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senior ERExpertPeerReviewStamp2x200We are all familiar with the concept of pediatric EDs. We see them as medical students, we train in them as residents, and we work alongside pediatric EM fellows. It is generally clear what pediatric EDs have to offer: smaller sized beds and equipment, nurses trained in pediatric triage and assessment who know how to put IVs in babies and calm crying kids, and physicians with training in pediatric Emergency Medicine. But what about the other end of the age spectrum? Over the last 10 years geriatric EDs, also called Senior EDs, have been popping up around the country. You may have been wondering why that is, and what they have to offer. Here are a few thoughts.

What are Geriatric EDs?

Geriatric EDs (or GEDs) are separate areas or buildings in which patients age 65 and over can receive emergency care. Their purpose is to provide excellent emergency care tailored to meet the needs of older adults in order to improve health outcomes in a cost-conscious manner [1]. Specifically, care should be timely, evidence-based, goal-oriented, and reliable. For example, one important role for GEDs is to help identify which patients need to be admitted, which patients can be discharged with additional services, and how each patient can be connected to relevant resources that can help them manage their health. Ideally this would help avoid the need for admission, repeat visits, and re-admissions. Guidelines for GEDs were released earlier this year [2] after approval by ACEP, SAEM, AGS (American Geriatrics Society), and ENA (Emergency Nurses Society). Currently there are around 36 hospitals with GEDs in existence or with plans to open GEDs this year [3].

Why have GEDs Emerged Over the Last Decade?

Big population changes are on the horizon. As the ‘baby boomer’ generation ages, the population of adults age 65 and older is expected to rise from 40 million in 2010 to 70 million in 2030. With this population change will come more ED visits by older adults who are more medically complex than younger patients on average, and require more resources in the ED. Older adults are more frequently transported by ambulance than younger patients [4]. They have longer ED stays and higher costs per ED visit [5]. The admission rate for older adults is higher, and they also have more frequent return visits and readmissions [6].

“Geriatric ED patients represent 43% of admissions, including 48% [of patients] admitted to the intensive care unit (ICU). On average, the geriatric patient has an ED length of stay that is 20% longer and they use 50% more lab/imaging services than younger populations. In addition, Geriatric ED patients are 400% more likely to require social services.” – The GED Guidelines

GEDs have the potential to provide improved care for this population by tailoring their services and staff to meet the needs of older patients, and by preparing in advance with systems of care to manage the anticipated increase in ED visits. A NY Times article reported on the Mt Sinai GED, and said that patient satisfaction was “off the scoreboard”. Under the ACA, if Medicare reimbursement is tied to patient satisfaction (a can of worms that I don’t want to open here), there could also be a financial incentive to creating GEDs for some hospitals.

What do GEDs Have to Offer?

The goal of GEDs is to provide improved care for older adults. There are many different features that GEDs can include, and each GED will not necessarily have all of these components. I have divided them into three main categories: Staff, Systems, and Structures.

Staff

The staff of GEDs will typically include physicians, nurses, social workers, and case managers, all of whom have had training in geriatric ED care.

Nurses: Nurses in a GED should have ongoing education in geriatrics as it pertains to their day-to-day activities. In triage, for example, this means understanding that older adults often are sicker than they appear, and that the classic ESI triage category fails to identify half of older patients who will require a life-saving intervention [7]. They will need an appreciation for the fact that “normal” vital signs in an older adult may not be normal for that patient. Just as in pediatrics, a heart rate of 90 in a neonate should raise concern, a heart rate of 90 in an 85-year old who is on beta-blockers should also raise concern. Having age-appropriate screening measure in triage may help identify sicker patients earlier. With appropriate education, nurses can also perform screening measures relevant to older adults to help identify delirium [8], cognitive impairment (dementia) [9], or falls risk [10].

