COMMENTARY

Geriatric Emergency Departments: Why the Trend Is Here to Stay

Robert Glatter, MD; Zia Agha, MD

Disclosures

June 27, 2017

Robert Glatter, MD: Hi. I'm Dr Robert Glatter, a member of the Medscape Emergency Medicine Editorial Board and attending physician in the Department of Emergency Medicine at Lenox Hill Hospital, part of Northwell Health. Today we will be discussing the growing trend of geriatric emergency departments (EDs) throughout the United States, and the reasons behind it.

Geriatric Emergency Department Statistics

Dr Glatter: According to recent estimates, up to 25% of patients seen in the ED are aged 65 years or older.[1] By 2030, this percentage may well increase, when at least 1 in 5 Americans will be aged 65 or older.[2] In 2012, the Icahn School of Medicine at Mount Sinai received an award from the US Department of Health and Human Services to implement a new model of geriatric emergency care in three large urban hospitals; Mount Sinai Medical Center in New York City; St. Joseph's Regional Medical Center in Paterson, New Jersey; and Northwestern Memorial Hospital in Chicago, Illinois.

The Geriatric Emergency Department Innovations through Workforce Informatics and Structural Enhancements project, otherwise known as GEDI WISE, received a $12.7 million grant for the project.[1,3,4] At the beginning of 2014, the ECRI institute, a nonprofit research organization dedicated to discovering the best in medical procedures, devices, drugs, and processes, estimated that there were 50 geriatric EDs in operation in the United States, with another 150 in development.[1]

In order to handle the specialized needs of geriatric patients and their unique medical conditions, many academic centers and universities have embraced evidence-based data that provide support for building these unique facilities. A reference source often cited is the Geriatric Emergency Department Guidelines.[5] It is a result of 2 years of consensus-based collaboration among representatives from the Society for Academic Emergency Medicine, otherwise known as SAEM; the American College of Emergency Physicians (ACEP); and the American Geriatrics Society, along with the Emergency Nurses Association. It is approved by the boards of directors of these four organizations.

Joining us today to discuss this growing trend is Dr Zia Agha, chief medical officer and executive vice president of clinical research, medical informatics, and telehealth, West Health, San Diego. We'll be highlighting their new geriatric ED, the Gary and Mary West Senior Emergency Care Unit at UC San Diego Health, which is set to open in 2018. Welcome, Dr Agha.

Dr Agha: Thank you. I appreciate the time, and I appreciate the focus and emphasis on geriatric emergency care.

Types of Care Provided to Seniors in the ED

Dr Glatter: What types of care are elderly patients currently getting at most EDs? What are they lacking in their care at this point in time?

Dr Agha: I think the conversation here is around what is possible. As the population grows, what types of services are possible to be presented and provided through the ED? ED physicians are some of the best doctors in terms of making a diagnosis, evaluating patients, and creating a care plan. Often, they are the ones who are deciding when a patient needs to be admitted or is discharged back into the community.

We recognize that whereas that model of care is very useful and helps with the younger population—those in their 40s and 50s, for example—when you think about seniors, it truly is a syndrome. It's a syndrome of health needs. It's obviously important to make the right diagnosis of pneumonia, for example, and understand how to treat that.

Often, however, these seniors are going to have other comorbidities. They may have functional limitations. They may have social issues that need to be addressed, and because of the type of healthcare delivery system we have today, addressing all of those different needs from an ED physician's perspective is challenging.

I think part of the work around geriatric emergency care is not only to improve the care that happens in the ED, but also to surround the ED staff with the resources that allow them to provide safe care outside of the ED facility—to onboard patients toward a better trajectory, so that they can do better and not have rebound admissions.

We know that one of the problems that EDs face is readmissions. When you look at the senior population, they have a higher readmission rate to the ED for the same condition or for a new condition.

The Care Team Approach

Dr Glatter: When you have a geriatric ED, you need a full complement of additional people, including social workers, physical therapists, and nurses specifically trained in geriatrics, as well as physicians who can come in and hopefully avoid some of these admissions. In the past, the mantra had been, "We can't figure out what's going on, so we'll just admit you." That's changing, obviously. Would you agree?

Dr Agha: Yes, I think that is changing. You're right that it is a team-based approach, because geriatrics is the ultimate team environment. You need all of these other supporting characters in the ED who are, of course, trained in the geriatric care model, but who are also then empowered by having resources that allow them to leverage things in the hospital—for instance, getting physical therapy consults in the ED—or also outside in the community.

We have a very innovative program of research with UC San Diego. They're leveraging the research on the hospital-at-home model. What this model is trying to study is the ability of an ED physician and the team in the ED to identify certain patients who have ambulatory-sensitive diagnoses, such as urinary tract infection (UTI), pneumonia, or cellulitis.

Start the care plan in the ED, but transition [elderly patients] home (perhaps with help in the home). Then provide telemedicine services as a wraparound to provide 72 hours of coverage and follow-up in the home, and then transition their care into their primary care doctor's office. Similar work has been done by Geisinger Health Plan[6] and others, who are also testing these innovative models where you have another option beyond admitting the patient.

