Geriatric Emergency Departments Research Articles

Clinical Frailty Scale at presentation to the emergency department: interrater reliability and use of algorithm-assisted assessment.

The Clinical Frailty Scale (CFS) allows health care providers to quickly stratify older patients, to support clinical decision-making. However, few studies have evaluated the CFS interrater reliability (IRR) in Emergency Departments (EDs), and the freely available smartphone application for CFS assessment was never tested for reliability. This study aimed to evaluate the interrater reliability of the Clinical Frailty Scale (CFS) ratings between experienced and unexperienced staff (ED clinicians and a study team (ST) of medical students supported by a smartphone application to assess the CFS), and to determine the feasibility of CFS assignment in patients aged 65 or older at triage. Cross-sectional study using consecutive sampling of ED patients aged 65 or older. We compared assessments by ED clinicians (Triage Clinicians (TC) and geriatric ED trained nurses (geriED-TN)) and a study team (ST) of medical students using a smartphone application for CFS scoring. The study is registered on Clinicaltrials.gov (NCT05400707). We included 1349 patients aged 65 and older. Quadratic-weighted kappa values for ordinal CFS levels showed a good IRR between TC and ST (ϰ = 0.73, 95% CI 0.69-0.76), similarly to that between TC and geriED-TN (ϰ = 0.75, 95% CI 0.66-0.82) and between the ST and geriED-TN (ϰ = 0.74, 95% CI 0.63-0.81). A CFS rating was assigned to 972 (70.2%) patients at triage. We found good IRR in the assessment of frailty with the CFS in different ED providers and a team using a smartphone application to support rating. A CFS assessment occurred in more than two-thirds (70.2%) of patients at triage.

Cost of U.S emergency department and inpatient visits for fall injuries in older adults

BackgroundFalls are a leading cause of injury and hospital readmissions in older adults. Understanding the distribution of acute treatment costs across inpatient and emergency department settings is critical for informed investment and evaluation of fall prevention efforts. MethodsThis study used the 2016–2018 National Inpatient Sample and National Emergency Department Sample. Annual treatment cost of fall injury among adults 65 years and older was estimated from charges, applying cost-to-charge and professional fee ratios. Weighted multivariable generalized linear models were used to separately estimate cost for inpatient and emergency department (ED) setting by injury type and individual demographic and health characteristics after adjusting for payer and hospital level characteristics. ResultsOlder adults incurred an estimated 922,428 inpatient and 2.3 million ED visits annually due to falls with combined annual costs of $19.8 billion. Over half of inpatient visits for fall injury were for fracture. Notably, 23% of inpatient visits were for fractures other than hip fracture and 14% of inpatient visits were for multiple fractures with costs totaling $3.4 billion and $2.5 billion, respectively. Annual ED costs were driven by superficial injury totaling $1.5 billion. Cost of ED visits were higher for adults 85 years and older (adjusted cost ratio (aCR): 1.11, 95% Confidence Interval (CI)I: 1.11–1.12) and those with dementia (aCR: 1.14, 95% CI: 1.13–1.15). Higher inpatient and ED visit cost was also associated with high-energy falls and discharge to post-acute care. ConclusionThe study found that more than 3 million older adults in the United States seek hospital care for fall injuries annually, a major concern given increasing capacity strain on hospitals and EDs. The $20 billion in annual acute treatment costs attributed to fall injury indicate an urgent need to implement evidence-based fall prevention interventions and underscores the importance of newly launched ED-based fall prevention efforts and investments in geriatric emergency departments.

62 Forecasting Areas of Need for Geriatric Emergency Care: Quantifying National Access to and Utilization of Geriatric Emergency Departments

62 Forecasting Areas of Need for Geriatric Emergency Care: Quantifying National Access to and Utilization of Geriatric Emergency Departments

An Outcome Comparison Between Geriatric and Nongeriatric Emergency Departments

We sought to describe diagnosis rates and compare common process outcomes between geriatric emergency departments (EDs) and nongeriatric EDs participating in the American College of Emergency Physicians Clinical Emergency Data Registry (CEDR). We conducted an observational study of ED visits in calendar year 2021 within the CEDR by older adults. The analytic sample included 6,444,110 visits at 38 geriatric EDs and 152 matched nongeriatric EDs, with the geriatric ED status determined based on linkage to the American College of Emergency Physicians' Geriatric ED Accreditation program. Stratified by age, we assessed diagnosis rates (X/1000) for 4 common geriatric syndrome conditions and a set of common process outcomes including the ED length of stay, discharge rates, and 72-hour revisit rates. Across all age categories, geriatric EDs had higher diagnosis rates than nongeriatric EDs for 3 of the 4 following geriatric syndrome conditions of interest: urinary tract infection, dementia, and delirium/altered mental status. The median ED site-level length of stay for older adults was lower at geriatric EDs compared with that at nongeriatric EDs, whereas 72-hour revisit rates were similar across all age categories. Geriatric EDs exhibited a median discharge rate of 67.5% for adults aged 65 to 74 years, 60.8% for adults aged 75 to 84 years, and 55.6% for adults aged >85 years. Comparatively, the median discharge rate at nongeriatric ED sites was 69.0% for adults aged 65 to 74 years, 64.2% for adults aged 75 to 84 years, and 61.3% for adults aged >85 years. Geriatric EDs had higher geriatric syndrome diagnosis rates, lower ED lengths of stay, and similar discharge and 72-hour revisit rates when compared with nongeriatric EDs in the CEDR. These findings provide the first benchmarks for emergency care process outcomes in geriatric EDs compared with nongeriatric EDs.

