This story was first published on Wednesday, May 1, 2019 in Emergency Physicians Monthly
You care for this patient every shift. An older person with multiple medical problems who is trying to live at home. Are they normally slightly confused? Does lying in bed for six hours in the ED during your work up without eating or drinking do them any harm? Are they safe to return home? What resources do they need? These are the issues that EM physicians struggle with every day, and the reasons why the Geriatric Emergency Department concept was developed.
Older adults account for 46% of all ED visits resulting in hospitalization1. Approximately one out of every 10 hospital admissions is potentially avoidable with the majority (60%) of those admissions for patients 65+2.
EDs around the country focused on improving their care of older patients can become accredited through the American College of Emergency Physicians (ACEP) as a Geriatric (appropriate) ED with ACEP’s Geriatric Emergency Department Accreditation program (GEDA.) The accreditation is the first of its kind and is part of an effort to improve the quality and standards of emergency care provided to the nation’s older patients. The program builds upon the foundational work and support of the Gary and Mary West Health Institute and The John A. Hartford Foundation to enhance geriatric emergency care across the country.
The geriatric ED accreditation process follows a series of related efforts. In 2013, ACEP and three other major medical professional associations vested in geriatric care released the Geriatric Emergency Department Guidelines. The guidelines were the product of two years of consensus-based work that specify broad domains and recommends measures ranging from adding geriatric-friendly equipment to geriatric-focused staff to more routine screening for delirium, dementia, falls and more.
Background
ACEP began accrediting in the spring of 2018 and has since granted 54 hospitals accreditation, with more than 190 U.S. emergency departments in the pipeline. A handful of international hospitals expressed interest in accreditation, demonstrating that similar challenges in geriatric care are present around the globe. Despite the growing geriatric population and the increasing number of EDs that have declared themselves “geriatric EDs,” (roughly 130 self-proclaimed) prior to the GEDA program, a standard definition did not exist for this designation.
In the interest of advancing clinical care in emergency medicine, the perceived need to accelerate improvements in clinical care to benefit our rapidly growing senior population, and transparency for the public, the GEDA program was born with a pledge to deliver on care standardization. In most cases, having a geriatric ED does not mean creating a separate space for older adults, but rather optimizing processes (screening for geriatric syndromes), provider and nurse education, structural enhancements (appropriate ED beds and dimmed lights) and community connections to better care for older adults.
This relatively new accreditation is setting a benchmark for geriatric care and for what it means to be a geriatric ED (GED). The program is voluntary and set up to work for any hospital from the smallest rural ED to a large, urban center with its own, separate GED space.
The accreditation program delivers on a level of standardization across geriatric EDs that has been lacking, said Dr. Kevin Biese, chair of the ACEP program and co-director of geriatric emergency medicine at the University of North Carolina School of Medicine.
“Geriatric EDs aren’t new concepts. Hospitals were thinking of this stuff already, but it was like sculpting fog,” Biese said. “The accreditation program really is an empowering tool to get the resources to do it more formally.”
The rapid growth during the 10 years of GEDs and the aggressiveness of the consumer marketing of many self-designated GEDs suggests that it is a concept that clearly appeals to hospital administrations. They see the growing population of older adults who will use their acute care facilities and the market advantage of having specialized centers of excellence focused on this population. The number of U.S. GEDs is likely to continue to grow. Simply put, the availability of GEDA may encourage EDs/hospitals who have not yet developed a geriatric ED to consider it.
Three Levels
Accreditation is provided at three levels similar to trauma designations. Level 1 is the most comprehensive designation with policies, guidelines, procedures and staff (within the ED and throughout the institution) providing a coherent system of care targeting and measuring specific ED outcomes for older adults that form an overall elevation in ED operations and transition of care both to and from the ED.
Level 1 requires an in-person, four-hour site visit. Levels 2 and 3 require the EDs to have at least one geriatric-trained physician and nurse, but less reporting requirements and stipulations than Level 1.
