Geriatric EDs: Designated space or not?

I recently visited three emergency departments that self declared senior-friendly environment (with very good reasons): Mount Sinai hospital and Presbyterian hospital in NYC and St-Joseph Healthcare in New Jersey. I met with these incredible ambassadors in geriatric emergency medicine: Dr Ula Hwang (MSH), Dr Michael Stern, Dr Tony Rosen and Dr Mary Mulcare (Presbytarian), Dr Marianna Karounos and Dr Mark Rosenberg (St-Jos) who first got the idea from his aging mother who asked him to build her an emergency department that she would fit in.

Here are a few key points that I learned.

We need to talk about is the idea of a separate physical space. Is it necessary? What are the advantage and the inconvenient?

Every one of these hospitals has a designated area for geriatric patients. They still come in by the same triage process (although there are a few alterations that I will talk about elsewhere), if they are critical they will go to the same resuscitation bay, but if they are not critical, they will preferably go to these designated areas.

The advantages are that it is better organized in terms of physical space and staffing:

  • Different flooring: not slippery and not shiny (Can you tell me why a normal ED would choose a slippery and shiny flooring anyway??)
  • Hallways not crowed + handrails (That is just emergency-friendly, not exclusively senior-friendly).
  • Space for visitors at bedside. I know visitors may represent sometimes a hazard in an urgent situation and I understand that it is important to maintain a clear circulation without too many people around (See, the argument for clear-hallways in the whole ED is back!!!), but they are most of the time very helpful with their loved ones, especially in geriatrics (they are helpful for us too!).
  • The walls are sounds-proof. I found it very impressive the difference between the geriatric and the normal ED. Stuff on the walls limits the echogenicity and an extra effort is made to limit sonar stimuli (Why not the whole ED, it would certainly improve the staff quality of life). Walls rather than curtains separate every bed.
  • There is a space for equipment storage. For example, the stimuli kit for dementia patients, the high risk of falls chariot (bracelet, gown, sheets in a bright yellow color), walkers and canes.
  • Natural light. EDs have the tendency to be in the middle of the hospital, or in the basement or anyway in a place without windows. If it is the case, absence of natural light may precipitate delirium in high-risk patients. A special lighting system is installed in the ceiling to reproduce the natural light, which changed as the day goes on. Interestingly, I am sitting in a plane right now, and it has the exact same thing!
  • The color of the walls is generally bright with major contrast for doors and nursing station.
  • The toolbox contains well-chosen article that can improve the ED experience for patient with dementia. For example, there is a doll, a soothing egg light, coloring books, etc.

 

The inconvenient lie into the efficiency of patient flow. What if your “regular” ED is full and there are 3 beds in the geriatric ED? The waiting patient will obviously go in the geriatric ED, which is not a big deal because they will receive the same care and probably a better experience. But the problem is that if the 4th patient is 85 years old and has to go in the regular ED because the geriatric ED is full. Back to square one. All this effort will not be beneficial for this patient and may even be destructive.

The other inconvenient is the staff. If you are a physician and is assigned to the geriatric ED, you will not see as many patients as you would in the other areas which may impact the money argument but also motivation. Because although I love geriatric patients, they are not easy to deal with, always complicated, and have more end of life issues. The other important thing is staff training. In these EDs, not every nurses are trained in geriatric but they will rotate at some point in the geriatric ED regardless of scheduling efforts. It may be difficult to manage in staff constriction situation and will definitely impact the older patients care.

In summary, I do not see the argument of having a separate geriatric ED space integrated in the whole ED. But what I see is the incredible benefit of designing the whole ED in a geriatric friendly manner with natural light, non-crowded hallways, handrails, visitors space, equipment storage, non slippery floors, etc. Because GERIATRIC CARE IS GOOD CARE FOR EVERYBODY.

So, if you are planning renovation in your ED, think about all these features to integrate into the plan and it will certainly improve care delivery and experience for every patients. And honestly…not significantly more costly.Geriatric EDs.

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