the geriatric ed st. joseph’s regional medical center … · st. joseph’s regional medical...

Copyright © 2002‐2012 Urgent Matters 1

THE GERIATRIC ED ST. JOSEPH’S REGIONAL MEDICAL CENTER

Publication Year: 2011

Summary:

St. Joseph’s Regional Medical Center designed an emergency department specifically equipped to meet the needs of

geriatric patients.

Hospital: St. Joseph’s Regional Medical Center

Location: 703 Main Street

Paterson, NJ 07503 Contact: Mark Rosenberg

Chairman of the Department of Emergency Medicine [email protected]

Category:

A: Arrival E: Exit from ED

Key Words:

Geriatric Follow‐Up Care Transitions

Hospital Metrics: (Taken from the American Hospital Directory)

Annual ED Volume: Approximately 130,000

Hospital Beds: 641 Ownership: Non‐Profit Trauma Level: II Teaching Status: Yes

Tools Provided:

How to Establish a Geriatric Emergency Department Checklist This tool is a list of tips provided by Mark Rosenberg, DO, Chairman of the Department of Emergency Medicine, St. Joseph’s Healthcare System.

Clinical Areas Affected:

Emergency Department Geriatric Emergency Department Seniors admitted through hospital in

other critical care departments

Staff Involved:

Nurses ED Staff Physicians Social workers/case managers Pharmacists Toxicologists Physical Therapists ED Palliative Care Team Ancillary Departments


Innovation St. Joseph’s Regional Medical Center designed an emergency department specifically equipped to meet the needs of geriatric patients.

Results Since the geriatric ED at St. Joseph’s opened in 2009, the rate of unscheduled returns of geriatric patients who return to the hospital within 30 days for the same illness or injury dropped from 20 percent to less than one percent. They have also seen an increase in patient satisfaction scores.

From the Experts “The key to success of a program like this is offering better continuity of care and, in particular, follow‐up with patients after they’re discharged.” Mark Rosenberg DO, Chairman of the Department of Emergency Medicine St. Joseph’s Healthcare System Timeline The implementation of the geriatric ED at St. Joseph’s Medical Center was completed in phases. The innovation began as a physician and nurse team performing geriatric consultations. The program evolved into the development of a space dedicated to geriatric patients. The entire process for implementation, including the developing of protocol and testing theory for the best possible model, took just over a year, beginning in January 2008 and ending with the opening of the geriatric ED in April 2009. Innovation Implementation The geriatric emergency department was created to address the complex medical issues geriatric patients face and prevent functional decline that occurs after they leave the ED. Upon arrival at St. Joseph’s, patients are triaged in the adult ED and are transferred to the geriatric ED, a separate, 14‐bed unit, if they are 65 years of age or older, don’t require stabilization, or meet criteria related to disability and functional capacity. The geriatric ED is located down the hall from the inpatient geriatric unit. If a patient requires hospitalization, the geriatric ED nurse coordinator facilitates admission and assists with their transition. The geriatric ED has its own dedicated staff that includes physicians who are double‐boarded in emergency medicine and internal medicine, nurses, social worker/case managers, pharmacists, and a toxicologist. Physical therapists are available to assist patients with ambulatory difficulties or other defined needs. These staff members were transferred from the adult ED when the new unit was established. Services Offered Special protocols of care enable staff to target high risk conditions in this vulnerable population.

o In consultation with a pharmacist and a toxicologist, a review of each patient’s prescription medication is conducted.

o If any harmful drug interactions are identified, the patient’s primary care provider is contacted and the providers collaborate to ameliorate the issue. o Every patient is evaluated for fall risk during their visit and, if necessary, precautions are taken to

prevent injury. o All patients discharged from the geriatric ED receive a call from a staff member within 24‐36 hours.

They’re asked a series of questions to check whether their condition is improving, any necessary prescriptions have been filled, and follow‐up appointments have been made.

o If the patient’s symptoms are not improving, they are asked to return to the geriatric ED for evaluation and are given an appointment so they won’t have to wait.


