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Service Delivery Innovation Profile

Separate Emergency Center for Older Patients Leads to High Levels of Patient Satisfaction, Detection of Polypharmacy, Increased Volume of Patients, and Low Rate of Return Visits


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Snapshot

Summary

Holy Cross Hospital established a separate senior emergency center to treat patients 65 and older who are experiencing acute, but not life-threatening, health problems. The center has several physical features intended to make seniors' stays more comfortable and safe, such as separate rooms, thicker mattresses, special lighting, reduced-glare floors, and a blanket warmer. In addition, all staff have received specialized training in geriatrics, enabling them to provide enhanced care tailored to seniors' needs. A geriatric social worker follows up with high-risk patients within 24 hours of discharge, while an administrative assistant conducts additional followup with all patients a few days after release. Patients treated at the senior emergency center report high levels of satisfaction with their treatment. The center has increased the number of patients identified as taking inappropriate medication or medication doses and has also experienced an increased volume of patients and low rates of return visits to the emergency department.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation results from patient satisfaction surveys, along with data on the percentage of patients who were taking an inappropriate medication or medication dose, treated in the senior emergency center, and returned to the emergency department after an initial visit.
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Developing Organizations

Holy Cross Hospital
Silver Spring, MDend do

Date First Implemented

2008
Novemberbegin pp

Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Age > Senior adult (65-79 years)end pp

Problem Addressed

The over 65 population in the U.S. is growing rapidly, and many seniors have chronic illnesses that result in frequent emergency department (ED) visits. Providing seniors with optimal emergency care can be challenging due to the fast-paced, hectic environment in most EDs, staff time constraints, and limited resources to provide patients with the needed followup support.
  • A growing population, with many chronic illnesses: The population of seniors in the United States is growing rapidly, with growth expected to continue in coming decades, especially among those over 80. In Montgomery County, MD, for example, 70 percent of the anticipated population growth over the next 2 decades will be among people older than 65,1 and the number of residents age 65 and older not living in nursing homes is expected to double over a 30-year period, from roughly 92,000 in 2000 to 187,000 in 2030.2 Many seniors have chronic illnesses (e.g., diabetes, heart failure, osteoporosis, chronic obstructive pulmonary disease, dementia) that result in frequent ED visits.
  • Stressful ED experience: Seniors often find the ED to be overwhelming due to factors such as loud noise, a lack of privacy, and the fast pace of interactions with staff. Poor hearing and neurological limitations often make it hard for seniors to understand what is occurring in the ED.
  • Little followup, leading to return visits: ED care traditionally focuses on treating patients' immediate health concerns and discharging them as quickly as possible so that additional patients can be seen. Given the emphasis on speed, older patients often do not receive or understand instructions on what they should do to address their health issues once they return home. In addition, factors such as limited transportation, unfamiliarity with technology, and difficulty dealing with bureaucracy may prevent them from going to followup doctor's appointments and/or obtaining needed medications in a timely manner. As a result, seniors have a high rate of return visits to the ED, leading to high costs.3

What They Did

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Description of the Innovative Activity