Social Workers: Social workers and case managers can play a major role in transitions of care for older adults [11]. Like the scenario described in another recent NY Times article I am sure all of us have admitted older patients to the hospital when the patient could potentially have been discharged if appropriate follow-up services were available, such as a home visit for a wound check. There are many risks that go along with a hospital admission for older adults, including iatrogenic injury, nosocomial infection, and delirium, as well as the financial burden of admission or observation costs [12]. When possible, discharge home is preferable if the patient does not absolutely require an inpatient admission. However, many older patients cannot be discharged home because they do not have anyone to help take care of them, transport to their appointments, and help with meals or medications.

Social workers and case managers can help connect patients with available resources to facilitate safe discharge [13]. These resources may include home health nurses, medical transportation, medical equipment or assistive devices, prescription assistance, someone to help with activities of daily living or meal programs, physical or occupational therapy, and follow-up with a primary care physician. Social workers and case managers can also help coordinate with the nursing or assisted living facilities where patients reside. Many long-term care facilities, for example, have designated areas for assisted living or skilled nursing levels of care. A patient who usually lives independently or in the assisted living areas could be moved to the skilled nursing area temporarily in order to have additional monitoring, management of medications, and nursing attention. This requires a knowledge of the local nursing homes and long-term care facilities, an awareness of the available options, and an individualized assessment of the patient’s needs. In a survey of existing GEDs, 90% had “direct follow up through patient call-backs”. [3].

Physicians: All Emergency Physicians should be comfortable caring for older adults. Minimum core competencies for EM residency graduates in geriatric care were published in 2010 [14]. In a GED, physicians may have further training in geriatric EM such a geriatric EM fellowship, or additional CME. According to the GED guidelines, they should receive ongoing training in the principles of geriatric care, including  atypical presentations of disease, trauma, transitions of care, cognitive disorders, elder abuse and neglect, medication management, and transitions of care. Physicians may participate in quality improvement projects that pertain to care of the elderly, or be on hospital leadership committees to assess care in the GED and promote improvements.

Systems

GEDs should have systems in place to help with patient care during their ED stay, to minimize potential harm, and to facilitate smooth transitions of care for older patients.

Transitions of Care: “Smooth” transitions of care are particularly important in older adults. Systems should be set up to communicate medication changes, results of the ED workup, and the medical plan to the patient, family caregiver, primary care physician, or facility where a patient resides. Designing transition of care processes and periodically evaluating their effectiveness can improve post-discharge patient care, reduce miscommunication, reduce preventable ED returns, and improve overall satisfaction.

Discharge information: With some pre-planning, GEDs can put systems in place that will give patients self-care information about their illnesses. They can help provide more detailed discharge care instructions for patients and family members, printed in larger fonts if needed.

Procedures and protocols: If a procedure or checklist is set up to occur automatically, either through the electronic medical record or intake paperwork, it saves the physician from having to remember to do it. For example, a policy or checklist on appropriate Foley catheter use can decrease unneeded Foleys and their associated UTIs. Automated medication reconciliation can help make sure physicians have an accurate list of the patient’s medications, and can have automatic cross-checking of any new medications for potential interactions. The GED guidelines recommend instituting screening protocols to help identify patients who are at risk of adverse events such as medication complications, falls, or elder abuse and neglect.

Geriatric Consults: Some studies have examined the use of geriatrics consults in the ED or an ED observation area and found that they can reduce admission rates. Data is somewhat mixed, but in one study:

“Yuen, et al. found that over 26 months, there were 2202 geriatric consultations (85 per month), with admission avoided in 85% (47% discharged home, 38% admitted to a “convalescent hospital”).” [15]  The GED Guidelines

Palliative Care: For patients at the end of life, GEDs should be prepared to provide palliative care where appropriate. This includes pain and other symptom management, providing family support, and coordinating with inpatient palliative care teams or hospice services.

“By providing multidisciplinary teams for palliative care interventions, recent literature suggests this will improve quality of life, reduce hospital length of stay and ED recidivism, improve patient and family satisfaction, result in less utilization of intensive care, and provide significant cost savings.” See the GED guidelines  for additional references.

