New U.S. Trend: Seniors' ER
New U.S. Trend: Seniors' ER | ACEP, SAEM, American College of Emergency Physicians, Society for Academic Emergency Medicine, geriatric emergency department, sundowners syndrome, Dr. Chris Carpenter, Baton Rouge General Medical Center, Louisiana Medical News, @BRGeneral
Baton Rouge General Medical Center’s Mid City facility has established a senior-focused emergency room, the region’s first such facility and one of a dozen or so nationwide.

The Mid City Emergency Department treats approximately three dozen elderly patients a day, and half of those seniors end up being admitted to the hospital.

“Baton Rouge General has embraced the pressing need to synergize emergency and geriatric medicine as the baby boomer population in our community continues to age,” the hospital’s website said.

The need in Baton Rouge, and nationwide, is growing.

In 2009, people 65 and older accounted for 15 percent of all visits to emergency departments, and those numbers are expected to jump as more baby boomers retire, according to the American College of Emergency Physicians.

Dr. Christopher R. Carpenter, president-elect of ACEP’s geriatric section, said those demographics are one reason the group hopes to catalog geriatric EDs nationwide and to establish minimum standards for the specialized departments.

Right now, no one really knows how many geriatric-only or geriatric-friendly departments there are, Carpenter said.

Members of the Society for Academic Emergency Medicine, which recognized the oncoming “geriatric baby boomer tsunami” more than a decade ago, now worry that some geriatric emergency departments are that in name only, he said.

Some departments may not have the expertise or staff training to deal with the needs of elderly patients, Carpenter said. The departments may not have made the infrastructure changes necessary to help those patients.

Creating a geriatric emergency department basically requires physically transforming the emergency department, specially trained nurses and physicians, and access to social workers for the aged, Carpenter said.

Baton Rouge General’s seniors ER, for example, has installed hand rails along the walls, anti-slip flooring, color-coded directions for ease of navigation as well as furniture and amenities made for senior use.

Every bed area has a heated blanket, caregiver seating and a comfortable mattress. Room lighting is softer, the colors are muted and tools are in place to make it easier for seniors to read any medical paperwork.

Baton Rouge General’s seniors ER team includes physicians specializing in geriatrics, emergency medicine and palliative care. Seniors ER nurses are also trained in geriatric emergency care. And the hospital has a patient navigator to help connect seniors and their families with additional services and community resources they may need once they return home. This may involve putting the patient in touch with a home health company, which can help with preventing falls.

The seniors ER staff is also trained to administer screenings and assessments to identify patients who may need additional assistance or resources outside of the hospital.

Carpenter said screening is important because up to a third of the elderly patients who come to emergency rooms can test positive for dementia, but 80 percent of the time that diagnosis never makes it into the patients’ chart.

“They’re just passing through undetected because we don’t routinely test for it,” Carpenter said.

According to SAEM, patients with unrecognized delirium who are sent home from the Emergency Department may be three times more likely to die within three months than patients whose delirium is identified by an emergency physician.

Carpenter said a geriatric ED should have access to geriatricians, who can come down and determine what to do with an elderly patient who isn’t sick enough to be admitted to the hospital but who isn’t well enough to go home.

“We can’t send them home. We can’t admit them. We can’t put them in nursing homes,” Carpenter said. “Where do we put them?”
An emergency department really needs access to geriatricians who help with the non-admitted patient population, Carpenter said, kind of like having a mobile acute care for the elderly unit.

In addition to specialized staffing, the geriatric ER requires a number of physical changes, such as natural lighting, Carpenter said.

Patients with dementia may suffer from sundowners syndrome when the boundary between day and night is blurred, he said.

Those patients can become very confused and agitated at night, Carpenter said. This form of delirium mandates that the patient be medicated so they don’t hurt others or themselves in the emergency department.

But the wrong medications can exacerbate the patients’ anxiety, Carpenter said.

The best thing to do is prevent that from happening at all, he said. The proper lighting plays a big part in prevention, but it also requires an infrastructure change.

All of this sounds like work involving the kind of money that the federal government can’t or shouldn’t spend, Carpenter said. But if hospitals can take care of the elderly safely and efficiently, those lessons can be applied to younger adults as well, reducing costs and ER wait times.

“I’m not saying we need to spend more money on everything. I think we need to find where we’re wasting money and direct that money into more effective emergency department care for older adults,” Carpenter said. “And there’s a lot of areas where we’re wasting money.”





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