4 Models to Operate Geriatric Emergency Departments

The four different approaches to establishing geriatric emergency department services vary in the amount of resources required.

Over the past five years, four primary models for geriatric emergency departments have emerged, according to a new journal article.

The number of Americans over age 65 is expected to double to nearly 100 million by 2060. With multiple chronic conditions and high costs of care at end of life, older adults have relatively higher healthcare costs compared to younger Americans. In 2010, citizens over age 65 were 13% of the population but accounted for 34% of healthcare spending.

In 2014, guidelines were published for the formation of geriatric emergency departments based on consensus reached by the American College of Emergency Physicians, The American Geriatrics Society, Emergency Nurses Association, and the Society for Academic Emergency Medicine.

"The guidelines were developed to help every ED improve its care of older adults. The geriatric ED guideline recommendations span the care continuum from out-of-hospital care, ED staffing, protocols, infrastructure, and transitions to outpatient care," the co-authors of the new journal article published by Annals of Emergency Medicine wrote.

The article presents four models that serve as "practical examples" for establishing geriatric EDs.

1. Geriatric ED unit

A geriatric ED unit is a dedicated space within an emergency department that can include enhancements such as flooring and beds that are designed for older adults to reduce risks, including falls and delirium.

Screening assessments are used to determine which older adult patients should be treated in a geriatric ED unit, the co-authors of the journal article wrote. "Screening tools or criteria for the unit are required because for most EDs the volume of older adults is higher than the capacity in these units, and ED resources must be focused on patients who will most benefit."

Advantages of geriatric ED units include having the expertise of a dedicated staff, which often features geriatric practitioners, social workers, physical therapists, occupational therapists, palliative medicine consultants, and pharmacists. In addition, training costs are relatively low because education is focused on a single team rather than the whole ED staff.

Limitations of geriatric ED units include the potential for limited operating hours because of staffing constraints and disparities of care when the unit is closed.

2. Geriatrics practitioner model

This model provides geriatric care throughout an ED rather than in a specialized unit within an ED, the journal article co-authors wrote.

"The entire ED adopts a geriatric-focused approach that may include structural changes, screening with geriatric assessment tools, or both. A geriatric nurse, nurse practitioner, allied health specialist, geriatrician, or all four are available in the ED. Evaluation by these geriatric practitioners occurs concurrently with routine ED care."

Geriatric practitioners work with social workers, case managers, or nurses who are adept at care transitions and matching patients with community resources such as home health care.

Advantages of this model include geriatric assessments provided by caregivers with specialist training as well as lower costs and increased flexibility compared to the geriatric ED model.

Limitations of this model include the potential for long ED length of stay to accommodate interdisciplinary geriatric evaluations.

3. Geriatrics champion model

In this model, there is no geriatrics clinician in the ED, but a geriatric champion plays a leadership role in initiatives and establishing care pathways.

"This model may be chosen because of small patient volumes or staffing costs of a geriatric practitioner. Instead, the model relies on initial assessment in the ED and close ties to outpatient resources and outpatient geriatric assessment for patients. The geriatric champion is a physician or nurse with expertise in geriatric ED care," the journal article co-authors wrote.

A key role of the geriatric champion is to provide staff training and to develop protocols that improve ED care.

When ED physicians determine that a patient needs a geriatric assessment, the patient is either hospitalized or is referred for timely follow-up with a geriatrician in an outpatient setting.

An advantage of this model is improving geriatric care at low cost.

A limitation of this model are barriers to outpatient care coordination. "Outpatient care coordination can be challenging to initiate during an ED visit if appropriate resources are not in place, and clinicians may revert to traditional care practices on high-volume days or when time is limited," the co-authors wrote.

4. Geriatric-focused observation unit model

This approach is a combination of the geriatric ED unit and the geriatrics practitioner models.

"An ED observation unit is a unit within the ED (typically 10 to 20 beds) that divides patients into cohorts for evaluations longer than a 4-hour ED stay but not requiring an inpatient stay beyond 48 hours. The targeted 8- to 24-hour observation period allows a full interdisciplinary geriatric assessment," the journal article co-authors wrote.

With the potentially long ED length of stay, patients can be held overnight then receive geriatric assessments from in-hospital consultants or interdisciplinary teams the next morning.

"This model can be used with a dedicated geriatrics team in the observation unit or in conjunction with the hospital's inpatient geriatric consultation service, eliminating the need to hire ED-specific staff. This model adapts and repurposes already existing inpatient services (geriatrics, physical therapy, speech therapy, occupational therapy, pharmacists, case managers, and other consultants) for ED patients," the co-authors wrote.

Advantages of geriatric observation units include decreasing return ED visits and hospitalizations, research shows.

Identifying patients who can benefit most from a geriatric observation unit can be difficult, the co-authors wrote. "High-risk patients may require greater resources than those available within a 24-hour stay, or may need a full qualifying admission for nursing facility placement."