Alexis Hernandez, a worker at the new geriatric emergency unit at UCSD Jacobs Medical Center, collects information from patient Frank Staffiero during a visit on Jan. 9. (Eduardo Contreras / San Diego Union-Tribune)
Gary and Mary West Foundation, county commit $700,000 toward helping hospitals obtain certifications
By PAUL SISSON
Hospital leaders from throughout the region made an unprecedented pledge Monday to make their emergency departments more senior friendly by 2021.
Gathering at UC San Diego Jacobs Medical Center, a large group of executives representing facilities from Oceanside to Chula Vista committed to pursuing special geriatric emergency certifications from the American College of Emergency Physicians (ACEP).
Accreditation provides a framework for training, changes to buildings and equipment, and protocols designed to help often-chaotic emergency centers operate with greater sensitivity to the specific needs of an aging population.
While changes to the physical environment such as gentler light, fewer loud noises, slip-resistant surfaces and recliners instead of hospital beds are the most-visible changes that set geriatric emergency units apart, they’re probably the least important parts of the movement to do a better job with older patients.
The accreditation process asks hospitals to go much deeper, changing the most fundamental aspects of how they operate which affects everything from assessing the severity of incoming health problems to screening for cognitive changes and fall risks. Hospitals must commit to working beyond the walls of their facilities, dedicating additional resources to make sure that patients who are sent home get what they need whether that’s a home visit from a therapist or a follow-up appointment with their primary doctor.
For too long, said Dr. Kevin Beise, an emergency medicine specialist and chair of ACEP’s Geriatric ED Accreditation Program, emergency departments have tended to operate under the assumption that their main concern is that which occurs within their walls.
“We believe that approach is no longer acceptable,” Beise said. “With the geriatric ED model, it’s not just about that fall that happened yesterday; it’s how do we help you not fall in the future?”
The physician, who traveled to San Diego for Monday’s announcement, confirmed that San Diego County’s approach is unique. Nowhere else in the nation, he said, has leadership at all levels come together to pursue the same goal.
“We believe this will be a template for how you bring health care systems together and drive forward geriatric emergency care for the community,” Beise said.
UC San Diego’s Jacobs Medical Center was the first facility in the area certified under the ACEP protocol and was one of the first three in the nation to be awarded the designation last year. A new ER opening at Alvarado Medical Center later this month is the second to earn the designation.
UCSD had more than a little help with executing its plans. West Health, a nonprofit founded by local philanthropists Gary and Mary West, gave the university an $11.8 million grant to help pay for the unit and to study how the care it delivers is different from the standard of care. The investment allowed Jacobs to receive ACEP’s top “level one” certification out the gate. Alvarado has started with a level three designation, which requires less dedicated staffing and less aggressive protocols.
Monday’s event announced an additional $700,000 in support from West Health and the County of San Diego. The Wests and the county, led by East County Supervisor Dianne Jacob, each contributed $240,000, with the balance of the investment in in-kind training and other services from West. Jacob said Monday that it was a suggestion from Robin Gomez, Alvarado’s chief executive, that convinced her to push for the county to support broad-based certification countywide.
The Wests said after the formal announcement that they continue to believe that seniors, the fastest-growing demographic segment of the American population, are getting short shrift in emergency departments nationwide. Funding certification, they said, is intended to level the playing field.
“No one is really addressing our aging population, and yet we know that it’s one of the biggest problems we face in our society,” Gary West said.
There are early indications that the certification program gets results. Dr. Ted Chan, chair of emergency medicine at UCSD, said that patients treated in Jacobs’ new senior-focused emergency department look statistically different from their peers in a few key ways.
“There is a 12 percent decrease in their risk of coming back to the ED within 30 days and there is a 20 percent decrease in their rate of (hospital) admission,” Chan said.
Such an approach is not just about delivering more humane care. Avoiding admissions can ultimately lead to more cost-effective care, a regular demand of those who pay the bills from private insurance companies to Medicare.
Geriatric emergency departments, Beise added, do things differently in four main areas:
Staff training brings to bear a more-sophisticated assessment of fall risk that emphasizes making sure that seniors are able to move safely rather than trying to minimize movement.
“We’re asking, how do we keep your strength up? How do we keep your conditioning up? How do we make sure you can move around safely in your home?” Beise said.
The second focus is around what doctors often call “polypharmacy,” the common situation where seniors often end up taking multiple drugs regularly even if they conflict with each other.
“When you come in, we need to seize that opportunity to look at your medication list and identify that your cardiologist and your primary care doctor put you on two medications that you shouldn’t be taking at the same time,” Beise said.
Cognitive impairment also gets additional focus, with screenings made a routine part of care. Patient communication also gets modified for those who may need a little more deliberate approach in order to truly understand what an emergency physician or nurse is asking them to do when they get home.
“If you have some cognitive impairment and I just rapid fire your discharge instructions at you, you know what, that’s just not gonna work,” Beise said.
The fourth key area, he said, involves frailty. As we age, our bodies do become more delicate. When we were younger, sitting in a crowded emergency room for hours on end was an annoyance. But it’s a much bigger deal for seniors, especially those in their 80s and beyond. This is where soundproofing, gentler lighting, better chairs and beds and other softer approaches can really help make sure that an emergency visit isn’t, in and of itself, a setback.
“We can’t fix frailty in the ED, but we can do things in a way that’s designed not to make it worse that it was when you arrived,” Beise said.
In addition to UC San Diego and Alvarado, the hospitals and health care systems that pledged to pursue geriatric emergency certification include: Kaiser Permanente San Diego, Palomar Health, Paradise Valley Hospital, Scripps Health, Sharp HealthCare, Tri-City Medical Center and VA San Diego Healthcare System.
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