Older adults visit emergency departments (ED) at a higher rate, and they often present with multiple chronic conditions and face more social and physical challenges than the general population. Once in the ED, older patients are more likely to have an emergent or urgent condition, be hospitalized, and be admitted to a critical care unit, placing them at greater risk for functional decline, mobility impairment, falls, and delirium.
Treatment plans are not straightforward for this population. Common conditions such as urinary tract infections can present differently depending on age and treatments may vary. There are numerous examples of suboptimal emergency care, including emergency department clinicians failing to diagnose dementia and delirium in a significant number of patients, and lack of adherence to guidelines for fall prevention.
Despite unprecedented growth in aging demographics – with 10,000 baby boomers turning 65 every day – the health care system has not adapting to address unique geriatric needs. Dr. Christopher Carpenter, an associate professor of emergency medicine with Washington University School of Medicine in St. Louis points to: “too few geriatricians, a shrinking primary care safety net, inadequate exposure to geriatric health issues in medical schools and a lack of related guidelines for family and internal medicine practitioners” as part of the problem (1).
For these reasons and more, some emergency departments are making changes to tailor their care and better meet the needs of older adults. Geriatric emergency departments have emerged to fill substantial gaps in care for older adults.
What is a geriatric emergency department?
Geriatric emergency departments (GEDs) ensure that their facilities have the necessary expertise, equipment, and personnel in place to provide optimal care for aging older adults. In GED models, geriatrics-trained interdisciplinary staff perform standardized screening assessments to identify older adults at higher risk for medication interactions, falls, functional decline, and delirium (2-6). Positive results may trigger additional hospital services, such as a consult for physical therapy, occupational therapy, pharmacy and psychiatric consult. They may also be a trigger for a community-based services, such as meal delivery, non-medical transportation, caregiver respite, or assistance with personal caregiving needs.
These are four basic components that set apart geriatric emergency departments:
- Structural enhancement – nonskid floors, diurnal lighting, blankets, thicker mattress pads all add comfort and safety for older adults more susceptible to confusion, falls, and bed sores.
- Screening process – a series of standardized geriatric screening assessment to identify older adults at a higher risk for medication interactions, falls, functional decline, and delirium
- Staff and provider education – specialized training about common geriatric syndromes, which goes beyond the curriculum taught in nursing or medical school
- Community connection – establish a connection to the patient’s community to keep them safer at home
These innovative geriatric emergency department models improve acute care for the geriatric patients during the ED visit and improve chronic care management upon discharge (7) GEDs can also improve systems-level metrics such as hospital throughput by reducing hospital and ICU admissions(8-10). An increasing number of studies (11-16) show that GEDs reduce the likelihood of avoidable hospital admissions (17-22) and readmissions (22) without increasing mortality risk.
Where can I find a geriatric emergency department?
The success of these models and growing demand for senior-specific care in the ED led to the 2014 multi-organizational consensus-based GED guidelines and the 2018 launch of the GED accreditation process, led by the American College of Emergency Physicians (ACEP), which has already accredited over 130 GEDs (23) around the world. The decision by hospitals to pursue accreditation and meet higher standards may serve “as a motivator and facilitator of local geriatric emergency medicine quality-improvement efforts,” Carpenter suggests, ultimately making ED care safer and more effective for tens of millions of older adults annually requiring acute care services.
- IHI. Age-Friendly Health Systems 2019; http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx Accessed 2/11/2019.
- Cossette S, Frasure-Smith N, Vadeboncoeur A, et al. The impact of an emergency department nursing intervention on continuity of care, self-care capacities and psychological symptoms: Secondary outcomes of a randomized controlled trial. International Journal of Nursing Studies. 2015;52(3):666-676.
- Guttman A, Afilalo M, Guttman R, et al. An Emergency Department–Based Nurse Discharge Coordinator for Elder Patients: Does It Make a Difference? . Academic Emergency Medicine. 2004;11(12):1318-1327.
- Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years —United States, 2014. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report. 2016;65(37):993-998.
- Burns E, Stevens J, Lee R. The direct costs of fatal and non-fatal falls among older adults – United States. J Safety Res. 2016;58:99-103.
- Mather M, Jacobsen LA, Pollard KM. Aging in the United States. Population Bulletin (Population Reference Bureau). 2015;70(2).
- Lesser A, Israni J, Kent T, et al. Association Between Physical Therapy in the Emergency Department and Emergency Department Revisits for Older Adult Fallers: A Nationally Representative Analysis. Journal of the American Geriatrics Society. 2018;66(11):2205- 2212.
- LaMantia MA, Stump TE, Messina FC, et al. Emergency Department Use Among Older Adults With Dementia. Alzheimer disease and associated disorders. 2016;30(1):35-40.
- Kent T, Lesser A, Howard J, et al. 30-Day Emergency Department Revisit Rates Among Medicare Beneficiaries With Dementia. Society of Academic Emergency Medicin; Indianapolis, IN.; 2018.
- Hwang U, Dresden SM, Rosenberg MS, et al. Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use. Journal of the American Geriatrics Society. 2018;66(3):459-466.
- Aldeen AZ, Courtney DM, Lindquist LA, Et al. Geriatric Emergency Department Innovations: Preliminary Data for the Geriatric Nurse Liaison Model. Journal of the American Geriatrics Society. 2014;62(9):1781-1785.
- Keyes DC, Singal B, Kropf CW, et al. Impact of a New Senior Emergency Department on Emergency Department Recidivism, Rate of Hospital Admission, and Hospital Length of Stay. Annals of Emergency Medicine. 2014;63(5):517-524.
- Wallis M, Marsden E, Taylor A, et al. The Geriatric Emergency Department Intervention model of care: a pragmatic trial. BMC Geriatrics. 2018;18(1):297.
- Conroy SP, Ansari K, Williams M, et al. A controlled evaluation of comprehensive geriatric assessment in the emergency department: the Emergency Frailty Unit. Age and Ageing. 2014;43(1):109-114.
- Wright PN, Tan G, Lliffe S, et al. The impact of a new emergency admission avoidance system for older people on length of stay and same-day discharges. Age and Ageing. 2014;43(1):116-121.
- Mion LC, Palmer RM, Meldon SW, et al. Case finding and referral model for emergency department elders: A randomized clinical trial. Annals of Emergency Medicine. 2003;41(1):57-68.
- Silvester KM, Mohammed MA, Harriman P, et al. Timely care for frail older people referred to hospital improves efficiency and reduces mortality without the need for extra resources. Age and Ageing. 2014;43(4):472-477.
- Caplan GA, Williams AJ, Daly B, et al. A Randomized, Controlled Trial of Comprehensive Geriatric Assessment and Multidisciplinary Intervention After Discharge of Elderly from the Emergency Department—The DEED II Study. Journal of the American Geriatrics Society. 2004;52(9):1417-1423.
- Miller DK, Lewis LM, Nork MJ, et al. Controlled Trial of a Geriatric Case-Finding and Liaison Service in an Emergency Department. Journal of the American Geriatrics Society. 1996;44(5):513-520.
- Ellis G, Whitehead MA, Robinson D, et al. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ. 2011;343:343.
- Dresden SM, Hwang U, Garrido MM, et al. Geriatric Emergency Department Innovations: The Impact of Transitional Care Nurses on 30-day Readmissions for Older Adults. Acad Emerg Med. 2020;27(1):43-53.
- ACEP-GEDC. American College of Emergency Physicians GEDC. Geriatric Emergency Department Accreditation Program. Irving, TX: American College of Emergency Physicians. In:2017.