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5 Essentials of a Geriatric Emergency Department

News  |  By Michelle Ponte  
   May 17, 2016

It is not enough for an organization to say it is geriatric-friendly. Geriatric EDs need to monitor hospital admission rates, readmission rates, patient transfers, patient outcomes, and patient experience to help prevent avoidable hospitalizations.

This article first appeared in the May 2016 issue of HealthLeaders magazine.

Hospital emergency departments have been challenged by a variety of factors, including the impact of healthcare reform, increasing numbers of people living with multiple chronic conditions, and a rapidly growing aging population.

One solution is the geriatric ED, which offers emergency care tailored to the specific needs of older adults, along with an opportunity to improve healthcare outcomes and reduce unnecessary hospitalizations and readmissions. In 2007, there were approximately 45 GEDs in the United States. "Today we believe there are over 100, and momentum is underway. It is very promising," says Terry Fulmer, PhD, RN, FAAN, president of the John A. Hartford Foundation in New York City, which supports initiatives to improve healthcare for older adults and seeks to grow the field of geriatric emergency medicine. Roughly 40 million Americans are 65, says Fulmer. What's more, she adds, is that people 85 and older are now the fastest growing population. As the population of older adults grows, emergency medicine experts believe GEDs could double in number.

GEDs are evolving and vary widely, from those with dedicated beds in a traditional ED to those with separate units that treat only older patients. Because GEDs are a relatively new care model, healthcare organizations may face various challenges when it comes to design, operations, staffing, and training. Successful GEDs implement clinical protocols and GED guidelines supported by multiple clinical associations that are aimed at helping providers quickly and efficiently assess, triage, and treat older patients. With the emergency room sitting at the intersection of outpatient and inpatient care, GEDs have the potential to significantly improve care for older patients.

"There's an opportunity now for the ED to be a partner in terms of care coordination and safely preventing avoidable hospitalizations," says Ula Hwang, MD, MPH, FACEP, an emergency physician, researcher, and an associate professor at the Icahn School of Medicine at Mount Sinai, who helps guide clinical GED operations at the 1,171-bed Mount Sinai Hospital in New York City. Not only that, but as GEDs evolve, they have the potential to change how care is delivered across the emergency department and throughout the entire hospital.

Success key No. 1: Design the right physical setting
Older adults have unique medical needs that typically are unmet by standard emergency departments. Aside from the complaints that prompt them to the ED, older adults often have underlying medical conditions, including frailty; sensitivities to light, heat, and sound; as well as delirium and, with growing frequency, dementia. Having the right physical environment in the GED—including special furniture, equipment, and visual elements—is important, says Fulmer. For example, when it comes to acoustics, older people often have hearing impairments. "You have to think about how you will talk to older individuals who might have hearing impairments while not shouting at others who do not have an impairment," she says.

"We opened up a separate physical space that catered more to and was better for older patients," says Denise Nassisi, MD, FACEP, director of the geriatric ED at Mount Sinai Hospital. The GED was launched in February 2012 to meet the needs of its patients age 65 and older, who otherwise would go to the hospital's busy main ED, which sees more than 100,000 visits per year. The GED has 14 treatment spaces, nonskid and nonglare floors, handrails, and high-back chairs that are easy to get in and out of. Mount Sinai's GED features also include reading glasses, hearing devices, and pressure-reducing mattresses. "It's just a quieter, more comfortable space… making it easier for patients to hear and to see, and less likely to become confused and delirious," says Nassisi, who is also associate professor in the departments of medicine and emergency medicine at the Icahn School of Medicine at Mount Sinai in New York City.

Success key No. 2: Build an interdisciplinary team
Geriatric emergency medicine is a team sport. "You start with the conviction that the best care will be delivered by interdisciplinary teams of people who have special credentialing," says Fulmer. She adds that geriatric EDs must have three key characteristics: special knowledge, special protocols, and special staff with expertise. It is this foundation that enables providers to recognize symptoms that are typical of and unique to geriatric patients. "Older adults may present with the same conditions as younger patients, but they also may have distinctly different symptoms," says Fulmer.