Accreditation requires hospital emergency departments to not only follow specific guidelines, but to have both a designated physician champion with specialized geriatric education covering the eight domains of geriatric EM, a nurse lead with geriatric training, meet specific environmental criteria, such as ensuring 24/7 easy patient access to food, water and mobility aids, and evidence of at least one geriatric-specific emergency care initiative such as standard delirium screening guideline, a guideline for standardized fall assessment, identification of elder abuse, pain control.
The 8 domains of Geriatric EM are:
- Atypical presentations of disease
- Trauma including falls
- Cognitive and behavioral disorders
- Emergency intervention modifications
- Medication management/polypharmacy
- Transitions of care
- Effect of comorbid conditions/polymorbidity
- End-of-life care
Benefits
The benefits of accreditation are three-fold. Hospitals seek accreditation to increase their brand recognition and market share. For providers, accreditation provides access to resources like a walker for patient use. Many EDs are now gaining increased pharmacy, social work and care management resources to better care for older adults. Accreditation provides a way for hospital leadership and physicians to align to improve care. It provides for accelerated change to introduce new ideas and processes and creates the potential to reap financial benefits in a reimbursement environment in which hospitals can be penalized for re-admissions and other poor outcomes.
An accredited Geriatric ED also helps build a bridge to value-based care delivery for hospitals and health care systems in our changing health care reimbursement ecosystem. Lastly, our nation’s seniors can rest-assured these EDs provide high-quality care for older adults, including providing a more positive and physical environment and steps to assist their safe return home.
Research published in recent years has highlighted how older adults, (defined as aged 65 years and older,) frequently struggle more medically and physically after an emergency visit, even if they were never admitted to the hospital. An accredited ED with a more sensitive environment furnished with dimmed lights, thicker comfortable mattresses, outfitted with a side-chair for family members, all help towards delivering a more positive patient experience, which can help alleviate some of those struggles.
The first cadre of baby boomers reached aged 65 years in 2011. By 2029, the entire demographic group will be aged 65 years or older, according to US Census Bureau data.3
With the number of older adults growing rapidly, administrators and providers alike recognize there is a critical need for more geriatric-focused care. The expertise that an ED staff can bring to an encounter with a geriatric patient can meaningfully impact not only a patient’s condition, but also impact the decision to utilize relatively expensive inpatient modalities, or less expensive outpatient treatments.4
EDs are uniquely positioned to play a role in improving care to the geriatric population.5 As an ever-increasing access point for medical care, the ED sits at a crossroads between inpatient and outpatient care.6 Preparing for accreditation allows the hospital and ED to focus on the needs of this complex and growing population and to ensure that the resources available to the ED meet the needs of the patients they serve.
The result of a GEDA program will be enhanced quality emergency care for older adults, public transparency regarding the capabilities of the ED to care for older adults, and, because of elevating the care of these vulnerable patients, improved care for all patients.
References:
1. WHI. Geriatric Emergency Department Factsheet (2013 HCUP-NEDS data). West Health Institute;2017.
2. Stranges E, Stocks C. Potentially Preventable Hospitalizations for Acute and Chronic Conditions, 2008. Rockville, MD: Agency for Healthcare Research and Quality;2010.
3.Colby SL, Ortman JM. The baby boom cohort in the United States: 2012 to 2060. US Census Bureau. Available at: https://www.census.gov/prod/2014pubs/p25-1141.pdf.
4. Jayadevappa R. Quality of Emergency Department Care for Elderly. Emerg Med. 2011;1: e107. Ryan D, Liu B, Awad M, et al. Improving older patients’ experience in the emergency room: the senior-friendly emergency room. Aging Health. 2011;7: 901-909.
5. Adams JG, Gerson LW. A new model for emergency care of geriatric patients. Acad Emerg Med. 2003;10: 271-274.
6.Hwang U, Morrison RS. The geriatric emergency department. J Am Geratr Soc. 2007;55: 1873-1876. Carpenter CR, Platts-Mills TF. Evolving prehospital, emergency department, and “inpatient” management models for geriatric emergencies. Clin Geriatr Med. 2013;29: 31-47.
