Catering to the elderly in the ED

St. Joseph's University Medical Center in Paterson, N.J., was one of the first geriatric emergency departments in the U.S.

The ED, which opened in 2009, was built in response to complaints from elderly patients that the adult ED was chaotic and stressful.

St. Joseph's relied mostly on patient recommendations to determine what services would be part of the geriatric ED. No industry guidelines were available at the time.

Since then, a lot has changed. The American College of Emergency Physicians came out with guidelines in 2014 for geriatric EDs. And this May, the ACEP launched a geriatric ED accreditation program.

St. Joseph's was one of the first hospitals in the country to be accredited in the ACEP program. The new designation gives medical center's long-standing geriatric ED affirmation, said Dr. Mark Rosenberg, chair of emergency medicine at the hospital's parent system.

“I can tell everyone at St. Joseph's that we were validated by a specialty society, so it's real. It's not the marketing department putting up a sign. And it gives validation to the public and to our colleagues,” he said.

The accreditation program also provides a level of standardization across geriatric EDs that has been lacking, said Dr. Kevin Biese, chair of the ACEP program and co-director of geriatric emergency medicine at the University of North Carolina School of Medicine.

Roughly 130 self-proclaimed geriatric EDs are in operation across the country, but many vary in the services available. Under the ACEP program, hospitals must follow specific guidelines to receive accreditation.

“These aren't new concepts. Hospitals were thinking of this stuff already but it was like sculpting fog,” Biese said. “The accreditation program really is an empowering tool to get the resources to do it more formally.”

An ED can receive one of three levels of accreditation from the ACEP. Similar to trauma-center accreditation, Level 1 is the most comprehensive designation. Levels 2 and 3 require the EDs to have at least one geriatric-trained nurse and physician but they don't have as many reporting requirements or stipulations about the environment as Level 1.

St. Joseph's earned Level 1 status.

The ACEP is currently reviewing about 35 applications, a process that takes about five months. Only eight EDs have been accredited so far.

St. Joseph's didn't have to make many changes when it decided to pursue Level 1 accreditation, said Dr. Marianna Karounos, chief of the hospital's geriatric ED. The 20-bed unit is open seven days a week typically from 8 a.m. to 2 a.m. It's part of the larger adult ED, but near the back so patients have more privacy and there is less noise.

In accordance with ACEP guidelines, the staff has received training in geriatric medicine. Four nurses oversee the ED at all times along with at least one of two geriatricians.

Upon admission, each patient is screened for dementia, delirium, depression and risk of fall. The patients' medications also are carefully reviewed.

Before discharge, nurse navigators ensure patients have follow-up appointments set up with their primary-care physicians. Patients are also called after discharge to make sure they have their medications and that they went to their appointment.

St. Joseph's also follows ACEP guidelines regarding the ED environment, including food and drink availability to patients and families, appropriate lighting, handrails and wheelchair-accessible bathrooms.

Although St. Joseph was already following ACEP's guidelines, the accreditation process was an opportunity to review its policies and ensure that the team was in compliance, Karounos said.

The ACEP conducts on-site visits before designating Level 1 EDs. It also requires Level 1 EDs to report and track at least five outcome measures that track things such as the number of older adults with repeat visits and the number of patients who stay longer than eight hours.

Rosenberg said the geriatric ED has reduced inpatient admissions at St. Joseph's. About 34% of geriatric patients are admitted to the hospital from the ED, down from 54% when it opened.

“Our patient satisfaction is much higher in the geriatric ED than it is anywhere else in the ED,” he added.