In 2010, St. Joseph’s launched a program called LSMA (Life‐Sustaining Management and Alternatives). When a patient in the geriatric or adult ED has a chronic or terminal illness or organ failure, the staff can order a bedside consult with the ED palliative care team. During the consult, the patient and family are given information about how the disease is likely to progress and how to access resources such as home hospice care. Cost/Benefit Estimate The geriatric ED team aimed to keep costs to a minimum and implement changes gradually. The biggest expense was training the staff. Every member of the ED staff ‐‐ not just those assigned to work in the geriatric unit ‐‐ received training in geriatric emergency medicine, using a curriculum designed by Dr. Mark Rosenberg and his colleagues. The staff learned how to tailor treatment for patients that often have chronic illnesses, multiple comorbidities, and are taking multiple medications. If it’s not feasible to secure a separate space for a geriatric unit, Rosenberg says there are a number of small changes that can be made to make an ED more comfortable for seniors. For example, you can select thicker mattresses and chairs with arms so patients can more easily push themselves up to a standing position. The benefits to these changes include reduced readmissions and increased patient satisfaction. The staff has also discovered that some patients are travelling from across the state to seek treatment in the geriatric ED. Advice and Lessons Learned

1. If you don’t have space for a Geriatric ED…. Make your entire ED a Geriatric ED. 2. If the ED is designed for the most frail and vulnerable ….. It will work for the strongest.

Tools to Download How to Establish a Geriatric Emergency Department Checklist

Related Resources Urgent Matters E‐Newsletter: Best Practices: The Geriatric Emergency Department, St. Joseph’s Regional

Medical Center Urgent Matters Webinar

o Listen to a Recording o Download Dr. Rosenberg’s Presentation

How to Establish a Geriatric Emergency Department

Tips from Mark Rosenberg, DO, Chairman of the Department of Emergency Medicine, St. Joseph’s Healthcare System, Paterson, NJ

1. Obtain support from hospital leadership.

2. Assess your hospital’s needs and determine the patient population you will serve: community-dwelling older adults (aged 65+), nursing home patients, or both.

3. Identify a location for the new unit. If possible, select a place that’s quiet and separate from the main ED. But if you don’t have extra room, you could still designate four beds in the main ED, for instance, for geriatric patients.

4. Find out if it’s �nancially and logistically feasible to make structural modi�ca-tions such as adding hand-rails, dimmable lighting, soundproo�ng, and non-glare �ooring.

5. Identify champions within the emergency department who will help run the program – in particular, a nurse who will be the program director and a doctor who will oversee the medical aspects of the unit.

6. Teach everyone who works in the emergency department how to improve care for seniors. Emphasize that it’s important to speak with these patients in a respectful way – for example; don’t call them by their �rst name.

7. Create a system for reviewing each patient’s prescriptions and identifying potential drug interactions. Dr. Rosenberg’s team uses Beers Criteria, a list of medications to avoid prescribing to the elderly.

8. Provide great follow-up care. This will be the key to the success of the pro-gram. Every patient should receive a call from a member of your team the day after they leave the ED. If the patient’s condition is not improving, they should be asked to return to the ED and prioritized for immediate treatment.


BEST PRACTICES: THE GERIATRIC EMERGENCY DEPARTMENT AT ST. JOSEPH’S REGIONAL MEDICAL CENTER Helping independent seniors maintain their quality of life was the goal when Mark Rosenberg, DO, Chairman of the Department of Emergency Medicine at St. Joseph’s Regional Medical Center, set out to create an emergency department (ED) for geriatric patients. Since the geriatric ED at St. Joseph’s opened in 2009, the rate of unscheduled returns of geriatric patients who return to the hospital within 30 days for the same illness or injury dropped from 20 percent to less than one percent. “This is because we’re providing much better care initially and have significantly improved our follow up care,” notes Rosenberg. “We wanted to address the complex medical issues geriatric patients face and make sure we’re preventing functional decline that could occur after they leave the ED,” he says. “For example, we decided to evaluate every patient for fall risk during their visit and, if necessary, take precautions to prevent injury.” Upon arrival at St. Joseph’s, patients 65 years of age or older are triaged in the adult ED and transferred to the geriatric ED, a separate, 14‐bed unit, if they do not require stabilization, or meet criteria related to disability and functional capacity. The geriatric ED is located down the hall from the inpatient geriatric unit. If a patient requires hospitalization, the geriatric ED nurse coordinator facilitates admission and assists with their transition. Rosenberg and his team designed the geriatric ED to be smaller and less chaotic than the adult ED. “It’s quieter and much more relaxed, with natural lighting rather than harsh, fluorescent lighting,” he says. They chose thicker mattresses because elderly patients are at greater risk for pressure injuries. To prevent falls, they selected flooring that isn’t shiny and installed handrails on every wall and in bathrooms.


