Growing a Geriatric Emergency Department

Abstract

The concept of the geriatric emergency department is well developed after more than a decade of evolution, and at least nine EDs throughout the country are now accredited by the American College of Emergency Physicians (ACEP) as part of the first wave of geriatric ED accreditations. At AMDA – the Society for Post-Acute and Long-Term Care Medicine’s Annual Conference, the medical director of one of these departments, Marianna Karounos, DO, described the geriatric-focused policies and protocols, quality initiatives, staff education, and operational changes that her geriatric ED has embraced since it launched in 2009. In an interview after the meeting, she told Caring that her institution, St. Joseph’s University Medical Center in Paterson, NJ, has seen significant decreases in returns to the ED and in hospital admissions as a result. The “physical plant” of the geriatric ED should focus on structural changes that promote a quieter, safer, and less chaotic environment: non-slip, non-glare flooring, for instance, as well as uncluttered and wide corridors, hand rails, thicker mattresses, and enhanced lighting. “And the truth is that the physical plant doesn’t have to be a separate space,” Dr. Karounos said at the Society meeting. “You can insert components for the most frail and vulnerable into your current model and make a difference — for them and for everyone.” Staff and provider education that touches upon the physiology of aging, end-of-life issues, geriatric assessment, pharmacology, and delirium is key, she said, as is the integration of geriatric-focused policies and protocols for quality improvement, screening, and transitions of care. At St. Joseph’s they implemented processes for falls risk assessment, for instance. They also use the Beers criteria for inappropriate medications and the “Identification of Seniors at Risk Tool,” which assesses the level of help needed, the state of the patient’s memory and eyesight, and the degree of polypharmacy, among other things. They also implemented screening for depression and delirium and fine-tuned the Emergency Severity Index (ESI) criteria — a triage algorithm used by nurses in the ED — to better capture the severity of illness in geriatric patients. Dr. Karounos said that her geriatric ED has a “robust” medication reconciliation program that engages a pharmacist in reviewing patients who are taking five or more medications a day. “I’m a big proponent of having a pharmacist in the ED,” she said. She also touted her ED’s “two-step call-back program,” in which each patient receives a personalized phone call within 24 to 48 hours after discharge and again on days 4, 7, and 14. “We ask, how are they doing — worse or the same? Have they filled their medications? Have they set up an appointment with their PCP?” she said. “Daily, I learn of at least two or three issues from the call-back nurse, and we intervene. It’s amazing what we can do remotely after we release [them].” The geriatric ED is using hospital resources that “we had before, but almost never traditionally used before,” such as social workers, care managers, physical therapists, pharmacists, and toxicologists. “They weren’t streamlined to be used with ease in the ED,” Dr. Karounos explained. “Now, they’re almost essential.” In addition, Dr. Karounos emphasized, the geriatric ED can offer “the first touch where we can have a discussion about end-of-life care, palliative care, and goals of care,” particularly for patients from the community. She noted that “a lot of patients aren’t getting this in primary care. When we see the fourth congestive heart failure exacerbation in 2 months, it may be time to ask the patients what they want,” she said. ACEP’s new voluntary accreditation includes three levels, similar to trauma designations, with specific criteria and goals. In 2013, guidelines for optimal care in the geriatric ED were developed by ACEP in collaboration with the American Geriatrics Society, the Emergency Nurses Association, and the Society for Academic Emergency Medicine (https://www.acep.org/geda/resources/pdfs/GEDA-Guidelines.pdf). Christine Kilgore is a freelance writer in Falls Church, VA.