follows up with patients who have any of these conditions. The hospital also has worked to improve communication with the patients' primary care physicians. The intent of these changes is to not only provide better service to seniors visiting the ED, but to uncover underlying chronic issues and reduce the number of repeat visits in the future.
“Everybody in the health care system has a responsibility to retool our systems for the aging boom that's coming,” Dr. Thomas said. “I don't care if you're talking about ambulatory surgery or radiology or the emergency department, solving these issues is critical because how health care handles older people during the first half of this century is an essential question.”
Today, upon arriving in the hospital's ED, a nurse triages senior patients. If they've suffered a traumatic injury or acute illness such as myocardial infarction, they are treated in the general ED. But about 75% of patients aged 65 and older have an illness that can be treated in the quieter, less chaotic confines of the senior emergency center.
Anecdotally, the changes seem to be alluring to senior patients. Holy Cross officials say they have already heard complaints from geriatric patients who, because the special unit's 8 beds were filled, had to go into the hospital's regular ED.
A physician familiar with the Holy Cross renovations, geriatrics expert Carmel Bitondo Dyer, MD, professor and director of the Division of Geriatric and Palliative Medicine at The University of Texas Medical School at Houston, said the hospital's physical and staffing modifications are the types of changes needed to address aging patients visiting EDs.
“It makes absolute sense,” Dr. Dyer said. “These are exactly the sorts of things we need to be doing to try and reduce repeat visits.”
When Holy Cross decided to add the senior center, physicians like Dr. Del Vecchio began looking around for models to emulate. A handful of hospitals around the country, such as the Nassau University Medical Center's Geriatric Emergency Room in East Meadow, NY, have opened emergency facilities specifically to treat geriatric patients. And dozens of hospitals around the country have Acute Care of the Elderly, or ACE units, with specialized staffing to handle geriatric patients. But no one was taking the comprehensive approach envisioned by Sexton and other Holy Cross leaders.
“We really had no intent of reinventing the wheel,” Dr. Del Vecchio said. “Initially we thought we could go out and see what other people had done. It was absolutely astonishing to see what little had been done elsewhere. We honestly could not find anybody else who had done something like this. It created a bigger project than we anticipated.”
During interviews for this story, physician after physician compared the need for a geriatric emergency medicine specialty to that which already exists for pediatrics. The same way that children are not just young adults, physicians said, geriatric patients are not just old adults.
That's why the approach taken by Holy Cross seems so promising to geriatrics experts like Dr. Dyer, who would love to see the concept of a senior emergency center applied at scores of other hospitals around the country. But especially at a time of fiscal uncertainty, Dr, Dyer said she expects most other hospitals to watch the Holy Cross experiment before jumping in themselves.
“I think what we'll have to see are the economics of it,” Dr. Dyer said. “There are a lot of things being done there that make sense, and my guess is when you do the right thing it also costs less because your emergency department is no longer a revolving door. But they need good results, and once they're able to demonstrate quality improvements and that they're using resources more responsibly, this will take off.”
Another physician who has studied seniors in the emergency department, Mary Pat McKay, MD, MPH, an Associate Professor of Emergency Medicine and Public Health at The George Washington University Medical Center, agreed that the model must prove cost effective before becoming widely adopted. But Dr. McKay thinks the program has a good chance of doing just that.
Seniors tend to be better insured through Medicare than most other populations that visit the ED, noted Dr. McKay, who is also director of the Center for Injury Prevention and Control at George Washington University. The program, therefore, may become profitable because Holy Cross is putting resources into a subgroup of patients that can pay.
In addition to the construction costs, Holy Cross will have extra costs in hiring support staff for the senior center including a geriatric nurse practitioner, Dr. Del Vecchio said. He doesn't see the senior emergency center becoming a “huge cash cow” for the hospital. But at the same time, he said, hospitals make money by filling beds, seniors are admitted at a higher rate than other patient classes, and there's clearly a growth market in geriatric patients.
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