The Geriatric ED: Structure, Patient Care, and Considerations for the Emergency Department Geriatric Unit

"The stay here is, of course, not appropriate for an old person": the perspective of healthcare providers on older patients in the emergency department

BACKGROUND

In aging societies, emergency departments (ED) face an increasing number of older, geriatric patients. Research shows that older emergency patients have a greater burden of comorbidities and a higher risk of adverse events. It has been questioned whether contemporary ED structures can meet the specific needs and characteristics of older patients. Little is known about how professional health care providers perceive and experience ED care for older patients. This study aimed to get insight into the perspective of healthcare providers working with older ED patients and to explore the challenges they experience in their daily work.

METHODS

The study used a qualitative research design with a social-constructivist perspective and a Grounded Theory based methodology. Data were collected through qualitative interviews with N = 25 healthcare providers from different urban EDs in Berlin, Germany, and adjacent healthcare institutions. Following the Ground Theory approach, categories and central themes were identified, analyzed, and interpreted to gain a comprehensive understanding of the healthcare provider perspective.

RESULTS

The interviews revealed a significant and increasing relevance of geriatric ED patients for healthcare providers. However, there was no shared definition of 'the geriatric patient'. Most interviewees found ED structures to be inadequate for older patients. They described specific challenges, such as information gathering and safety risks in the ED, as well as an increased use of resources (both time and personnel) when caring for older patients. In addition, specific problems in the collaboration with other professions and institutions were addressed, namely nursing homes, hospital wards, consultations, and the hospital social service.

CONCLUSION

Healthcare providers experience a structural mismatch between contemporary EDs and the specific needs of geriatric patients. They are aware of the vulnerabilities of geriatric patients and try to compensate for inherent structural shortcomings. Such structures and limited resources often cause practical, organizational, and ethical problems. There is a great need to develop, implement, and evaluate systematic approaches and care concepts that address the specifics of ED care for geriatric patients.

The adherence of Turkish emergency departments to geriatric guideline recommendations

OBJECTIVES

This study aims to determine the availability of geriatrics-friendly protocols, pieces of equipment, and physical environments alongside potential opportunities of improvement in the emergency departments of our country.

METHODS

This prospective, cross-sectional study was conducted between the 1st and 29th of February, in the year 2024, within the AI, AII, B group- and university hospitals in Turkey. A questionnaire form consisting of three subdivisions in which general pieces of information, information regarding appropriate personnel/management for geriatrics-friendly emergency departments, equipment/materials, and the presence of physical environments was presented online to the participants and the responses that were provided online were evaluated.

RESULTS

The study was conducted with a total of 175 participants from hospital emergency departments. The number of hospitals with monthly older patient application amounts of 500 and above was 133 (76.0%). It was observed that personnel/management knowledge was, relative to guideline suggestions, at low levels. When the appropriateness of personnel/management knowledge and total equipment/materials were compared to hospital roles, it was determined that university hospitals adhered closest to the guideline and that inter-group differences were significant (p < 0.001).

CONCLUSIONS

It was determined that the compliance of emergency departments in Turkey with the criteria specified in the geriatric emergency department guidelines is at very low levels.

Optimizing older patient care in emergency departments: a comprehensive survey of current practices and challenges in Northern Italy

BACKGROUND

The progressive aging of the population and the increasing complexity of health issues contribute to a growing number of older individuals seeking emergency care. This study aims to assess the state of the art of care provided to older people in the Emergency Departments of Lombardy, the most populous region in Italy, counting over 2 million people aged 65 years and older.

METHODS

An online cross-sectional survey was developed and disseminated among emergency medicine physicians and physicians affiliated to the Lombardy section of the Italian Society of Geriatrics and Gerontology (SIGG), during June and July 2023. The questionnaire covered hospital profiles, geriatric consultation practices, risk assessment tools, discharge processes and perspectives on geriatric emergency care.

RESULTS

In this mixed method research, 219 structured interviews were collected. The majority of physicians were employed in hospitals, with 54.7% being geriatricians. Critical gaps in older patient's care were identified, including the absence of dedicated care pathways, insufficient awareness of screening tools, and a need for enhanced professional training.