Tailoring Care The geriatric ED has its own dedicated staff that includes physicians who are double‐boarded in emergency medicine and internal medicine, nurses, social workers/case managers, pharmacists, and a toxicologist. Physical therapists are available to assist patients with ambulatory difficulties. These staff members were transferred from the adult ED when the new unit was established. Special protocols of care enable staff to target high risk conditions in this vulnerable population. In consultation with a pharmacist and a toxicologist, a review of each patient’s prescription medication is conducted. If any harmful drug interactions are identified, the patient’s primary care provider is contacted and the providers collaborate to ameliorate the issue. Every patient is also evaluated for fall risk during their visit and precautions are taken to prevent injury. In addition, all patients discharged from the geriatric ED receive a call from a staff member within 24‐36 hours. They are asked a series of questions to check whether their condition is improving, any necessary prescriptions have been filled, and follow‐up appointments have been made. If the patient’s symptoms are not improving, they are asked to return to the geriatric ED for evaluation and are given an appointment so they will not have to wait. “The key to the success of a program like this is offering better continuity of care and, in particular, following up with patients after they’re discharged,” Rosenberg says. In 2010, St. Joseph’s launched a program called LSMA (Life‐Sustaining Management and Alternatives). When a patient in the geriatric or adult ED has a chronic or terminal illness or organ failure, the staff can order a bedside consult with the ED palliative care team. “We found that it’s important to initiate a discussion with these patients so they better understand their disease and can make appropriate choices,” says Rosenberg. During the consult, the patient and family are given information about how the disease is likely to progress and how to access resources such as home hospice care. Lessons Learned Rosenberg says that hospital administrators, and in particular William "Bill" McDonald, the CEO of St. Joseph’s Healthcare System, supported the development of the geriatric ED from the beginning. He suggests “starting at the top” to build support if you want to create a similar program and finding a physician and a nurse on your staff who will champion the cause and lead development of the program.


The geriatric ED team aimed to keep costs to a minimum and implement changes gradually. The biggest expense was training the staff. Every member of the ED staff ‐‐ not just those assigned to work in the geriatric unit ‐‐ received training in geriatric emergency medicine. Nurses completed eight hours of training and physicians completed six hours of training, using a curriculum designed by Rosenberg and his colleagues. The staff learned how to tailor treatment for patients that often have chronic illnesses, multiple comorbidities, and are taking multiple medications. “This was a department‐wide initiative and we wanted everyone to be comfortable taking care of older patients and to understand their unique needs,” says Rosenberg. If it is not feasible to secure a separate space for a geriatric unit, there are a number of small changes that can be made to make your ED more comfortable for seniors. For example, you can select thicker mattresses and chairs with arms so patients can more easily push themselves up to a standing position. A Growing Demand As a result of providing more comprehensive care to elderly patients, St. Joseph’s has seen an increase in patient satisfaction scores and a decrease in geriatric readmissions. The staff has also discovered that some patients are travelling from across the state to seek treatment in the geriatric ED. “When you start getting people visiting from 60 miles south who want to be seen in your department, it’s hugely rewarding for the entire staff,” Rosenberg says. Rosenberg receives several calls every week from hospitals around the country interested in developing their own geriatric ED. “The baby boomers are hitting 65 and will have more healthcare needs as time goes on,” he says. “I predict we’re going to see geriatric EDs in a large percentage of the nation’s hospitals over the next five years.” Mark S. Rosenberg, DO, MBA, FACEP, FACOEP‐D, Chairman, Department of Emergency Medicine, St. Joseph’s Healthcare System, Paterson, NJ.

Mark Rosenberg, DO, MBA, FACEP, FACOEP‐DChairman, Department of Emergency MedicineGeriatrics and Palliative MedicineSt Joseph’s Healthcare SystemSt Joseph’s Regional Medical CenterPaterson , NJ

Chairman, Geriatric Emergency Medicine SectionAmerican College Emergency Physicians

Spring 20111

Disclosures

Nothing to Disclose

2SrED and LSMA © 2010 Mark Rosenberg, DO, MBA, FACEP

Lecture Design

Experience at St Joseph’s Regional Medical Center

Discussions with Dozens of Hospitals

Not a Lecture on Geriatric EM

My Hope …. This is a How To…. Guide

End of Life Case Presentations

SrED and LSMA © 2010 Mark Rosenberg, DO, MBA, FACEP 3

St Joseph’s Regional Medical Center

641 Bed Tertiary Care Teaching Hospital

Paterson NJ

Emergency Department

130,000 Total Visit/Year

41,000 Pediatric Emergency Department

38,000 Geriatric Emergency Department (April 2009)

200 Emergency Department Palliative Medicine (Jan 2010)

Comprehensive Stroke Center

Trauma Center

Resuscitation Center

Heart Failure Center

Toxicology Reference Center


Geriatric Emergency Department Development

Why?

