Operations Management Committee: Geriatric Patient Experience in the Emergency Department

OPERATIONS MANAGEMENT

COMMITTEE Geriatric Patient Experience in the Emergency Department

Samita M. Heslin, MD MBA MPH MA and Eric J Morley, MD MHA MS

There are 54 million Americans who are 65 or older, a 30% increase in the last decade and it is predicted this population will almost double by 2060. Geriatric patients currently comprise more than 15% of Emergency Department (ED) visits and over 35% of hospital admissions. Caring for older adults requires attention to atypical disease presentations, polypharmacy, and more complicated transitions of care and social needs. Geriatric patients are also more likely to have a longer length of stay in the ED. It is important to engage this population and address their specific needs to improve their satisfaction and overall care. Below we highlight some ideas and initiatives that can dramatically improve the experience geriatric patients have while in the ED.

1. Access to food and water. We often fail to attend to these basic needs of our geriatric patients. We can increase access to food and water by placing NPO orders only when absolutely required (i.e., dysphagia) and having refrigerators stocked with food in multiple zones in the ED where patients and staff can access them. We should also communicate with patients regularly about when they can eat. Since many of these patients have challenges related to problems with ambulation and vision, we recommend that ED staff frequently round on these patients and supply them with food and drink when appropriate.

2. Access to toileting. Toileting can be challenging for some older patients. Since most patients will have to walk to a communal bathroom in the ED, this might be a difficult task for some and may lead to falls. We recommend that bedside commodes be available in patient rooms so that ED staff don’t have to search for these items. Particular attention should be paid to patients who may have dementia or delirium and others who cannot advocate for themselves. Screening programs can be implemented in the ED to help identify these patients early in their hospital course. These patients may need assistance with toileting, including using the bedside commode. Patients who are fall risks should be offered bed pans and non-invasive urinary catheters (i.e., non-invasive suction catheters for women and condom catheters for men). In-dwelling urinary catheters increase the risk of infections and should only be used when absolutely required.

3. Ambulation and Sensory aides. Many geriatric patients have difficulty hearing and seeing, which may lead to difficulty communicating with medical providers and may also trigger delirium. It is useful to keep reading glasses, magnifying glasses, and auditory aides (i.e., hearing aids, audio amplifiers) in the ED. Additionally, dry erase boards and point-to-boards in multiple languages can also assist patients with communicating with ED staff. We also recommend maintaining a supply of four-point canes and rolling walkers for patients to use while in the ED.

4. Engaging the patients’ family and primary care physicians. Aftercare and transition of care for our geriatric patients is critical. Many patients will have challenges with home care, getting prescriptions, accessing outpatient follow-up care, and addressing other needs. Engaging the family and primary care physician (PCP) is important to help produce a positive outcome. We recommend that families and PCPs be notified when geriatric patients are admitted to the hospital. If possible, notifying families and PCPs of the ED workup and results for patients being discharged can also be beneficial. Of course, permission should be first granted by the patients if they have capacity. Physical Therapy, Social Work, and Case Management consults may be needed to provide a safe discharge for the geriatric patient.

Geriatric ED patients have unique needs. Building a system that addresses these needs is important to make sure their experience is optimal during the ED stay. Additional geriatric-specific policies and procedures, such as screening tools, fall risk protocols, and delirium and dementia prevention guidelines, can help us better identify and care for at-risk geriatric patients and improve the overall care we give in the ED.

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