How to Improve Care for Geriatric Patients in the Emergency Department

Doctor Talking To Senior Female Patient In Wheelchair

As the population ages and life expectancies increase, there’s now, more than ever, a need within emergency departments for care tailored specifically for geriatric patients. The U.S. Department of Health and Human Services’ Administration on Aging (AoA) notes more than 46 million people in the country are age 65 or older — over 14 percent of the entire U.S. population. That number is expected to rise to 22 percent by 2040 and double to 98 million people 65 and older by 2060.  

The health and well-being of this segment of the population will continue to be a concern for the healthcare industry as a whole, with emergency departments continuing to serve as an important point of access to care.

Currently, only 44 percent of men and women 65 and older characterize their level of health as excellent or very good, and most seniors have at least one chronic condition, if not more. According to the AoA, arthritis and heart disease were most common, with 49 percent and 30 percent of older Americans experiencing these conditions, respectively. Even more telling, nearly 7 million people age 65 and older spent at least one night in the hospital in 2014.

In collaboration with The American Geriatrics Society, Emergency Nurses Association, and the Society for Academic Emergency Medicine, the American College of Emergency Physicians (ACEP) has developed a set of guidelines for EDs to follow to improve care for geriatric patients. If you’re an ED or hospital leader wanting to effectively refine the quality of care geriatric patients presenting to your ED receive, consider implementing these strategies as outlined by ACEP:

Staffing and Education

Emergency departments with high volumes of geriatric patients may want to consider employing dedicated staff and leadership trained in geriatric care. Depending on hospital resources, these positions could be filled with physicians and nurses with specialized training as well as ancillary service providers, such as occupational and physical therapists.

Education is another way to train your current team in understanding the needs of your elderly patients. Hospital leaders may want to consider developing  training programs to increase awareness among staff about how to provide the highest quality of care to geriatric patients or encourage staff to take part in continuing education or outside programs focused on geriatric care.

Follow-up Care

Effective communication is often key when it comes to patients — no matter their age — successfully receiving follow-up care after an ED visit. ACEP notes, “Older ED patients identify misinformation as a primary course of dissatisfaction with their emergency care, a problem confounded and magnified by ongoing under-recognition of cognitive dysfunction, lower health literacy, and financial impediments for prescriptions and recommended outpatient follow-up.”

When EDs ensure discharge instructions are relayed to patients and caregivers –– along with pertinent information about treatment and continuity of care –– geriatric care will improve significantly, and satisfaction will increase. ACEP recommends delivering the following facts, figures, and information to patients at discharge:

·      Presenting complaints

·      Test results and interpretation

·      ED therapy and clinical response

·      Consultation notes (in person or via telephone) in ED

·      Working discharge diagnosis

·      ED physician note, or copy of dictation

·      New prescriptions and alterations with long-term medications

·      Follow-up plan

·      Clinical information will be presented in a format in a way best suited for older adults

·      Large font discharge instructions

·      Health Insurance Portability and Accountability Act (HIPAA) compliant copied discharge instructions should be provided to family and care providers.

Equipment

The type of equipment and supplies utilized by EDs have a great effect on the quality of care a geriatric patient receives. Consider making exam chairs more comfortable and accessible for older patients and using soft, moisture-proof upholstery. Special equipment such as warm blankets, non-slip mats, and walkers are also valued and appreciated by geriatric patients and their caregivers. Small touches such as painting the wall with light, non-glare paint, soft overhead lighting, and allowing natural light to fill rooms also go a long way to improve the well-being of elderly patients.

The benefits of improving the quality of care geriatric patients receive in your ED are great. EDs with care plans tailored for senior citizens can expect an increase in patient satisfaction scores, staff morale, and increased patient safety. I discussed just a few strategies hospital and ED leaders should take based on ACEP’s guidelines. If you’re interested in learning more about what your ED can do to serve geriatric patients better, feel free to schedule a complimentary phone consultation with me to discuss in detail additional steps you and your team may want to take.

