By Beth Baker
Special to The Washington Post
Tuesday, January 27, 2009
When Barbara Rayner, 78, came to the emergency room at Holy Cross Hospital in Silver Spring last month with severe lower back pain, she was expecting a long wait and harried staff. But within minutes she was whisked into a separate area, called the senior emergency center. It is one of the nation's first ERs designed to serve a population 65 and older.
"It's a really forward-thinking idea," said Rayner. "I think senior citizens will appreciate it a great deal -- and their families."
Staff training in geriatrics and communication as well as a comprehensive approach to care and patient follow-up set the center apart from the typical emergency room. "They're actually structuring acute emergency services around the needs of the people they're taking care of, rather than forcing older people to conform to the operations of the hospital," said geriatrician William H. Thomas, a professor of aging studies at the University of Maryland Baltimore County's Erickson School who helped the hospital design the new area.
While patients in the main ER typically share a room crowded with monitors and equipment, separated from one another only by a flimsy curtain, each patient in the new center has an uncluttered cubicle, with a comfortable chair for a family member or visitor. Rayner said she appreciated the extra privacy. She also was grateful for the mattress -- twice as thick as other ER beds and specially designed to prevent skin breakdown that leads to bedsores, which can develop rapidly in elderly patients. There are plenty of blankets -- kept toasty in a blanket warmer -- and pillows.
Holy Cross consulted with the Erickson School on all aspects of the center and drew on experts in lighting and audiology to make the experience as soothing as possible on aging eyes and ears.
Walls are painted a warm gold, with wooden handrails for safe walking. Rather than slick linoleum, the floor is made of faux wood. Each patient has a television with headset, a large-face clock and overhead lighting controlled by a dimmer switch. There are just eight rooms, clustered near a small nurse's station. During a recent visit, the only disturbance was the squawk of the hospital-wide intercom -- and according to Bonnie Mann, director of Holy Cross's office of seniors, the center will soon switch to wireless paging to eliminate that distraction.
Staff members are given training in geriatrics, including techniques for communicating with patients whose hearing may be impaired or who process information slowly but don't want to be patronized. "Senior citizens frequently feel they're invisible," said Rayner. "People walk in front of you in line or talk over your head. No one's been condescending here. They've been respectful."
She added: "My previous experience in the emergency room certainly was not bad, but I was left alone longer. This time you had the feeling someone was paying attention the whole time."
Dolores Bartlett of Damascus was in the senior emergency center with her mother, Margaret Fenwick, 96, a fiercely independent woman who lives alone in Wheaton and still rakes her own leaves. Fenwick had fallen and fractured two ribs. She was to be admitted to the hospital and was waiting for a private room to open up.
Bartlett was impressed that the staff had brought down a hospital bed so that her mother would be more comfortable.
"The nurses have all been so pleasant, so calm, so caring," said Bartlett. When she asked to speak to the doctor, she said, "it wasn't long before he came and gave me an in-depth explanation of what was going on, in layman's terms, that encouraged me to encourage her." The staff even looked out for Bartlett, offering her a bed to nap on and bringing her a box lunch.
Bartlett's only complaint was when her mother was taken to radiology. Bartlett felt the technicians positioned her mother too roughly, causing her excessive pain.
Judith Rogers, the hospital's vice president of patient care services, said she was disappointed but not surprised to hear this. "We started geriatrics-specific training with registered nurses in the ER, then nurses on the medical floors, and we're beginning now to train the ancillaries" such as radiology and respiratory therapy staff, she said.
Holy Cross chief executive Kevin Sexton said the idea for an emergency room for older people came to him after he got a call from his mother from an ER in New Jersey. "It was clear she was really stressed out," he said. "It was the combination of her being there quite some time and it being very crowded and chaotic. It came to me we really do treat seniors poorly in that setting."
The aging of Montgomery County contributed to the decision to open the center: 70 percent of anticipated population growth over the next decade will be people older than 65, according to Sexton. "An enormous demand for services is going to befall hospitals," he said. "Figuring out how to do it better without bankrupting us all is going to be one of the challenges."
The senior emergency center is a first step in the hospital's long-term plan to become known for serving older people. It's an unusual concept: An expert at the Society of Academic Emergency Medicine could think of only one similar facility, located at Nassau University Medical Center in New York.
Holy Cross spent $150,000 on its center, raised through an annual gala, to renovate an existing space and to train nursing staff. The hope is that the center will run more efficiently than the general ER, getting test results more quickly, for example. The staff will also monitor whether the improved assessment and follow-up lead to fewer return admissions for these patients. Mann stresses that most of the extra services are low-cost.
Not all older patients end up in the senior emergency room. Those arriving with traumatic injury -- from a car accident, for example -- or in acute distress such as a heart attack will still be treated in the general ER. Nearly three-quarters of people over 65, though, come to the emergency room not in life-threatening crisis but because of a fall, chest pain, shortness of breath or other problem related to chronic conditions.
Once the patient is stable, nurses screen for cognitive loss, depression, possible interactions from taking multiple medications, and alcohol and drug use. They also perform a risk assessment for falls, neglect or abuse. Those who test positive in any of these areas are referred to community resources and receive a follow-up call from a geriatric nurse practitioner or social worker.
Holy Cross hopes not only to provide first-class service to seniors at no extra cost, Sexton said, but also to deliver health care more efficiently by reducing future hospital stays. A trip to the emergency room, then, is not only about fast treatment and discharge, but it is also an opportunity to uncover chronic problems that need attention.
When planning the new ER, Holy Cross conducted focus groups with older people to find out what they'd like to see in an emergency room. Mann was struck by the common themes that emerged. "Over and over we heard, 'Keep me informed' and 'Keep me warm,' " she said.
Focus group participant Betty Ann Barnes, 73, of Silver Spring said she was impressed that the hospital would solicit the opinions of older people as part of the planning process and not just as an afterthought. She was pleased that her group's request for warm blankets was met, although another wish -- free valet parking for older people -- was not. After touring the center, Barnes declared it "magnificent."
Augusta Widmer, 82, a patient who arrived at the ER with pain in her hip, agreed. "Everybody's been wonderful," she said. "I couldn't ask for anything nicer. Other emergency rooms I've been to were much more hectic and noisy, and you wait a long time."
Asked if she would add anything, she suggested, "Soft music. And a cup of coffee. Other than that, no."
In fact, both these requests were already met. Using their television remote, patients can select a soft music channel or one with pastoral scenery to view. Coffee, bouillon and juice are also available. "We're on a learning curve," said Mann. "Now we have to make sure the staff let patients know what we offer."