Holy Cross Hospital established a separate senior emergency center to treat patients 65 and older who are experiencing acute, but not life-threatening health problems. The center has several physical features intended to make seniors' stays more comfortable and safe, such as separate rooms, thicker mattresses, special lighting, reduced-glare floors, and a blanket warmer. In addition, all staff have received specialized training in geriatrics, enabling them to provide enhanced care tailored to seniors' needs. A geriatric social worker follows up with high-risk patients within 24 hours of discharge, while an administrative assistant conducts additional followup with all patients a few days after release. Key elements of the senior emergency center include the following:
  • Location and setup: The center adjoins the main ED, in space formerly used as a patient overflow area. It contains a nursing station, eight patient rooms, and one large room for private family consultations.
  • Environmental enhancements: The center includes a number of physical features designed to reduce patients' anxiety and discomfort and enhance safety:
    • Larger, private rooms: Unlike a typical ED with cubicles separated by curtains, the senior center has rooms divided by thick walls that are large enough for a comfortable chair for a family member or visitor. Patients can converse with staff and guests with reduced noise distraction from other staff–patient interactions. To further minimize noise, staff communicate via wireless phones to limit the use of the intercom system.
    • Comfortable beds and appealing environment: Beds have mattresses twice as thick as those in the standard ED that are specially designed to prevent skin breakdown and pressure ulcers. Walls have been painted a warm gold with contrasting white space, which appeals to the aging eye and reduces stress. Patients can control the overhead lighting with a dimmer switch. Each room has a television, allowing patients to watch programs or nature images or listen to soothing music. Each room also has a large clock and a phone with larger than normal buttons. Patients can request coffee, tea, bouillon, or juice, and can use blankets directly from a blanket warmer.
    • Additional safety features: Other safety features include a floor made of nonreflecting faux wood rather than the typical linoleum (which produces glare that can cause missteps and falls) and hand rails that line the center's walls to further reduce the risk of falls. Staff rely on digital hand-held cardiac monitoring devices to monitor patients instead of large machines that can make it hard for patients to move around.
  • Staff trained in geriatric care: All emergency physicians and nurses receive specialized training on common health problems facing seniors and on strategies for providing compassionate care to them. Two staff members with additional expertise in geriatric care—a nurse practitioner and social worker—work exclusively with patients in the senior center. The social worker serves as a general problem solver who gets to know patients as much possible, makes sure they are comfortable and not left alone for long periods, tries to find underlying causes to the problem(s) that led to the ED visit, and answers questions about care (e.g., what will happen next and when this will occur).
  • Screening for polypharmacy: When a senior patient is noted to be on 5 or more medications (including prescription and over-the-counter drugs, as well as herbal remedies), nurses are trained to initiate a "Senior Polypharmacy" referral. This information is automatically transmitted to the pharmacist, who reviews the medication profile and identifies drugs or doses of medications that are not appropriate for older adult patients. If an inappropriate drug or dose is detected, the pharmacist contacts the physician providing care for the patient to alert him/her and recommends alternative medications or doses.
  • Assessments and followup care: Once the patient is stable, nurses screen for cognitive loss, depression, and alcohol and drug use. They also perform risk assessments for falls, neglect, or abuse; assess physical function and risk of followup problems; and refer patients to the appropriate level of care. Within 24 hours of discharge, a geriatric social worker calls each high-risk patient to check on his or her status and answer any questions. All patients receive a followup phone call from an administrative assistant within a few days of discharge (typically 2 to 3 days and no more than 1 week) to help them address any challenges they may be facing, such as obtaining medications, reducing household safety hazards, setting up home visits from nurses, or arranging for hospice care.

Context of the Innovation

Holy Cross Hospital, a 450-bed, not-for-profit teaching hospital located just north of Washington, DC, primarily serves residents of Maryland's two largest jurisdictions, Montgomery and Prince George's counties. The hospital offers inpatient and outpatient primary and specialty services, with expertise in surgery, neuroscience, cancer, women and infants' care, and senior care. The rapid growth in the population of senior citizens in the area, combined with the observation that the typical emergency department is a challenging environment for many seniors, convinced hospital leaders of the need to find ways to improve the experience of older patients in the ED.

Did It Work?

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Results

Patients treated at the senior emergency center report high levels of satisfaction with their treatment. The center has increased the number of patients identified as taking inappropriate medication or medication doses and has also experienced an increased volume of patients and low rates of return visits to the ED.
  • High patient satisfaction: A survey of 1,047 patients treated in the senior emergency center between November 2008 and October 2009 found that 98 percent of respondents rated their ED experience as excellent (selecting the top option). Additionally, the following percentage of respondents selected the top response to the listed question: 98 percent when asked if senior emergency center staff listened to them; 96.7 percent when asked if staff kept them well informed; 97.3 percent when asked if staff were caring and compassionate; 98.4 percent when asked about the noise level in and around their room; 87.2 percent when asked about the waiting time for tests or treatment; and 99 percent when asked about the likelihood of recommending the senior center to others.
  • Improved screening for inappropriate medications: The center averages 450 patient visits each month, 50 percent of whom are prescribed 5 or more medications. Of these 450 patients, the "Senior Polypharmacy" referral has identified approximately 20 percent who were taking an inappropriate medication or medication dose that was subsequently corrected.
  • Increased patient volume: The volume of patients treated in the senior emergency center increased 16 percent from 2008 to 2009, compared with a 10 percent increase in the hospital's volume of nonsenior patients treated in the main ED.
  • Few return visits: Since the center opened in November 2008, approximately 3 percent of patients return to the ED within 72 hours, while 15 percent return within 30 days. Comparison data specific to seniors are not available.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation results from patient satisfaction surveys, along with data on the percentage of patients who were taking an inappropriate medication or medication dose, treated in the senior emergency center, and returned to the emergency department after an initial visit.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Committee formation: In 2007, the hospital formed a steering committee comprising senior hospital executives, the ED's medical director, two ED physicians, and five nurses to explore how the hospital could enhance seniors' experience in the ED. The committee decided to convert a large area adjoining the main ED into a separate emergency center for seniors.
  • Consultation with outside experts and focus groups: Committee members met several times with a geriatrician and professor of aging at University of Maryland Baltimore County's Erickson School of Aging Studies. These specialists provided suggestions on how the new area could be designed to reduce patient stress and anxiety. The committee also consulted experts in lighting and audiology and held focus groups with community seniors who tested out mattresses of varying thicknesses and offered insights on their priorities (e.g., wanting warm blankets and to be kept informed).
  • Key structural and policy decisions: Based on their consultations and research, the committee settled on a design plan that called for eight rooms with the previously described privacy, comfort, and safety features. After reviewing ED patient age patterns and considering several possible minimum ages for eligibility, the committee decided that the minimum age to qualify for treatment at the center should be 65.
  • Fundraising: Each September, the hospital dedicates the proceeds from an annual dinner/dance/auction to a specific project inside the hospital. Hospital executives agreed to devote funds from the 2007 event to the construction of the senior emergency center.
  • Center design and construction: In the fall of 2008, contractors converted the existing space into the senior emergency center and installed the comfort and safety features.
  • Training: Also in the fall, ED staff completed a 12-hour geriatric training program at the hospital. These sessions, taught online, focused on topics such as treatment of specific health issues, assessment and screening, and techniques for communicating with patients whose hearing is impaired or who process information slowly due to neurological limitations.
  • Opening: The senior emergency center opened in November 2008 with a ribbon-cutting ceremony.

