EMERGENCY ROOM

The hospital emergency department has become a very important access point for health care for elderly persons and this trend will likely continue. The emergency room serves as the site of hospital entry for many patients, with scheduled admissions largely restricted to elective surgical procedures. Elderly patients are more likely to enter the hospital via the emergency room than younger patients (Sanders). Typically, the overall hospital admission rate from an emergency room will be 10 to 30 percent, but admission rates in the population over sixty-five may exceed 40 percent.

Due to twenty-four-hour availability and the access to hospital-based technology, the emergency room has become an attractive site for patients with nonemergency medical problems. Call sharing by primary care physicians and their relative decline in numbers may result in increased emergency department use, although elderly persons are more likely to have a personal physician than are younger patients.

The emergency room has also become a safety net when a smooth transition from one health care facility or state of health is disrupted. With reductions in hospital length of stay, and the general patchwork of available home care, the emergency room has reluctantly assumed this role.

Numerous studies have confirmed the appropriateness of emergency room utilization by the elderly population (Gold and Bergman). Elderly adults tend to have multiple medical conditions, atypical presentation of common diseases, and significant issues in caregiver support, requiring complex assessment in the emergency room and high admission rates to hospital. Use of emergency medical services (ambulances) is also higher in the elderly population (Moir et al.). Although concerns have been raised about the appropriate use of ambulance services, often there are few alternatives for elderly adults because of limited transportation services, mobility problems, and the decline of the primary care physician house call.

The emergency room visit—what to expect

Due to high visit volumes, all emergency rooms utilize a triage system to sort patients by severity of illness or injury. This system inevitably results in waiting periods, especially for those with less acute problems. This can be frustrating for patients and family. Attempts should be made to make the emergency room environment more receptive to the needs of the elderly patient. A visit to the emergency room may be a key decision point in the health care of an elderly person. The decisions made during this visit may result in hospital admission, consideration of admission to a long-term care facility, or significant alterations in the home environment.

The medical history is a key component to the evaluation. This can be challenging and time consuming in a busy emergency environment. Obtaining a collateral history from family members, consulting with the primary care physician, and a review of all health records are critical. A precise review of current medication is important due to the high rate of polypharmacy in elderly persons and should include the use of over-the-counter medication.

Communication may be difficult due to cognitive deficits and reduction of hearing. A dignified approach to history taking cannot be overemphasized, since the Emergency Department is a confusing and frightening place for many patients. Use of a mental status screening tool such as the Mini-Mental Status Exam is a valuable tool to guide further evaluation (Moir et al.).

The physical examination needs to be thorough due to the often nonspecific symptoms of serious illness in elderly patients. Important features include a focused cardiovascular exam, abdominal assessment, skin exam for evidence of cellulitis or skin ulcers, and an assessment of joint mobility (Wofford, Schwartz, and Byrum). Perhaps the most important part of the physical exam is observation of the ability to stand and walk independently. Many elderly patients live alone. If a patient cannot stand and walk, they cannot be safely discharged from the emergency room without significant additions of home care resources, usually beyond the scope of most current programs.

Due to the presence of many chronic medical conditions and high medication use, the use of laboratory and other tests such as x-rays is an important component of the emergency evaluation. Testing for low blood, blood sugar, and kidney function are routinely done. The high rate of osteoporosis means that x-rays should be requested liberally to detect fractures. Often a CT scan (brain x-ray) is necessary to determine head injury after a fall, or change in mental condition. The need for additional testing may prolong an emergency room visit but will help to make the correct disposition decision (Sinclair, Svendsen, and Marrie).

The disposition decision in the emergency room for an elderly patient is perhaps the most complex in emergency medicine. A functional approach must be made since often a definitive diagnosis cannot be made. Consideration of home support and social factors is paramount. The emergency room must act as a patient advocate due to the reduced availability of hospital beds, and fragmented home care resources. Patients and family need to be active participants in these decisions.

Many progressive emergency rooms have now added resources such as a discharge planning nurse and social workers to attempt to improve care for the elderly patient (Boyak and Bucknum). Traditional home care programs have limited use in the emergency department setting because of the length of time required for intake and limited resources available to individual patients. Home care programs specifically designed for the emergency department (often called Quick Response Programs or QRPs) include a rapid emergency department intake, and front-end loading of resources, including nursing, home support, rehabilitation services, and pharmacy support, to enable the safe discharge of patients who would have been admitted to hospital (Weir et al.).

Another recent innovation in emergency room care is the provision of a multidisciplinary geriatric assessment team for consultation (Gold and Bergman). This team may complete assessments in the emergency room or in the home environment and provide follow-up and admission to geriatric day hospitals or other programs. In conclusion, a visit to the emergency room is an often unavoidable event for an elderly person. Hopefully, a better understanding of its crucial role in health care decisions will assist patients and families during this stressful period.

Douglas E, Sinclair, M.D.

See also Assessment; Balance and Mobility; Geriatric Assessment Unit; Home Visits.

BIBLIOGRAPHY

Eagle, D. J.; Rideout, E.; Price, P.; et al. "Misuse of the Emergency Department by the Elderly Population: Myth or Reality?" Journal of Emergency Nursing 19, no. 3 (1993): 212–218.