Structures

In one sense, the structural modifications and enhancements of a GED are the easiest to implement, because they do not require changes in the staff culture, education, or systems of care. Some simple modifications include improved lighting, easily readable signs in larger fonts, non-slip anti-glare flooring, and thicker mattresses. Some patients may benefit from the use of recliners or chairs instead of beds to allow them to get up and down more easily. A quieter space without distracting noises is preferable. Having bedside commodes available can be helpful for patients with unsteady gaits who cannot walk to a bathroom. All of these changes may help improve the safety for older adults in the ED as well as help reduce delirium, which is an independent factor for mortality [16], [17].

“The physical plant of a Geriatric ED should focus on structural modifications that promote improvements in  safety, comfort, mobility, memory cues, and sensorial perception both with vision and hearing for elders in the ED” The GED Guideline

Where is it all going?

Having separate GEDs makes medical and financial sense in some communities and hospitals, but will not work everywhere. Only time will tell how widespread GEDs will become across the country and the world. However, every ED and hospital can adopt some of the GED guideline principles and suggestions to improve their care of older adults.

What do you think?

In what ways has or could your ED become more ‘geriatric-friendly’? What are the main challenges to implementing the GED guidelines in your ED? What else should future revisions of the guidelines include? – Leave a comment.

Summary and Take-Home Points:

  1. GEDs have been opening up around the United States at an increasing pace since 2008 and offer theoretical advantages for the care of older patients.
  2. Process improvement efforts to date have focused on the staff, systems, and structures
  3. Understanding the value of GEDs and of specific components of the GED guidelines is an active area of research that will hopefully help guide future GED efforts.
  4. Most hospitals will probably not open GEDs, but all EDs can learn from GED practices and apply some of the same principles to make their ED more geriatric-friendly.

Expert Peer Review 

April 22, 2014

Christina aptly outlines the new American College of Emergency Physicians/American Geriatric Society/Emergency Nurses Association/Society for Academic Emergency Medicine “Geriatric Emergency Department Guidelines” in this ALiEM post. Effective geriatric adult health care is a multidisciplinary activity so involving each of these professional organizations and their designated diplomats to the two-year GED Guideline development process was essential. As 21st Century emergency medicine confronts the silver tsunami of aging baby-boomers for the next few decades, the “team sport” approach to geriatric care ought to permeate every adult ED as they develop management protocols, continuing medical education priorities, quality improvement initiatives, and transition of care processes.

As noted by Christina, the most important components of a GED ED also apply to ED’s that care for aging adults but lack the resources, space, or personnel to designate a portion of the ED for older adults only. These components include staff education, in addition to pre-established and collaborative protocols between physicians/physician extenders, nursing, social workers, and case managers knowledgeable about geriatric resources available in their community. Since the landscape of what we know about geriatric EM care continues to evolve rapidly, ongoing geriatric EM-specific education for ED staff is essential.  The infrastructure is the least important of the GED Guideline recommendations.

The GED Guideline authors recognize that these recommendations are largely consensus-based, although the authors reviewed and discussed thousands of original research references in constructing the published guidelines. Nonetheless, many (perhaps most) of these recommendations are not truly evidence-based. The tired academic statement of complacency that “more research is needed” unfortunately applies to the components of these GED Guidelines, as well as the overall existence of the GED Guidelines themselves. A few specific examples of what we need to better understand include

  1. How will high-risk geriatric patients in the busy ED be identified? No screening instruments exist that accurately differentiate geriatric patients who are at increased risk for short-term (1-3 month) preventable ED returns, hospital admissions, functional decline, or institutionalization. Similarly, screening protocols to risk-stratify patient’s individual risk for post-ED falls and injurious falls do not exist. Once accurate and reliable instruments exist, protocols to screen patients using ancillary ED personnel, technology, or over-tasked nurses and physicians are needed.  These research priorities have been previously described.
  2. What strategies will be used to prioritize the multiple GED Guideline recommendations? Efforts are underway to develop a transparent process to do so.
  3. Is the GED concept, either in part or in whole, efficacious and cost-effective?  Assessing which components of the GED Guidelines provide the triple aim of optimal care for improved health at reduced costs is an important short-term priority.
  4. How will the GED Guidelines be disseminated heterogeneous EDs worldwide: rural and urban; academic and community; resource rich and resource challenged? The simultaneous publication of these guidelines in peer-reviewed format with an executive summary in Annals of Emergency Medicine, Academic Emergency Medicine, and the Journal of the American Geriatrics Society is one approach. E-mail blasts to the members of the ACEP Geriatric Section and SAEM Academy for Geriatric Emergency Medicine is another strategy. Lay press coverage by the NY Times (as noted above by Christine) and SiriusXM Doctor’s Radio also help. In addition, posting the GED Guidelines on the AGS website and the new International Consortium for Emergency Geriatrics help to disseminate the principles across specialties and geographic borders.