CONCLUSIONS

Tailored protocols and geriatric educational programs are crucial for improving the quality of emergency care provided to older individuals. These measures might also help relieve the burden on the Emergency Departments, thereby potentially enhancing overall efficiency and ensuring better outcomes.

Routine statins use is associated with less adverse outcome in patients above 70 years of age admitted to hospital with COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can lead to multiorgan insufficiency and death, particularly among the older adults. Statins have been suggested as potentially protective drugs due to their pleotropic effects, but the actual benefit of statin use among the older population in this setting is not clear. This study aimed to evaluate the association between preadmission statin use and the presentation and clinical outcomes of hospitalized COVID-19 patients older than 70 years of age.

METHODS

A historical cohort study of all patients above 70 years of age who were hospitalized with COVID-19 infection in a large academic hospital between March and August 2020 was performed. The association between preadmission statin use and patients' presentation and adverse outcome was studied. Adverse outcome was defined as any of the following: shock, invasive or non-invasive ventilation, organ insufficiency, myocardial infarction, cerebrovascular accident, in-hospital or 30-day post-admission mortality, hospital stay longer than the median length of stay of all COVID-19 patients, referral to nursing home or rehabilitation center.

RESULTS

Seventy-two (44%) of the 163 studied patients (median age 82 years, 45% males) had been preadmission treated with statins. The statin-treated patients (STP) had a higher prevalence of diabetes (40% vs 24%, p = 0.028) and cardiovascular disease (58% vs. 34%, p = 0.002). Seventy two percent of the STP had adverse outcome, compared to 86% of the non-STP (p = 0.033). After adjustment for potential confounders, prior statin use was associated with decreased risk for an adverse outcome (odds ratio = 0.4, 95% confidence interval 0.18-0.92, p = 0.03).

CONCLUSIONS

The preadmission use of statins was associated with a lower risk of adverse outcome in older adults hospitalized with COVID-19. Continuation of statin treatment might be implemented for risk reduction of adverse outcomes in the older population in the era of new SARS-CoV-2 variants and less effective vaccines.

Models of care for frail older persons who present to the emergency department: A scoping review of the literature

BACKGROUND

People aged ≥65 years comprise approximately 20 % of all emergency department (ED) presentations. Frailty amongst this cohort is common yet can go undetected.

OBJECTIVE

To summarise the evidence regarding models of care for frail older people in the ED.

METHODS

The Joanna Briggs Institute scoping review framework was used. Literature searches were conducted in five electronic databases published from 2009 to 2022. Original research that met the criteria: frail older people aged ≥65 years, models of care and ED were included.

RESULTS

A total of thirteen articles met the criteria for inclusion in this review. These comprised four studies of frailty care models and nine studies of care models using different assessment tools to identify frail older people. Care models were comprised of various specialist team members (e.g., geriatrician/ED physician and nurse). Processes underpinning these models included tools to support clinicians in the assessment of frail older adults, particularly around functional status, comorbidities, symptom distress, quality of life, cognition/delirium, and social aspects. Outcomes of care models for frail older people included: shorter ED length of stay, lower hospital admission rates, cost savings and increased patient satisfaction rates.

CONCLUSION

A variety of models, supported by a variety of assessment tools, exist to identify and guide care delivery for frail older people in the ED. Careful consideration of existing policies, guidelines and models is required before implementing new service models.

Emergency Department Interventions for Frailty (EDIFY): Front-Door Geriatric Care Can Reduce Acute Admissions

OBJECTIVES

The EDIFY program was developed to deliver early geriatric specialist interventions at the emergency department (ED) to reduce the number of acute admissions by identifying patients for safe discharge or transfer to low-acuity care settings. We evaluated the effectiveness of EDIFY in reducing potentially avoidable acute admissions.

DESIGN

A quasi-experimental study.

SETTING

ED of a 1700-bed tertiary hospital.

PARTICIPANTS

ED patients aged ≥85 years.

MEASUREMENTS

We compared EDIFY interventions versus standard care. Patients with plans for acute admission were screened and recruited. Data on demographics, premorbid function, frailty status, comorbidities, and acute illness severity were gathered. We examined the primary outcome of "successful acute admission avoidance" among the intervention group, which was defined as no ED attendance within 72 hours of discharge from ED, no transfer to an acute ward from subacute-care units (SCU) within 72-hours, or no transfer to an acute ward from the short-stay unit (SSU). Secondary outcomes were rehospitalization, ED re-attendance, institutionalization, functional decline, mortality, and frailty transitions at 1, 3, and 6 months.

