New guidelines for geriatric EDs
Recommendations cover many ED strategies
As documented in the CDC’s National Hospital Ambulatory Medical Care Survey (NHAMCS), the population of patients being seen in American EDs continues to get older, except in EDs with a mission to serve children. This continues to be a quiet success story for the emergency system, as emergency care and public health efforts to reduce premature death from trauma, burns, and cardiac arrest have allowed the American population to enjoy much longer and healthier lives. Hospitals are increasingly focused on policies and practices that can more effectively meet the care needs of seniors. A number of hospital systems have opened specialized units or sections within their traditional EDS that are devoted to caring for older patients. However, until recently, hospital and ED administrators have had little in the way of guidance on how to proceed in developing a senior-focused ED, and most experts would acknowledge that data regarding outcomes and costs are still very much lacking in this area.
All hospitals except pediatric facilities are serving older populations, and there are already more than 50 EDs set up to cater to the needs of older populations, with more to follow. A cadre of groups, including the American College of Emergency Physicians (ACEP), the American Geriatrics Society (AGS), the Emergency Nurses Association (ENA), and the Society for Academic Emergency Medicine (SAEM), has jointly issued a comprehensive set of Geriatric Emergency Department Guidelines. (The full guidelines can be accessed at www.acep.org/geriEDguidelines/.)
While the guidelines provide a template of sorts, delineating what is required in terms of staffing and infrastructure to set up a geriatric ED, the authors stress that the new guidance is not just designed for administrators who are planning to open senior-focused facilities or units.
"The development of the guidelines was intended to really look at an evidence-based approach to not only managing care for seniors, but in developing a system of care for seniors when it comes to their emergency care, emergency management, and emergency partners," explains Mark Rosenberg, DO, MBA, FACEP, FACOEP-D, chairman of ACEP’s Geriatric Emergency Department Guidelines Task Force, and chairman of Emergency Medicine, Geriatric and Palliative Medicine, St. Joseph’s Healthcare System, Paterson, NJ. "So the guidelines involve not only the environment of care, but also transition of care strategies, and the assessment of delirium, dementia, depression, and a host of other screenings that are necessary when you are dealing with an older geriatric patient."
Rosenberg likens the emerging trend toward the creation of geriatric EDs to what happened with respect to pediatrics a generation ago when hospital systems were building children’s hospitals and pediatric EDs. "Now we are starting to see these [specialized] needs for seniors," Rosenberg states.
"The [intent] of the guidelines was to develop a standardization or at least a goal for EDs who want to specialize in better care for seniors."
Health care experts broadly agree that older patients have unique healthcare needs, but rapidly changing demographics and regulatory pressures have clearly pushed hospitals to consider these needs in a more comprehensive way. The new guidelines point out that according to the latest census figures, there were more than 40 million Americans older than the age of 65 in 2010, and that the population aged 85 and older is growing at a rate that is nearly three times faster than the rate of the general population.
The NHAMCS data also clearly show that older adults have a high demand for emergency care, notes Timothy Platts-Mills, MD, a co-author of the new guidelines and an assistant professor of emergency medicine at the University of North Carolina at Chapel Hill. "Older adults have a very high rate of acute, severe illness and injury and additionally they have a lot of requirements for after-hours care," explains Platts-Mills, noting that he is speaking as a researcher and clinician rather than on behalf of the other guideline authors or of the sponsoring organizations. "Are there ways we can do this better? I think even though the evidence is not overwhelming for this, the answer is definitely yes. There are better and less better ways to do this."
To be sure, there are some documented benefits to senior-focused care. For instance, Rosenberg points out that patients who receive services in senior-focused EDs are more satisfied with their care. "We also know statistically that patient admissions go down, and this is measurable and quantifiable," says Rosenberg. "At my institution, we went from 54% to 46% of our seniors who would be admitted [from the ED]. And we know that we have seen a decrease in returns to the ED for the same complaint. Practically, that is because of improved patient transition-of-care strategies."
Even though more cost and outcomes data are needed, an increasing number of older adults are seeking emergency care, and more geriatric EDs are being developed. "This is all moving forward so we thought that at least having some expert consensus around what it is to have a geriatric ED, and what that should look like, was important even if the evidence isn’t there yet to support every suggestion we made," says Platts-Mills.
It takes a village’
Through structure and organization, the guidelines emphasize three main areas: staffing, follow-up and transitions of care, and education, says Platts-Mills. "These areas are where there is a lot of [potential] for administrators to improve the quality of care for older adults," he says.
Of particular importance is the way organizations use these three areas to identify and address the priorities of care for the older patient, says Platts-Mills. "Older patients vary a lot in terms of what their priorities are. Some are very high functioning and are sick and want maximal care, and some are not high functioning and they are sick and they may not actually want maximal care," he says. "Then some older patients aren’t too sick, and they are able to go back to the community, but they may have a lot of disabilities, and so the potential for a well-run ED to help older adults return home or return to a nursing home safely is large. I think there is a lot of potential added value."