Resources Used and Skills Needed

  • Staffing: The center is primarily staffed by physicians, nurses, and administrative personnel who were already working in the regular ED; this staff now covers both EDs. A geriatric social worker and geriatric nurse practitioner with significant expertise in geriatric care were hired to work exclusively in the senior emergency center.
  • Costs: Converting the existing space and purchasing the requisite equipment cost approximately $150,000. Additional incremental operating costs include salaries and benefits for the two newly hired individuals, along with other expenses associated with the space (e.g., incremental utility costs).
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Funding Sources

Holy Cross Hospital pays for the program, including compensation of newly hired staff, from the annual operational budget; as noted, funds to cover the conversion of the existing space and the purchase of new equipment came from an annual fundraiser sponsored by the hospital.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Research patient demographics: Gain a solid understanding of the surrounding area's population before deciding whether to set up a senior emergency center (or how large it should be). As part of this process, consult with local municipalities to get estimates of how rapidly the senior population is expected to grow in coming decades.
  • Involve ED staff early: Include ED physicians and nurses from the outset, as their involvement will likely make them champions for the new center.
  • Seek hospital staff support outside the ED: Also engage other hospital staff members such as allied health workers, physical plant personnel, and organizational planners, because the opening of the center will impact their work.
  • Solicit outside input: Experts from local universities and senior community volunteers often contribute excellent ideas for enhancing comfort and safety.

Sustaining This Innovation

  • Maintain focus on emergency care: Although it is feasible and beneficial to provide patients at the senior emergency center with certain services they might not receive at a standard ED (e.g., screening for additional health issues, assessing the risk of falls), expanding service offerings too much creates the potential for the center to lose its focus on emergency care. Providing indepth examinations and treatment that patients could get elsewhere (e.g., in the main hospital or from primary care doctors or specialists) can lead to longer wait times inside the ED. Keeping a close watch on patient volume can help ED administrators strike the appropriate balance.

More Information

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Contact the Innovator

Judith Rogers, PhD, MSN, RN
President
Holy Cross Hospital
1500 Forest Glen Road
Silver Spring, MD 20910
(301) 754-7082
E-mail: rogerj@holycrosshealth.org

Innovator Disclosures

Dr. Rogers has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Baker B. Serenity in Emergencies: A Silver Spring ER Aims To Serve Older Patients. Washington Post. January 27, 2009. Available at: http://www.washingtonpost.com/wp-dyn/content/article/2009/01/26/AR2009012601872.html

Shapiro J. An emergency room built specially for seniors. National Public Radio. February 19, 2009. Available at: http://www.npr.org/templates/story/story.php?storyId=100823874

Tomassini J. Holy Cross ER Offers Seniors Specialized Care. The Gazette. February 4, 2009. Available at: http://www.gazette.net/stories/02042009/gaitnew211442_32481.shtml

Footnotes

1 Baker B. Serenity in emergencies: A Silver Spring ER Aims To Serve Older Patients. Washington Post. January 27, 2009. Available at: http://www.washingtonpost.com/wp-dyn/content/article/2009/01/26/AR2009012601872.html
2 Tomassini J. Holy Cross ER Offers Seniors Specialized Care. The Gazette. February 4, 2009. Available at: http://www.gazette.net/stories/02042009/gaitnew211442_32481.shtml
3 Counsell SR, Callahan CM, Butttar AB, et al. Geriatric Resources for Assessment and Care of Elders (GRACE): a new model of primary care for low-income seniors. J Am Geriatr Soc. 2006;54(7):1136-41. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 21, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 25, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

Back Story
Partnering with family members is a key element of the patient-centered care offered at the senior emergency center of Holy Cross Hospital in Silver Spring, MD. The importance of focusing on family concerns was evident when clinicians at the center evaluated 75-year-old Mary (name and details have been changed), who...

Read more