Justin Binstead webFew people give much thought to emergency care. But unless your life is in imminent danger, you might benefit from a bit of research to determine which nearby emergency department is best prepared to meet the specialized needs of older adults.

Justin Binstead, DO, Medical Director, Department of Emergency Medicine at St. Luke’s Miners Campus, said illness and injury can present very differently in older adults compared to the younger population. Patients should seek emergency rooms staffed with health care professionals who understand these differences and more effectively evaluate, diagnose, and treat older patients.

“It’s not just a one-size-fits-all mentality in our ER,” he said. “Just having the awareness that certain medications interact differently might affect your evaluation and treatment recommendations. Also, the injury pattern of someone who has a fall in their 80s is a lot different from someone in their 30s.”

One way to determine if an emergency department is sensitive to the needs of older patients is whether they have geriatric accreditation from the American College of Emergency Physicians (ACEP). To attain accreditation, the emergency departments must demonstrate that they have integrated best practices for emergency care of older adults. St. Luke’s Miner’s Campus became geriatric accredited in October 2021. St. Luke’s Monroe Campus also has achieved this accreditation.

Geriatric patients account for a large percentage of ER patients. According to data from the National Hospital Ambulatory Care Survey, adults aged 65 and over had an emergency department (ED) visit rate of 12 per 100 persons for injury and 36 per 100 persons for illness during 2012 – 13.

To meet ACEP geriatric accreditation requirements, emergency departments must demonstrate that they provide geriatric-focused staff education and apply standardized best-practice approaches to addressing common geriatric issues. They must ensure optimal care transitions from the emergency department to their home or care facility and engage in geriatric-focused quality improvement projects.

Dr. Binstead led the St. Luke’s Miners Campus accreditation pursuit process with Brittany Garris, RN, BSN, Clinical Coordinator of the Emergency Department. Both Garris and Dr. Binstead have received additional education in caring for geriatric patients. Furthermore, the charge nurses on each shift became NICHE (Nurses Improving Care for Healthsystem Elders) certified. NICHE provides educational tools to help nurses meet older adults’ unique health care needs through evidence-based geriatric care. Dr. Binstead continually educates physicians on geriatric medicine during monthly departmental meetings.

In addition, the accreditation process requires applicants to complete a geriatric-specific quality improvement initiative to elevate the level of eldercare. Dr. Binstead worked with the St. Luke’s pharmacy, geriatrics, psychiatry, and toxicology departments to develop a stepwise plan for proper medication usage. The program aims to reduce chemical restraints, thereby avoiding oversedation, drug-to-drug interactions, and other side effects.

“The first subject we approached was implementing non-pharmacological interventions to treat agitation and anxiety,” he said. “This included such things as lavender patches that are supposed to be calming and soothing. We also implemented the use of special vests with buttons to keep older adults with cognitive impairments occupied. This not only helps with manual dexterity but can also prevent them from becoming agitated.”

Also, the staff emphasizes placing older patients at risk of falling within sight of the nurses’ station or in the room with a private bathroom, Garris said. The fall-risk patients wear yellow non-skid socks. Moreover, the staff provides hearing amplifiers for heard-of-hearing patients and urinal holders for men who have manual dexterity challenges.

“We’ve also worked with our volunteers to have them visit the rooms of older patients and keep them company,” he said.

Regarding medications, Dr. Binstead and colleagues developed stepwise guidelines on the best pharmaceutical treatment for patients from mild- to moderate- to severe-agitation. The protocols include when to use certain medications and in what dosage. Besides St. Luke’s professionals, Dr. Binstead worked with the ACEP Geriatric Committee Chairman, a published author and expert on pharmaceutical intervention.

The accreditation application required six months of data showing baseline performance compared to performance post-geriatric guideline implementation. Data demonstrated a marked improvement in falls and patient safety.

A recent patient demonstrates the importance of understanding how illness can present differently in an elderly patient. A nursing home had sent a patient to the ER with a possible urinary tract infection that can be very serious for older adults and can cause the person to become confused. Following a comprehensive evaluation, the physician determined the 11 cause of the pain was critical. The patient had a volvulus of the intestine, a life-threatening condition in which the bowel twists on itself. Surgeons operated that night.

“A young patient would be jumping off of the bed screaming in pain,” he said. “In this older patient, there was some abdominal tenderness, but it wasn’t dramatic. If the physician hadn’t been thorough in the exam, and aware of the differences in physical exam findings in older patients, it would have been catastrophic. She probably wouldn’t have made it through the night.”

Tips for Older Adults Visiting the ER
Whether you’re an older adult visiting the Emergency Department or taking an elderly loved one to the ER, it’s important to prepare. St. Luke’s offers these suggestions.
Be sure to bring
• a list of medications, including over-the-counters, vitamins, and other supplements. Include the doses or bring the bottles.
• a list of allergies. Include medication allergies, such as penicillin. They recommend you list the reaction to the medication (i.e., rash, hives, anaphylaxis, etc.).
• insurance cards: Private, Medicare, Medicaid, or Veterans. If the patient has supplemental or secondary insurance, bring those cards, too.
• picture identification, such as a driver’s license or passport.
• a list of the patient’s physicians, including the primary care doctor and any specialists, such as a cardiologist, oncologist, endocrinologist, or psychiatrist.
• advance directives, such as medical power of attorney or do-not-resuscitate orders.

Be sure to tell the ER staff about Injuries
• falls and accidents. Share any details you can. Mention if the patient hit their head, or could have, and on what: a table, the floor, the wall, the car’s dashboard. Head injuries can cause bleeding in the brain that requires immediate treatment.
• any blood thinners that could result in more bleeding.
• past injuries, e.g., if the patient falls often and has broken bones during prior falls. Also, mention treatment for osteoporosis or brittle bones.

• symptoms, when they began, and became worse.
• if the patient has had a fever.
• similar illness in the past, how it was treated, and the patient’s reaction to treatment.

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