ED Leaders Take Multiple Paths to Improve Geriatric Emergency Care
It has been several years since the Geriatric Emergency Department (GED) Guidelines were published and then endorsed by the American College of Emergency Physicians (ACEP), the Emergency Nurses Association (ENA), and other groups.1 But although it is well understood the U.S. population is rapidly aging, experts agree only a few EDs provide the kind of care the GED Guidelines recommend. Where’s the disconnect?
“Some of the things EDs need [to align with GED Guidelines] are help from a pharmacist, expanded physical therapy coverage and, most important, a social worker or some person who can help arrange extra care for some of these patients,” says Richard Shih, MD, professor of emergency medicine at Florida Atlantic University and a medical toxicologist. “These are great things to strive for, but there is no specific funding for them, and they require time, resources, and personnel.”
In his communications with geriatricians, Shih has observed many of these specialists incorrectly assume the kind of care described in the GED Guidelines is delivered in the ED because guidelines generally drive what practices are appropriate and accepted.
To clear up this misconception, and to hopefully help EDs consider how to best move toward providing better care to older adults, Shih participated in a panel discussion at the American Academy of Emergency Medicine’s (AAEM) Scientific Assembly held last year. The panel, which included both emergency physicians and geriatricians, focused on how to best balance the aspirations of the GED Guidelines with what the panel members viewed as realistic expectations of what many EDs can reasonably hope to achieve.
More recently, in a summation of the discussion, Shih and colleagues highlighted three significant medical issues that frequently arise in the care of older adults: delirium, falls, and polypharmacy.2 “If you don’t have the ability to meet the GED Guidelines, [consider] what ways you can practically address these three areas,” Shih says.
Regarding delirium, Shih and colleagues noted 10% of older adults who present to the ED experience this condition, but it is only recognized about one-third of the time. “It is hard to tell sometimes if [a patient has] dementia ... or delirium,” Shih observes. “Delirium implies there is an acute medical process that is causing a patient’s presentation, but many patients have background dementia that has been there or is gradually getting worse over a period.”
The distinction is important because while dementia is not reversible, the acute medical process that may be causing delirium is important to identify and address. Further, if clinicians miss delirium, studies show patients experience worse outcomes over time, according to Shih. “What we are recommending is No. 1, pay attention to this issue,” he explains. “No. 2, you can do a brief delirium screen, and if the patient is at high risk for having delirium as opposed to dementia, then start really assessing for that ... through blood testing.”
Shih acknowledges delirium is a more complex diagnosis to pin down than a heart attack or stroke, particularly during a pandemic when access to knowledgeable family members or caretakers is limited. “This is difficult, and [delirium] does get missed sometimes,” Shih says. “When it gets missed, the patients don’t do as well.”
Falls are a big problem for older adults. Data show that close to one-third of adults older than age 65 years who live in the community experience a fall each year. Further, older adults who present to the ED following a fall are at serious risk of experiencing functional decline and depression in the next six months.3,4
While the GED Guidelines advocate for a comprehensive approach to evaluating and managing patients who have fallen, Shih notes many EDs lack the resources to comply with such recommendations. “For a busy ED that is taking care of multiple patients, it is hard to do a full fall assessment and make a plan for the patient in the ED unless you have a dedicated person to do it,” he says. In the absence of such resources, Shih and colleagues recommend emergency clinicians focus on educating patients and caregivers about the significance of the fall. For instance, patients who have fallen are at extremely high risk of experiencing another fall leading to a subsequent injury. Shih advises clinicians to urge patients who have experienced a fall to follow up with their primary care physician (PCP) to learn what steps they can take to reduce their risk of subsequent falls.
Emergency clinicians with more time or resources at their disposal also may be interested in taking advantage of Stopping Elderly Accidents, Deaths, and Injuries (STEADI), an initiative of the CDC that gives healthcare providers resources pertaining to screening, assessment, and interventions related to fall risk in older patients. At the very least, this program offers educational materials that can be passed on to patients and/or their caregivers.5
Regarding polypharmacy, older adults often take multiple medications, and this can lead to adverse events, but what can EDs reasonably do to address the problem? Shih says the American Geriatrics Society’s Beers Criteria lists dozens of medications that can lead to adverse events in older adults, but it is difficult for emergency providers to stay on top of so many drugs.6 Consequently, Shih and colleagues suggested highlighting a much smaller list of medications that are particularly problematic. “Find five to 10 groups of medications that are especially high risk,” he advises.
For instance, the most common drug classes that cause adverse effects in older patients who present to the ED include hematologic agents, hypoglycemics, cardiovascular medications, psychoactive medications, and antibiotics. However, Shih acknowledges it is unclear how to manage a patient who is on a potentially problematic drug or drug combination. “I believe that [issues related to polypharmacy are] best dealt with by the primary care physician, someone who is looking at everything,” Shih offers.