However, these passive dissemination strategies are only a first step and likely to provide incomplete penetration into the emergency medicine community if we stop there. Therefore, the GED Guideline authors plan to develop a “Geriatric Emergency Department Boot Camp” program with the assistance of ACEP and SAEM.  We envision a 2-3 day workshop in which the instructors travel to the hospital so that nurses, EM physician and physician extenders, geriatricians, surgeons, social workers,  and case managers can evaluate the recommendations within the context of their institution’s patient population, priorities, and resources. This immersion in the GED Guidelines will permit the end-users to critically evaluate the recommendations with the original authors. Participating programs will be encouraged to develop quality improvement projects before the workshop and the QI project progress will be monitored for the next one-year.

Many emergency medicine providers will question the need for GED Guidelines, since most adult EDs already care for large numbers of critically ill or injured older adults every day in a highly competent, compassionate, and professional manner. Others question the value or ethics of focusing scant resources on any specific population based on gender, race, age, or other criteria. The GED Guideline developers believe that there is room for improvement and that a reasonable focus on an aging population could provide societal benefit on multiple levels. For example, EDs crowded with geriatric adults awaiting complex work-ups, inpatient beds, or discharge will inevitably prolong the wait for patients of all ages. Expediting ED processes for geriatric adults, while improving the experience and outcomes of emergency care for patients and families could be a win-win-win for the geriatric patient, all other patients, and the ED providers. The challenge is on the ALiEM readers to improve the first-generation GED Guidelines.  Consider joining the ACEP Geriatric Section, the SAEM Academy for Geriatric Emergencies, the AGS Section for Enhancing Geriatric Understanding and Expertise Among Surgical and Medical Specialist, and/or International Consortium for Emergency Geriatrics today!

Christopher R. Carpenter, MD, MSc, FACEP, FAAEM, AGSF, Chair, ACEP Geriatric Section, GED Guideline Co-Author

 

Follow Dr. Carpenter at @GeriatricEDNews

 

Image credit [1]

 

