By Sandy Keefe, MSN, RN
There is growing concern among healthcare professionals that the current model of care in EDs across the U.S. is not designed to meet the needs of elderly patients.
In fact, researchers have found older adults are at greater risk for medical complications, functional decline and poorer health-related quality of life after discharge than they were before their ED visit (Hwang, U. & Morrison, R.S., 2007. Journal of the American Geriatric Society).
To correct this situation, experts from the Mount Sinai School of Medicine in New York have developed a model for geriatric EDs that recommends structural modifications such as nonskid floor surfaces and visual aids, as well as protocol interventions that include early identification of patients at risk for adverse health outcomes, minimum use of urethral catheters and other "tethering" devices, and discharge coordinators to improve continuity of care and reduce the risk of return visits. (Hwang, 2007)
A Growing Population
Carol Velasquez, RN, CEN, ED manager at Marshall Medical Center in Placerville, CA, a Sierra Nevada foothill community with a significant number of retirees, has made a number of changes over the years to make her department more geriatric-friendly.
"As our population of elderly retired adults continues to grow, we’re making changes to improve their care," she said. "The large baby boomer population is creating a large older-adult population. They are now accessing healthcare services more often, with everything from flu and pneumonia to trauma associated with falls or hard work on large, rugged foothill properties."
In Newport Beach, CA, Carla Schneider, MSN, RN, director of the ED at Hoag Memorial Hospital Presbyterian, described a similar situation.
"We have a large population of older adults in our community, and have set up our ED to meet their needs," she said. "For example, we place our elderly patients in an area where there’s a nurse all the time."
Schneider and her team have made a number of structural modifications to reduce stimuli that contribute to agitation. "Noise pollution concerns everyone, so every nurse and patient care tech here in the ED has a phone that can be used to contact them, eliminating the use of the overhead system," she said.
A little forethought also can create a less confusing environment.
"Remember, when you’re lying on a gurney, you’re looking straight up," Schneider said. "We use dimmer switches to reduce the light in their eyes when we’re not doing an assessment or performing a procedure."
At Marshall, elderly, confused patients are bedded near the nurse’s station if they’re not accompanied by family members.
"In addition, we ask family members to notify staff if they are leaving the department," Velasquez said.
Minimal Use Of Tethering Devices
ED nurses at Hoag recognize the importance of giving patients as much freedom as possible, and use tethering devices only when clinically necessary.
"If a patient comes in with a fractured hip, for example, we don’t automatically insert a urinary catheter," Schneider said. "The patient isn’t incontinent and is able to use the bedpan; there’s no need for that intrusive device."
Marshall nurses also minimize the use of devices that limit patient movement, such as pulse oximeters.
"Once we’ve established a good baseline and determine it’s not essential to monitor the oxygen saturation continuously, we’ll remove the sensors that can be so irritating to patients," Velasquez said.
Schneider’s staff members use physical restraints only when absolutely necessary for patient safety.
"We have clinical-care extenders, volunteers with bachelor’s degrees who can sit at the bedside and remind patients to stay in bed," she said. "These volunteers provide our older patients with company, conversation and observation for their own safety."
When elderly patients come to the ED, whether by ambulance or private vehicle, timely risk assessments are crucial. According to Schneider, staff performs a number of assessments in triage, including those for falls, suicide risk and abuse.
"Our automated EMR (electronic medical record) prompts the nurse to ask about a history of falls within the past six months as well as any dizziness, gait issues and mental status changes," she said. "We also consider the patient’s medications and their effects. Patients who are at risk for falls have an orange armband so everyone knows to put the bed in the low position with rails up, educate the family about the importance of staying with the patient, etc."
At Marshall, patients at high risk for falls are identified with yellow wristbands, and nurses take the process one step further, adding a red stripe if someone is on an anticoagulant that increases the risk of bleeding.
The EMR at Hoag features special review screens that target other risk factors in the elderly.
"In addition to asking the patient questions about abuse, we’ll look for red flags such as a caregiver who won’t let the patient answer questions posed by the staff," Schneider said. "During our more focused admission assessment, we look at the patient’s neuro status, ability to get around, mental status and other factors that can indicate potential risks."
Schneider follows up to ensure compliance with these procedures.
"We audit regularly to make sure all of these assessments are being done at the time of triage and admission," she said. "If they’re not completed, we go back to the caregiver and reinforce their importance in terms of safety and comfort for our elderly patients."