Elderly patients can deteriorate hourly in the ER. This team works against the clock to get them out

It's 7 a.m. in the emergency department of St. Mary's Hospital in Montreal, and geriatric nurse Leeza Paolone is starting her day in front of a screen filled with patient names, taking note of each one highlighted in blue.

"We're fighting against the clock to get these patients seen, and hopefully out of there," Paolone told Dr. Brian Goldman, host of CBC Radio's White Coat, Black Art.  

The blue names belong to patients 75 and over who've been identified by triage nurses as at risk of functional decline in the hospital. The longer these patients spend in the ER, the worse their outcomes are likely to be, due to a phenomenon known as hospital-associated deconditioning. It refers to physical and often cognitive decline that happens as a result of being hospitalized. 

The geriatric multidisciplinary ER team at St. Mary's targets these patients from the moment they arrive.

Given the number of Canadians 85 and over will triple in the next 20 years, medical professionals and researchers are sounding the alarm about keeping older adults out of the hospital, spreading the word that — perhaps counterintuitively — the hospital isn't always the safest place for them. 

Research has shown that deconditioning is a catastrophe for elderly patients in hospital ERs. A study published in the Canadian Geriatrics Journal in 2017 found that one in five patients over 65 developed delirium — a serious change in mental state involving confusion and a lack of awareness — after spending 12 hours in the ER.

It also found that delirium often extends hospital stays by a week or more, setting in motion a domino of decline. At worst, an elderly person enters the hospital as someone who lives independently and never goes home.

To avoid this, the first step is preventing an elderly patient from waiting a second longer than needed.

"In the ER specifically, the environment can be much harder on the geriatric patient," says Paolone.

With the frenetic surroundings of an ER — lights and noise that disrupt sleep, no windows, meals and medication given sporadically or skipped — a patient can grow delirious in just a couple of hours. Then they have to be admitted.

And that's bad news, says geriatrician Dr. Julia Chabot, the team's co-founder. "We know that for every day an elderly patient spends in a bed or on a stretcher, it will take an average of three days for them to recover."

Plus, once a geriatric patient is admitted, their average stay at St. Mary's is 28 days, which costs the hospital tens of thousands of dollars, says Chabot. 

So the mission of this team — just over halfway through a two-year pilot — is to proactively screen, assess and treat elderly ER patients in the hope they can be discharged with proper support in place.

On any given day, nurse Leeza Paolone is joined by a physiotherapist, occupational therapist, social worker and one of four geriatricians.