SOURCES:

U.S. Department of Health and Human Services Administration for Community Living: Administration on Aging (AoA) Aging Statistics

U.S. Department of Health and Human Services Administration for Community Living: Administration on Aging (AoA) Profile of Older Americans: 2015

American College of Emergency Physicians: Geriatric Emergency Department Guidelines

3 Ways to Encourage Continuity of Care Among Patients in the ED

Nurse Checking Patient's Heartrate

Many patients visiting emergency departments suffer from chronic conditions. They’re often older adults battling various ailments that require long-term care, such as asthma, diabetes and heart disease. And often, they aren’t receiving the treatment necessary for sustained health. That only increases the likelihood that they’ll have to visit the ED again in the near future.

It’s important that ED staff can identify these people and help transition them to an appropriate care setting or treatment center at discharge. The odds that these same people will return to the ED are high if no long-term care plan is implemented.

Not only is that bad for the patient, it can have a negative impact on wait times, crowding, patient safety and patient satisfaction. By taking a proactive approach and encouraging continuity of care for ED patients suffering from chronic conditions, your emergency department will be able to counteract those effects.

So, what can EDs do to ensure patients with chronic conditions seek out and receive appropriate care upon discharge from the ED?

Plan for Discharge

First, make sure your ED has a strong discharge checklist in place that has specific instructions about:

  • medication and dosage
  • information about follow-up appointments

contact information for organizations and healthcare providers in the community that can help the patient develop and follow an overall care plan

Make sure your staff takes the time to carefully go over the discharge checklist with their patients, as well as their families and caregivers. By taking a few extra moments to answer any questions about the treatment plan, along with where and how to seek care outside the ED you’ll likely reduce the chances of a return visit to the ED. A referral to a primary care physician, community support group or treatment center may all be appropriate.

Carefully Assess Patients, Including for Chronic Conditions

Additionally, EDs must accept that their role in healthcare has evolved into something much more than providing emergency care. Patients, understandably, aren’t always able to determine whether they’re symptoms or conditions merit emergency medical attention, as this issue brief from the Kaiser Family Foundation points out. As a result, EDs are often making the clinical assessments patients need to begin long-term treatment.

While these diagnoses and assessments are a first step, they shouldn’t be the last step taken in the emergency department. As the issue brief makes clear, these assessments can no longer be deemed an inappropriate use of the ED by patients. It’s now the norm, especially in EDs serving vulnerable populations who may have limited access to primary care.a first step, they shouldn’t be the last step taken in the emergency department. As the issue brief makes clear, these assessments can no longer be deemed an inappropriate use of the ED by patients. It’s now the norm, especially in EDs serving vulnerable populations who may have limited access to primary care.

Identify Barriers to Care

EDs must utilize all the resources at their disposal to empower their patients to take action outside the ED. This will require EDs to identify the barriers preventing their patients from seeking long-term care. Short surveys during the triage process can be an effective means to determining what these barriers may be. Whether it’s limited access to transportation, financial restraints or a lack of knowledge regarding available care options, EDs can be help patients navigate the healthcare landscape to overcome these hurdles.

Recent studies show that continuity of care reduces the likelihood that patients will visit the ED, or make a return visit. The emergency department should serve as a jumping off point to continued care and better health for its patients. As a bonus you’ll reduce the effects of crowding, increase patient satisfaction and provide the highest quality of care possible.

What do you think? What can EDs do to encourage continuity of care outside the emergency department? Share your thoughts below or feel free to drop me a line.

 

SOURCES:

The American Journal of Nursing: “Transitional Care: Moving patients from one care setting to another.”

The Henry J. Kaiser Family Foundation: “Safety-Net Emergency Departments: A Look at Current Experiences and Challenges.”

Science Daily: “Seniors with more continuity of care use the ER less.”

The 2 Greatest Threats to Patient Safety in the ED

Threats to Patient Safety Donovan and Partners

Emergency departments face several threats when it comes to patient safety and quality but the top two are overcrowding and a shortage of on-call specialists, according to the American College of Emergency Physicians (ACEP).

