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Senior Emergency Departments Deliver The Best Care for Older Americans

In January of this year, just as the first of the Baby Boomers turned 65, six hospitals in Michigan opened Senior Emergency Departments increasing to eight the number of these specialized emergency centers in the state. While Michigan currently holds the record for the number of Senior ERs, it’s not alone in recognizing and responding to the need for emergency facilities dedicated to Americans aged 65 and over. This critically important healthcare trend started in 2008 when Holy Cross Hospital in Silver Spring, MD opened the nation’s first Senior Emergency Department. Since then, Galichia Heart Hospital in Wichita, KS, St. Joseph’s Regional Medical Center in Paterson, NJ and Park Plaza Hospital and Medical Center in Houston, TX, also opened senior-friendly ERs bringing the national total—thus far—to an even dozen. A vital sign of the times? You bet. According to the AARP, 70 million people are estimated to be Medicare beneficiaries over the next 20 years, compared to 45.2 million in 2008. That’s a huge increase in patient load with serious human and economic repercussions. “With the US population aging at this unprecedented rate, the healthcare system desperately needs to be proactive in addressing the complexities of caring for older Americans,” says Marie Boltz, PhD, RN, GNP-BC, practice director of NICHE (Nurses Improving Care for Healthsystem Elders). NICHE is a nurse-driven program that has been extremely effective in helping hospitals implement protocols and advance policies to enhance the quality of care for older Americans. Six of the facilities with Senior ERs have already achieved NICHE-designation, a distinction that affirms the hospital’s commitment to the highest standards of elder care. Others are in the process.

Room for Improvement

“Age is a known risk factor for certain complications. “We know that in older people, infections such as pneumonia and urinary tract infections can masquerade as changes in mental status,” says Dr. Boltz. “We know that older patients respond to and metabolize drugs differently. Age is a factor in diagnosis and care. That’s why we have neo-natal emergency care, for example. That’s age-related, too.” Age appropriate care is the mantra at St. Mary Mercy in Livonia, which opened Michigan’s first Senior Emergency Department on July 14, 2010. While the Senior ED is only a short distance from the main ER, this six-bed unit is so strikingly different in design and tempo that it might as well be in another solar system. “Everything about the unit was designed to improve the hospital experience and the quality of care for our older patients,” says Michelle Moccia, RN, MSN, ANP-BC, Senior ER Program Director. And it shows. The six private rooms are softly lit and painted in eye-soothing earth tones. Non-glare, non-skid floors and safety rails cut down on falls, a major cause of injury in hospitalized older patients. Pressure-reducing mattresses decrease the incidence of bedsores, another concern for older patients. Large print signage makes navigating easier. While adapting the physical environment is important, it’s not enough. “You have to educate the staff in best practices, implement evidence-based protocols and work to change the hospital culture,” says Moccia. To that end, Moccia handpicked most of the ER’s dedicated and enthusiastic nursing staff. Along with physicians trained in geriatrics, the team includes a social worker, case manager and other staff, all of whom have undergone additional geriatric training. And that training is applied every day. “We see 1100 patients per month in the ER who are age 65 plus, and about 30 percent are transferred to the Senior ER,” says Moccia. When patients arrive in the main ER, they are triaged according to the Emergency Severity Index, a 1 to 5 scale. Patients with life threatening conditions such as airway obstruction, stroke or cardiac symptoms are immediately treated in the main ER. Using many of the NICHE “Try This” Tools, the nurses evaluate the patient’s cognitive function and screen for depression and delirium. Those brought to the Senior ER receive follow-up assessments. “We look at their physical, social and spiritual well-being,” says Moccia. In addition to monitoring patients’ cognitive and other functions, the ER team follows protocols to ensure that “we make the patient well while maintaining their level of function,” says Moccia. “When we sit with the patient and talk to them about their lives and their feelings, we’re creating a bond and establishing trust with the person,” says Moccia. The level of interpersonal interaction, compassion and the quality of care has earned the Senior ER rave reviews from the community. “The patients sense the difference the minute they walk in,” says Moccia. And when patients leave the hospital, the team follows up. “Our social worker calls within a few days to make sure the patient understands his or her aftercare instructions, reminds them about follow up visits and reviews any questions regarding their medication schedule.” In addition, if called for, the social worker sets up a home fall risk analysis and arranges for meal delivery or home health care. For instance, if a patient is struggling with some task of daily living, it may be that he or she needs a transfer device or a home health care worker to help with bathing or nutrition supplementation. “We try to identify the specific problems and provide simple solutions,” says Moccia. “I’m confident that this level of care and intervention will help us decrease complications and reduced associated costs,” she says. And that brings us back to economics. Preventing complications is simply smart medicine. According to the Centers for Disease Control, in 2000, the total cost of all fall injuries for people 65 and older exceeded $19 billion. By 2020, it’s expected to reach $54.9 billion. And with Medicare now looking more critically at readmission rates, hospitals stand to lose reimbursements if Medicare deems that a preventable complication led to readmission in less than 30 days. Better care means fewer complications, says Moccia. “We’re learning from our patients every day. They are our teachers and inspiration,” she adds. “And with our recent NICHE designation, we know that the education, excitement and engagement will only increase.” The only downside, says Moccia, is that she’s developed an addiction along the way. “I’m constantly on the NICHE website learning all that I can,” she says. Her dedication hasn’t escaped the attention of her three daughters. “They’re always kidding with me that I love the Senior ER more than I love them,” says Moccia. “I tell them, ‘I’m paving the path and preparing for your future so when you are older, and I’m gone, someone will be there to take my place, to give you the expert medical care you need and to provide that care with respect, compassion, tenderness and kindness.”


NICHE (Nurses Improving Care for Healthsystem Elders) is a multifaceted program specifically designed to improve the quality of care for hospitalized older adults by increasing awareness of geriatric issues, improving staff competence in geriatric care and supporting the implementation of evidence-based geriatrics protocols. NICHE’s mission is to engage, encourage and inspire nurses and other healthcare practitioners to identify gaps and needs in geriatric care and implement solutions to close those gaps. NICHE provides an extensive array of resources and tools that guide, support and educate healthcare professionals and facilities throughout the process of achieving NICHE designation. Since its launch in 1992, NICHE has evolved into a self-sustaining program based at the Hartford Institute for Geriatric Nursing at New York University College of Nursing. As of November 2010, there are 300 NICHE-designated hospitals in the U.S. and Canada. For more, visit,