RESULTS

We recruited 100 participants (mean age 90.0 ± 4.1 years, 66.0% women). There were no differences in baseline characteristics between intervention (n = 43) and nonintervention (n = 57) groups. Thirty-five (81.4%) participants in the intervention group successfully avoided an acute admission (20.9% home, 23.3% SCU, and 44.2% SSU). All participants in the nonintervention group were hospitalized. There were no differences in rehospitalization, ED re-attendance, institutionalization and mortality over the study period. Additionally, we observed a higher rate of progression to a poorer frailty category at all time points among the nonintervention group (1, 3, and 6 months: all P < .05).

CONCLUSIONS AND IMPLICATIONS

Results from our single-center study suggest that early geriatric specialist interventions at the ED can reduce potentially avoidable acute admissions without escalating the risk of rehospitalization, ED re-attendance, or mortality, and with possible benefit in attenuating frailty progression.

Should age be incorporated into the adult triage algorithm in the emergency department?

OBJECTIVE

To compare resource utilization and mortality between older and younger adult patients with similar ED chief complaints and ESI triage levels.

METHODS

This was an observational study of consecutive adult patients (age ≥ 40) who presented to an academic ED over a 1-year period with chest pain, abdominal pain, altered mental status, generalized weakness, or headache. Patients were categorized into 40-64, 65-79, and ≥ 80-year old groups. Mortality and utilization outcomes were compared between age groups through logistic regression models or Cox proportional hazards adjusting for ESI level and chief complaint. Odds ratios (OR) and hazard ratios (HR) were calculated with 95% confidence intervals (CI).

RESULTS

A total of 9798 ED visits were included. As compared to younger adults (age 40-64), older adults, independently of ESI level and chief complaint, had higher ED laboratory use (OR 1.46 [CI 1.29, 1.66] for age 65-80; OR 1.33 [CI 1.15, 1.55] for age ≥ 80), ED radiology use (OR 1.40 [CI 1.26, 1.56]; OR 1.48 [CI 1.30, 1.69]), hospital admission (OR 1.56 [CI 1.42, 1.72]; OR 1.97 [CI 1.75, 2.21]), and ICU admission (OR 1.38 [CI 1.15, 1.65]; OR 1.23 [CI 0.99, 1.52]). Despite similar ESI and chief complaint, patients age 65-79 and ≥ 80 had higher 30-day mortality rates (HR 1.87 [CI 1.39 to 2.51] and 2.47 [CI 1.81 to 3.37], respectively).

CONCLUSIONS

Older adults with similar chief complaints and ESI levels than younger adults, have significantly higher ED resource use, hospitalization rates, and mortality.

Concepts in Practice: Geriatric Emergency Departments

In 2018, the American College of Emergency Physicians (ACEP) began accrediting facilities as "geriatric emergency departments" (EDs) according to adherence to the multiorganizational guidelines published in 2014. 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. Hospitals interested in making their EDs more geriatric friendly thus face the challenge of adopting, adapting, and implementing extensive guideline recommendations in a cost-effective manner and within the capabilities of their facilities and staff. Because all innovation is at heart local and must function within the constraints of local resources, different hospital systems have developed implementation processes for the geriatric ED guidelines according to their differing institutional capabilities and resources. This article describes 4 geriatric ED models of care to provide practical examples and guidance for institutions considering developing geriatric EDs: a geriatric ED-specific unit, geriatrics practitioner models, geriatric champions, and geriatric-focused observation units. The advantages and limitations of each model are compared and examples of specific institutions and their operational metrics are provided.

Management of elderly people with Stroke: strategies based on action research

OBJECTIVE

To elaborate and implement, through an educational intervention with the nursing team of the Emergency Unit, strategies that contribute to the management of elderly people suspected/affected by Stroke.

METHOD

Action research with eighteen nursing professionals working in the Emergency Unit of a reference hospital. The data were collected through five pedagogical workshops and systematized through the thematic analysis.