Cut the Crowds: It is Not Always a Staffing Shortage Issue

Overcrowding is a well-known problem — there are news reports every week about how EDs are short on beds, and how patients are unable to receive the treatment they need because of it. Hospitals often tackle the problem with multi-million dollar expansions, ambulance diversions or by bringing on additional staff. Sometimes these solutions work; many times they don’t.

As health care professionals we know treating a patient’s symptoms only provides temporary relief. For example, it’s not the recurring headache that’s the problem; it’s what causes these headaches that we need to be concerned with. We have to do the same type of digging to diagnose a troubled ED.

To remedy overcrowding we have to look at it as a symptom with a wide variety of potential root causes, none of which are necessarily universal. Just because one ED is overcrowded because of “boarding” — which ACEP suggests is the primary cause — doesn’t mean that another ED facing a shortage of beds is having trouble for the same reason.

Look Beyond Boarding Issues

While boarding may be the predominate cause of overcrowding for a vast number of EDs, it too, is just a symptom of even more underlying problems. Maybe the ED across town closed recently, or your area is in the grasps of an opioid epidemic. Overcrowding could be a result of inefficient staffing in the ED, or inopportune scheduling of in-patient surgery in the hospital itself. When it comes to overcrowding there are a wide variety of causes — and combination of causes — that could be at the root. And in order to remedy it, a dynamic and tailored plan of action has to be implemented.  

What’s Causing the Specialist Shortage?

This same idea holds true for the shortage of on-call specialists. At the root of this shortage of neurologists, trauma and orthopedic surgeons, and the like, isn’t that there’s an actual decrease in the number of specialists able to treat patients. It’s because these specialists are often opting out of on-call responsibilities, typically mandated by EMTALA, by leaving the hospital setting. So the solution isn’t more specialists — it’s encouraging the ones we already have on staff to stay.

Again, the shortage of on-call specialists is a symptom of deeper issues. Specialists aren’t leaving the hospital setting because they don’t care about these patients or don’t want to treat them. According to ACEP, it’s typically because:

  • they believe there’s an increased liability that exists when working in the ED;
  • or that they think on-call pay is inadequate;
  • or because of the quality of life concerns that stem from being on call.

Be a Detective — Dig!

When it comes to these two threats to patient safety and quality, we have to remove our blinders. It takes a broad view with many sets of eyes to identify the real issues that inhibit our ability to deliver the safe and quality care our patients deserve. Threats like overcrowding and a lack of on-call specialists are obvious, but in many instances, the roots of the problems remain buried. In order to solve these problems, we have to dig them up.

If you need help getting to the bottom of challenges in your ED, drop me a line. I’d be honored to chat about how I might be of help. And, for a broad look at the services my consulting agency provides, check out our website:http://donovanpartners.com/


Sources:
American College of Emergency Physicians: “Patient Safety and Quality of Emergency Care.”
American College of Emergency Physicians: “Study: Shortage of On-Call Specialists Spreads Nationally Could 'cripple' emergency, trauma care.”
Nathan R. Hoot, PhD, and Dominik Aronsky, MD, PhD: “Systematic Review of Emergency Department Crowding: Causes, Effects, and Solutions.

Pay Attention to Safety and Caring and Patient Satisfaction Scores Will Rise

Four Areas to Target Including One Surprise

Patient satisfaction can seem like an ephemeral thing. Is there anything tangible you can focus on to boost it?

Pay Attention to Safety and Caring and Patient Satisfaction Scores Will Rise.jpg

Several studies have indicated that yes, yes there is. It is all about getting back to the basics. It appears that by focusing on things that improve safety and caring, patient satisfaction scores will rise as well.

A review published in the British Medical Journal in 2013 looked at 55 studies that measured care and patient satisfaction in several types of healthcare settings. The idea for the review came about in an effort to answer the question: should patient satisfaction even be used as a measure to rate hospitals?

The review found that, higher patient satisfaction scores were often linked to higher safety and clinical efficiency scores.

“Overall, it was more common to find positive associations between patient experience and patient safety and clinical effectiveness than no associations,” said the authors.

If patient satisfaction scores were high, the same hospital was likely to have high patient safety and patient experience scores as well.

