In recognition of the fact that older adults present unique care needs, the American College of Emergency Physicians (ACEP) has taken a leading role in a new effort to provide Geriatric Emergency Department Accreditation (GEDA) to EDs that meet the standards spelled out in the Geriatric Emergency Department Guidelines, a series of recommendations the ACEP board of directors and several other national emergency medicine and geriatrics organizations endorsed in 2014.

Kevin Biese, MD, MAT, the vice chair of academic affairs and the co-director of the division of geriatric medicine at the school of medicine at the University of North Carolina at Chapel Hill, is leading the accreditation effort for ACEP. “We just launched on Jan. 1, so there are eight hospitals doing pilots at different levels [of accreditation],” he explains.

Biese anticipates that the accreditation program will be available to all hospitals by this summer, and his goal is to accredit at least 50 EDs by the end of 2018. Biese notes that this is a conservative number that should be easily achievable.

“We already know of 30 sites that have pre-emptively said that they want to apply for accreditation,” he notes.

Given the reality that hospitals have differing levels of resources at their disposal based on an array of factors such as trauma level, size, demographics, and community needs, the accreditation program includes three tiers, with tier one representing the most comprehensive accreditation level.

“The [three tiers] are essentially based on how many of the [27 geriatric ED guidelines] you are able to meet, and as you go higher up you are meeting more of them,” Biese notes. “To be a tier two, you need to do 10 of the guidelines, and to be a tier one, you need to do 20 of them. However, not every tier one ED is going to do the same 20 guidelines.”

Biese notes that some hospitals may not employ an ED-based pharmacist, while others will lack case management. In more rural settings, hospitals may need to collaborate to obtain these services, he says. Tier three accreditation is designed primarily for smaller hospitals that may not have 24/7 access to advanced imaging or full-service labs. They also may face staffing challenges. To obtain this lowest level of accreditation, there are no requirements for outcome measures, but the ED will need to offer mobility aids and show evidence of adherence to a urinary catheter avoidance policy. Further, the ED must employ one physician and one nurse who can provide geriatric-focused education.

Biese anticipates that accreditation at the tier three level primarily will involve submitting information online to document that the ED meets the required standards. For tier two accreditation, EDs will need to submit information showing they meet the standards for tier two, and there will be the option of a site visit by a member of the board of governors for ACEP’s GEDA initiative. Tier one will require submitting information online to show that hospitals meet the tier one standards and also will involve a site visit.

Consider the Benefits

Why is ACEP addressing accreditation in this area? Biese notes that the organization recognizes the growing role that emergency medicine plays in the care of older adults, especially in a value-based health system.

“There is a clinical role, and there are all the downstream decisions that are made,” he explains. “As emergency medicine’s role in overall health system resource utilization evolves, ACEP sees setting standards for how older adults are treated in the ED as part of the evolution.” While EDs will not face any penalties if they decline to pursue GEDA, there is potential upside for those that do, Biese shares.

“We know there is interest in the country for geriatric EDs because hospitals are proclaiming that they have geriatric EDs, so this speaks to the recognition of a need and an attempt to address that need,” he says. “We also feel there is a need for clarifying what that means for the public. If [a hospital] says it has a geriatric ED, what should that mean regarding how older Americans are cared for in that ED? That is what we are trying to build.”

Currently, there are more than 100 self-proclaimed geriatric EDs in the United States, and Biese anticipates that many of these facilities will want the recognition afforded by the GEDA process. “We feel there is a good bit of interest because we haven’t marketed the approach yet, but there is a long line of folks waiting to apply as soon as we get through the pilot phase,” he says. In the meantime, Biese and colleagues are working with the pilot sites to fine-tune the accreditation criteria and work out any bugs in the process.

Hospitals or EDs interested in the GEDA process should first thoroughly review the Geriatric ED Guidelines, Biese advises. “It lays out a good listing of things that one ought to be thinking about relating to how to make the ED better for older adults, but also with the knowledge that not all of the guidelines will necessarily be applicable to your site,” he says. “It points you in the right direction.”

Second, identify both a nurse and a physician champion who would like to help move this work forward. Asking both a nurse and a physician to take the lead on this task is critical, Biese advises.

Third, by this summer, when GEDA should be ready for dissemination, explore the program and consider reaching out to leaders of the effort to get more insight on what is needed to move forward.

“The accreditation process is a good tool for accelerating this work in the ED,” Biese notes. “It gives the ED a voice to advocate for the resources it needs to healthcare leadership. Healthcare systems respond to recognition.”

SOURCE

  • Kevin Biese, MD, MAT, Vice Chair, Academic Affairs; Co-director, Division of Geriatric Medicine, University of North Carolina at Chapel Hill School of Medicine. Email: kbiese@med.unc.edu.