References

  1. T.F. Platts-Mills, and S.W. Glickman, "Measuring the value of a senior emergency department: making sense of health outcomes and health costs.", Annals of emergency medicine, 2013. http://www.ncbi.nlm.nih.gov/pubmed/24342812
  2. C.R. Carpenter, M. Bromley, J.M. Caterino, A. Chun, L.W. Gerson, J. Greenspan, U. Hwang, D.P. John, W.L. Lyons, T.F. Platts-Mills, B. Mortensen, L. Ragsdale, M. Rosenberg, S.T. Wilber, and . , "Optimal older adult emergency care: Introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine.", Annals of emergency medicine, 2014. http://www.ncbi.nlm.nih.gov/pubmed/24746436
  3. T.M. Hogan, T.O. Olade, and C.R. Carpenter, "A profile of acute care in an aging america: snowball sample identification and characterization of United States geriatric emergency departments in 2013.", Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2014. http://www.ncbi.nlm.nih.gov/pubmed/24628759
  4. M.N. Shah, C. Glushak, T.G. Karrison, R. Mulliken, J. Walter, P.D. Friedmann, D.C. Hayley, and M.H. Chin, "Predictors of emergency medical services utilization by elders.", Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2003. http://www.ncbi.nlm.nih.gov/pubmed/12511315
  5. B.M. Singal, J.R. Hedges, E.W. Rousseau, A.B. Sanders, E. Berstein, R.M. McNamara, and T.M. Hogan, "Geriatric patient emergency visits. Part I: Comparison of visits by geriatric and younger patients.", Annals of emergency medicine, 1992. http://www.ncbi.nlm.nih.gov/pubmed/1610036
  6. S.F. Jencks, M.V. Williams, and E.A. Coleman, "Rehospitalizations among patients in the Medicare fee-for-service program.", The New England journal of medicine, 2009. http://www.ncbi.nlm.nih.gov/pubmed/19339721
  7. T.F. Platts-Mills, D. Travers, K. Biese, B. McCall, S. Kizer, M. LaMantia, J. Busby-Whitehead, and C.B. Cairns, "Accuracy of the Emergency Severity Index triage instrument for identifying elder emergency department patients receiving an immediate life-saving intervention.", Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2010. http://www.ncbi.nlm.nih.gov/pubmed/20370755
  8. J.H. Han, A. Wilson, E.E. Vasilevskis, A. Shintani, J.F. Schnelle, R.S. Dittus, A.J. Graves, A.B. Storrow, J. Shuster, and E.W. Ely, "Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method.", Annals of emergency medicine, 2013. http://www.ncbi.nlm.nih.gov/pubmed/23916018
  9. C.R. Carpenter, E.R. Bassett, G.M. Fischer, J. Shirshekan, J.E. Galvin, and J.C. Morris, "Four sensitive screening tools to detect cognitive dysfunction in geriatric emergency department patients: brief Alzheimer's Screen, Short Blessed Test, Ottawa 3DY, and the caregiver-completed AD8.", Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2011. http://www.ncbi.nlm.nih.gov/pubmed/21496140
  10. C.R. Carpenter, "Evidence-based emergency medicine/rational clinical examination abstract. Will my patient fall?", Annals of emergency medicine, 2008. http://www.ncbi.nlm.nih.gov/pubmed/19231669
  11. C. Kessler, M.C. Williams, J.N. Moustoukas, and C. Pappas, "Transitions of care for the geriatric patient in the emergency department.", Clinics in geriatric medicine, 2013. http://www.ncbi.nlm.nih.gov/pubmed/23177600
  12. M.C. Creditor, "Hazards of hospitalization of the elderly.", Annals of internal medicine, 1993. http://www.ncbi.nlm.nih.gov/pubmed/8417639
  13. S.K. Sinha, E.S. Bessman, N. Flomenbaum, and B. Leff, "A systematic review and qualitative analysis to inform the development of a new emergency department-based geriatric case management model.", Annals of emergency medicine, 2011. http://www.ncbi.nlm.nih.gov/pubmed/21621093
  14. T.M. Hogan, E.D. Losman, C.R. Carpenter, K. Sauvigne, C. Irmiter, L. Emanuel, and R.M. Leipzig, "Development of geriatric competencies for emergency medicine residents using an expert consensus process.", Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2010. http://www.ncbi.nlm.nih.gov/pubmed/20370765
  15. T.M.Y. Yuen, L.L.Y. Lee, I.L.C. Or, K.L. Yeung, J.T.S. Chan, C.P.Y. Chui, and E.W.L. Kun, "Geriatric consultation service in emergency department: how does it work?", Emergency medicine journal : EMJ, 2012. http://www.ncbi.nlm.nih.gov/pubmed/22447816
  16. J. McCusker, M. Cole, M. Abrahamowicz, F. Primeau, and E. Belzile, "Delirium predicts 12-month mortality.", Archives of internal medicine, 2002. http://www.ncbi.nlm.nih.gov/pubmed/11863480
  17. R. Kakuma, G.G. du Fort, L. Arsenault, A. Perrault, R.W. Platt, J. Monette, Y. Moride, and C. Wolfson, "Delirium in older emergency department patients discharged home: effect on survival.", Journal of the American Geriatrics Society, 2003. http://www.ncbi.nlm.nih.gov/pubmed/12657062
Christina Shenvi, MD PhD

Christina Shenvi, MD PhD

Geriatric Emergency Medicine Fellow
University of North Carolina