Results from a Patient Safety and Quality Care survey of studies in 2008 speculated that this might be because the same things that help prevent serious complications, patient identification errors, infections, medication errors and falls also happen to improve patient satisfaction.

What Steps Can Your Emergency Department Take to Improve Safety, Caring and Satisfaction?

There are many things you can do and I am happy to talk to you about a unique plan for your hospital but for the purpose of this post, we’ll take a look at four biggies.

1) Take a look at communications. Make sure you have procedures in place to make communication of patient information easy. Areas to look at? Transfer of information between caregivers, shifts and different departments within your hospital. Looking at your procedures for intake and discharge can be especially effective.

Nursing leaders, you can reinforce the importance of communication in your rounding and bedside reporting to oncoming nursing staff. Modelling this behavior yourself -- leading by example -- can help ensure the whole nursing staff adopts this approach.

2) Make sure staffing coverage meets the demand for patient care.AHRQ’s Patient Safety Network has concluded what most of us know -- nurses are critical in ensuring patient safety. So let’s help set them up for success. Staff that aren’t pressed for time and stressed running from one emergency to the next has the time to provide quality care. Appropriate coverage also minimizes mistakes.

So how can you make this a reality? Experienced nursing leadership knows the wisdom of a data-driven staffing and scheduling approach. You can use healthcare analytics to understand demand and your functional capacity to solve your staffing challenges.

3) Encourage an environment of trust and non-judgmental for reporting errors. Staff is less likely to report errors or perform well when there is a “blame game” type of atmosphere. Patient safety and satisfaction suffer. Fostering the right culture can help remedy this.

A “just culture” -- one that strikes the right balance between openness and accountability -- improves safety without being arbitrarily punitive. The Leapfrog Group, a circle of large employers focused on improving health care safety, has recognized the importance of a fair and just culture in improving safety.

There is a methodology and algorithm you can apply to help you implement this type of culture and spell out guidelines for appropriate actions when errors are made.

 

4) Limit noises to promote healing and focus. This one may come as a bit of a surprise. Patient satisfaction surveys tell us patients are not as happy in loud environments. Studies have found that noise hinders healing, causes sleep deprivation, and increases pain.

So upon a second look -- it also makes sense that chaotic unscripted emergency department noise can compromise safety. Researchers have found that louder healthcare environments produce more medical mistakes. It makes it hard to concentrate, may desensitize staff to important alarms, and interferes with the effective communication between caregivers. The Joint Commission made a National Patient Safety Goal on managing clinical alarms systems in 2014. They recognized that if they are not properly managed, they can compromise patient safety.

To take control of noise you need to understand it. Every interaction, every piece of equipment, every medical alarm, every emergency page, and every phone creates noise. Even patients, visitors and others add to it.  

To solve this multi-faceted problem, engage everyone in pinpointing sources of noise and taking personal responsibility to limit it. Sometimes changes to the physical environment can help too.

So Why Does Improving Safety Yield Other Benefits?

None of the study authors pinpointed the whys behind the link between good safety scores and high patient satisfaction. Perhaps emergency departments that rate well on patient satisfaction measures are also paying more attention to safety rules too.

Or maybe it is because people go to emergency departments to get better. When adverse events are kept to a minimum and safety is a priority, people are more likely to improve and heal. It’s natural that those patients will be more satisfied.

What I do know for sure is that when you invest in improving processes and communication to improve safety and care it can yield a double-win!

If you need help examining safety protocols or your patient satisfaction survey results and finding ways to improve, I can help. Contact me. I’d love to talk over your emergency department’s unique situation with you.

SOURCES:

Patient Safety and Quality Healthcare: “Safety and Satisfaction: Where are the Connections?”

BMJ Open: “A systematic review of evidence on the links between patient experience and clinical safety and effectiveness.”

AHRQ PSNet: “Nursing and Patient Safety.”

Hospitals and Health Network: “Runaway Noise in the Hospital.”

New England Journal of Medicine: “Balancing "no blame" with accountability in patient safety.” Wachter RM, 2009.

The Joint Commission: “The Joint Commission Announces 2014 National Patient Safety Goal.”