Age-Friendly ED at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital Hospital and Trauma Center Expands Services

In 2024, the Age-Friendly Emergency Department (AFED) at the Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) earned Level 3 accreditation from the Geriatric Emergency Department Accreditation program of the American College of Emergency Physicians. The AFED is now seeking Level 2 accreditation by expanding its services for older patients in the ED and beyond.

Delivering Age-Friendly Care Efficiently

Today, in the ZSFG ED, if a patient is age 65 or older, a bedside nurse administers a frailty screening to identify patients who may benefit from ZSFG AFED care. If the screen identifies frailty, the department’s tracking board highlights these patients with a silver box. This alerts the dedicated patient navigator, Melina Shapiro, to perform a more comprehensive geriatric evaluation.

“The screening allows us to focus our efforts on unaddressed needs,” says Eric Isaacs, MD, director of the ZSFG AFED.

The patient navigator evaluation results in the delivery of one or more of the age-friendly interventions the AFED has implemented. Among them:

• A dedicated social worker, Alicia Gray, attends to families and family dynamics, including caregiver stress, housing, and transportation.
• Clinicians use a geriatric order set that defaults to specialized doses and medications for older adults.
• Special clinical pathways address everything from hip fracture to delirium prevention.
• A dedicated, full-time physical therapist, Donell Babino, DPT, was hired in 2024 after a successful pilot program in which Lora James, DPT, was instrumental in creating workflows and protocols. Babino evaluates patients, identifies their needs for equipment or help at home, and facilitates delivery of services.

In addition, two nurse champions – Elizabeth (Beth) Clevenger and Cecilia (Ceci) Carvajal – with expert training in geriatric syndromes and screening tools, dedicate two days a week to helping colleagues work with these patients.

A Department-Wide Effort Addresses Challenges for Older Adults in the ED

Isaacs says it is helpful that UCSF Health has its own version of an AFED at UCSF Helen Diller Medical Center at Parnassus Heights because, “We talk frequently, and though we have different models and different patient mixes, it helps to share what works and what doesn’t."

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And the challenges are frequent. Take patient boarding, a national problem where patients who have been admitted remain in the ED when there are no beds available in the hospital. Isaacs says the AFED team has found older adults, especially those with dementia, often wind up boarding in the ED for longer periods than other patients, likely because it can be difficult to find hospital beds that can address the unique needs of patients with dementia.

"We understand that no patient benefits from a prolonged stay in the emergency department, but [because of the stressful atmosphere in an ED], boarding particularly exacerbates geriatric syndromes, like delirium, so we need to pay special attention to these patients when they are boarding,” he says.

Partly with that in mind – and partly as a result of talks they have had with a patient and family council they have formed – the ZSFG AFED has established its Purple Bracelet Project, which involves each patient with a dementia diagnosis wearing a purple bracelet, since the condition is not always easily discernible on a first encounter and requires specific communication strategies. The AFED team also sees to it that these patients have a sensory cart at their bedside (pictured), filled with items to keep them engaged.

“The most effective intervention has been robotic pets,” says Isaacs. “It’s remarkable and dramatic how they calm people and decrease agitation.”

Coordinating Care Beyond the ED

To ensure continuity of care once these patients leave the ED, the patient navigator also does the legwork necessary to help ensure care continues outside the ED. This might involve everything from arranging adult day care for patients with dementia or home-based physical therapy through facilitating connections to services for averting loneliness, depression, or food insecurity.

Together, says Isaacs, “These interventions support the AFED’s efforts to continually improve the care of older adults while they are in the emergency department and to connect them effectively to community resources."