Emergency Rooms Are No Place for the Elderly
Dr. Pauline Chen on medical care.
The elderly man lived alone in an apartment complex not far from the hospital. A younger neighbor, who’d watched him hobble down the building’s stairwell for nearly a week, insisted on taking him to the emergency room. Doctors there immediately diagnosed an infection in his painful toe and prescribed antibiotics for him to take at home.
But they also advised the man to be sure to take his diabetes medicine, since the infection could elevate his blood sugar to dangerous levels. And as the surgical consultant, I urged him to keep his foot up, check the toe once a day and come to our vascular surgery clinic in a week to make sure the infection was clearing up. He needed close follow-up to prevent serious complications, even the loss of his foot.
“Of course, if things get worse before the week’s up,” I said, raising my voice to be heard over the clatter beyond the makeshift curtain walls of the E.R. examining room, “come back here right away.”
Under the glaring fluorescent lights, there was no mistaking the blank look that passed over the man’s face. He was overwhelmed.
But so was the emergency room.
None of the staff members had been trained in coordinating the complex outpatient care this elderly patient needed. None knew of a way for the emergency department to check on him a day or so after discharge to ensure his care was proceeding as planned. And when a social worker from another department agreed to pitch in with outpatient care, the emergency room doctors and nurses became alarmed rather than relieved, because arranging such follow-up could take several hours. With patients spilling out of the waiting room and into the hallways, they were under pressure to either admit or discharge patients as quickly as possible.
An older nurse finally pulled me aside. “Just admit him,” she whispered. “It’ll cost more, but it’s the only way you’ll be sure he’s getting the right care.”
I remembered the nurse’s advice, and the patient I ended up admitting, when I came upon a recent paper and report on the care of elderly patients in American emergency rooms.
The number of older people seeking health care is expected to increase significantly over the next 40 years, doubling in the case of those older than 65, potentially tripling among those over 85. In a health care system already critically short of primary care providers and geriatrics specialists, many of these older patients will likely end up in emergency rooms.
But given longstanding trends in American medicine, it’s hard to imagine a health care setting more ill suited for the elderly than today’s emergency rooms.
Over the last five decades, quality emergency care has become synonymous with speed. Survival rates for patients in the throes of a stroke, heart attack or traumatic injury depend on the number of minutes needed to triage, diagnose and treat. Even the physical environment where emergency care takes place has become a paragon of medical efficiency — large echoing spaces that can be divided at a moment’s notice with panels of curtains, slick linoleum floors that can be mopped up in minutes and bright fluorescent lights.
More recently, as overcrowding has become a significant problem, the drive for efficiency has become more pronounced, with doctors and nurses having to work as quickly as possible simply to see all the patients.
But when it comes to elderly patients, it is nearly impossible to work quickly. Many are plagued by multiple chronic diseases like diabetes, high blood pressure and heart disease, take numerous prescription drugs that can cross-react in potentially dangerous ways and suffer from ills like dementia that can make the answer to even the simplest of questions – What brought you to the emergency room today? – difficult to understand.
For several years now, a small but dedicated group of emergency medicine and geriatrics specialists has been working to improve this situation. And over the last three months, first in an article published in the national health policy journal Health Affairs, then in an impressive set of evidence-based guidelines supported by several national professional medical and nursing organizations, they have issued a call to arms to the rest of the medical profession.
To meet the needs of the rapidly growing elderly population, these specialists assert, medical centers must “geriatricize” their emergency departments.
And they offer a plethora of practical advice for doing so. Among their suggestions: Hire providers trained in caring for older patients. Routinely administer quick but effective screening tests for dementia and other cognitive impairments. Install non-slip flooring and more sound-absorbing materials to decrease the risk of falls and dampen noise levels. And train all staff members to be more attuned to social factors that can affect care for the elderly, like the necessity of arranging for transportation to get to follow-up medical visits, the need for walkers, canes and other medical equipment to get around the home and for extra help to get prescriptions filled and taken correctly.
Similar changes have already been put in place to improve pediatric, trauma and cardiac emergency care. But a larger stumbling block remains: getting a greater proportion of hospital administrators, health care providers and the public at large to become interested in care for the elderly.
“Older adults aren’t the kind of patients people gravitate toward,” said Dr. Ula Hwang, lead author of the paper in Health Affairs, a member of the task force that compiled the guidelines and an associate professor of emergency medicine and geriatrics and palliative care at the Icahn School of Medicine at Mount Sinai. “There’s a reason you don’t see the frail, cognitively and functionally impaired older patient on television medical shows.”
Nonetheless, Dr. Hwang and her colleagues remain optimistic. About 50 medical centers have incorporated such changes into their emergency departments, a notable improvement from a decade ago, when none existed. And by emphasizing close attention to the individual’s experience, many of these redesigned departments are not only improving care but also redefining what is possible for doctors and patients, even in one of the most critical of care settings.
“We can really become partners in improving care, instead of just putting a Band-Aid on the problem,” Dr. Hwang said. “We can give our elderly patients, our parents and our grandparents the kind of respect and understanding that we owe them.”