Why should we have a ‘geriatric’ emergency department?

Rosa McNamara is a consultant in emergency medicine in London, with a special interest in geriatric emergency medicine. She tweets @rosamcnamara

So we all know that the world is growing older – it is now common for emergency department (ED) clinicians to spend the majority of their day looking after frail older adults. In emergency medicine (EM) we are going through a longish period of reflection on how best to care for older adults (EM is just over 40 years old, and for 30 of those years there has been discussion about this). Interest in the needs of frail older adults has widened and many solutions have been tried in EDs worldwide, with mixed results. These include rapid response teams, liaison geriatrics, interface geriatrics and the development of seniors EDs.

The push to improve stroke services

Adhi Vedamurthy is a consultant geriatrician with a special interest in stroke, and Chair of the BGS Wales Council.

It was a typical Monday morning in a district general hospital. Loads of elderly medical patients had spent the night in the emergency department waiting for a bed. About a dozen ambulances were outside the hospital unable to offload patients.

I had just done a third of my ward round with the foundation year one doctor when the bleep went off. A patient with potential need for thrombolysis had just arrived. Apart from the stroke nurse, there was no other suitable senior doctor available to assess the patient.

I abandon the ward round to assess the patient, organise the scan, push the trolley with the stroke nurse to take the patient to the stroke unit and initiate thrombolysis. This takes nearly an hour. During this time, the patients on the ward are still waiting for my assessment and management plan. Two discharges get delayed and a few scans were not booked on time and they had to wait for another day.

This scenario is very common in many hospitals where geriatricians have more than one role. Time is of the essence when treating stroke patients, but this comes at a cost if commissioners do not invest to improve services and expect existing services to stretch. This also applies to therapy services who are asked to prioritise stroke patients.

To meet targets, a patient with a suspected stroke (many do not have a stroke) must get a bed in a stroke unit within four hours. But it seems entirely acceptable for patients with heart failure, pneumonia, a fall, delirium, etc., who have far higher mortality, to spend hours on a trolley in the emergency department.

There is no argument that acute stroke is an emergency and should be treated accordingly. However this should not come at the expense of other services in geriatric medicine.

A majority of geriatricians in Wales felt that an improvement seen in stroke services has come at the cost of compromising services in geriatric medicine.

Is this the case in the other devolved nations? I would love to hear your views.

Is there ever a case for shared rooms in hospitals?

Jacqui Close is a consultant in Orthogeriatrics at the Prince of Wales Hospital in Sydney, Director of the Falls and Injury Prevention Group at Neuroscience Research Australia and President of the Australian and New Zealand Society for Geriatric Medicine. Her research interests range from injury epidemiology, to intervention studies and implementation research.

The days of the Nightingale ward are thankfully gone. No longer do we see two long neat rows of beds with starched sheets.  Whilst the occupants of the bed were rarely encouraged to roam freely, the close proximity of the beds allowed for easy spread of highly mobile viruses and bacteria. Even in the absence of an understanding of infection risk, many complained about the lack of dignity and privacy resulting from this ward design.

Time has moved on and there is recognition of the multiple benefits of single rooms for all patients including older people. Single rooms allow for the delivery of health care which minimizes infection risk, respects privacy, promotes dignity and on the whole reflects with wishes of those people unfortunate enough to require a period in hospital. But is a single room right for everyone and can we be flexible in the way we deliver care?