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Hospitals focus on baby boomers and elderly, but will it boost patients’ health and save money? – The San Diego Union

By providing senior-specific care in the emergency room, health providers hope to reduce the number of seniors who get admitted to hospitals, help them avoid having to return to the emergency department and support independent seniors in their desire to continue living at home instead of a care facility.

A new approach

Though a new geriatric emergency department for UC San Diego’s La Jolla medical campus is still being built, some senior-specific protocols are already underway inside the new Jacobs Medical Center.

Since Dec. 1, Thomas Crisman has been filling the newly minted role of geriatric resource nurse. He tracks his patients by age, typically putting the oldest ones at the top. He pops into room after room to conduct a series of assessments that gauge patients’ mobility, nutrition and cognition.

On a recent day, one of those patients was 94-year-old Elnora Astor, who came to the hospital with abdominal pain. After reading through her chart, Crisman asked whether Elnora had fallen at home. Family members shared that yes, she had taken two or three tumbles at home, though none had resulted in an injury. That report, combined with accounts of vertigo, were enough for the nurse to move to the next level.

“Elnora, could you get up and walk with me a little bit?” he asked.

“I could give a good try, couldn’t I?” she responded.

Soon nurse and patient were holding hands face-to-face, slowly moving past the exam room’s wide sliding glass door, out into the hallway then back to the bed. The process ended with cognitive tests that showed some signs of dementia.

The work-up spurred Crisman to order physical therapy for Astor once she returned home.

Back in her bed, Astor said she didn’t mind the extra attention. “They take an interest in you. They listen to what you say. They don’t just say ‘yes, yes’ and mark it down,” she explained.

At Scripps Memorial Hospital La Jolla, the Barbey Family Emergency and Trauma Center feels more like a retreat than an emergency department. Soft music plays in the sunlight-filled waiting area. Photos of flowers, seashells and the ocean adorn cream-colored walls.

Inside, the 51-private-bed facility is disarmingly quiet. Glass doors shield each patient room from outside noise, and alarms alert nurses to a potential fall if a patient tries to get up without assistance.

The emergency department has nurses, pharmacists, a social worker and case manager trained to screen and work with geriatric patients. Are they at risk of falling? Do they show signs of dementia? Could they be taking too many or the wrong mix of medications? Are they physically able to take care of themselves outside the hospital? Do they have the necessary caregiving support at home?

If necessary, patients stay in the department’s observation area for up to 48 hours so they can be fully evaluated and have necessary interventions set up, Evans said.

“Sometimes we get patients who, for example, come in and have had a fall at home and there are no other issues. But one of the things in the examination is that you may notice that their nails are unkempt or … you look at their feet and you can tell that the self-care is not there,” said Nancy Coleman, a clinical social worker who works in the emergency department. “What that does is raise the red flags. We’re able to assess that and begin to be proactive to provide services for them so that when they go back home, they’re not in a (bad) situation.”

In North County, Palomar Health is trying to keep seniors’ time in the hospital as short as possible through its new hip-fracture pathway. The program fast-tracks the process of getting older hip-fracture patients admitted for surgery, and the local-anethesia protocol — instead of using narcotics — is meant to accelerate recovery times.

The health district is still collecting data to measure the program’s effectiveness, but the impact seen so far has been encouraging, said Palomar Health medical director Jaime Rivas.

“We know anecdotally from talking to a number of anesthesiologists that these patients are doing very well. Eighty-nine-year-old patients are coming out of the surgery just fine and up and about,” Rivas said. “They’re recovering quicker, they’re awake, and when you start to get them out of the hospital sooner and they can begin their rehab sooner, they’ll recover sooner.”

From east to west

Specialized geriatric emergency departments are relatively new.

St. Joseph’s Regional Medical Center in Paterson, New Jersey built one of the first and most widely recognized in 2009. By 2013, a national survey of hospitals revealed that just 36 emergency departments were catering to older adults, mostly in the nation’s Northeast and Midwest regions.

Dr. Tess Hogan, director of geriatric emergency medicine at the University of Chicago and co-author of the 2013 survey, said the number could be as high as 150 today, although she doesn’t have an updated count. Unfortunately, some hospitals claim to provide geriatric emergency care but in reality offer none of those services, she said.

To encourage best practices, the American College of Emergency Physicians, in collaboration with other medical and geriatric organizations, published guidelines for geriatric-friendly emergency departments in 2014. They’re now working on an accreditation system for these facilities.

Kimberlee Roberts, senior director for clinical services at Scripps and a member of the hospital’s design team, said the group came up with its own geriatric-friendly design by consulting the guidelines from the American College of Emergency Physicians, gathering staff input and amassing ideas from tours of 12 hospitals in California and one in Chicago. She said most of these sites didn’t have emergency departments designed specifically for geriatric patients, but were newer hospitals with features that worked well to improve senior care, such as natural lighting and a separate observation area.

Does it work?

So far, research on geriatric-focused emergency departments is thin.

A 2014 study of one department in Michigan found geriatric-specific emergency practices did nothing to stop seniors from returning to the emergency room within 30 days or decrease their average time spent in the hospital.

In contrast, research out of Northwestern University’s geriatric emergency department in Chicago has shown that hospital admissions of seniors receiving specialized emergency care decreased by almost half compared to a control group, and that readmissions to the emergency room within 30 days of discharge dropped dramatically. Mount Sinai Hospital in New York and St. Joseph’s geriatric emergency departments also report positive results, Hogan said.

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