Leveraging Technology in Geriatric ED Care

Dr Glatter: Are you incorporating telehealth as part of this model through video visits, in order to assess patients? Or is it more just a nurse providing home-based care, or another therapist?

Dr Agha: I'm using the word "telehealth" in its broadest sense. I think the most effective tool, if you talk to Dr Ted Chan and Jim Killeen from UCSD, is their ability to have this TigerText communication. It's like an instant messaging tool that allows the home nurses to connect with the ED physicians 24/7, rather than sending faxes, which is the traditional way that home healthcare teams would communicate with the doctors.

In addition to that, they are using phone calls and, when needed, simple web-based videoconferencing. Believe it or not, most of the time, it's the ability to have a quick virtual rounding on the patient through this texting mechanism that allows them to stay connected in the care paradigm.

Early Outcomes Data on the Value of the Geriatric ED

Dr Glatter: Do you have any internal data just from your ED that justify the need to have this geriatric ED? In other words, looking at a small portion of patients over the age of 65 whom you've studied, where you have used measures to reduce readmission rates, [do the data] justify the need for building this ED?

Dr Agha: I think there is some evidence that we have seen. We are looking at it from different perspectives. Some of this is looking at large data, and I'll give you an example of a very simple analysis of patient falls we did, using Medicare data from 2012 and 2013.[7] [Editor's note: This research is to be presented later this year at the ACEP Research Forum.] In the senior population, falls are a significant morbidity. You can imagine patient falls leading to hip fractures and even nursing home admissions.

[During those years], there were 400,000 ED diagnoses nationwide of primary fall—what is called a "ground-level fall"—in the 65-and-over population.[7] Of that population, guess how many received a physical therapy (PT) consult, at least on their Centers for Medicare & Medicaid Services (CMS) claim at discharge? (This is the discharge order from the ED.) It was less than 4%. Immediately, you identify that there is a need to create decision-support tools or awareness within the ED setting, so that if someone comes in with a ground-level fall, the physician will consider having the patient seen by a physical therapist or rehab specialist at some point.

The second thing we saw—and again, these aren't big numbers—but when we looked at readmission for another fall within 60 days and 180 days, we found that those people who actually got the PT consult had a lower risk for coming back to the hospital with that problem versus those who did not have a PT consultation. It's a small peek at the data. I think it's missing many critical points, so it's by far not a perfect study. However, it helps us to identify certain areas to study further.

At a smaller level, we are studying our acute care at home program. We have shown that of 50-odd patients whom we have transitioned home safely from the ED and avoided a hospital admission, more than 90% of them have successfully been managed in the home setting without requiring a revisit to the ED or readmission. I think it is possible for us to provide services outside of the hospital setting to a carefully selected group of patients and still provide the same level of outcomes that you would expect to receive in the hospital—and potentially even better outcomes, in terms of satisfaction and other things.

Dr Glatter: I want to switch gears for a second. Mark Rosenberg, who is the chief of geriatric emergency medicine at St. Joseph's Regional Medical Center in Paterson, New Jersey, made a statement in the past, and I want you to comment on this. The concept is that if the ED is designed for the most frail and vulnerable patients, it will work for the strongest patients as well—arguing that we should build all EDs to be geriatric-friendly. In other words, make geriatric care the common denominator—that this is our baseline standard level of care.[8] How would you respond to that?

Dr Agha: I know Mark really well, and I think what he is trying to say is that the types of principles that we should be using to care for our seniors are also the principles that will provide good care for everyone else. I know seniors have more falls and have bigger problems, but there are people who have falls who are younger. If we don't screen them for mobility issues and don't make the appropriate referrals, these patients are not going to receive the full benefit of that treatment.

I'm going to point out some work around medication reconciliation. There is a big emphasis in the geriatric literature and in the Geriatric Emergency Department Guidelines on medication reconciliation, because seniors are at risk for drug/drug interactions, drug/food interactions, and other adverse events. Some of the work represents good medical practice: using the Beers Criteria[5] and other screening tools to help identify those "at-risk" patients, then having a pharmacy consultation to either fine-tune their medication list, or revise the medication list.

I think that's good medical practice and should be instituted for all other patients who have polypharmacy. These patients could benefit from it also. I think there are lots of parallels between good care for a senior and good care for everyone else.

Resources to Support the Geriatric ED

Dr Glatter: What do you say to hospital systems that don't have the funds to build such facilities that aren't graced or blessed with the revenue to go forward? How would they design their ED? Any specific pointers you can give?

Dr Agha: I think that's a very good point. When we started our geriatric initiative, we were very aware of the fact that what we are building and what we are investing in is a learning opportunity. It's a learning laboratory where we can test certain principles, but with a goal that these principles should be able to be extended and be disseminated to all EDs in the country.

There's already work happening around the guidelines that you mentioned that have been developed by the ACEP and other organizations.[5] If you review the guidelines, within each category—whether it's around education and training, staffing of a geriatric ED, or care protocols—there are some really simple "low-hanging fruit" concepts that we feel every ED in this country caring for seniors can adopt. These efforts will not require tremendous infrastructure resources or changing the physical structure.