For example, a younger individual having a heart attack might present with chest pain, while an older person might come in with confusion or jaw pain," says Fulmer. "When an older person presents to the emergency room with a change in mental status, or they appear confused, that can be the harbinger of any number of acute problems. The presentation can be pretty unique in older people and needs to be managed appropriately by knowledgeable people."

Lining up a strong interdisciplinary team before day 1, is critical, Nassisi says. A lot of planning took place before Mount Sinai's GED opened. "We formed a very broad interdisciplinary team to address some of the complex issues that elderly patients who come to the emergency department face," says Nassisi, noting that it was important to "make a cultural change in emergency medicine." For example, she says, in the traditional ED culture, a frail elderly patient who takes a lot of medications and has multiple comorbidities, as well as a gait disturbance, will be treated with an abundance of caution. "The culture in the past was, 'There's a lot going on. I want to make sure they're OK. I had better just admit them,' " says Nassisi.

Today, however, the interdisciplinary team, which is trained to work with older adults, is establishing new processes and advanced care coordination. "We partner with a medical team, including nurses, social workers, physical therapists, our geriatric medicine colleagues, and pharmacists to look at the evidence first," says Nassisi, stressing that hospitalization may not be in an older person's best interest. "Older patients who get admitted often do worse. They tend to get delirium, have iatrogenic complications, and they also undergo a functional decline that they may not recover from," says Nassisi.

The interdisciplinary model may involve bringing a social worker to the ED to meet with the patient and assess the need for home health services. Or a physical therapist may evaluate that a patient's gait is safe, says Nassisi. "We also have our pharmacist meet with and work with patients to get an accurate medication list and identify any medications that might not be appropriate for them to be on." GED experts stress that it is important to be able to offer these services 24 hours a day to avoid having to admit patients to the hospital.

Nassisi also notes that providing access to transitional care nurses in the GED has been a game-changer in terms of helping patients navigate the healthcare system. "They do on-site assessments of the patient, are able to screen for delirium, cognitive dysfunction, and depression, and are able to assess what their needs are in the home," she says. They also do outpatient referrals and coordinate with homecare services to make sure the patient has the appropriate follow-up. "Usually, we have a call in 24 to 48 hours to see how the patient is doing at home and then further follow-up calls," says Nassisi. "They're at regular intervals just to make sure that everything has transitioned successfully in the outpatient setting. The patients are getting good-quality care and are happy."

Success key No. 3: Hone screening, triage processes
Older patients are at risk for geriatric syndromes, including delirium and dementia.

Successful geriatric EDs have finely honed systems that allow them to accurately assess, screen, and triage older patients early on during the visit. Triaging can be a lengthy process in the traditional ED because case management usually happens late in the visit, and generally after the physician has assessed the patient. This may mean an older patient has to wait hours for staff and outside agencies to coordinate services and medications before going home or transitioning to a new care environment.

This and other care practices for the elderly didn't sit well for an innovative emergency physician at the University of North Carolina. And so a decade ago Kevin Biese, MD, a geriatric emergency physician and associate professor and vice chair for academic affairs of the department of emergency medicine at UNC's Chapel Hill School of Medicine, started implementing new education and care processes for older patients.

Today, along with many other care practices, Biese and his team are piloting a patient vulnerability assessment that includes a questionnaire with 16 questions that is filled out by patients or family members of all patients over the age of 65 who present at UNC's two emergency departments, which have been offering geriatric emergency services over the past year.

"That information is given to case management up front to help them identify who to see so that they can be doing their evaluation at the same time that I'm doing my evaluation," says Biese. "Then we can decide together, based on available resources, the best outcome for that patient," he adds. "We have had some good success with it, and it is helping case managers get the information that they need in our ED to identify who they should be seeing earlier on."