For instance, if an older patient presents to the ED because he fell in a nursing home, the care decisions made by a provider can vary greatly, says Platts-Mills. "You can spend a lot of money very quickly by doing tests in the ED, and I think emergency physicians realize this," he says. "But it requires extra time and support to have conversations with the people in the nursing home who saw what happened, with the family members to get a better understanding of what the preferences are, and then coordinating things at home to make sure that yes, there is a neighbor who can check on the patient and yes, there are home health people who can come by the following day, and yes, the primary care physician can see the patient within 48 hours."
All of this extra work takes time and energy, and EDs can only accomplish these tasks with the proper staffing and organization, but such resources can add tremendous value both to the patient and to the healthcare system, says Platts-Mills. "If you have a geriatric ED or the components of a geriatric ED — meaning a social worker, connections to a primary care system that can take care of the patient, and resources in the community — then you can really make a big difference," he says. "Yes, it is complicated. It sort of takes a village to take care of older adults, so part of the role of the ED is being at the center of the village or one of the hubs of the village, and being connected to the other parts of the village."
Further, clinician education is central to providing effective care to the older patient, says Platts-Mills. "Medications are a common contributing factor to all sorts of adverse events, including falls," he says. "Also, [education about] looking for more subtle symptoms or presentations in the setting of trauma or acute coronary syndrome; signs and symptoms in older patients sometimes will not be as obvious."
Effectively caring for a geriatric patient requires added training in many different areas, adds Platts-Mills. "Some of this involves developing a comfort level in communicating with older adults and their families, treating their pain, and addressing their symptoms without having a fear of legal concerns or something else," he says.
Aim for a protocol-driven care system
Rosenberg reiterates that it is not reasonable or financially feasible for all hospitals to establish separate geriatric EDs or units. However, they can still rely on the guidelines to improve the care they provide to older adults. In fact, he notes that many of the changes that the guidelines recommend are not just good for seniors; they’re better for all patients. For instance, with respect to environmental factors, non-slip, non-glare floors, dimmable lighting, thicker mattresses, and soothing paint colors make sense for all patients, he says.
All types of hospitals and EDs are planning to improve the delivery of services to older patient populations. Rosenberg recalls the administrators of a 6,000-visits-a-year ED wanted to create a senior-friendly ED — even though they only had about a half-dozen beds to work with. "I said let’s make the whole ED more senior friendly," he says. "Let’s look at the lighting and those types of things, but also for the 65-and-older population, let’s come up with policies, protocols, and care strategies that will be uniquely beneficial for that age group, and that’s what we did."
In his own setting, Rosenberg says there have been many improvements in care for senior patients, but one particularly obvious stride is that clinicians are doing a much better job of diagnosing cases of delirium — one of the conditions commonly misdiagnosed in the senior population. "It is hard to imagine how many cases we would have missed under the old model of care, but we are now doing delirium screening on everybody and we are picking up more cases," he says.
Similarly, by performing nutritional assessments on patients, clinicians are picking up more cases of malnutrition, a condition that puts seniors at risk for revisits to the ED, says Rosenberg. "It is not just painted walls, sound-proofing, and thicker mattresses. It is a whole protocol-driven care system that is unique for the needs of seniors," he says.
However, Rosenberg acknowledges that the guidelines offer so many recommendations that it may be difficult for administrators to discern where to begin their senior-focused improvement efforts. Consequently, he is working with ACEP’s geriatrics section to put together a work group to prioritize the recommended steps and practices. This way, if an administrator is planning to open up a geriatric ED, he or she will be able to focus on the most important things first, explains Rosenberg.
"Some things are very, very easy. The cost of creating a geriatric ED should not be unobtainable within the budgetary constraints that hospitals are going through," says Rosenberg. "You don’t have to add big expense to get better care, better patient satisfaction better management of patients whether they need admission or don’t need admission, and better transitions of care. Much of this can be done by just coordinating [existing] resources."
If the Affordable Care Act helps to link more seniors with primary care providers, that should help EDs better focus their efforts on behalf of senior patients as well, says Platts-Mills. "Then, hopefully, there will be somebody who has a clear sense of what the patient’s priorities are and what sorts of problems they face," he says.
However, Platts-Mills hastens to add that emergency providers should not worry that they will somehow be displaced by PCPs. "There is a common misconception that primary care, once it is set up properly, will make the need for emergency care go away, and that is not supported by any of the data that we have," he says. "Emergency care and primary care are not substitutes. Primary care increases the recognition that patients have medical problems and one of the ways that we treat medical problems is through emergency care."