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For the Elderly, Emergency Rooms of Their Own
By Anemona Hartocollis, New York Times
April 9, 2012
Image Credit: Yana Paskova, New York Times
Phyllis
Spielberger, a retired hat seller at Bendel’s, picked at a plastic dish
of beets and corn as her husband, Jason, sat at the foot of her
hospital bed, telling her to eat.
Although she had been rushed to Manhattan’s busy Mount Sinai Hospital
by ambulance when her leg gave out, the atmosphere she encountered upon
her arrival was eerily calm.
There were no beeping machines or blinking lights or scurrying medical
residents. A volunteer circulated among the patients like a flight
attendant, making soothing conversation and offering reading glasses,
Sudoku puzzles and hearing aids. Above them, an artificial sun shined
through a skylight imprinted with a photographic rendering of a
robin’s-egg-blue sky, puffy clouds and leafy trees.
Ms. Spielberger, who is in her 80s, was even getting into the spirit of
the place, despite her unnerving condition. “It’s beautiful,” she said.
“Everything here is wonderful.”
Yet this was an emergency room, one specifically designed for the
elderly, part of a growing trend of hospitals’ trying to cater to the
medical needs and sensibilities of aging baby boomers and their
parents. Mount Sinai opened its geriatric emergency department, or
geri-ed, two months ago, modeling it in part after one at St. Joseph’s
Regional Medical Center in Paterson, N.J., which opened in 2009.
Holy Cross Hospital in Silver Spring, Md., opened one of the first
geriatric emergency departments, which it calls a seniors emergency
center, in 2008, and its parent organization, Trinity Health System,
runs 12 nationwide, primarily in the Midwest, and plans to open six or
seven more by June, a spokeswoman said.
Dr. Mark Rosenberg, chairman of emergency medicine at St. Joseph’s,
said he had consulted on more than 50 geriatric emergency rooms to be
opened across the country, from Princeton, N.J., to California,
overcoming initial resistance from doctors and nurses who saw
assignments to the units as scut work.
“They thought it was a bedpan unit, focused on nursing home patients,”
Dr. Rosenberg said. “When they finally realized this was the unit that
gave better health care to their parents and grandparents, they jumped
onboard.”
Hospitals also have strong financial incentives to focus on the
elderly. People over 65 account for 15 percent to 20 percent of
emergency room visits, hospital officials say, and that number is
expected to grow as the population ages.
Under the Affordable Care Act, the health insurance overhaul passed by
Congress in 2010, hospitals’ Medicare payments will be tied to scores
on patient satisfaction surveys and how frequently patients have to be
readmitted to the hospital. (The Supreme Court is considering whether
to overturn another section of the law, and if it does, whether it
would have to throw out the entire law.)
Even in their early stages, patient satisfaction ratings for Mount
Sinai’s geri-ed are “off the scoreboard,” said Dr. Andy Jagoda, the
hospital’s chairman of emergency medicine.
Patients who are picked up by ambulance can choose which hospital to go
to, if circumstances and travel time allow.
At Mount Sinai, all arrivals go through triage in the regular emergency
department and are sent to the geriatric department if they are over
65, know their name, were able to walk before the day of the hospital
visit and are ranked 3, 4 or 5 on a standard emergency severity index
of 1 to 5, with 1 being the sickest. Someone with a broken hip would
probably qualify, but someone with an acute heart attack would most
likely have to be stabilized in the regular emergency room first, said
Dr. Kevin M. Baumlin, the vice chairman of emergency medicine, who
founded the geriatric emergency room.
The geriatric E.R. — eight beds and six examining rooms — resembles a
clinic more than it does an emergency room: there are nonskid floors,
rails along the walls, reclining chairs for patients and thicker
mattresses to reduce bedsores. To keep the noise down, the curtain
rings and rods around the beds are made of plastic instead of metal.
“One of my pet peeves is the noise that curtains make,” Dr. Baumlin
said. “You know, that metal clackety-clack sound.”
Volunteers interact with patients to keep them alert. The artificial
skylight, which turns dark at night, is intended to combat “sundowning”
— agitation and confusion at the end of the day. “I have to say I
thought it was the hokiest thing I ever heard of, but it turns out it’s
a big satisfier,” Dr. Jagoda said.
Then there is one of Dr. Baumlin’s favorite innovations, what he calls
the geriPad, an iPad that lets patients have a two-way video
conversation with a nurse, or touch the screen to ask for lunch, pain
medication or music.
A calmer patient is usually a satisfied one, but advocates of the trend
toward geriatric E.R.’s say there are also medical reasons for placing
a special focus on the elderly. Being treated in the emergency room is
often the beginning of a slide for older patients: within three months
of being sent home, up to 27 percent have another emergency, are
admitted to the hospital or die, studies show.
Dr. Ula Y. Hwang, a researcher at Mount Sinai who co-wrote a 2007 paper
on the concept of the geriatric emergency department, said the classic
emergency room focus on speed could lead to mistakes with elderly
patients, whose condition is often complicated by their being on many
medications, having more than one sickness and being unable to express
what is wrong with them clearly.
Dr. Rosenberg, of St. Joseph’s, said his hospital had been able to
reduce unscheduled return visits to the emergency room to 1 percent of
cases, from 20 percent. Patients still return, he said, but they return
because the hospital has called them at home, found they are not
getting better, and called them back to the hospital before their
condition, like pneumonia, becomes a crisis.
Still, the move toward specialized emergency rooms for the elderly has
skeptics, who see them as little more than marketing gimmicks.
Dr. Alfred Sacchetti, chief of emergency services at Our Lady of
Lourdes Medical Center in Camden, N.J., said he thought setting up
geriatric emergency rooms, or even pediatric emergency rooms, was a
distraction from the goal of giving optimal treatment to all.
Dr. Sacchetti said he had not seen evidence that geriatric emergency
rooms provided better outcomes for patients, but to the degree they did
improve care — for instance, if the thicker mattresses did cut down on
bedsores — then those improvements should be extended to all emergency
patients.
“What’s the best outcome for the patient?” he said. “I don’t miss your
diagnosis, I treat you appropriately, I treat you quickly and you have
a good outcome. Or, I miss all of those things but son of a gun, we
look like the Four Seasons. There’s nothing that says you can’t do
both.”
Dr. Jagoda, the emergency medicine chairman at Mount Sinai, admitted
that he, too, was skeptical at first. But, he said, up to eight elderly
patients a month were falling in the regular emergency room, and that
alone was troubling enough for him to want to try something new. None
have fallen in the geriatric E.R., he said.
One mission of the geriatric emergency room is to look at the context
of the emergency. So a pharmacist might look at drug interactions, and
a visiting nurse might be sent to the home of a patient who fell to
look for trip hazards.
As for Ms. Spielberger, who was taking 13 or 14 drugs, the pain in her
leg led doctors to find a heart problem, her husband said later. She
was admitted to the hospital for one night and sent home, Mr.
Spielberger said, with the advice to let it be. It is a visit she would
rather forget, except for that skylight.
“It was fantastic,” she said. “I called my family to tell them about
it.”
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