RESULTS

After a situational analysis and identification of the difficulties in the management of these elderly, a synthesis chart was prepared with strategic actions, responsible professionals and perspectives for implementation in the short, medium and long term. Short-term strategies had, for the most part, immediate implementation; the others were agreed on the need for further implementation.

FINAL CONSIDERATIONS

The educational intervention allowed the construction of strategies that were implemented or agreed with the management for later applicability, sensitizing the group regarding the importance of the qualification and prompt care in the management of the elderly suspected/affected by Stroke.

White Paper-Geriatric Emergency Medicine Education: Current State, Challenges, and Recommendations to Enhance the Emergency Care of Older Adults

Older adults account for 25% of all emergency department (ED) patient encounters. One in five Americans will be 65 or older by 2030. In response to this need, geriatric emergency medicine (GEM) has developed into a robust area of academic and clinical interest, with extensive evidence-based research and guidelines, including clear undergraduate and postgraduate GEM competencies. Despite these developments, GEM content remains underrepresented in curricula and licensing examinations. The complex reasons for these deficits include a perception that care of older adults is not a core emergency medicine (EM) competency, a disjunction between traditional definitions of expertise and the GEM perspective, and lack of curricular capacity. This White Paper, prepared on behalf of the Academy of Geriatric Emergency Medicine, describes the state of GEM education, identifies the challenges it faces, and reviews innovations, including research presented at the 2018 Society for Academic Emergency Medicine (SAEM) Annual Scientific Meeting. The authors propose a number of recommendations. These include recognizing GEM as a core educational priority in EM, enhancing academic support for GEM clinician-educators, using social learning and practical problem solving to teach GEM concepts, emphasizing a whole-person multisystem approach to care of older adults, and identifying ageist attitudes as a hurdle to safe and effective GEM care.

Comprehensive geriatric assessment pilot of a randomized control study in a Swedish acute hospital: a feasibility study

BACKGROUND

Comprehensive geriatric assessment (CGA) represent an important component of geriatric acute hospital care for frail older people, secured by a multidisciplinary team who addresses the multiple needs of physical health, functional ability, psychological state, cognition and social status. The primary objective of the pilot study was to determine feasibility for recruitment and retention rates. Secondary objectives were to establish proof of principle that CGA has the potential to increase patient safety.

METHODS

The CGA pilot took place at a University hospital in Western Sweden, from March to November 2016, with data analyses in March 2017. Participants were frail people aged 75 and older, who required an acute admission to hospital. Participants were recruited and randomized in the emergency room. The intervention group received CGA, a person-centered multidisciplinary team addressing health, participation, and safety. The control group received usual care. The main objective measured the recruitment procedure and retention rates. Secondary objectives were also collected regarding services received on the ward including discharge plan, care plan meeting and hospital risk assessments including risk for falls, nutrition, decubitus ulcers, and activities of daily living status.

RESULT

Participants were recruited from the emergency department, over 32 weeks. Thirty participants were approached and 100% (30/30) were included and randomized, and 100% (30/30) met the inclusion criteria. Sixteen participants were included in the intervention and 14 participants were included in the control. At baseline, 100% (16/16) intervention and 100% (14/14) control completed the data collection. A positive propensity towards the secondary objectives for the intervention was also evidenced, as this group received more care assessments. There was an average difference between the intervention and control in occupational therapy assessment - 0.80 [95% CI 1.06, - 0.57], occupational therapy assistive devices - 0.73 [95% CI 1.00, - 0.47], discharge planning -0.21 [95% CI 0.43, 0.00] and care planning meeting 0.36 [95% CI-1.70, -0.02]. Controlling for documented risk assessments, the intervention had for falls - 0.94 [95% CI 1.08, - 0.08], nutrition - 0.87 [95% CI 1.06, - 0.67], decubitus ulcers - 0.94 [95% CI 1.08, - 0.80], and ADL status - 0.80 [95% CI 1.04, - 0.57].

CONCLUSION

The CGA pilot was feasible and proof that the intervention increased safety justifies carrying forward to a large-scale study.

TRIAL REGISTRATION

Clinical Trials ID: NCT02773914. Registered 16 May 2016.