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Best Practices: The Geriatric Emergency Department, 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 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 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.
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. And 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 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.
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.
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, if necessary, 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’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. 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. “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.
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’s 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.