Gerson, L. W., and Skvarch, L. "Emergency Medical Service Utilization by the Elderly." Annals of Emergency Medicine 11, no. 11 (1982): 610–612.

Gold, S., and Bergman, H. "A Geriatric Consultation Team in the Emergency Department." Journal of the American Geriatrics Society 45 (1997): 764–767.

Moir, V.; Wilcox, V.; Rukowski, V.; and Hiris, J. "Functional Transitions Among Elderly: Patterns, Predictors and Related Hospital Use." American Journal of Public Health 84, no. 8 (1994): 1274–1280.

Sanders, A. B. "Care of the Elderly in Emergency Departments: Conclusions and Recommendations." Annals of Emergency Medicine 21, no. 7 (1992): 830–834.

Sinclair, D.; Svendsen, A.; and Marrie, T. "Bacteremia in Nursing Home Patients: Prevalence Among Patients Presenting to an Emergency Department." Canadian Family Physician 44 (1998): 317–322.

Weir, J.; Browne, G.; Byrne, C.; et al. "The Efficacy and Efficiency of the Quick Response Program: A Randomized Controlled Trial." Canadian Journal of Aging 17, no. 3 (1998): 272–295.

Wofford, J. L.; Schwartz, E.; and Byrum, J. E. "The Role of Emergency Services in Health Care for the Elderly: A Review." Journal of Emergency Medicine 11 (1993): 317–326.

HOSPITALS AND THE HILL-BURTON ACT

The Hospital Shortage

In the early 1940s, if you needed to go to the hospital, you might have had to travel quite a distance to find one. During the Great Depression of the 1930s little building of new hospitals occurred, and many of the existing hospitals deteriorated. More than one thousand counties in the nation had no hospital facilities of any type. During the war emergency, communities crowded with workers in the munitions and other wartime plants encouraged the building of many small hospitals, often of flimsy construction. After the war the hospital industry was desperate for aid. Its needs had been deferred for a decade and a half of depression and war. Conservatives in Congress were finally induced to build new hospitals as an alternative to national health insurance.

The Hill-Burton Act

Two hospital-construction programs were adopted immediately after the war, one to expand the Veterans Administration hospitals for the millions of returning veterans who would need medical attention, the other to aid the nation's community hospitals. In 1942 the Commission on Hospital Care was formed by joint action of the American Hospital Association and the U.S. Public Health Service. In 1946 Congress enacted the Hospital Survey and Construction Act (the Hill-Burton Act, named after its Senate sponsors, Lister Hill and Harold H. Burton), based on the recommendations of the federally appointed Commission on Hospital Care. The purpose of the act was to provide funds to the states for the planning and construction of hospitals. Proposals for national health insurance made by President Truman favored financing morecomprehensive medical services. But the measures adopted via the Hill-Burton Act put the power of public finance behind hospitals alone.

No Government Control of Medicine

The HillBurton Act expressly forbade governmental interference in the operation of the hospitals. Federal administrators had no say about the amount of funding any state or individual hospital would receive. The states were to estimate regional hospital needs; when an applicant from an area received a grant, the area would go to the bottom of the list and had to wait to apply for further grants. Advocates of the Hill-Burton Act argued that the program would help provide access to hospital care for poor families and impoverished communities that otherwise could not afford to build hospitals. Funding provisions of the act itself, however, gave most federal assistance to middle-income communities. Initially the act required two-thirds of the construction cost to be supplied from local funding sources, meaning the poorest communities— the very ones that needed help the most—rarely were able to raise the initial capital. Many hospitals in the South, moreover, refused to treat black people, who were among the poorest of American citizens. The law itself prohibited racial discrimination by any federally assisted hospital, though it accepted the construction of separate but equal facilities. The Supreme Court ruled these provisions of the Hill-Burton Act unconstitutional in 1963. In the Hill-Burton program states' rights and community autonomy limited federal intervention. Despite the growth of government aid to medicine in the 1940s, American culture and constitutional heritage once again worked against government control of medicine.

A PRESCRIPTION FOR LONGEVITY

In 1944 a German refugee physician, Dr. Martin Gumpert, published a book, You Are Younger Than You Think, suggesting that it is possible for most people to live to be at least one hundred. To get to that ripe-old age Gumpert suggested the following:

• Moderate indulgence in drinking and smoking.
• Do not retire: "Idleness is [a] ticket to death."
• An active (but not too active) sex life: Gumpert advised against December-May marriages; they often killed the older partner.
• Eat fewer calories but more vitamins and minerals. Breakfast in bed is good for the elderly, along with a hearty lunch and light supper. One should consume a diet of mild cheeses, milk, butter, scrambled eggs, lean meat, macaroni, well-cooked vegetables, bananas, and stewed fruit. Oldsters should avoid raw or smoked meat, raw vegetables, and rich cheeses.
• Avoid extremely hot or cold baths or long soaks. For elders the best routine is a daily sponging with warm water.

Source:

"Life Begins at 60," Time (14 April 1944): 56+.

Sources:

James Bordley III and A. McGehee Harvey, Two Centuries of American Medicine (Philadelphia: Saunders, 1976), pp. 434-435;

Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), pp. 347-351.

e·mer·gen·cy room • n. the department of a hospital that provides immediate treatment for acute illnesses and trauma.