Geriatric emergency medicine – growing patient numbers drive demand

Just like pediatric emergency units were developed to serve children, healthcare experts are recognizing that older adults require specialized forms of emergency care, which differ from the general population. Indeed, emergency rooms can be unforgiving for the elderly, many of who are often traumatized by the experience.
New geriatric emergency departments have recently begun to emerge, led by the US. They not only provide more appropriate care for older people, but can bring cost savings to a hospital, too.

A major and growing challenge
In the US, up to 25% of ED patients are aged 65 years or older. Indeed, geriatric ED patients represent 43 percent of all admissions, including 48 percent admitted to the intensive care unit (ICU). Geriatric patients in the ED also have an average length of stay that is 20 percent longer than younger populations.
There are no consolidated figures for Europe. However, there are both similarities and differences vis-a-vis the US. In the UK, a Nuffield Trust report in 2009 found nearly 40 percent of all ED admissions being for the over-65s and 10 percent for people aged 85 and above. However, it also observed that “at most, 40 percent of the increased number of emergency admissions” over a four-year period could be explained by the effects of population ageing.

The numbers of elderly are not insignificant.
In the US, the 2010 Census found 13 percent of the population, corresponding to over 40 million people, were over 65 years in age. Their numbers too showed a sharper increase than other population groups, with people in the 85+ age group growing at almost three times the rate of the general population. 
The situation in Europe is even more demanding, with 19.2 percent of the population in the 65+ age group in 2016, up from 16.8 percent a decade previously.

Benefits for both elderly and hospitals
There are several benefits which the elderly can derive from a geriatric ED. The most important is optimization of care. This is achieved by focusing resources, attention and capability to their most common risks and needs; the latter differ in several respects from other age groups.
Conversely, a geriatric ED can also provide benefits to a hospital. Improved standards of care for a large patient population are a useful marketing or public relations tool. In the US, hospitals have been marketing the geriatric ED to attract older patients who utilize higher reimbursing programmes. Finally, the case for special geriatric attention has become compelling due to the Affordable Care Act. This reduces reimbursement, should a patient return to the hospital due to iatrogenic complications such as infections and wounds.

Paradigm change for both emergency and geriatric care
Traditionally, ED teams were not provided with training for the care of older people. The ED environment was instead organized according to single organ management. For elderly ED admissions, a more holistic approach was considered as best practice, especially in terms of frailty and geriatric syndromes. Several such attitudes continue to this day.

In parallel, geriatric medicine (GM) has historically avoided paying attention to emergency care contexts, and competencies specifically associated with the elderly (e.g. management of falls, confusion, dementia, delirium, the risk of adverse drug-drug or drug-food interactions); these are as important in an acute care setting as in a geriatric ward. Indeed, various studies have pointed out that underlying vulnerabilities which led to an ER visit may go undetected and unaddressed by emergency room staff.

Compelling evidence
However, it has also become clear that dedicated geriatric EDs can make a major difference in delivering quality care to the elderly. One study used Medicare data from 2012 and 2013 to study falls by the elderly, a significant cause of morbidity – leading to hip fractures and nursing home admissions. The researchers found that less than 4 percent received a physical therapy (PT) consult. On the other hand, they also discovered that readmission rates for another fall within 60 and 180 days dropped significantly in patients who had a PT consult.

A brief history of the geriatric ED
The concept of a geriatric ED took root in the US in 2008. Since then, such facilities have become increasingly common in the country. Figures from the non-profit ECRI institute state there were 50 geriatric EDs in operation in the US in early 2014, with another 150 in development.
The first American hospital to develop a geriatric ED model was Holy Cross Hospital in Silver Spring, Maryland, part of the St. Joseph Mercy Health Systems. The geriatric practice was inspired by the fact that nearly one of five of its ED patients was 65 or older. Moreover, its CEO made a more prosaic observation – that the hospital’s ED was not well suited to take care of his mother.
The Holy Cross Hospital was used to pilot the concept of a geriatric ED. Since then, other St. Joseph Mercy’s hospitals have developed geriatric EDs, as have other hospital groups.
In 2012, the Icahn School of Medicine at Mount Sinai received an award from the US government’s Department of Health and Human Services to implement a geriatric ED model at three major urban hospitals, namely Mount Sinai Medical Center in New York City, Northwestern Memorial Hospital in Chicago and St. Joseph’s Regional Medical Center at Paterson, New Jersey.

Common sense innovations
The practices prescribed by Holy Cross for its pioneering geriatric ED involved simple environmental standards such as natural glare-free lighting, soothing colours, beds rather than gurneys equipped with better mattresses and non-skid flooring.  Posters and scales were equipped with larger print, and reading glasses made available. The designers also ensured that rooms/units were large enough to accommodate family members, whose role in care delivery of the elderly is now widely acknowledged.

