Growth of senior-specific EDs holds quality promise but raises cost issues

A small but growing number of hospitals are building emergency departments specifically for elderly patients at a time when the senior population is growing and hospitals are incentivized to develop new ways to prevent readmissions and improve patient satisfaction.

That trend made the ECRI Institute's annual C-Suite Watch List of 10 clinical developments, tools and technologies that raise questions about whether they improve outcomes and are cost-effective. The list also includes catheter-based renal denervation for treatment-resistance hypertension, real-time MRI adaptive radiation therapy, and broader categories such as “big data” and “intelligent” pills, which are designed to improve medication adherence and help prevent readmissions.

On geriatric EDs, Robert Maliff, director of ECRI's applied solutions group at ECRI, a Plymouth Meeting, Pa.-based not-for-profit research organization, asked, “Is this money being well spent? There are some instances where this might improve readmission rates. (But) true robust data is not yet available for outcomes for senior-specific EDs.”

More than 50 U.S. hospitals have opened EDs for elderly patients since 2011 and at least 150 more have senior-specific EDs in development, according to ECRI. But that doesn't mean that senior-specific emergency departments are right for every hospital. Limited data exist so far that show geriatric EDs save money for hospitals or patients.

St. Joseph's Regional Medical Center in Paterson, N.J., in 2009 was one of the first U.S. hospitals to open a geriatric emergency room. When the hospital built a new emergency department in 2012, it allocated 24 of the 88 beds for elderly patients. About 12% of the hospital's emergency department visits each year involve elderly patients.

Elderly patients account for up to a quarter of all ED visitors worldwide. They are more likely to have complex comorbidities, require longer diagnostic workups, and be readmitted. They often end up in the emergency department after a fall or not taking their medications correctly.

Physicians and hospital leaders hope that providing specialized care to the elderly can reduce readmissions and improve patient satisfaction. Under the Patient Protection and Affordable Care Act, hospitals are penalized financially for having higher readmission rates for heart attack, heart failure and pneumonia patients.

Diane Robertson, director of ECRI's health technology assessment information service, said ECRI sees an uptick in the planning of hospitals and systems to implement senior-specific EDs. Some hospitals are building new geriatric-focused emergency departments while others are carving out part of their existing ED for seniors.

The growth can be attributed to several factors, including the healthcare reform law's rules on readmissions and patient satisfaction as well as the aging baby boomer population and their anticipated increased use of emergency services.

The geriatric ED rooms at St. Joseph's are soundproofed to be quieter, have thicker mattresses to prevent bed sores and use flooring that does not have a glare, which can lead to a fall. Patients on average see a doctor within 13 minutes of their arrival at the hospital. ED nurses receive specialized training, and geriatric nurse practitioners and nurse managers are part of the staff. Staff members call patients the first, third and seventh days they are home after a visit to the ED. The hospital reported that its 30-day post-emergency department return rate for senior patients with the same condition fell from 20% in 2009 to 1% in 2010.

Dr. Shari Welch, a researcher at the Intermountain Institute for Health Care Delivery Research in Salt Lake City who studies how to make EDs more efficient, said hospitals that treat at least 50 elderly patients a day, or 18,000 a year, should consider building senior-specific EDs.

But as more hospitals look at building specialized EDs for elderly patients, or allocating space within an ED for these patients, questions remain about whether senior-specific EDs improve outcomes. The costs associated with this kind of ED can range from $150,000 to $3.2 million, depending on the number of beds; retrofitting and structural modifications; and new processes, protocols and staffing.

Maliff said hospitals receive no immediate financial payback from a geriatric-focused ED because there's no difference in reimbursement based on the type of ED. “It's those outcomes which will really drive whether this financially and clinically makes sense,” he said.

Follow Jaimy Lee on Twitter: @MHjlee