BY: JUDITH ANN ROGERS, R.N., M.S.W., Ph.D.
Dr. Rogers is vice president, patient care, Holy Cross Hospital, Silver Spring, Md.
Editor's note: The Seniors Emergency Department at Holy Cross made national news when it opened in late 2008 and has been featured in CHA's publication Catholic Health World. For this Health Progress report, Dr. Rogers looks to the future as she explains more fully the rationale, planning and operational strategies that helped to ensure the program's success.
Softer Surroundings Meet Seniors' Special Needs
Holy Cross Hospital in Silver Spring, Md., wanted to improve the way it delivers emergency care to a rapidly growing elderly population. Its solution was its eight-bed Seniors Emergency Department, opened in November 2008. The unit integrates senior-friendly design elements and a geriatric-specific care model.
At the special unit, senior patients are triaged at levels one through five (situations considered non-life threatening). Care is designed to attend to immediate medical needs, conduct thorough risk assessments, define ongoing care needs and make appropriate referrals. Seniors with emergent, life-threatening conditions are still treated in the main emergency department.
Patients with less serious conditions are taken to the Seniors Emergency Department. Here the walls are painted in soft colors and the lighting reflects from faux wood floors in a way designed to prevent falls. Mattresses are thicker than elsewhere in the hospital; the blankets are kept warm. The buttons on the telephones are extra-large, as are the faces on the clocks. It's all designed to create a more soothing emergency department experience for seniors.
Three primary factors drove Holy Cross Hospital's decision to launch the Seniors Emergency Department project: community commitment, market demographics and impact on hospital utilization.
In considering the hospital's commitment to the most vulnerable patients in the community, it became clearly evident that the needs of the elderly population required attention. Today, only one in every eight people in Montgomery County, Md., is over 65, but within the next 10 years that age group will grow at a rate five times faster than any other. The county's 2005-2015 population growth (approximately 100,000) will have the same impact on hospital demand as if the under-65 population had grown by 325,000, with a projected increase in inpatient days of 200 more patients per day by 2018.1
For input into the center's design, the project team turned to the geriatric care experts of The Erickson School at the University of Maryland in Baltimore County, whose mission is to enhance the lives of older adults. The team also organized focus groups to elicit ideas from older adults in the community. Additionally, the hospital restructured the patient care model to support the management of the multiple co-morbidities and age-specific requirements of the elderly population.
Background
Nationwide, patients age 65 and older constitute an ever-greater proportion of the volume of emergency department visits; industry leaders estimate that the number of visits by elderly patients to the nation's emergency departments could double by 2013, reaching 11.7 million annually. In Montgomery County, seniors will account for 70 percent of anticipated population growth across the next decade.2
The clinical imperative for a new approach to seniors' care in an acute care emergency center is evident when the current structure of emergency services is considered. Older persons use emergency department services more frequently, are admitted more often, stay a longer time in the emergency department (sometimes 50 percent longer), and are readmitted to the emergency department after discharge twice as often.3
Emergency departments in general will be increasingly challenged by the complexities of providing care to geriatric patients. The current model of emergency care in the United States was designed for acutely ill and injured patients, not geriatric patients, who often are medically complicated, slow-moving and functionally impaired. In fact, emergency department processes are usually inadequate and inhospitable for the older person. The rapid triage and care process is often unable to elicit a full understanding of the person, needed to enable optimal care.
The unique yet essential requirements of senior care in urgent and emergent situations are influenced by age-specific variables. The full breadth of medical conditions, a long list of medicines, communication challenges, and sometimes slowly evolving problems rather than clear and acute events all impair effective understanding of an elderly patient's chief complaint. Additionally, the ambient environment, the noisy waiting room, the hard gurneys, the crowded department, the lack of pillows, the rushed history and physical examination, the harried caregivers, the separation from friends and family, and even the lack of effective information delivery systems all demonstrate a design that does not enable optimal care for the elderly.
Project Scope and Design
The approach to the development of the Seniors Emergency Department design and key inclusions for care (the "what-makes this-different" factor) included:
- Performing a needs assessment for senior services at Holy Cross Hospital and the community.
- Developing a strategic plan for senior services.
- Articulating a vision for a senior emergency center.
- Completing a literature search for existing models.