Geriatric Emergency Departments as Laboratories for Innovation

Geriatric Emergency Departments as Laboratories for Innovation

Examination of geriatric care processes implemented in level 1 and level 2 geriatric emergency departments.

Older adults constitute a large and growing proportion of the population and have unique care needs in the emergency department (ED) setting. The geriatric ED accreditation program aims to improve emergency care provided to older adults by standardizing care provided across accredited geriatric EDs (GED) and through implementation of geriatric-specific care processes. The purpose of this study was to evaluate select care processes at accredited level 1 and level 2 GEDs. This was a cross-sectional analysis of a cohort of level 1 and level 2 GEDs that received accreditation between May 7, 2018 and March 1, 2021. We a priori selected five GED care processes for analysis: initiatives related to delirium, screening for dementia, assessment of function and functional decline, geriatric falls, and minimizing medication-related adverse events. For all protocols, a trained research assistant abstracted information on the tool used or care process, which patients received the interventions, and staff members were involved in the care process; additional information was abstracted specific to individual care processes. A total of 35 level 1 and 2 GEDs were included in this analysis. Among care processes studied, geriatric falls were the most common (31 GEDs, 89%) followed by geriatric pain management (25 GEDs, 71%), minimizing the use of potentially inappropriate medications (24 EDs, 69%), delirium (22 GEDs, 63%), medication reconciliation (21 GEDs, 60%), functional assessment (20 GEDs, 57%), and dementia screening (17 GEDs, 49%). For protocols related to delirium, dementia, function, and geriatric falls, sites used an array of different screening tools and there was heterogeneity in who performed the screening and which patients were assessed. Medication reconciliation protocols leveraged pharmacists, pharmacy technicians and/or nurses. Protocols on avoiding potentially inappropriate medication administration generally focused on ED administration of medications and used the BEERs criteria, and few sites indicated whether pain medications protocols had dosing modifications for age and/or renal function. This study provides a snapshot of care processes implemented in level 1 and level 2 accredited GEDs and demonstrates significant heterogeny in how these care processes are implemented.

Geriatrics emergency medicine: The need of time.

Madam, Since the inception of Emergency Medicine (EM) in Pakistan, it has been an ever-growing field, and one such current need is the development of geriatric emergency care. Older patients have a longer Emergency department (ED) stays and more frequent admissions, with an increased risk of special care and intensive care admissions. These patients have unusual presentations and multiple comorbidities, are more prone to complications, are easily affected by their surroundings and require an understanding of their social needs and thorough counselling, complicating their care. The elderly population also termed the ‘silver tsunami’ shares a significant burden of the ED in Pakistan.1 According to the 2017 national census, nearly 13.7 million people in Pakistan, were over the age of 60, accounting for roughly 7% of the total population,2 which is anticipated to double in the coming years, increasing the burden of geriatric patients. This highlights the urgent need todevelop a specialised system for the elderly in acute care settings. Although several programmes in Pakistan focus on elderly care under Family Medicine, there remains a huge gap in emergency care, which is crucial in providing 24/7 healthcare service delivery. Geriatrics curriculum must be incorporated in emergency medicine residency programmes to facilitate patient outcomes, decrease mortality, and prevent functional decline in that age group. The American College of Emergency Physicians (ACEP) certified hospitals as "Geriatric Emergency Departments" (GEDs) in 2018 based on GED guidelines established in 2014. The purpose was to assist in providing more effective care to the elderly population. 3 According to Kaeley et al., a considerably higher number of older people (2965, 54.9%) were hospitalised from the ED, with approximately 651, or 21.9 % admitted to the intensive care unit.4 Geriatric Emergency Medicine Fellowship training provides EDs with expertise to meet the need of a growing geriatric population. (Figure 1) These programmes can serve as a foundation for clinical innovation, research, and education focusing on the elderly population. Work on this is being done globally., Pakistan must play a role in this aspect of emergency medicine, owing to the rapidly increasing older population and advancement in GEM practice worldwide.3,5 A proper healthcare infrastructure at the government level will help geriatric patients cope with limited health resources, financial burdens, and palliative care. A better understanding of geriatric care will assist us in better allocating and utilising the limited resources we have available to alleviate the financial burden. ---Continue