People

Coordinator

Nurses

Physicians

Clinical Quality and Practice

Education

Triage

Patient Management and Safety

Patient Follow up

Facilities

Community and EMS Outreach

Disease Management

Frailty

Organ Failure

Terminal Illness


Why?

79 Million Baby Boomers become 65

Age 65 and over have increase healthcare

needs

ED Utilization of Seniors

Contributing Factors

Outcomes

Paradigm Shift


Geriatric Utilization Rates

15‐20% of all Patients

7 x More Usage of ED Services

43% of all Admissions

48% of all Critical Care Admissions

20% Longer Length of Stay

50% more Lab

50% more Radiology

400% more Social Service Interventions


Contributing Factors

1.

Shrinking Primary Care Pool

Deficit of 25,000 Gerontologists by 2030

FP Residents Decreased by 50%

IM Residents Into Primary Care Dropped from 54% to 22%

2.

Lack of Financial Incentives

Medicare Is Primary Insurance of the Elderly

Medicare Pays 25‐31% less than private insurers

3.

Complexity of Care

Multiple Chronic Diseases compounded by Social Issues

Outpatient Management Issues• Cognition• Mobility• Transportation• Subspecialist Availability Difficult

4.

ED Most Appropriate Venue

One Stop Shopping

Labs; X‐ray; Specialist

Not

More Expensive


Current Model: Poorer Outcomes for Seniors

1.

Delay in Dx and Tx

Acute MI

Sepsis

Appendicitis

Ischemic Bowel

2.

Unsuspecting Dx

Delirium

Depression

Cognitive Impairment

Drug and Alcohol

Elder Abuse

Polypharmacy

3.

Under treatment

Low Rate of PCI in MI

TPA in Stroke

Less Surgical Intervention

Inadequate Pain Management

4.

Overtreatment

High Rate of Foley Cath

Adverse Drug Events

Overuse of Sedation


Two Paradigms

Single complaint

Acute

Diagnose and treat

Rapid disposition

Multiple problems

Medical

Functional

Social

Acute on chronic, subacute

Control symptoms,

Maximize function,

Enhance quality of life

Continuity of care

ED ED GeriatricsGeriatrics


Call for Action: A New Model of ED Care

Organized Emergency Medicine Has Responded Before and Will Respond Again

Pediatrics ED’s

Trauma Care

Chest Pain Centers

The Time is Now:“The Geriatric Emergency Department”


People

Program Coordinator

Nurses

Physicians

Support Staff


Program Coordinator

Nurse, Physician vs. Administrative Type

Responsible for Program Operations

Possible

Separate Position

Nurse Manager

Administrative Director

ED Medical Director


Nurses

Must Have Geriatric Skill Set

Several Options

Geriatric Nurses

ED Nurses with Geriatric Education

Geriatric Nurse Practitioner


Physicians

Must Have Geriatric Skill Set

Several Options

ED Boarded with Geriatric Education

Geriatric Nurse Practitioner

ED with Geriatric Fellowship

ED with Internal Medicine

ED with Family Practice


Support Staff

Social Workers

Case Managers

Pharmacists

Administrative Support Staff

PT and OT

Home Care

Toxicologist



Define Your Goal

Education

Triage

Practice Environment

Patient Safety

Follow‐up


Define The Goal

Define Your Population

Better Emergency Care For Seniors

Maintain Independence

Decrease or Increase Admissions

Marketing Strategy


Education – 10 Major Areas

1.

Physiological Changes of Aging

Decrease Functional Reserve2.

Abdominal Pain

Always Bad3.

Falls

A Fractured Wrist is not a Fractured Wrist4.

Infectious Disease5.

The Dizzy Patient6.

Poly‐pharmacy7.

Chest Pain

Cardiac USUALLY presents without Chest Pain8.

Delirium vs. Dementia9.

General Assessment10.

