White Coat Black Art26:30Saving elderly patients from the hazards of the ER
It’s 7 a.m. in the emergency department of St. Mary’s Hospital in Montreal, and geriatric nurse Leeza Paolone is starting her day in front of a screen filled with patient names, taking note of each one highlighted in blue.
“We’re fighting against the clock to get these patients seen, and hopefully out of there,” Paolone told Dr. Brian Goldman, host of CBC Radio’s White Coat, Black Art.
The blue names belong to patients 75 and over who’ve been identified by triage nurses as at risk of functional decline in the hospital. The longer these patients spend in the ER, the worse their outcomes are likely to be, due to a phenomenon known as hospital-associated deconditioning. It refers to physical and often cognitive decline that happens as a result of being hospitalized.
The geriatric multidisciplinary ER team at St. Mary’s targets these patients from the moment they arrive.
Given the number of Canadians 85 and over will triple in the next 20 years, medical professionals and researchers are sounding the alarm about keeping older adults out of the hospital, spreading the word that — perhaps counterintuitively — the hospital isn’t always the safest place for them.
Research has shown that deconditioning is a catastrophe for elderly patients in hospital ERs. A study published in the Canadian Geriatrics Journal in 2017 found that one in five patients over 65 developed delirium — a serious change in mental state involving confusion and a lack of awareness — after spending 12 hours in the ER.
It also found that delirium often extends hospital stays by a week or more, setting in motion a domino of decline. At worst, an elderly person enters the hospital as someone who lives independently and never goes home.
ERs not designed for the elderly
To avoid this, the first step is preventing an elderly patient from waiting a second longer than needed.
“In the ER specifically, the environment can be much harder on the geriatric patient,” says Paolone.
With the frenetic surroundings of an ER — lights and noise that disrupt sleep, no windows, meals and medication given sporadically or skipped — a patient can grow delirious in just a couple of hours. Then they have to be admitted.
And that’s bad news, says geriatrician Dr. Julia Chabot, the team’s co-founder. “We know that for every day an elderly patient spends in a bed or on a stretcher, it will take an average of three days for them to recover.”
Plus, once a geriatric patient is admitted, their average stay at St. Mary’s is 28 days, which costs the hospital tens of thousands of dollars, says Chabot.
So the mission of this team — just over halfway through a two-year pilot — is to proactively screen, assess and treat elderly ER patients in the hope they can be discharged with proper support in place.
On any given day, nurse Leeza Paolone is joined by a physiotherapist, occupational therapist, social worker and one of four geriatricians.
Preventing ER ‘bouncebacks’
One “blue” patient on the triage board the day White Coat, Black Art observed is 84-year-old Maria Pastore, who’s come in with painful bursitis in her hip made worse by a recent fall. She also has a blood clot in her leg. This is the third Montreal ER she’s been to in the past few months.
At the first, she was given a cortisone shot in her hip following a 10-hour wait. At the second, a prescription for a walker. But with no follow-ups to make sure, she never got it.
For the team at St. Mary’s, one major goal is to prevent “bouncebacks” like this.
“She needs the follow-up, otherwise she’s going to end up at different ERs throughout the city,” says physiotherapist Natalie Ilienko.
Ilienko and occupational therapist Stephanie Yung do a detailed intake encompassing everything from how independent Pastore is — she does her own cooking and cleaning — to her medical history, physical strength, medications and mobility.
Leeza Paolone chats with Pastore in Italian, which, she tells Dr. Brian Goldman, she learned from the grandparents who helped raise her. “They’re the strongest people I know,” said Paolone.
Paolone starts stitching together a care plan. Pastore is a widow; her son lives in New York, and she has no family doctor. But when Paolone makes a call to the seniors’ residence where she lives, it turns out there is a family doctor who works on site.
An hour later, everything is set up.
“So we have a rheumatology follow up. We have a hematology follow up… And I’m going to fax everything to the doctor at the residence.” She also updates hospital records with Pastore’s current phone number — a small but crucial detail given the appointments and follow-ups now on the books.
Longer waits, higher mortality
Dr. Robert Drummond, an emergency medicine specialist who has worked at St. Mary’s for 30 years, says when the elderly have to wait, “it’s not a mere inconvenience for them. It represents a greater risk for morbidity and mortality.”
A 2023 study from France found that patients 75 years and up who waited overnight in the ER had a “significantly higher in-hospital mortality rate.”
Drummond says the new ER team has “made a huge difference. They’re very proactive.”
For example, the team gauges whether sufficient supports are in place for geriatric patients to go home, and gets them the right care when that’s not the case. Like when they learn patient Thi Truong Nguyen, 77, lives at a Buddhist temple where she won’t get the round-the-clock help she needs to recover from a shoulder fracture.
“I feel lucid,” says Nguyen, “but I cannot move much.”
Yung and Ilienko fit Nguyen with a sling to help the shoulder heal, and request an orthopedic consult to determine whether surgery is needed.
But Nguyen uses a walker, and that won’t work with only one good arm. So the team requests a transfer to a rehab facility and gets her a bed upstairs while she waits.
Connecting the dots
Elderly patients who need Nguyen’s level of care are the norm, not the exception, says Dr. Brittany Ellis, an ER doctor in Saskatoon and chair of the Geriatric Emergency Medicine Committee for the Canadian Association of Emergency Physicians (CAEP).
CAEP data shows seniors make up 20 to 40 per cent of all ER patients.
Ellis says access to comprehensive geriatric ER care is “extremely variable” across Canada. Though she knows of only a “handful” of teams comparable to St. Mary’s, she says there are ER-delirium-prevention programs in provinces like Saskatchewan, B.C., and Newfoundland and Labrador. Ontario, meanwhile, has implemented a program to train nurses in geriatric emergency care.
With some creativity, Ellis she says it’s possible to apply this approach anywhere. “For example, a small hospital probably doesn’t have in-house physiotherapy, occupational therapy, geriatricians, or a pharmacy,” she says, but could partner with these other experts in the community for more comprehensive care.
Discharging quickly and safely
While the St. Mary’s pilot is still underway, Dr. Chabot said preliminary data are promising enough she’s confident the team will become permanent. Geriatric patients now spend an average of 10.5 hours less in the ER than before, and 28 per cent fewer are admitted.
Like Maria Pastore, who the team is determined to get safely on her way by the end of day. Ilienko arrives with a brand-new walker, free of charge because it’s covered by the province for her condition.
The team helps Pastore get up, adjusts the walker to fit, then stands back as she makes her way down the corridor with her new wheels.
“Wonderful. She looks steadier,” says Chabot. “As a whole team, I think this was a great intervention.”
“Que bella, signora!” says nurse Paolone as she watches Pastore walk safely out of the ER.