LEVERAGING THE STRENGTH OF UNIQUE PARTNERS TO IMPROVE GERIATRIC EMERGENCY CARE IN RURAL CRITICAL ACCESS HOSPITALS

Abstract Developing a level 1 accredited geriatric emergency department during the pandemic was challenging. The greater challenge has been to support rural critical access hospitals on their journey of becoming level 2 accredited geriatric emergency departments. This has been accomplished through a novel collaborative approach between the level 1 accredited emergency department, a newly established Geriatric Center of Excellence at Dartmouth-Hitchcock Health and a HRSA funded Geriatric Workforce Enhancement Program. This talk will focus on bringing together system partners and funders who have a history of success through: (a) development, testing and dissemination of tool kits and implementation guides; (b) boot camp training that includes interprofessional team training, QI and specific geriatric content training; (c) implementation support and coaching using data and QI methodology through learning collaboratives; (d) scaling successful models of evidence based geriatric care; (e) expertise in implementation science; (f) expertise in evaluation and (g) disseminating findings to achieve our goals.

15 Facilitating Emergency Department Research on Older Adults Through Creation of a Research Data Warehouse

15 Facilitating Emergency Department Research on Older Adults Through Creation of a Research Data Warehouse

Intermediate Care Technicians-A Novel Workforce for Veterans Affairs Geriatric Emergency Departments

Intermediate Care Technicians-A Novel Workforce for Veterans Affairs Geriatric Emergency Departments

295 Positive Cognition Screening a Geriatric Emergency Department

Geriatric emergency departments (EDs) have become more common in recent years. Along with these expansions have come targeted interventions and assessments for older adult patients in the ED to assess several social and clinical factors specific to a patient. Cognitive tests are frequently used to assess older patients’ ability to make decisions to gauge resources that they may need. The objective of this study was to understand who may be more likely to have positive cognitive test in the ED. This was a retrospective multicenter study among older adult patients (>=65 years) presenting to two EDs (urban level one trauma center and suburban academic hospital with combined annual census of ∼80,000). Patients were qualified for specialized geriatric screenings if they were identified as being at risk by the Identification of Seniors at Risk (ISAR) screen and has an Emergency Severity Score (ESI) of 3. Screening tools used to identify potential cognitive issues included the Montreal Cognitive Assessment (MoCA), and the Abbreviated Mental Test 4 (AMT4). Demographic and clinical characteristics were assessed for all patients who received a screen. Logistic regression was used to identify factors independently associated with a positive test. Adjusted odds ratios (AOR) and 95% Confidence Intervals (CI) are reported. There were a total of 1850 cognitive tests ordered. Of those tests ordered, 903 (48%) were able to be completed and scored. Of those 903 tests scored, 226 (25%) were positive. Between those who tested positive and negative, individuals were more likely to have a positive test if they were age 85+ compared to 65-74, (AOR=2.01, 95% CI=1.36, 2.97; p=<0.001) and less likely if they were patients who were non-Hispanic Whites compared to other Races and Ethnicities (AOR=0.59, 95% CI=0.42, 0.83; p=0.002). Sec, mode of arrival and disposition were not associated with a positive cognitive score. Screening tools are important instruments to help identify patients with potentially cognitive issues. Although their use in the ED have been limited in the past, they are becoming utilized more often with the increasing senior population and the development of geriatric ED in the United States. Findings from these assessments help to inform providers of the needs of older adult patients and their caregivers.

167 The PEAGE Study: Patient Experience After Geriatric Evaluation

Based on United States (US) Census data, by 2030 the geriatric population (adults aged 65 and older) is expected to be 20% of the population. Currently there are 46 million older adults in the US, and this is projected to reach 90 million by 2050. As the population of the US ages, the population of patients evaluated in the emergency department (ED) will increase as well. In 2018, the American College of Emergency Physicians (ACEP) began a formal accreditation process for Geriatric Emergency Departments (GED).

Reach and Adoption of a Geriatric Emergency Department Accreditation Program in the United States

The objectives of this study were to describe the reach and adoption of Geriatric Emergency Department Accreditation (GEDA) program and care processes instituted at accredited geriatric emergency departments (EDs). We analyzed a cross-section of a cohort of US EDs that received GEDA from May 2018 to March 2021. We obtained data from the American College of Emergency Physicians and publicly available sources. Data included GEDA level, geographic location, urban/rural designation, and care processes instituted. Frequencies and proportions and median and interquartile ranges were used to summarize categorical and continuous data, respectively. Over the study period, 225 US geriatric ED accreditations were issued and included in our analysis-14 Level 1, 21 Level 2, and 190 Level 3 geriatric EDs; 5 geriatric EDs reapplied and received higher-level accreditation after initial accreditation at a lower level. Only 9 geriatric EDs were in rural regions. There was significant heterogeneity in protocols enacted at geriatric EDs; minimizing urinary catheter use and fall prevention were the most common. There has been rapid growth in geriatric EDs, driven by Level 3 accreditation. Most geriatric EDs are in urban areas, indicating the potential need for expansion beyond these areas. Future research evaluating the impact of GEDA on health care utilization and patient-oriented outcomes is needed.

