Seniors getting specialized emergency care

It was in the mid-1950s that Canada started to open pediatric emergency rooms, recognizing that pint-sized patients would be better served with specialized care. Older adults also have different physiological and psychological needs than other patients. Should they also get emergency care tailored to them?The whyThink about what a busy emergency room is like for an older adult, especially for someone with cognitive impairment. It’s loud, it’s busy, the lights are always on, the space is unfamiliar and the behaviour of other patients may be erratic and confusing. All this contributes to delirium, which has a higher mortality rate than acute myocardial infarction, noted Dr. Sam Sabbah, medical director of emergency medicine at University Hospital Network (UHN), and assistant professor of medicine at the University of Toronto.An older adult presenting in the emergency department (ED) usually has needs beyond why they came in. A broken wrist doesn’t just require a cast: Mobility must be assessed, home safety considered, physiotherapy booked, and community services enlisted to provide meals. “You need a dedicated team that’s going to go over all these things and collect collateral information while supporting the patient’s needs while they’re in the department and preventing harm,” Dr. Sabbah said.Just being in the ED could bring harm to older adults. For example, as people age, the curvature of their spine changes, forcing their gaze downward. Often, this means the ER lights create a glare on the floor, hiding potential tripping hazards. For patients with cataracts, floor-based navigation (“follow the purple dots to the MRI!”) creates the illusion of an obstacle in their path, increasing the risk of falls. “Falls are very common in the emergency department, especially among older patients,” Dr. Sabbah explained.The solutionEnter the John and Myrna Daniels Foundation, which gifted $52 million to UHN to establish a geriatric emergency centre. While it’s officially called the Myrna Daniels Seniors Emergency Medicine Centre, the donation will fund much more than a new space at Toronto Western Hospital. That will be part of it, but it also establishes a whole program for UHN’s emergency services.“The space is not the point,” said Dr. Tessa Ringer, staff emergency physician at UHN, medical director of the centre and assistant professor at the University of Toronto. “The space is an enabler of a model of care and a level of care. You do not need a physical space to do that.”The new geriatric ED is set to open in 2025, but some components are already in place. A team of allied healthcare professionals dedicated to older patients have been hired for both Toronto Western and Toronto General hospitals. This includes occupational therapists, social workers and geriatric emergency nurses.Avoiding admissionOne aim of the new UHN program is to avoid a trip to the ED in the first place. Patients could have a virtual care consultation to deal with smaller issues such as a prescription renewal or some concerns could be resolved with an appointment at a specialized geriatric clinic.If a patient does need emergency care, Dr. Ringer said they’re hoping to make sure all information is gathered before they arrive at the hospital. Staff may even work on ways to bypass the ED. For example, if the patient has cancer, can they be directly admitted to their oncology team instead of going through the ED?“That involves partnerships with internal medicine and oncology but that’s another pathway we could consider,” Dr. Ringer explained.How to avoid hospital admissions from the ED has already been studied at other centres. One of the best ways is to engage interdisciplinary care. Having physiotherapists, pharmacists, geriatric emergency nurses, social workers and others engaging with the patient can help reduce the need for hospital admissions. Dr. Ringer said a team like this can provide a “geriatric tune-up” for some patients with social issues, making it safe for them to go home.Avoiding admission brings “considerable downstream effects,” said Dr. Brittany Ellis, physician lead of geriatric emergency medicine for the Saskatchewan Health Authority and associate professor at the University of Saskatchewan. “When we admit older people to the hospital, they have significant decline.” Older adults tend to stay longer in hospital, and some decline to the point of needing to wait for alternative levels of care. All this creates full hospital wards, making it harder to move people who have to be admitted through the ED.A space designed for geriatric careBack to the new space that is part of the Myrna Daniels Seniors Emergency Medicine Centre: from the ground up, it’s specifically made for the older patient, with specialized rooms, non-slip floors, special lighting and more. The goal is to make older patients more comfortable. “We want to get them to an environment where they’re less likely to develop delirium,” Dr. Ringer explained. Some older patients may arrive directly to the Myrna Daniels Seniors Emergency Medicine Centre space while others will be transferred from the other UHN EDs.It’s also going to be a space for active innovation. It won’t only help patients at UHN, but identify what changes or models of care provide the greatest impact. For example, if an ED can only hire one new allied health professional, who should they hire? Or, does circadian lighting translate into better outcomes? The findings can be scaled for other centres.