Geriatric EDs improve care, reduce utilization
Main article: Innovation in action: The genesis of the geriatric ED
Adults ages 65 and older account for about 18% of total emergency department (ED) visits, according to the American College of Emergency Physicians (ACEP). That percentage has increased steadily in the past decade and will do so for the foreseeable future. There were 43 million adults in that age range in 2012, with the number expected to nearly double to 83 million by 2050.
Many older adults who seek emergency care have an underlying condition that is the source of the problem. For example, patients who present with a fracture from a fall may be overmedicated, suffering dementia or simply need to remove the throw rugs that are creating a falls hazard in their homes.
That’s why the most important component of a geriatric ED — and a criteria required for all levels of ACEP accreditation — is training for clinicians in the special needs of frail elderly patients, says Kevin Biese, MD, co-director of the Division of Geriatric Emergency Medicine at University of North Carolina-Chapel Hill and chair of ACEP’s accreditation program.
Other key components of a geriatric ED include:
- Processes and procedures (e.g., screening for mobility issues or delirium) that recognize the unique needs of older adults
- Integration with community resources such as Meals on Wheels and home health services that can increase a patient’s ability to remain healthy at home
- Comfortable accommodations that make a patient’s ED experience as easy as possible
“A geriatric emergency department doesn’t usually mean a separate emergency department for older adults. It means an emergency department that’s dedicated to taking excellent care of older adults, along with the rest of its population,” Biese says.
The physicians and nurses who treat elderly patients in the ED at Carroll Hospital Center in Westminster, Md., receive ongoing training from geriatrician Nicole Cimino-Fiallos, MD. She coaches nurses to be on the lookout for common issues that might not be immediately apparent and trains them to use tests that screen for depression, falls risk, elder abuse and delirium.
Physicians are trained to consider a patient’s age as an important factor in assessing medical complaints and choosing treatment plans. For example, the bacteria that causes pneumonia is different for an elderly person than for a younger patient, Cimino-Fiallos says, so different medications are needed. Moreover, elderly patients may be taking other medicines that need to be considered when a new a prescription is added, and pneumonia may be more life-threatening for a frail senior than for a young patient.
At St. Joseph’s University Medical Center in Paterson, N.J., the 20-bed geriatric unit is equipped with non-slip floors, special lighting and thick mattresses. A nurse navigator is responsible for making sure all care plans for senior patients get proper follow-through. A case manager works to ensure that a safe discharge with the proper support — whether that’s a commode delivered to the patient’s home or an appointment with a specialist, for example — is arranged before the patient leaves the ED. All elderly patients are screened for fall risk, dementia, delirium, nutrition issues and depression.
“If we identify any of those problems, we provide specialty care to help keep the person functionally independent at home,” says Mark Rosenberg, DO, chairman of emergency medicine at St. Joseph’s Health.
Interviewed for this article: Interviewed for this article: Kevin Biese, MD, co-director, Division of Geriatric Emergency Medicine, University of North Carolina-Chapel Hill, Chapel Hill, N.C.; Nicole Cimino-Fiallos, MD, Carroll Hospital Center, Westminister, Md.; Mark Rosenberg, DO, chairman of emergency medicine and chief innovation officer, St. Joseph’s Healthcare System, Paterson, N.J.