The physical environment is an important part, and a lot of the EDs that call themselves geriatric EDs have invested some time, energy, and resources into creating a safer environment that's more patient-centered—less noisy and with nonskid floors, for example. These things are important; however, they are not the only things that are going to improve the care of seniors.

I think it is important to have care protocols that identify people at risk, with a heavy emphasis on screening and triaging patients beyond their primary complaint. Such tools as the Identification of Seniors at Risk (ISAR), which is a very simple patient checklist that can be completed at the point of entry, [can be used] to identify patients at risk.[9] This sort of triage mechanism identifies people at risk and leads to further questioning; [it] identifies a person at risk for falls, [so that] you can do a fall assessment, [or] identifies someone at risk for delirium, [so that] you can do a delirium assessment. I think those types of simple screening measures can be implemented across the nation and will pay big dividends in terms of improved outcomes, which themselves will pay for those extra steps we are taking.

Dr Glatter: I would argue that in this process of triage, before the physician or physician assistant actually sees the patient, there would already be a care team in place—whether it's case managers or social workers—already completing these types of surveys and analyses. By the time the care provider sees the patient, this has already been accomplished, and we already have a plan to go forward.

Dr Agha: Exactly. That is what we are seeing at most of the geriatric EDs that we are working with—that it is not the physician's role, or even the nurse practitioner who's taking care of the patient. It's someone even more proximal who is going to do the early screening, and with your electronic health record, you can create a screening tool set with a simple logic and decision support built into it. We are also very aware that we don't want to overburden the system.

Crowding in the ED is a big problem. We certainly don't want to slow things down. We also feel that if you identify certain issues early on, you can potentially save time. If you can identify that a patient has a mobility issue when they're checking into your ED, you can start working on getting a wheelchair ordered for them and not have to say, "Okay the patient is ready to go home, but he can't even walk." In this case, with advance planning, the wheelchair is ready.

So now we have to get some prosthetics or someone else involved. There is a little bit of an investment of time. I think it'll more than pay back in terms of how you coordinate the care and provide the right services.

The Geriatric ED and Length of Stay

Dr Glatter: To wrap this up, have you looked at any length of stay issues within the ED itself when you do have a geriatric ED? Does the time spent seem to be less in general?

Dr Agha: There was a recent study by Keyes and colleagues,[10] where they looked at three outcomes; length of stay was one of them. That was not affected. It was not better, but it wasn't significantly worse. They looked at primary hospitalizations, although that number was lower, so they had an impact on reducing the number of people who were admitted to the hospital. The third thing they looked at was readmission or recidivism rates. Those were not affected.

I think there are some early data coming out. We are very interested in studying these things at a deeper level; we've already started doing some ethnographic research to do some observation studies to look at the flow. I think length of stay is much more of an outcome of the workflow and the flow of the patient through the ED than any one specific intervention. Understanding the workflow, and then understanding how to optimize it, is critical.

Disseminating Learning to Other Sites

Dr Glatter: Is there anything else to add to the discussion?

Dr Agha: The call to action for us is that we should be able to provide good geriatric care to all seniors, no matter which ED they're going to, and it's going to be perhaps at different levels, as you pointed out. There may be some centers that are going to adopt some basic principles that will improve geriatric care, and there will be the centers of excellence that are going to be doing innovative, clinical trials, and offering these types of services to their seniors.

I'm really excited about the future of this whole geriatric care movement within ACEP and the physician community, but also on a broader perspective from the health system side, given our shift toward population health.

Dr Glatter: Can you also fill us in on any specifics of your ED that you planned for, opening in 2018—any early tidbits of information of how the layout will be, and so forth?

Dr Agha: The Gary and Mary West Senior Emergency Care Unit is going to be located in La Jolla at the University of California, San Diego, campus. It's a joint project with them. We have funded it through a capital grant, but we also provided substantial funding to start to do education and training and also health services research, and to look at outcomes.

It's going to be a physical build-out of around 18 new beds—a dedicated space in this ED. This is a large ED, with 40,000+ visits currently. Their capacity is going higher and higher. It will definitely take off some of the pressure in terms of having more beds available. What's more important is that we will also have specially trained nurses. That work is already under way—specially trained and focused clinicians.

We're going to bring together geriatric pharmacologists, rehabilitation specialists, and geriatric doctors to provide the full set of services, including social work, that a senior requires. We're truly excited about this opportunity not only because of what we will do here, but also as to how the learning will then be disseminated to other sites.

Dr Glatter: Then you plan to have video-based conferencing—taking advantage of all the technology that exists right now to interface with providers at home as well as in the ED?

Dr Agha: Yes, that is definitely in the works. As I mentioned, we've already started one project where we're using video-based technology to connect with assisted living sites in San Diego.

I think when you look at telehealth and video as a tool to an end, it's not about doing telehealth; it's about how you provide the right care at the right time to patients.

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