Dr. Ted Chan + Dr. James Killeen: Emergency Medicine for America’s Aging Population

Each day, the percentage of the American population over the age of 65 increases, and most emergency departments are not designed to meet the pressing needs of America’s aging population. In this video, Dr. Ted Chan and Dr. James Killeen, two emergency medicine physicians at the University of California San Diego (UCSD), explain how they redesigned their emergency department to create new best practices for meeting the emergency medicine needs of the aging population. In the process of designing new standards of care for the elderly, they developed systems that could improve the quality of care for all patients.

Dr. Chan started the presentation by explaining the demographic trends that motivate the work they are doing in the UCSD emergency department, “America is approaching the time where 20-25% of the population will be over the age 65. If the current trends continue, by 2060 there will be over 100 million people in America over the age of 65, and 20 million will be over the age 85.” The current healthcare infrastructure’s inability to manage the unique needs of the growing geriatric population has led to leaders in emergency medicine developing the Geriatric Emergency Department Accreditation Program to, “ensure our oldest patients receive well-coordinated, quality care at the appropriate level at every ED encounter.”  The staff at UCSD observed these trends and wanted to go a step beyond accreditation. They wanted to design systems that provided the best possible care for seniors.

Knowing that their current structure was not getting the job done, the staff at UCSD wanted to redesign their emergency department from scratch. Dr. Killeen said, “We threw out the book on how to make a hospital emergency room, because the current model was too much like a casino. No windows, lots of blinking lights, and lots of noise.” Instead of an environment closed off from the natural world, they saw opportunities for patients to benefit from being connected to the natural world.

They started with lots of natural light. They put large windows in each of the patient rooms, so people could see the outside world. They also replaced the lighting systems. Dr. Killeen explained, “Instead of the traditional fluorescent lights, it’s now LED lights programmed to align with the circadian rhythm of the patients.” The lighting in the patient rooms dims with the sunset and brightens with the sunrise. They also applied the latest lighting technology for the staff work areas. For example, the nursing stations were designed with purple lighting intended to disrupt the circadian rhythm of the staff to help keep them awake during night shifts.

There were several design concepts incorporated to help keep the emergency department a quiet and peaceful place. For example, all the art work and the ceiling panels were made with sound absorbing material. Much of the noise in an emergency department comes from care providers who have to raise their voices to communicate with elderly patients who are hard of hearing. To save the voices of the providers and reduce noise clutter, the patient rooms were strategically designed to maximize the patients’ ability to hear providers speak. Each of the rooms includes a speaker system that syncs with the microphones that the providers wear on their lapels. The speakers, that were custom designed by UCSD engineers, direct all the sound to the head of the bed. This allows the patients to experience an amplified version of the provider’s voice without creating more noise for others in the room and the rest of the emergency department.

“Part of our goal is to get rid of wires. We want to get’em up and get’em moving. We don’t want people to feel tied down."

UCSD also partnered with a technology company to provide wireless vital sign monitoring. These wearable biosensors allowed the staff to monitor heartrate, respiration, body temperature, and the location of the patients. Dr. Killeen explained the thinking behind their investment in wireless sensors, “Part of our goal is to get rid of wires. We want to get ’em up and get ’em moving. We don’t want people to feel tied down.”

Taken together, these changes have been effective in producing positive health outcomes for patients. The new approach to providing care for the seniors led to longer than average emergency department stays, but more importantly it decreased the average length of total hospital stay for seniors. So instead of just triaging, the emergency department is actually helping seniors recover.

Part of the redesign process included improved EMR systems for referring the seniors to the proper support. A nurse conducts an ISAR (Identifying Seniors At Risk) survey with every patient. This information is automatically sent to the patient’s primary care providers. Dr. Chan explained the significance of the this, “ISAR has been used in geriatrics for a long time, but it just hasn’t been used in emergency departments before. If we want to provide comprehensive care and reduce the likelihood of people coming back to the emergency department, we need to do these things.”

“The median cost for treating a person in-patient for cellulitis is $15,928 while the median cost of treating cellulitis with out-patient systems is only $1,582.”

Tracking this information led the staff to identify insights that led to the creation of services that reached far beyond the emergency department. Dr. Chan observed that, “Many of the issues were more social determinants rather than acute medical problems.” To address these issues they implemented telehealth programs to communicate with seniors. Through this process they also realized that many of the patients were healthy enough to be treated at home. Treating patients in their own homes, helped the patients maintain their lifestyle routines, and it led to dramatic cost savings. As just one example, Dr. Killeen stated, “The median cost for treating a person in-patient for cellulitis is $15,928 while the median cost of treating cellulitis with out-patient systems is only $1,582.” These numbers demonstrate how providing the best possible care for patients requires moving away from a hospital-centric way of thinking.  The staff at the UCSD emergency department has shown how you can improve patient outcomes by thinking beyond the hospital and beyond short term revenue.

At Worrell we specialize in helping healthcare organizations design for better outcomes. If you’re interested in learning more about the facilities and practitioners we collaborate with or how Worrell could help your organization design the future of healthcare, please reach out. We look forward to starting the conversation.