hospital impact

guest post by Dr. Marc Rothman

We already have the Pediatric ER, the Psychiatric ER… so why not a Geriatric ER as well? That’s the upshot of an interesting article from last months Journal of the American Geriatrics Society. A prominent leader in emergency medicine and geriatrics from Mount Sinai writes that the special care needs of older adults are just not aligned with current ER priorities, practice patterns, or physical design. Think about it: your average adult over age 70 has multiple chronic diseases and comorbidities, takes around a dozen meds, and may have functional and cognitive impairments. Acute illness in these folks never looks the way it does in younger healthy adults.

Case in point: we had a man in our Veteran’s Hospital ER last month with back pain. He was obviously ill but nothing on exam or labs was a slam dunk. It took over 6 hours to rule out all the usual suspects and eventually diagnose him with acute appendicitis! A rare diagnosis in the elderly, presenting in a most unusual way.

Think about how the ER feels to an older person with poor hearing, vision, and memory who is weak and dehydrated. The constant din of voices, the appearance and disappearance of faces as shifts change, the glaring lights, and the lack of windows; these things can only disorient people or cause delirium. Stretchers are high, bays narrow, and floors slippery; a recipe for falls and injuries. And the rapid ‘diagnose and treat’ approach of emergency room care increases the risk of misdiagnosis and adverse drug effects (when the medicine given interacts with one of a dozen meds the patient is taking).

I’d have to ask my colleagues, but I think delirium, falls/injuries, and medication errors are among the top three in-hospital complication today (and coincidentally where most of the dollars are being spent to improve inpatient outcomes?). Maybe we need to back our quality improvement strategies all the way to the point-of-entry to our hospitals… the ER?