“Our goal is to be the global leader in this space and to be a laboratory where we can figure out the best way of doing this and then sharing that expertise globally so we can improve the care everywhere,” Dr. Ringer said.Education is a big part of the centre, with bedside clinical teaching and a new position of fellow in geriatric emergency medicine planned. The only other such fellowship position is at nearby Mount Sinai Hospital under the direction of Dr. Don Melady. All the educational resources will be shared, so other centres and healthcare providers can excel in geriatric emergency medicine.As part of the teaching there’ll be simulation programs. This will include suits that mimic the restrictive mobility people with arthritis experience, goggles that replicate vision with cataracts, and ear covers that simulate hearing loss. “Providers can experience for themselves what it’s like to be an older patient in this environment,” Dr. Sabbah said.EDs embracing changeOther emergency departments across Canada are working to make their EDs better for older adults. Some are working with very explicit objectives and others are at the stage where they’re recognizing something needs to be done, Dr. Ellis said. Chair of the geriatric emergency medicine committee of the Canadian Association of Emergency Physicians (CAEP), Dr. Ellis meets regularly with geriatric emergency medicine specialists across the country.Some hospitals have gone through the geriatric emergency department accreditation process through the American College of Emergency Physicians, with Dr. Audrey-Anne Brousseau leading the way at the Centre hospitalier universitaire de Sherbrooke, the first Canadian hospital to gain accreditation.As well as the American College of Emergency Physicians standards, EDs wanting to improve care for older adults can also look to the eight recommendations made by CAEP in 2022. One recommendation is to use tools to screen all patients for delirium. “We know we’re not very good at it but we’ve got great tools we know that we can use,” Dr. Ellis said. Another is to involve caregivers and family members early on in the patient’s care.Another recommendation is to develop standardized approaches to common geriatric presentations. Having these standard practices reduces the cognitive load on physicians and makes sure patients have their basic needs met.People who are over the age of 65 years old make up between 20% to 40% of all ED visits in Canada, depending on the location, according to a 2014 study published in the Canadian Geriatrics Journal and supported by recent data from the Canadian Institute for Health Information. Most emergency physicians would estimate older adults make up a much larger portion of the ED population, Dr. Ellis said, because of the time and cognitive load these patients require. Cutting through the complexity with a series of standard practices would help both patients and physicians.Other guidelines for geriatric emergency medicine exist, from international emergency medicine groups (e.g., European Society for Emergency Medicine) and provincial bodies (e.g., Ontario Ministry of Health). “The vast majority of people don’t know they exist,” Dr. Sabbah said.“There’s something every emergency department can do, and it doesn’t have to be building a specialized emergency room for seniors,” Dr. Ringer said. “You’re not alone. Lots of places are confronting this and there’s a surprisingly robust amount of evidence and a pretty big community focus on making things better.”“There are things you can do and those things actually work,” Dr. Ringer added.There’s an added benefit to delivering better care to older people. In general, changes made in EDs that improve the care for elderly patients are usually good for all patients, Dr. Ellis said.A new focus on geriatric emergency medicine could help repair the moral injury physicians feel when they think about the healthcare situation in Canada. No one wants to see a senior on a stretcher in the hallway. “A lot of us have a lot of despair and anxiety on how we treat older adults,” Dr. Ringer said. But things can improve. “I don’t think I’m being Pollyanna-ish when I say that. It should be believed that we can make things better for these people.”

Seniors getting specialized emergency care

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