Nurses with a mission: Send older ER patients home with help

CHICAGO – When 86-year-old Carol Wittwer took a taxi to the emergency room, she expected to be admitted to the hospital. She didn't anticipate being asked whether she cooks. Whether she has friends in her high-rise. Or whether she could spell lunch backward.

"H-C-N-U-L," she said, ruling out a type of confusion called delirium for the geriatrics-trained nurse in a special wing of Northwestern Memorial Hospital's emergency department. Wittwer's care is part of a new approach to older patients as U.S. emergency rooms adapt to serve the complex needs of a graying population. That means asking more questions, asking them earlier and, when possible, avoiding a hospital stay for many older patients.

The surprising truth? Hospitals can make older patients sicker. Infections, incontinence and weakening muscles from bed rest can cascade into delirium, frailty and death. More than 30 percent of older adults go home from a hospital stay with a minor or major health problem they picked up at the hospital.

But for an ER doctor, sending an elderly patient home sometimes feels risky. "The doctors are not comfortable sending you home unless you're safe," said Northwestern Medicine's Dwayne Dobschuetz, a nurse practitioner who makes house calls by bicycle. "It's easier to admit older patients than to send them home."

Emergency rooms have been called the hospital's front door, so that's where reformers are starting.

Early research shows care from geriatrics-trained nurses in the ER can reduce the chances of a hospital stay after a patient's emergency visit and for a month afterward. About 100 U.S. hospitals have opened geriatric emergency departments or trained ER teams in geriatrics care. These teams can arrange home services such as light housekeeping or a break for a caregiver.

In June, for instance, a man in his 90s arrived at the emergency department at University of California, San Diego's La Jolla medical campus. His left arm and shoulder hurt. He couldn't stand because of weakness.

Crisman identified caregiver strain, weight loss and swallowing difficulties. He organized home physical therapy for the man, connected him with a nutritionist and speech therapist and invited church members to help with the resource planning.

This kind of emergency medicine is only about a decade old. An influential 2007 article described the emergency department of the future, designed to prevent confusion and falls in the elderly and to increase their comfort. It would have windows and skylights, pressure-reducing mattresses, soundproofing.

Above all, it would hire nurses to untangle the complex complaints of aging, slowing down the frenetic pace of the ER enough to fully evaluate each patient.

Now, the ideas are catching fire. Northwestern's geriatrics ER has soundproofed rooms with comfortable beds and windows. Hospitals in New York, New Jersey, Pennsylvania, North Carolina, Wisconsin, Illinois and Georgia formed a collaborative to share ideas.

Northwestern's GEDI team — it's pronounced "Jedi" like in "Star Wars" — regularly works beyond the scope of a traditional emergency department.