Nonetheless, that does not mean the ED physician cannot begin a dialogue about the issue with the patient. For example, in the case of a patient who is on two sedation medications, Shih will tell the patient he is worried he or she could become too sedated, leading to a potential fall. But Shih also will advise the patient to discuss the issue with his or her PCP. “You have to be very tactful and respectful to the PCPs and all the other physicians involved,” he explains. “If a physician makes a change without [the PCP’s] knowledge and without making sure they are both on the same page, people get frustrated.”
Shih notes there might be good reasons why a patient needs to be on a medication that is on the potentially problematic list. “The PCP probably knows the patient better than we do ... and a lot of patients have very complex medical problems,” he says.
Still, drug-related adverse events occur most commonly in older adults. Shih says the ED encounter is an opportunity to identify any medication concerns and to discuss these concerns with the patient.
To align their care of older adults with at least some of parts of the GED Guidelines, a growing number of departments are following ACEP’s Geriatric Emergency Department Accreditation (GEDA) program. Begun a little more than three years ago, the program offers three different tiers of accreditation to suit the capabilities and resources of different EDs.7
The GEDA requirements closely align with the GED Guidelines, although EDs have options in determining which best practices they intend to implement. “You can start by taking the interventions that are attainable to you with your resources and your patients, beginning with level three, which is the lowest level. Then, work your way up to level two or level one,” explains Kevin Biese, MD, FACEP, chair of ACEP’s GEDA accreditation team. “Start with what you can do and build on that record of success.”
Even with the COVID-19 pandemic straining resources, the GEDA program has continued to grow. Currently, Biese notes there are 300 EDs that have achieved some level of GEDA accreditation, with 100 more in the process. “That’s 6% or 7% of [all U.S.] EDs. It’s not enough, but we are making progress,” Biese says.
Biese concurs the GED Guidelines are aspirational at this point, but he likens the move toward improvements in geriatric care in the ED to the push that took place some years ago to improve pediatric emergency care. In an earlier era, many hospitals balked at the idea they were supposed to handle many extra tasks for kids. “But some hospitals really rose to that challenge and made themselves full-fledged pediatric EDs and centers of excellence in that area,” Biese observes. “All hospitals and all EDs over time incorporated some of those best practices and made care better for all of those patients.”
Biese agrees falls, delirium, and polypharmacy are important areas of focus for EDs that want to improve their care of older adults. He views the AAEM panel’s recommendations as practical and applicable. Other areas EDs commonly choose to focus on within the GEDA accreditation process include the identification of elder mistreatment and the appropriate use of urinary catheters.
Although lack of funding is cited as one reason why the GED Guidelines are difficult to meet, Biese notes there is funding available to EDs that choose to make improved geriatric care a priority. “Align with your [accountable care organization], Medicare Advantage, or risk-based contracting. [Recognize] that you can improve quality and decrease costs,” he says. “That can help with the resources to make [improved geriatric care] a reality.”
Biese also points to a program underway at Dartmouth-Hitchcock Medical Center in Lebanon, NH, where staff are using telemedicine to connect some of its in-house geriatric expertise with critical access hospitals in surrounding rural areas. The goal is for EDs to improve the emergency care they are providing to older adults while also meeting the requirements for GEDA accreditation.
The push to improve the emergency care of older adults is gaining momentum. “Everyone knows it is the right thing to do,” Biese says. “The challenge is just how do we work together to get it done.”
- Geriatric Emergency Department Guidelines.
- Shih RD, Carpenter CR, Toila V, et al. Balancing vision with pragmatism: The geriatric emergency department guidelines-realistic expectations from emergency medicine and geriatric medicine. J Am Geriatr Soc 2022; Mar 12. doi: 10.1111/jgs.17745. [Online ahead of print].
- Sirois MJ, Émond M, Ouellet MC, et al. Cumulative incidence of functional decline after minor injuries in previously independent older Canadian individuals in the emergency department. J Am Geriatr Soc 2013;61:1661-1668.
- Carpenter CR. Deteriorating functional status in older adults after emergency department evaluation of minor trauma — opportunities and pragmatic challenges. J Am Geriatr Soc 2013;61:1806-1807.
- Centers for Disease Control & Prevention. About STEADI. Page last reviewed July 16, 2020.
- American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2019;67:674-694.
- American College of Emergency Physicians. Geriatric Emergency Department Accreditation Program.
It has been several years since the Geriatric Emergency Department (GED) Guidelines were published and then endorsed by several groups. But although it is well understood the U.S. population is rapidly aging, experts agree only a few EDs provide the kind of care the GED Guidelines recommend. Where’s the disconnect?
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