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'Seniors-only' ED draws raves from patients
Revamping existing space kept down costs
The senior emergency center at Holy Cross Hospital in Silver Spring, MD, may be a rarity, but based on the responses of patients and staff — not to mention our increasingly aging population — perhaps more EDs should consider creating a separate unit for older patients.
"Since we opened [in November 2008], we have averaged between 97% and 99% in patient satisfaction," reports Bonnie Mahon, RN, BSN, MSN, senior director of medical, surgical, and senior services.
David Cummings, RN, CEN, the Holy Cross emergency center director, says, "Based on the patient responses, they are very appreciative of being placed outside the general ED population in a quiet area where the staff is more attuned to their specific needs."
The senior center is located within the ED itself. The space formerly was used for express care, which has been moved to another floor. The senior center has its own entrance and exit doors. All patients present in the main triage area of the ED. At that point, a set of criteria are used to determine if they should be placed in the senior center. First, they must be age 65 or over. Secondly, their placement is determined by the initial symptoms.
They use a scale of 1 to 5, Mahon explains. "If they are clutching their chest, for example, and are possibly having an MI, they are Category 1 and are immediately taken back to the acute side of the ED," she says. If MI, stroke, and acute bleeding are ruled out, which puts them in Categories 2 to 5, they are eligible for the senior emergency center.
Once the patients are placed in a room, the primary nurse conducts a six-question assessment. The assessment includes issues such as history of falls, the last time they were in an ED, and their current medications. "We want to see if they are at risk for return," Mahon explains.
If a patient responds positively to five or more questions, the nurse puts in a request for a pharmacy consult, Mahon says. "The pharmacist will review all the medications," she says. "We have had several 'saves' since we opened." For example, Mahon recalls a patient who came into the ED after falling. A review of the medications indicated the dosage level was too high, so adjustments were made. "We consider that a save," she says. A score of 2 or more triggers a visit from a social worker, Mahon adds.
Two weeks after discharge, a coordinator in the hospital's office of seniors conducts a follow-up survey. The survey asks patients how well the staff listened to them, if they were kept well informed, how they would rate the care and compassion with which they were treated, what they thought about noise levels, and if they would recommend the facility.
Multi-unit team designs senior ED
Once the decision was made in July 2007 to create a senior emergency center at Holy Cross Hospital in Silver Spring, MD, Bonnie Mahon, RN, BSN, MSN, senior director of medical, surgical, and senior services, put together a team that included two ED physicians, the chief nurse, the nurse manager, and a director of case management.
Fortunately, there was space available within the ED itself to create a separate department. "We just knocked down a wall," she says. "It had its own nurses' station, six bays, and two rooms."
The team changed the lighting based on the recommendations of elder care expert Bill H. Thomas, MD, and his colleagues from the University of Maryland Baltimore County Erickson School. The school offers a major in management of aging services, and it describes itself as "part business school, part aging studies, and part public policy." "Their specialty is aging," says Mahon. Upon their recommendation, the shiny linoleum floors were replaced with nonskid faux wood. Light dimmers were placed in all bays, with switches in the nurses' stations. "Normal fluorescent lighting creates 'hot spots' on the floors that can affect depth perception and cause falls," she explains. The walls were painted in warm colors such as gold, and all rooms or bays have a clock and/or a TV.
The renovations cost a total of $150,000, Mahon reports. "We were very fortunate that in 2007, the hospital fundraiser was dedicated to seniors, so the money raised went toward creating the center," she says.
For more information on creating a senior ED, contact:
ED staff volunteer for senior center
Most of the staff in the new senior emergency center at Holy Cross Hospital in Silver Spring, MD, came from the main ED, says David Cummings, RN, CEN, the hospital's emergency center director.
"What we have done is find people who really want to work with this population and ask them to work there permanently," he says, noting that it is similar to what happens with a pediatric ED. "In 'peds,' you have mostly pediatric RNs, which is a subspecialty, and we created a subspecialty of nurses who are interested in and understand the needs of the population," Cummings says.
This unit did not leave the main ED understaffed, he says. "This was an area that was previously staffed that we carved out, so people were just differently assigned," Cummings explains.
All the nurses who work in the ED have received special training, says Bonnie Mahon, RN, BSN, MSN, senior director of medical, surgical, and senior services. "We used the Geriatric Emergency Nurses' Education program from the Emergency Nurses Association [ENA]," she says. Mahon estimates the total cost of the course was $8,000, which included a fee of several hundred dollars each for the separate modules required for each nurse. "It was really good and comprehensive," she adds. [Editor's note: ENA sources say the course is currently being revamped and is temporarily unavailable. They estimate that it will be available in its new format by the fall. ENA can be contacted at (847) 460-4123 or firstname.lastname@example.org.]