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Published On September 6, 2018

CLINICAL CARE

Should Older Patients Have Their Own ED?

Advanced age brings special needs, especially in the emergency department. So some hospitals are changing designs and processes for their senior patients.

In August, a 75-year-old Wisconsin woman with chronic leukemia fell and called 911 for the third time in a single day. Paramedics finally convinced her to go to the emergency room. Rather than just tending to her injuries, the attending physician in the ED put her through a new “falls” protocol for elderly adults that included not only blood pressure screening but also a TUG, or “timed up and go,” test, which measures how quickly a patient can stand and walk. When she didn't want to be hospitalized, the physician also ordered physical therapy for her at home, to initiate a treatment plan, review her home environment and suggest modifications.  

The falls protocol at Aurora St. Luke’s South Shore hospital, in Cudahy, Wisc., is part of a larger effort by the hospital’s parent network, Aurora Health Care, to “geriatricize” its emergency departments, says Michael Malone, medical director for senior services for the group of 14 acute care hospitals. Falls are a priority because they account for 10% of emergency room visits for older patients. For elderly adults, they are the leading cause of death from trauma.

Aurora Health Care is a member of the Geriatrics Emergency Department Collaborative (GEDC), a group of nine hospital systems that have been working since 2015 to revamp the emergency care they offer. Funded by $7 million in grants from the John A. Hartford Foundation in New York City and West Health in La Jolla, GEDC aims to add another 50 hospitals over the three years.

This push for geriatric-specific emergency care comes at a time when a growing body of research points to the emergency department as a perilous place for elderly patients. The current system of emergency acute care for older adults, especially when it results in hospitalization, is “incredibly costly and often not aligned with the needs of elderly patients,” says Kevin Biese, co-director of geriatric emergency medicine at the University of North Carolina, Chapel Hill, and a GEDC leader. Biese cites unwanted or unneeded hospitalizations as well as frequent readmissions as signs that the current system isn’t working. “That’s despite wonderful physicians, nurses and others trying to provide the best care they can,” Biese says.

In 2013, a coalition of emergency medicine organizations and the American Geriatrics Society made 42 specific recommendations to improve emergency department care that, according to Biese, can be grouped into four broad categories. First is design, which entails creating an environment that avoids jarring elements such as hard cots and fluorescent lights. Next is process—screening for delirium, dementia and mobility and then connecting patients with available resources. Third is education, the training of nurses, doctors, pharmacists and case managers to recognize older adults’ special needs. Finally, its "connections with community" program encompasses measures that help patients obtain access to social support outside the hospital.

Recently there were 140 self-described specialized geriatric care emergency departments in the United States. That’s up from 24 in 2013, but it is still just a tiny fraction of the more than 5,000 EDs in the country. Meanwhile, a growing number of standard emergency departments, like the one at Aurora St. Luke’s, are attempting to provide specialized care for geriatric patients who need it. Yet the leaders of most EDs haven’t even read those 2013 recommendations, according to Biese.

To help ensure that EDs advertising specialized geriatric care are actually providing it, early this year the American College of Emergency Physicians launched a geriatric ED accreditation program that lays out 27 best practices. The accreditation is split into three tiers, which correspond to the number of best practices implemented. So far, 13 hospitals have been awarded the credential, and interest in geriatric emergency medicine is suddenly booming, says Christopher Carpenter, director of evidence-based medicine for the Division of Emergency Medicine at Washington University School of Medicine in St. Louis, and a past president of the Academy of Geriatric Emergency Medicine for the Society for Academic Emergency Medicine.

The question is: Does specialized geriatric care really work? There is, so far, scant data to support the effectiveness of geriatric EDs, says Carpenter, and some hospitals have been reluctant to pour resources into an unproven concept. But more research is coming, says Ula Hwang, an investigator in the departments of emergency medicine and geriatrics at the Mount Sinai School of Medicine in New York City and another leader of the GEDC initiative. This year, Hwang published research from three medical centers showing that elderly ED patients who are evaluated by ED nurses with geriatric training to help assess and coordinate health care support are less likely to be hospitalized. In addition, according to data that Hwang and her colleagues presented at a spring conference, hospitals that provided specialized geriatric care reduced their Medicare costs and total expenditures. Hwang recently received funding to create a data repository for GEDC hospitals, and a forthcoming grant from the National Institutes of Health would help fund research evaluating outcomes related to geriatric emergency medicine care.

Ultimately, Biese believes significant improvements in geriatric emergency care are inevitable. As more families take parents or grandparents to emergency rooms, they will see that the system isn’t working and must change. “It’s not a hard sell,” he says.