Emergency Department Spotlight: Alice Peck Day Memorial Hospital

Alice Peck Day Memorial Hospital 

Alice Peck Day Memorial Hospital (APD), a member of Dartmouth Health (DH) is the first critical access hospital in the United States to have achieved Level 1 Geriatric Emergency Department Accreditation (GEDA). Located in Lebanon, N.H., the hospital serves patients from both New Hampshire and Vermont. The hospital’s patient volume has nearly tripled in the past 4 years, and the emergency department (ED) has expanded from seven beds to include two surge spots with four beds each. The ED receives an estimated 13,000 annual visits, with approximately 5,500 of those visits being older adult patients. In 2024, the ED received the American College of Emergency Physicians (ACEP)’s Rural GED Performance Award. The APD ED has received the Press Ganey Guardian of excellence award for the last two years in a row. The Guardian of Excellence award given by Press Ganey is awarded to departments and organizations that perform at or above the 95^th percentile in key performance measures.

APD is situated in a tight-knit, rural community and is known for its attentive staff and outstanding patient care. 

“We are so embedded in our community and so loved by our community,” said Kristie Foster, RN, MSN, Director of the Emergency Department and Urgent Care for APD’s ED. “The community is just very dedicated to APD, and I think that it speaks to our culture. One of our values is kindness, and you can truly feel that in every interaction that you have with the staff. We truly are community taking care of community.”

Foster, who served as nurse champion for the hospital’s work to earn Level 2, and ultimately Level 1, GEDA accreditation, has led numerous quality improvement initiatives to improve care for older adults in the ED. The initiatives were part of DH’s efforts to pursue GEDA accreditation, for GEDC hosted bootcamps.

One such initiative was the creation of a Take Care Kit for older adult patients that includes distraction devices, music and other calming items. The goal of the kit is to help decrease the extra stimulation that occurs in the emergency department and prevent the onset of delirium. This kit also includes a baby doll, which has been successfully used to soothe patients with delirium. 

“We have a baby doll that we give out, and it’s amazing how effective that intervention can be for a patient who is delirious. The patient may go from trying to pull their lines and drains out, to holding the baby and finding comfort in that doll. One patient in particular got the biggest smile on her face and calmed immediately.”

APD also provides yellow socks to patients identified as fall risks to help staff members ensure that those patients are ambulating safely and using appropriate mobility devices when necessary. 

Foster is most proud of the hospital’s callback program, through which care providers follow up with patients aged 70 and older after an emergency department visit and connect them with additional care if needed. These patients are discharged from the ED and either have a primary care provider outside of APD or do not have a primary care provider at all. 

The program is guided by a process that Foster created to help older adults receive better continuity of care. Patients who spend hours in the emergency department are often tired and hungry and may not be able to retain all of the important discharge information they’re given, Foster said. 

The call back program ensures that patients understand the instructions and next steps in their care. Additionally, the call back program looks to help bridge care gaps after ED discharge, whether that means helping patients get a PCP, an appointment with a specialist or to connect them to community resources such mobile integrated health or community nurse programs. 

“When I was trying to navigate the system for the patient, it just became so clear to me that this is a huge need,” Foster said. “We need to connect patients to the next steps and make sure they understand their discharge instructions.” 

APD’s callback program has seen great success since its inception, and Foster said that even patients who don’t require additional care have expressed their gratitude for the follow-up. The program encouraged many patients to shift their primary care to APD. 

“I can’t even explain how rewarding it was to do a call and [the patient] may not need anything, but the fact that somebody cared to connect with them meant so much,” Foster said. 

Foster recently created and implemented a three-tiered Social Determinants of Health (SDOH) screening tool to identify older adult patients who may need assistance with issues like food insecurity or pharmaceutical costs. 

“We looked at ways we could utilize the ED visit to identify resources and risk factors that could affect a patient’s success post-discharge or contribute to a repeat ED visit,” Foster said.

The SDOH screening tool allows for immediate assistance as well as an automatic function that auto populates community resources based on identified need in their discharge paperwork. For example, a patient who screens for food insecurity receives a meal bag to take home after their emergency department visit and local resources auto populate in their discharge paperwork. 

Through numerous initiatives, Foster and her team have found ways to improve older adult patients’ experience at APD. They are now working to implement more age-friendly practices across their organization. 

“We’re just trying to make sure that we are all aligning,” Foster said. “You know, everyone was doing little pockets of things, but now we’re truly bringing best practices forward so no matter where the patient is in our organization, they’re getting the type of care they want and deserve.” 

Learn more about GEDA accreditation to improve geriatric care