- Collaborating with The Erickson School on such elements as a visioning and brainstorming exercise, a literature search, a patient satisfaction survey, a post-launch assessment, a retreat for the senior program management team and sensitivity training for staff members.
- Drawing up a project charter.
- Refining a program definition, including mission, target population, key elements, dependencies, desired outcomes and go-live date.
- Developing care processes and tools; staffing mode; training and education; and environment.
- Conducting a marketing campaign at kick-off and three months later.
- Measuring outcomes.
The Seniors Emergency Department Program
The overarching goal of the project was to ensure that seniors who seek treatment at Holy Cross Hospital experience competent and compassionate care in an environment that provides comfort and eases anxiety for the senior and his or her loved ones. Three main elements support this goal: unique care processes, age-specific care models and staffing patterns, and a soothing environment.
Care Processes
When patients arrive, they are triaged using a one to five scale in order to assign their care to either the seniors' program or to the main emergency department. Those whose chief complaint is considered non-life threatening are admitted to the Seniors Emergency Service. There, the patient's primary complaint is managed by the emergency department medical and nursing staff. Additionally, significant risk variables are assessed using a triage risk screening tool in an effort to establish referral and follow-up requirements. Particular attention is paid to issues such as potential polypharmacy, and special consideration is given to general comfort care. Discharge planning for seniors who live alone or lack family support is a priority.
Staffing
The Seniors Emergency Department nursing staff is specially trained in providing care to older adults. A geriatric nurse practitioner supports the emergency room physician staff. A geriatric social worker is responsible for follow-up care coordination and appropriate referral assignments.
Senior-Friendly Environment
The environment in the Seniors Emergency Department is characterized by ambient lighting, special comfort mattresses, a soothing color scheme and specific safety features such as non-slip, non-glare flooring. The defining characteristic is the commitment to low noise and the provision of a quiet and soothing milieu.
Lessons Learned
Many lessons were learned and continue to be appreciated as volume in the department grows. The main focus of care is to ensure that all care structures support the staff's ability to get to know "the person who is the patient." Looking back, it is appreciated that enhancements to information sharing and electronic access to seniors' information databases served an important purpose as the project developed. For example, embedding senior assessment documentation in our automated systems was vital.
Much of the success of the program is attributed to having initially formed a highly collaborative and functional project team including nursing staff, physicians and older adults. Bringing the hospital's community services for seniors into the planning process to ensure that linkages were embedded into the care process also proved important for follow-up and referral success.
From the beginning, the hospital's financial support and commitment to the project was ever-present. This included a commitment to ensuring sufficient staffing to operate the Seniors Emergency Department around the clock. Additionally, the decision was made to extend as much as possible the same care experience afforded the elderly in the new Seniors Emergency Department to patients in the acute side of the main emergency department.
Evaluating Success
Our ongoing process of surveillance and evaluation includes several key indicators for success. These include: effective screening and referral, appropriate consults when indicated, interventions necessary to address polypharmacy, patient satisfaction, volume (growth), and a reduction in re-hospitalization within 30 days of the emergency department visit. To date our data are reassuring. For example, between the same time frame in the last fiscal year and this one, we experienced a 13 percent increase in senior discharges, a 15 percent increase in Senior Emergency Department visits and a 17 percent increase in senior admissions. Additionally, our patient satisfaction scores are overwhelmingly top box for "general satisfaction" and "likelihood to recommend." However, we continue to struggle to move the needle on reducing readmissions, and this indicator is now the primary focus of our planning sessions.
Looking Forward
The agenda for the future of the Seniors Emergency Department is clear. We continue to improve program operations and intraoperability. Our plan is to afford continued refinement of the care pathway and provision of the care experience to seniors anywhere in our emergency department. We are also committed to forging closer integration of community resource departments with the Seniors Emergency Department discharge planning and follow-up. We are eager to build our research capabilities and to enhance our outcomes tracking. Finally, we would like to replicate what works in the Seniors Emergency Department to build other senior-focused services and to position Holy Cross as a leader in senior care.
NOTES
- Maryland Department of Planning for Population Projections; Health Services Cost Review Commission discharge database for 2005 inpatient days. Available at www.mdoa.state.md.us/statistics.html.
- Maryland Department of Planning for Population Projections.
- Steven R. Lowenstein et al., "Care of the Elderly in the Emergency Department," Annals of Emergency Medicine 15 (1986): 528.