End of Life Issues


Triage

Be Aware of Vague Complaints

Normal Vitals

Normal BP in a Hypertensive

“I Just Don’t Feel Well”

Presentation of Ischemic Heart Disease

Abdominal Pain

Strategies

ESI Triage Levels Increase

Prepare for the Worst……


Practice Management

The Environment

Beds

Thick Mattresses

Hospital Beds

Non Shiny/Non Slip Floors

Lighting

Hand Rails

Location

Blankets

Room For Family and Visitors


Practice Management

Safety

Drug Interactions

5 Meds = 70% chance of Drug Interactions

7 Meds = 100% chance of Drug Interaction

Beers Criteria

Archives of Internal Medicine December 2003

Potentially Inappropriate Medication Use in Older Adults

Falls Assessment

Get up and Go Testing

Home Assessment


Beers Criteria:


BeersCriteria


28

Get Up AndGo Test…

SrED and LSMA © 2010 Mark Rosenberg, DO, MBA, FACEP

Follow up

Role of Patient Call Backs

Five Concerns

Status

Meds

PMD

ADL

Support


Two Step Emergency Department

40% of Geriatric ED Patients Have Functional Decline Within 30 Days of ED Discharge.

The Two Step ED Process Prevents Functional Decline

Screening Tool Identifies Patients at Risk

Patients at Risk Have Full Complement of

Hospital and Community Resources


Geriatric Emergency Depart

GEM Team Indicated, APN

Coordinated CareHospital

Resources Mobilized

Admit to Hosp Two Step Process


Two Step ‐ Home Follow‐up

Called by Geriatric Team Within 24 Hours of ED Discharge

Further Screening Tools Used

Further Needs Identified

Pharmacologist and Toxicologist Review

Hospital and Community Resources Coordinated

Primary Care Doctor Notified


Facility Options: Is it …..

Process

Separate Unit

Functional

Universal Design


Universal Design in the ED

Staff

Mattresses

Lighting

Floors

Hand Rails

Blankets

Follow up Processes


Take Home Message

If you don’t have space for a Geriatric ED…. Make you entire ED a Geriatric ED.

If the ED is Designed for the Most Frail and Vulnerable ….. It will work for the Strongest.



Marketing

Education

Nursing Homes

Assisted Living

SNF

LTAC

Community Outreach

EMS

DNR and Advance Directives

Disaster Kits

“The Disaster Shoulder Bag”

©

Meds

DNR

Health History

39SrED , LSMA, Disaster Shoulder Bag © 2010 Mark Rosenberg, DO, MBA, FACEP

Palliative Care in the ED or the Revolving Door

Elderly Disease Management: The ED Revolving Door

Frailty

Organ Failure

Terminal Illness


Assessment of Illness Trajectory and Decline


Annals of EM, April 2011


Annals Of EM, March 2011


Early Palliative CareProlongs Quality Life and Mood


WHO definition….“The active total care of patients whose

disease is not responsive to curative treatment”

(1990).

Goals…“To prevent and relieve suffering and to

support the best possible quality of life for patients (all ages) and their families,

regardless of the stage of the disease or the need for other therapies”

(WHO, 1990).

46

Palliative Care


Hospice

Branch of palliative care

Less than 6 months to live

Accepting death as a part of life

No longer want to prolong nor hasten


49

Hospice and Palliative Care

World Health Organization, Cancer Pain & Palliative Care, 1990


51

WHO(1994)

: Which Older Adults Need Palliative Care?

Important:•Disease

•Diagnosis•Co-

morbidities

•Prognosis•Trajectory

Cancer

Heart Failure

Dementia

SrED

and LSMA © 2010 Mark Rosenberg, DO, MBA, FACEP

Results

Improved Care

Less Functional Decline

Decreased Return Visits

Increased New Visits

Improved Patient Satisfaction

Improved Staff Satisfaction

Prevents The Revolving Door

52SrED


Putting it all Together

Why?

People

Coordinator

Nurses

Physicians


Education

Triage

Patient Management and Safety

Patient Follow up

Facilities


Disease Management

Frailty

Organ Failure

Terminal Illness

53SrED


Thank you

Mark Rosenberg, DO, MBA, FACEP, FACOEP‐DChairman Emergency MedicineGeriatric and Palliative MedicineSt Joseph’s Healthcare [email protected] ‐

Assistant

973.224.0570 –

Cell

54SrED


mailto:[email protected]

the geriatric ed st. joseph’s regional medical center … · st. joseph’s regional medical...

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