Biese says the geriatric emergency services program is making steady progress at UNC. "We don't have a separate geriatric ED at UNC, nor do I necessarily think we should. Through education and care processes, and now starting on structure, we are in the process of making the entire ED geriatric appropriate." Both EDs, UNC Main Campus and UNC Hillsborough Campus, will continue to explore opportunities to expand geriatric emergency services.

Success key No. 4: Provide geriatric training for all
Because elderly patients can often have unique symptoms and conditions, geriatric ED programs must be vigilant about keeping up with training and education. "We offer education for everyone, including registration associates, nursing staff, ER techs, physician assistants, residents, and providers," says Nassisi. "There is a core team, but also it is making sure that everyone who works in the department is aware of patient issues and is trained," says Nassisi.

Mount Sinai also has dedicated pharmacists in the emergency department who went through geriatric certification, notes Hwang, an early proponent of geriatric emergency care. "This is something that puts some teeth behind the belief in what's happening as opposed to just saying, 'Well, that's great, go do it,' but then you don't actually provide them any support."

"We have robust educational processes for our physicians and nurse champions, as well as enhanced case management support for our physicians and innovative protocols for integrating their input into the care of older adults."

She also notes that Mount Sinai Hospital, along with two other hospitals, participates in the Geriatric Emergency Department Innovations in Care through Workforce, Informatics and Structural Enhancements, a Centers for Medicare & Medicaid Services clinical demonstration program. GEDI WISE is a three-year program designed to provide clinical, workforce, and informatics support to geriatric emergency care.

When Biese finished his emergency medicine training in 2006, he and his colleagues had little exposure to geriatrics. "I became concerned about the way older adults were treated in our emergency departments by very caring nurses, physicians, and the whole team, who all wanted to do the best thing. Without the training, without systems to support best practices, without even knowing what best practices are, it was obvious that older adults were getting hurt," he says.

"There needs to be a physician education program to really help train the ER docs in some geriatric principles of care," Biese says. "We have robust educational processes for our physicians and nurse champions, as well as enhanced case management support for our physicians and innovative protocols for integrating their input into the care of older adults." Additionally, Biese helped start a geriatric emergency medicine fellowship at UNC, which graduated its first fellow in 2014. He has also helped write guidelines for national fellowship programs. As a result, he says there are five national geriatric emergency fellowships.

Success key No. 5: Be vigilant about metrics
It is not enough to say you are geriatric-friendly. Geriatric EDs care can vary widely from very specific approaches to really just cosmetics, notes Fulmer. Organizations need to be monitoring hospital admission rates for older adults, readmission rates, patient transfers, patient outcomes, and patient experience.

Patient outcome areas include how well they avoided adverse drug events and reduced hospital lengths of stay, says Hwang, noting that it is also important to look at the ED length of stay. While it is too early to share results from Mount Sinai's participation in GEDI WISE, she says she is optimistic that the GED will get good marks in terms of cost and admission data. "We have some early preliminary data demonstrating that our interventions are in fact reducing patients' risks of admission," says Hwang, who is also collaborating with Biese, several healthcare associations, and the John A. Hartford Foundation to teach geriatric emergency department boot camps to hospitals interested in developing a GED.

"We've had lots of success stories in being able to navigate the patient to transition into the home in cases where they would otherwise have been admitted," says Nassisi. "We also have been able at times to send patients directly from the emergency department to a subacute rehab or other care facility when we've determined that it's not safe for them to go back home." The Mount Sinai GED has been so successful around care transitions that the organization is looking to expand the model to include younger patients who are at-risk for hospitalization.

At UNC, Biese notes that readmissions are going down. "With support from UNC Health Care leadership, the UNC ED has an enhanced and innovative case management program that contributed, along with other hospitalwide programs, to the relative rate of readmissions for the hospital dropping by over 10% and the absolute rate dropping by more than 3%."

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