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Tailoring emergency care for older adults

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Written by Jeannie Bryant, administrator, and Stephanie Herbers, manager of the Harvey A. Friedman Center for Aging

Emergencies happen. And for older persons and their families, navigating emergency departments can be stressful.  Christopher Carpenter, MD, Washington University emergency medicine faculty and physician, is working with colleagues to develop and implement new models for effective care.

Emergency care for older persons is complex because of underlying physical, social, cognitive and situation needs.1 For example, patients with cognitive impairments, such as dementia, may be easily disoriented or unable to provide an accurate medical history. 1 Challenges with hearing or vision, or effects of an infection, can also cause disorientation, particularly in a medical setting with lots of activity and noise. This makes it a challenge to pinpoint the best approach for care in a timely manner.

In Missouri the rate of emergency visits per 1,000 people in 2014 was 375 for all Missourians, 378 for Missourians under 65 years, and 295 for Missourians over 65 years.2 Rates of emergency visits ranged from 73 in Lewis County to 650 in Iron County for residents over 65. One out of five—in some areas one out of three—emergency room visits in 30 counties were by residents over 65 (see hash marked counties on map); this is double the number of counties just five years prior.

In order to improve the quality of care for adults 65 years and older, Dr. Carpenter and colleagues developed geriatric emergency department guidelines that address the complexities of treating older patients and provide a means to accredit emergency departments that adhere to these guidelines.3 The guidelines outline recommendations for staffing, equipment, education, policies and procedures, etc., that can effectively improve care and are feasible to implement. According to the GED Guidelines, one of the goals of the geriatric ED is to recognize those patients who will benefit from inpatient care, and to effectively implement outpatient care to those who do not require inpatient resources.3

Guideline Recommendations

(Click here for the complete document.)

Staffing/Administration

  • Staffing protocols in place to provide for geriatric-trained providers, including physician and nurse leadership.
  • Education/training to ensure high-quality geriatric care

Follow Up and Transition of Care

  • Discharge protocols in place that facilitate the communication of clinically relevant information to the patient/family and outpatient care providers, including nursing homes.
  • Process in place that effectively provides appropriate outpatient follow up either via provider-to-patient communication or the provision of direct follow up evaluation.

Education

  • Initial implementation sessions that involve multi-disciplinary teams in-person.
  • Community awareness, involvement and outreach, particularly for EMS personnel, older persons, and families.
  • Regular educational assessment and implementation of site-specific educational needs.

Quality Improvement

  • Geriatric program shall be developed and monitored by a Geriatric Medical Director and Geriatric Nurse Manager.
  • Geriatric report shall be generated and delivered to the ED committee no less than quarterly by the Geriatric Medical Director.
  • Program shall include an interface with pre-hospital care, ED, trauma, critical care, alternative level care facilities and hospital wide QI activities.

Equipment and Supplies

  • Changes to physical setting focused on structural modifications that promote improvements in safety, comfort, mobility, memory cues and sensorial perception both with vision and hearing.
    • Common key features are those that enhance lighting, colors and enhanced signage.

Policies, Procedures and Protocol

  • Screening for risk of added needs assessment, consultation and intervention.
    • Ongoing education and reinforcement for physician, mid-level and nursing providers. Compliance of the completion of the initial assessment be assessed on a regular basis.
  • Use of urinary catheters.
    • Screening and appropriate identification of patients with indwelling catheter placement, proper technique, education for staff on infection rate auditing and limited duration of use.
  • Medication management.
    • High-risk medication lists will be reviewed annually. Tracking and trending of adverse drug response admissions and pharmacist interventions for admitted patients noted with either polypharmacy or high-risk medications.
  • Fall assessment.
    • Home assessments for safety for all patients evaluated for a fall.
  • Delirium and dementia.
    • Special attention to directing interventions towards improving reversible causes and limiting factors that extend or cause delirium. Limit use of chemical and physical restraints to only when necessary.
  • Palliative care.
    • Provide access to palliative care and end-of-life care for medically complex patients.

Learn more about the geriatric emergency department guidelines and accreditation in this podcast with Dr. Carpenter.4

Partners Involved in Development of GED Guidelines

  • American College of Emergency Physicians 
  • The American Geriatrics Society 
  • Emergency Nurses Association 
  • Society for Academic Emergency Medicine 

References

  1. Hwang, U, Shah, M, Han, J, Carpenter C, Siu A, Adams J, Hunt LA, Murphy CF, Carr D, Duchek JM, Buckles V, Morris JC. Transforming emergency care for older adults. Health Aff (Millwood) 2013; 32(12):2166-21.
  2. Missouri Department of Health and Senior Services. Emergency Room Visits Per 1,000 Residents- Missouri Information for Community Assessment (MICA). Accessed October 2017. https://webapp01.dhss.mo.gov/MOPHIMS/MICAHome
  3. American College of Emergency Physicians. Geriatric Emergency Department Guidelines https://www.acep.org/geriEDguidelines/#sm.0000qgfdjqrz3fabtm21qdm9jpgsr
  4. New Geriatric ED Accreditation – and why you should care GEMCAST, posted on May 23, 2017 https://gempodcast.com/2017/05/23/new-ged-accreditation/

By Jeanie Bryant and Stephanie Herbers, Harvey A. Friedman Center for Aging at the Institute for Public Health

Emergencies happen. And for older persons and their families, navigating emergency departments can be stressful.  Christopher Carpenter, MD, Washington University emergency medicine faculty and physician, is working with colleagues to develop and implement new models for effective care.

