Helping Your Care Recipient During an Emergency Room Visit
By Wayne Guerra, MD, MBA and CMO, Healthagen LLC
(Editor’s Note: On a regular basis, we invite health care professionals and family caregivers to share insights as a guest blogger on Caregiving.com. In light of last week’s study results about hospital readmissions, we invited Wayne to share his tips to help you and your care recipient during emergency room visits.)
Elderly patients presenting to the emergency department have more adverse events than other age groups. In one study of VA patients older than 65 years of age, one in three discharged from the emergency department had a significant adverse outcome within 90 days of discharge (http://tinyurl.com/ce3nchwithin). The reasons for these poor outcomes include complicated medical histories, multiple pre-existing medications, decreased reserve, and poor communication between the healthcare providers and patients. As advocates for your care recipients, you can positively affect their care by becoming more involved.
Try to be seen as an asset rather than an adversary to the emergency department physician and personnel. Introduce yourself to the staff and get HIPAA clearance from your care recipient (if you are not already the power of attorney) so you can receive your care recipient’s medical updates. Be polite but firm, and state that your goal is to ensure your care recipient receives the best care possible. The emergency department is often a chaotic place and one where your care recipient’s needs may not be fully met without such advocacy. We will discuss 10 steps to help maximize your care recipient’s care and prevent an avoidable poor outcome.
Step 1: Be There
Your presence provides a sense of security. Being physically present makes communication with the doctor and nurses that much easier. If possible, have a friend join you; your friend can sit with your care recipient if you must leave the bedside. If you care from a distance or simply cannot be present, call and speak to the nurse and physician taking care of your care recipient. Make sure they have your contact information.
Step 2: Have Your Care Recipient’s Medical Information and Medication List
It cannot be overstated how important it is for the medical providers to have this information. Many times older patients cannot give a full past medical history or remember their medications. Consider that the average community-dwelling older adult takes 4.5 prescription drugs and 2.1 OTC medications (http://tinyurl.com/d2nqkt). This vital information will give the physician and staff the opportunity to consider all possible causes of the presenting complaint and prevent an avoidable adverse drug reaction. I know it is easy to think the hospital will already have this information, but only 10% of hospitals have a comprehensive electronic medical record.
Step 3: Help With Why Your Care Recipient Is In The Emergency Department
Many times the emergency medicine physician and staff cannot get a reliable history from the patient. This could be due to some cognitive impairment, but we also see older adults minimize their complaints because they want to go home. This especially important when older adults present with falls. The cause of the fall is often more important than the injury. Did the patient pass out, have a seizure, or simply trip? Having this information can be life saving and direct the medical staff to look for serious diseases such as heart attacks, intestinal bleeding, medication reactions, stroke, or life threatening infections. Make sure to tell the staff if your care recipient has been ill, or recently been placed on a new medication, even over the counter (OTC) medications.
Step 4: Ask About What Diseases The Doctor Is Considering
Remember that this population has atypical presentations to serious diseases. As many as 20% of elderly patients with a heart attack will never have chest pain. Instead, they will complain of weakness, vomiting, shortness of breath, abdominal pain, or fainting. Every older adult presenting with new confusion should have medication reaction, pneumonia, and urinary tract infection ruled out as the cause. Asking the physician about these possibilities can increase the likelihood that a more thorough work-up will be done. The secure physician should not view this as confrontational but as appropriate behavior from a concerned family member, and should use this opportunity to explain why a certain test is or is not being done.
Step 5: Make Sure Your Care Recipient Eats And Takes Essential Medications
Emergency department visits for older adults can be complicated and lengthy, requiring multiple lab and radiology tests. Some of these tests have to be done in sequential order, i.e. ensuring the kidneys function normally before a contrast CT scan can be done. Some patients will not be allowed to eat or drink until test results return. Many times these patients will not ask about meals and can miss two meals waiting for their tests. Similarly, some essential medications can be overlooked and not administered while waiting for tests. Ask the staff about meals and medications to reduce this possibility.
Step 6: Ask If The Treatment Medications Are Safe With The Current Medications
Adverse drug reactions are two-to-three times more common in this age group. Some authorities believe this estimate is low as older adults may not report such reactions (http://tinyurl.com/d9dble). Drug interactions are very common and asking the doctor or pharmacist about this possibility will decrease the incidence of this preventable poor outcome. The following medications are especially problematic in the elderly and the risk-benefit of using them should be discussed with the treating physician (http://tinyurl.com/d2nqkt): antidepressants (amitriptyline), antihistamines (Benadryl), antipsychotics (Haldol), long acting benzodiazepines (Valium, Ativan), certain cardiac or high blood pressure medications, anticoagulants/blood thinners (Coumadin, Plavix), anti-inflammatories (Motrin, Alleve, Indocin), pain medications (narcotics, tramadol).
Step 7: Make Sure Your Care Recipient One Is Safe To Go Home–Part A
Every older adult leaving the emergency department should have gait testing performed before being discharged. Gait testing is as simple as getting the patient out of the emergency department gurney and watching the care recipient walk. Make sure the patient has the tools normally needed to ambulate such as braces or a walker. This is typically done with two staff members at the bedside to prevent a fall and injury. As a risk manager, I have seen cases of patients being brought to the emergency department by ambulance for a fall. Lab tests and x-rays were done and found to be normal. The patient was sent back to the nursing home only to return the next day with a fractured hip. The patient never complained of hip pain, but they were never walked in the department prior to discharge. Gait testing should ensure the patient is back to his or her baseline, whether that be independent walking or with assistance. Failure to ambulate normally can also expose undiscovered metabolic abnormalities as well as missed intracranial injury such as bleeding or bruising of the brain.
Step 8: Make Sure Your Care Recipient Is Safe To Go Home–Part B
This is especially important for patients going home to be alone. Will they be able to get to the bathroom, feed themselves and take the medications? You can ask for discharge planning assistance, and many times have a visiting nurse check on your care recipient. This can be arranged through the emergency department or the primary care doctor’s office.
Step 9: Get The Primary Care Doctor Involved
Ask the treating physician if he/she has spoken to the primary care doctor. This brief conversation can lay out the plan for discharge home and help set up the necessary follow-up. In a recent study on patients discharged home from the hospital, the failure to see their doctor in follow-up was one of the primary reasons patients failed at home, prompting a re-admission (http://tinyurl.com/cgzl77). If possible make your care recipient’s follow-up appointment from the emergency department before you leave, and make sure he or she keeps the appointment.
Step 10: Ask For Copies Of Lab And Radiology Reports
Again, relying on the electronic medical record is spotty at best. This information is crucial for the follow-up appointment, or if your care recipient happens to visit a different emergency department in the near future.
I hope the 10 steps above will help you become a better advocate for your older loved one. As healthcare workers, we should embrace this involvement since it can greatly decrease the likelihood of a poor outcome.
Wayne, a Board-certified and practicing Emergency Medicine Physician, is Chief Medical Officer and co-founder of Healthagen LLC and iTriage. He’s also a Board member and Vice-President of Serio LLC, a large physician service
management company. He’s a risk manager with more than 10 years experience overseeing 500,000 annual emergency department visits for Serio. You can follow Wayne on Twitter.
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