Staff training
However, the most important developments at the Holy Cross ED concerned staff training and responsibilities.  ED staff were given special training in geriatrics, while pharmacists were charged with reviewing medications of every elderly patient, to monitor and analyse them as causative  factors for a medical emergency.  Lessons from Holy Cross, including the maxim that geriatrics care is the ‘ultimate team environment’, have been transferred to other US healthcare facilities and to hospitals in Europe and elsewhere too.

The expertise a well-trained ED team bring to interactions with a geriatric patient directly impact the latter’s condition. Studies have shown that trained ED staff also lead to the use of relatively less expensive outpatient treatments.
The advantage of training nurses for an ED role was highlighted by the ‘Journal of the American Geriatrics Society’ in January 2018. The article, which studied 57,287 patients over 65, reported that an ED-based transitional care nurse (TCN) programme focused on geriatric care was able to reduce the number of unnecessary hospitalizations by 33 percent. Its co-author, Scott Dresden, MD, an Assistant Professor of Emergency Medicine at Northwestern University wrote that the programme “created an otherwise non-existent safety net for this vulnerable population.”
Holy Cross’ first ED also ushered in a full-time, trained geriatric social worker, dedicated to emergency rooms. According to some estimates, geriatric ED patients are 400% more likely to require social services than the general population. Indeed, social workers play a key role in advising and assisting elderly patients to get post-ED care, after discharge. They also seek to know the patients and discover underlying reasons for their coming to the ED.

Reducing re-admissions and penalties
Overall, US hospitals are being compelled by the Affordable Care Act to reduce iatrogenic  complications in the elderly. One study showed that 40 percent of emergency room patients older than 65, who had been denied admission, returned to EDs with conditions which had worsened.  An article in ‘Modern Physician’ found that 27 percent of elderly patients either returned to the ED for admission or died, in the first three months after a hospital visit. 
The ‘Modern Physician’ article, however, observed that 30-day readmission rates for the elderly at Holy Cross Hospital halved after it set up a geriatric ED, from 10.9 percent to 5.2 percent.  Results at another geriatric ED, at St. Joseph Regional Medical Center in Paterson, New Jersey, were even more dramatic: returns of elderly ED patients dropped from 20 percent to just over 1 percent.

Guidelines
Geriatric ED practices are the target of new guidelines in the US, developed by The American College of Emergency Physicians (ACEP), the American Geriatrics Society (AGS) and the Society for Academic Emergency Medicine (SAEM). These call for education and training of medical staff, making specific risk-assessments of senior patients and screening those considered to be vulnerable for co-morbidities such as cognitive problems, falls, etc., performing a comprehensive review of medication, and providing a comprehensive discharge plan.
As part of their geriatric risk management, some hospitals are emphasizing the screening and triaging of elderly patients beyond their primary complaint. One popular tool here is the Identification of Seniors at Risk (ISAR), a simple patient checklist to be completed at the point of entry.
Another innovation is the use of telemedicine as part of ED discharge plans, with a typical 72 hours of coverage at home via video monitoring, and then transitioning care to a primary care physician.

Accreditation
On its part, ACEP has recently launched an accreditation programme for emergency rooms, with three levels of accreditation — basic, intermediate and advanced.
All ACEP accredited facilities must provide elderly patients with walkers, canes and reading glasses. Intermediate accreditation requires provision of suitable lighting and non-slip floors, along with hearing aids, thicker mattresses and warm blankets. Advanced accreditation targets physician-supervised improvement initiatives, such as limiting the use of urinary catheters in older patients.

Europe launches GEM curriculum
In Europe, too, efforts are being made by professional societies to develop a validated curriculum on geriatric emergency medicine (GEM). The curriculum is thorough and covers a full spectrum of activity: pre-hospital care, primary clinical assessment and stabilization, secondary clinical assessment, medication, pain management, palliative care and transitional care, along with  continuous attention to typical co-morbidities in the elderly and to differences in care paradigms and challenges vis-a-vis younger age groups.

Geriatric friendly – a new standard?
In the long run, we may well witness some major re-thinking about the impact of geriatric ED.  Mark Rosenberg, who heads geriatric emergency medicine at St. Joseph’s – one of the three hospitals that received US government funding in 2012 for implementing a geriatric emergency practice – suggests that if an ED is designed for the most vulnerable patients, it will work for the strongest patients as well. In other words, he argues that all EDs should be designed to be geriatric-friendly, as a baseline standard.