Benavidez G, Garrido M, Frakt A. Transforming Emergency Departments to Better Care for Elderly Patients. JAMA Forum Archive. Published online September 12, 2018. doi:10.1001/jamahealthforum.2018.0036
Many people don’t realize that if an elderly individual needs to go to an emergency department (ED), how the person is cared for may differ greatly, depending on which ED they visit. Unless they’ve discussed the issue with a clinician, they’re likely unaware that not all EDs are designed, prepared, or staffed to meet the complex care needs of older adults.
Fortunately, a recent initiative by the American College of Emergency Physicians (ACEP) to accredit geriatric emergency departments is encouraging EDs to better address the needs of older patients and is providing guidance on which EDs are best able to care for such patients.
Older patients present with unique physical, pharmacological, cognitive, and social needs. They are at greater risk than younger patients of falls and fractures, have high rates of using 5 or more medications concurrently (polypharmacy), and often present with Alzheimer disease or related dementias (ADRDs). The number of US residents living with Alzheimer disease is expected to almost triple by 2050. Older adults also often experience loneliness, which is a risk factor for mortality comparable with obesity and substance use disorders.
In a typical ED setting, 2 main issues make it difficult to care for patients like this: a lack of specialized clinicians and an environment not conducive to geriatric care.
First, polypharmacy in the older population is a dangerous problem. A study of 2057 older adults in Italy found that polypharmacy is a risk factor for adverse outcomes after ED visits. Clinicians not trained in geriatric medicine may lack the clinical expertise to manage potential adverse consequences of polypharmacy, including medication nonadherence, drug interactions, and drug reactions. They may be unable to properly manage an older patient in a state of delirium. They may miss opportunities to refer patients to relevant social services and hospitalize them instead. Providing options like home-based care and around-the-clock support services of multidisciplinary teams can speed the discharge process and help avoid unnecessary hospital admission.
Second, the physical design of the typical ED was not created with older patients in mind. Slippery floors, harsh lighting, and beds that are difficult to get in and out of may pose safety concerns to older patients. For example, there’s evidence that lighting can have negative effects on sleep patterns, depression, and agitation of nursing home residents with ADRD, and that lighting designed to increase daytime circadian stimulation may help alleviate such effects. Research also indicates that proactive measures can be effective in preventing ED falls.
Inability to provide proper care may result in adverse health outcomes, longer stays, and unnecessary hospitalizations and costs. Properly caring for older patients requires a specialized design and coordinated care management strategy.
This year, the ACEP started accrediting geriatric EDs. This process is an important step to ensure that these EDs meet adequate standards of care for the population they’re intended to serve. The ACEP and the American Geriatrics Society provide geriatric ED guidelines to facilitate design and implementation. Adherence to these staffing, care coordination, and structural guidelines is necessary for accreditation. Depending on services, design, staffing, and compliance with guidelines, geriatric EDs are given a Bronze, Silver, or Gold ranking.
Having geriatric emergency specialists on staff, as well as having inpatient staff and coordinators on call, is intended to optimize visits and deliver quality, comfortable, and cost-effective care. Other guidelines focus on reducing hospital admissions. Geriatric EDs have been successful in reducing admissions. One innovative way some geriatric EDs do this is the inclusion of a transitional care nurse, whose purpose is to coordinate older adults’ transition from the ED to home, ideally avoiding inpatient admission as well as unnecessary patient risks and costs. A recent study found that among older patients of similar age and acuity who sought care in 3 geriatric EDs, those who saw transitional care nurses were less likely to be admitted to the hospital than those who did not.
Quality improvement programs embedded in the geriatric ED monitor metrics relevant to the population, such as geriatric volume, identification of abuse or neglect, return to ED within 72 hours, polypharmacy, and falls. The geriatric ED must also be designed to be accessible, easy to navigate, and equipped with supplies necessary to care for the population they serve. Equipment may include exam chairs designed to facilitate the exam process, beds and mattresses designed to reduce bed sores and falls, walking aids, nonslip surfaces, and warming blankets.
By 2050 the number of people aged 65 years or older will more than double, and those aged 85 years or older will more than triple. The demand for geriatric care will grow rapidly because of this. In addition to meeting the needs of our parents and grandparents now, geriatric EDs may help hospitals prepare to meet the care quality needs of the rapidly expanding geriatric population.
In its first round of geriatric ED review, ACEP accredited 8 pilot hospitals where such EDs were first implemented. The second round of accreditation began in August 2018 (ACEP reported to us that they have 50 EDs in queue currently waiting for accreditation).
Corita Grudzen, MD, vice chair for research and associate professor of emergency medicine at New York University School of Medicine, told us by email that “[t]he incorporation of geriatric ED guidelines, paired with the appropriate training for emergency staff, has the potential to transform geriatric emergency care.” An ACEP stamp of approval will serve patients and systems, by both raising standards and providing a trusted indicator of which EDs can best meet the emergency needs of older patients.
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