Patient Engagement, Health IT, Hospitals

How to improve geriatric care in the ER, which today lies between wilderness and cruise ship medicine

A fireside chat at MedCity’s ENGAGE conference explored how to improve geriatric care in the ER from using ambient lighting and reducing noise levels to providing support for stressed family caregivers.

Dr Zia Agha of West Health (left) and Dr. Ted Chan of University of California San Diego department of emergency medicine

Dr. Zia Agha of West Health (left) and Dr. Ted Chan of University of California San Diego Department of Emergency Medicine.

Although the rising senior population is widely acknowledged, the need to change  geriatric care in emergency rooms in light of the “silver tsunami” is not. Seniors generally have more complex conditions than the typical emergency room patient, posing challenges for ER staff. Add dementia to the equation and their visit may be a troubling sign that a family caregiver is overwhelmed and can no longer take care of them.

But there are several ways that hospitals are trying to address these challenges. Dr. Zia Agha of the nonprofit West Health Institute, and Dr. Ted Chan, chair of Department of Emergency Medicine, University of California San Diego  discussed some of those changes in a fireside chat at the MedCity ENGAGE conference last week. West Health is providing a large grant to fund the building of a nearly $14 million emergency department at UCSD in La Jolla designed specifically for geriatric patients.

While geriatric patients in the ER have very specific needs, the state of overall ER care leaves a lot to be desired. Agha called attention to the state of ER care by highlighting his experience at the recently-concluded annual meeting of the American College of Emergency Physicians (ACEP) in Las Vegas which he attended along with Chan.

“Right now, unfortunately, emergency medicine sits somewhere between wilderness medicine and cruise [ship] medicine,” Agha said to laughter from the audience. “The room that I was in where we had our meeting was literally between wilderness medicine and cruise ship medicine and if you think about it, one in four persons that we are taking care of [in the ER] is geriatric and it’s only going to become bigger. I think there’s room for improvement. We will work with our partners at ACEP and others to bring national spotlight on geriatric care in the ER. I think the ER is a wonderful place to address that problem.”

UCSD Health’s collaboration with West Health involves testing different models for the ED to determine what would be most effective.

One way health systems are working to improve treatment for geriatric patients in the ER is through the Geriatric Emergency Department Collaborative, of which UCSD is a member. This research partnership with the John A. Hartford Foundation, launched by the West Health Institute, and a few other institutions seeks to improve the quality of care that older adults receive in EDs across the country, according to the foundation’s website. Four national organizations are taking part in the collaborative, including ACEP, the Society for Academic Emergency Medicine, the Emergency Nurses Association, and the American Geriatrics Society, along with nine health systems. The plan is to add more members over time.

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The collaborative is designed to build on the work of the Geriatric ED Guidelines and a pilot Boot Camp program to help emergency departments implement quality improvement projects.

Mount Sinai School of Medicine is the lead site for Geriatric Emergency Department Innovations through Workforce, Informatics and Structural Enhancements. Chan observed that Mount Sinai has a ward within the emergency department for seniors and has rounds twice a day.

Some of the other hospitals that Chan singled out for their approach to geriatric care in emergency departments include Northwestern Memorial Hospital in Chicago and St. Joseph’s Regional Medical Center in Patterson, New Jersey.

St. Joseph’s opened a geriatric emergency department in 2010. What makes this even more noteworthy is that St Joseph’s is neither an academic hospital nor an integrated health system. Northwestern designates a nurse to do case management for seniors, Chan said.

When UC San Diego Health opens its new geriatric ED in La Jolla, it will use ambient or natural light so seniors don’t suffer from sundowning, and become disoriented in that setting. It also plans to reduce noise levels to avoid distracting ambient sound that can add to that sense of disorientation.

Chan noted that EDs could also do more to screen for signs of early signs of cognitive decline.

Although there’s interest in creating an intervention tool within electronic medical records when caregivers come to the ER multiple times with family members, Chan said health IT vendors and facilities have failed to agree on what a standardized protocol would look like. If they can agree on that, there’s potential to implement such a protocol to give stressed out family members a way to explore or revisit their options.

Meanwhile, emergency care is itself evolving.

“The ER is finding itself at the crossroads of population health management and acute care management,” Agha said. “The ER is becoming the place where patients don’t just come in to get admitted to the hospital but are often being transitioned back into the community. They are being held accountable …and with these new payment models, there’s an opportunity for the emergency physician community to be leaders in the space to sort of coordinate the care transitions.”

Correction: This post is an updated version of an earlier story which misquoted Dr. Zia Agha and incorrectly attributed the quote to Dr. Ted Chan. We apologize for the error.

Photo: Ivan Hundric