Emergency care for older persons is complex because of underlying physical, social, cognitive and situation needs.1 For example, patients with cognitive impairments, such as dementia, may be easily disoriented or unable to provide an accurate medical history. 1 Challenges with hearing or vision, or effects of an infection, can also cause disorientation, particularly in a medical setting with lots of activity and noise. This makes it a challenge to pinpoint the best approach for care in a timely manner.

In Missouri the rate of emergency visits per 1,000 people in 2014 was 375 for all Missourians, 378 for Missourians under 65 years, and 295 for Missourians over 65 years.2 Rates of emergency visits ranged from 73 in Lewis County to 650 in Iron County for residents over 65. One out of five—in some areas one out of three—emergency room visits in 30 counties were by residents over 65 (see hash marked counties on map); this is double the number of counties just five years prior.

In order to improve the quality of care for adults 65 years and older, Dr. Carpenter and colleagues developed geriatric emergency department guidelines that address the complexities of treating older patients and provide a means to accredit emergency departments that adhere to these guidelines.3 The guidelines outline recommendations for staffing, equipment, education, policies and procedures, etc., that can effectively improve care and are feasible to implement. According to the GED Guidelines, one of the goals of the geriatric ED is to recognize those patients who will benefit from inpatient care, and to effectively implement outpatient care to those who do not require inpatient resources.3

Guideline Recommendations

(Click here for the complete document.)

Staffing/Administration

  • Staffing protocols in place to provide for geriatric-trained providers, including physician and nurse leadership.
  • Education/training to ensure high-quality geriatric care

Follow Up and Transition of Care

  • Discharge protocols in place that facilitate the communication of clinically relevant information to the patient/family and outpatient care providers, including nursing homes.
  • Process in place that effectively provides appropriate outpatient follow up either via provider-to-patient communication or the provision of direct follow up evaluation.

Education

  • Initial implementation sessions that involve multi-disciplinary teams in-person.
  • Community awareness, involvement and outreach, particularly for EMS personnel, older persons, and families.
  • Regular educational assessment and implementation of site-specific educational needs.

Quality Improvement

  • Geriatric program shall be developed and monitored by a Geriatric Medical Director and Geriatric Nurse Manager.
  • Geriatric report shall be generated and delivered to the ED committee no less than quarterly by the Geriatric Medical Director.
  • Program shall include an interface with pre-hospital care, ED, trauma, critical care, alternative level care facilities and hospital wide QI activities.

Equipment and Supplies

  • Changes to physical setting focused on structural modifications that promote improvements in safety, comfort, mobility, memory cues and sensorial perception both with vision and hearing.
    • Common key features are those that enhance lighting, colors and enhanced signage.

Policies, Procedures and Protocol

  • Screening for risk of added needs assessment, consultation and intervention.
    • Ongoing education and reinforcement for physician, mid-level and nursing providers. Compliance of the completion of the initial assessment be assessed on a regular basis.
  • Use of urinary catheters.
    • Screening and appropriate identification of patients with indwelling catheter placement, proper technique, education for staff on infection rate auditing and limited duration of use.
  • Medication management.
    • High-risk medication lists will be reviewed annually. Tracking and trending of adverse drug response admissions and pharmacist interventions for admitted patients noted with either polypharmacy or high-risk medications.
  • Fall assessment.
    • Home assessments for safety for all patients evaluated for a fall.
  • Delirium and dementia.
    • Special attention to directing interventions towards improving reversible causes and limiting factors that extend or cause delirium. Limit use of chemical and physical restraints to only when necessary.
  • Palliative care.
    • Provide access to palliative care and end-of-life care for medically complex patients.

Learn more about the geriatric emergency department guidelines and accreditation in this podcast with Dr. Carpenter.4

Partners Involved in Development of GED Guidelines

  • American College of Emergency Physicians 
  • The American Geriatrics Society 
  • Emergency Nurses Association 
  • Society for Academic Emergency Medicine 

References

  1. Hwang, U, Shah, M, Han, J, Carpenter C, Siu A, Adams J, Hunt LA, Murphy CF, Carr D, Duchek JM, Buckles V, Morris JC. Transforming emergency care for older adults. Health Aff (Millwood) 2013; 32(12):2166-21.
  2. Missouri Department of Health and Senior Services. Emergency Room Visits Per 1,000 Residents- Missouri Information for Community Assessment (MICA). Accessed October 2017. https://webapp01.dhss.mo.gov/MOPHIMS/MICAHome
  3. American College of Emergency Physicians. Geriatric Emergency Department Guidelines https://www.acep.org/geriEDguidelines/#sm.0000qgfdjqrz3fabtm21qdm9jpgsr
  4. New Geriatric ED Accreditation – and why you should care GEMCAST, posted on May 23, 2017 https://gempodcast.com/2017/05/23/new-ged-accreditation/

 

This post is part of the “Transforming Healthcare in Missouri” series of the Institute for Public Health’s blog. Subscribe to email updates or follow us on Twitter and Facebook to receive notifications about our latest blog posts.