Geriatric Guideline Implementation Remains Unrealistic in Most EDs

Heidi Splete

March 03, 2022

Many emergency departments are currently unable to provide care for geriatric patients that meets best practices and guidelines recommended by several major medical organizations, but a panel discussion at the American Academy of Emergency Medicine's Scientific Assembly in 2021 identified three areas in which realistic improvements might be achieved.

In an article published online last month in the Journal of Emergency Medicine, Richard D. Shih, MD, of Florida Atlantic University, Boca Raton, and colleagues synthesized the presentation and discussion of an expert panel on the topic of the GED guidelines and the current realities of patient care.

The Geriatric Emergency Department (GED) Guidelines published in 2014 were endorsed by the American College of Emergency Physicians (ACEP), American Geriatrics Society (AGS), Emergency Nurses Association, and Society for Academic Emergency Medicine.

"With the substantial challenges in providing guideline-recommended care in EDs, this article will explore three high-impact GED clinical conditions to highlight guideline recommendations, challenges, and opportunities, and discuss realistically achievable expectations for non–GED-accredited institutions," the authors write. The article addressed the ED patient with delirium, the ED fall patient, and the ED patient with polypharmacy.

Geriatric Patients and Delirium

When delirium in older adults is not identified in the ED, the patient's 6-month mortality rate significantly increases, but few EDs have delirium screening protocols, the authors said. Challenges included the time and money needed to educate staff, on top of multiple mandatory training requirements on other topics, they said. Delirium screening in the clinical setting also requires personnel to conduct assessments, and time to document symptoms and screening results in medical records.

"Perhaps the highest priority challenge for delirium experts is to evaluate and publish effective delirium intervention strategies because current evidence is completely lacking for ED-based delirium prevention or treatment," they said. In the meantime, developing outcome measures for quality improvement of delirium care will require institutional support as well as education, they added.

Geriatric Patients and Falls

Approximately one third of community-dwelling adults older than 65 years suffer falls, but data suggest that fewer than half of these individuals report falls to their doctors. "Older adults who present to an ED after a fall have an approximately 30% greater risk of functional decline and depression at 6 months after the event," the authors note.

The GED guidelines call for a comprehensive approach to evaluating and managing falls in older adults, but many of these "are untested in the ED," the authors say. The recommended protocol includes an initial assessment of fall risk, followed by, for those at low risk, tailored recommendations for education and the use of community resources. Additional recommendations for those at high risk of falls include multifactorial assessment of modifiable risk factors, including peripheral neuropathy, balance/gait assessment, and medication review.

However, this best practice workflow is beyond the resource capacity of most EDs, the authors noted. "When ED resources are insufficient to support best practices, the care should focus on educating patients and caregivers about the significance of a fall event, providing educational materials (eg, CDC's STEADI materials), and assessing safety with respect to mobility for immediate return to the home environment and follow-up with a PCP," they write.

Geriatric Patients and Polypharmacy

Polypharmacy is common among older adults by virtue of their greater number of illnesses and comorbid conditions, and polypharmacy also has been associated with more adverse drug reactions, the authors said. The AGS Beers Criteria identifies medications associated with adverse drug reactions, but it is not practical for use in a busy ED setting, they said. Instead, they suggested a more practical approach of focusing on a smaller list of common medications that tend to cause the adverse events that may result in ED visits.

"Perhaps targeting patients on multiple (three or more) psychoactive medications, drugs that can cause hypotension, or hypoglycemics could not only be done quickly, but identify patients in whom deprescribing should be considered in the ED," the authors write. However, deprescribing is a complicated process, and may be more effective when done via the patient's primary care provider or in a geriatric consultation, they said.

The GED Guidelines highlighted the specific needs of the geriatric population in the ED, the authors said. Widespread implementation remains a challenge, but many organizations provide resources to help improve care of geriatric patients in the ED and beyond, they noted.

In particular, the Geriatric Emergency Care Applied Research Network and Geriatric Emergency Department Collaborative provide funding opportunities, updated and focused published reviews, and webinars (some including free continuing medical education) for the entire healthcare team, including hospital administrators, the authors said.

Article Brings Attention to Clinical Realities

"The reality is that the overwhelming majority of emergency departments in the United States, if not globally, are simply not equipped — operationally or financially — to meet the rigorous standards that are required to fulfill the goals of operating an accredited geriatric ED," Robert D. Glatter, MD, an emergency medicine physician at Lenox Hill Hospital, New York City, told Medscape Medical News.

"Drawing attention to this important gap in accreditation is critical to not only inform hospitals, healthcare providers and stakeholders, but the public, patients, and their families about the important work that needs to be done to better equip all EDs with the proper tools and educational approaches to more effectively care for the geriatric community," Glatter emphasized.

"There are currently three tiers of accreditation, with level 1 being the highest," he explained, but there are only 100 geriatric emergency department accreditation-certified hospitals across the United States, he said.

"I am not surprised at all by the challenges of implementing current GED guidelines," said Glatter. "It comes down to operational and budget considerations, which ultimately compete with many other departments and regulatory constraints in any given hospital," he said.

However, "the bottom line is that such guidelines are designed with patient safety in mind, making them important issues in the eyes of any hospital administrator looking to improve outcomes and reduce medico-legal risk or exposure impacting geriatric patients in the emergency department," he noted. 

Ultimately, guideline adherence "comes down to budget decisions, and where hospitals must invest their money to meet the bottom line," said Glatter. "Making modifications to hospital infrastructure and architecture to accommodate geriatric patients may not be the top priority of hospital administrators when confronted with multiple competing interests. But, if it impacts patient safety, the decision to invest in structural and operational improvements may certainly have additional and important considerations," he said.

"Until Medicare, or even the Joint Commission on Accreditation of Hospitals 

(JACO), adopts geriatric guidelines in emergency departments as a requirement for accreditation, there may not be adequate incentives in place currently to satisfy the intent of having a rigorous set of guidelines in the first place," Glatter added. 

Despite the limitations of applying the current guidelines, there are some steps hospitals can take, said Glatter. "They can institute new measures in a graded fashion, with the goal of taking the important steps to satisfy at least some components of the guidelines," he said. "Attention to details can go a long way, such as rails in bathrooms, better lighting, and treads on floors that may reduce the risk of falls in the emergency department itself.

"Attention to fall prevention by assessing contributors including polypharmacy, gait instability, and quality of footwear can impact risk of future ED visits. Having incentives in place by Medicare or JACO may force the hand of hospital administrators to comply with geriatric guidelines and place emphasis on compliance," noted Glatter.

More research is needed that "looks at costs of implementing geriatric guidelines in typical community and academic EDs and how this impacts key metrics such as length of stay, effect on reimbursement per ICD-10 code, and savings, if any, realized in reduced malpractice claims related to missed diagnoses (such as delirium), injuries, (patient falls), or medical misadventures due to polypharmacy," he said.

The article received no outside funding. The authors have disclosed no relevant financial relationships. Glatter has disclosed no relevant financial relationships, and serves on the advisory board of Medscape Emergency Medicine.

J Emerg Med. Published online February 15, 2022. Abstract

Heidi Splete is a freelance medical journalist with 20 years of experience.

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