New research published in Annals of Emergency Medicine evaluated ED utilization patterns and clinical needs among geriatric patients in California. Their findings show that patients over the age of 65 who frequently use the ED:
- Constitute an outsized proportion of visits: Nearly 6% of geriatric patients visited the ED at least six times in a year, accounting for 21% of visits; and
- Are clinically complex: While geriatric frequent users most likely visit the ED for pain or injury, they also have a high number of comorbid conditions (e.g., 26% have diabetes, 22% have chronic pulmonary disease).
But emergency care is just the starting point. If these patients' underlying needs go unaddressed, an ED visit can signal the start of a very complex care journey. For example, up to 27% of elderly ED patients are admitted to the hospital or die within three months of their visit. Also, seniors are 14% more likely to acquire a disability (e.g., inability to independently bathe, climb stairs) within six months of an ED visit than those without a visit.
To meet the needs of this population, leading hospitals are creating specialized geriatric EDs. Among pioneers in this space is St. Joseph's University Medical Center, which established two 10-bed geriatric ED units in 2009. St. Joseph's transformed part of an existing ED to be senior-friendly (e.g., non-slip floors, thicker mattresses) at low-cost. Its team redeployed some existing ED staff and trained them to manage the unique needs of geriatric patients, including palliative care needs.
Dedicated geriatric ED team surfaces and addresses often-overlooked senior patient gaps across 3 steps
- Streamlined triage maximizes resource efficiency among older patients
St. Joseph's uses the five-level Emergency Severity Index (ESI) as an ED triage tool. However, after noticing that level-three seniors experienced longer wait times, leadership streamlined the process by mandating geriatric patients be assigned to only levels one, two, four, and five to more clearly prioritize elderly patients. Once patients are triaged and stabilized in the geriatric ED, staff perform medication reconciliation and a comprehensive assessment.
- ED-based assessments kick-off cycle of palliative care and comfort services
Following the initial assessment, a nurse and nurse navigator connect with patients' caregivers, PCP, and specialists for consultation (as needed). Specific diagnoses (e.g., cancer) and presence of unmet palliative care needs initiate a palliative consult from their Life-Sustaining Management and Alternatives team. A patient liaison focuses on patient comfort by bringing reading glasses, warm blankets, and pillows. If patients' symptoms escalate, they are quickly triaged to the nearby inpatient unit.
- Post-discharge support geared to help seniors maintain quality of life
Before patient discharge, the nurse navigator coordinates needed support services (e.g., adult day care, home health aide, walker, Meals on Wheels) and notifies a case manager of more complicated concerns (e.g., elder abuse). The nurse navigator performs a warm hand-off to PCPs, ensuring the patient is seen within seven days post-discharge. They also call patients four times (1, 3, 7, and 40 days post-discharge) to reassess conditions and schedule needed care.
Make your patients healthy and your ED happy with community paramedicine
For organizations assuming population health risk, top priorities include reducing the rates of avoidable ED visits, avoidable admissions, and readmissions. But most organizations don't have all the staff they need to engage patients and support robust care management.
Our infographic explains how community paramedics can help extend the care team to prevent avoidable visits to the ED.
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Chronic Care Management,