Developing and Implementing a Geriatric Emergency Department (GED): Overview and Characteristics of GED Visits.

The traditional model of emergency care may not be sufficient to address the complex care needs of older adults, who present to the emergency department with multiple comorbidities, geriatric syndromes, and social determinants of health, complicating diagnosis and management. Geriatric emergency departments (GEDs) have emerged throughout the last decade to address these concerns and improve the emergency care of older adults. Our aim was to describe the policies, procedures, and workflow of our GEDs, and to provide data on patient outcomes and discuss challenges and recommendations in the development and implementation of a GED. Our GED includes interdisciplinary staff trained in geriatric emergency medicine, evidence-based protocols for geriatric care, physical modifications to accommodate older adults' functional limitations, administration of geriatric assessments, care coordination with case managers and social workers, and referrals to care. Assessments screen for geriatric syndromes and social determinants of health. Quality improvement is a critical component and includes a robust medication safety plan to reduce use of potentially inappropriate medications. Hospital administrators considering developing a GED should create a care planning team, conduct an institutional needs assessment, and identify the GED model that will most efficiently help them achieve an age-friendly health system. The GED will play an important role in addressing the diverse health care needs of older adults in the coming decades. Future research studies of health outcomes among older adults receiving care at GEDs compared with traditional EDs will be critical in informing future improvements and innovations in geriatric emergency care.

Ethnic Disparities in COVID-19 Among Older Adults Presenting to the Geriatric Emergency Department.

BackgroundThere is a dearth of epidemiological data on ethnic disparities among older patients with COVID-19. The objective of this study was to characterize ethnic differences in clinical presentation and outcomes from COVID-19 among older U.S. adults.MethodsThis was a retrospective cohort study within two geriatric emergency departments (GEDs) at a large academic health system. One hundred patients 65 years or older who visited a GED between March 10, 2020 and August 9, 2020 and tested positive for COVID-19 were examined. Electronic medical records were used to determine presenting COVID-19–related symptoms, comorbidities, and clinical outcomes. Descriptive statistics are reported with associated 95% confidence intervals (CIs).ResultsIn the overall sample, mean age was 75.9 years; 18% were 85 years or older; 50% were male; and 46.0% were Hispanic. Relative to non-Hispanic patients with COVID-19, Hispanic patients with COVID-19 had a higher percentage of shortness of breath (78.3% vs. 51.9%; difference: 26.4%; 95% CI 7.6–42.5%), pneumonia (82.6% vs. 50.0%; difference: 32.6%; 95% CI 14.1–47.9%), acute respiratory distress syndrome (13.0% vs. 1.9%; difference: 11.1%; 95% CI 0.7–23.9%), and acute kidney failure (41.3% vs. 22.2%; difference: 19.1%; 95% CI 0.9–36.0%). Rates of other poor outcomes, including hospitalization, intensive care unit (ICU) admission, return visits to the GED within 30 days of discharge, or death, did not significantly differ between Hispanic and non-Hispanic patients with COVID-19.ConclusionsThese preliminary data show that older Hispanic patients relative to non-Hispanic patients with COVID-19 presenting to a GED did not experience worse outcomes, including hospitalization, ICU admission, 30-day return visits to the GED, or death.

Profiles of Frequent Geriatric Users of Emergency Departments: A Latent Class Analysis.

Frequent geriatric users of emergency departments (EDs) represent a complex and heterogeneous population. Identifying their specific subgroups would allow the development of interventions better customized to their needs and characteristics. Thus, this study aimed to develop profiles of frequent geriatric ED users using the individual characteristics of patients. This was a retrospective cohort study. Databases from the Régie de l'assurance maladie du Québec (RAMQ) were utilized. PARTICIPANTSThis study included individuals aged 65 years or older living in the community in the Province of Quebec (Canada), who consulted in an ED at least four times in the year after an ED index date (an ED visit, chosen randomly, during an index period of January 1, 2012 to December 31, 2013) and who had received a diagnosis of ambulatory care-sensitive conditions (ACSCs) in the 2 years preceding the index date. A latent class analysis was used to identify subgroups of frequent geriatric ED users according to their individual characteristics, including ACSC type, dementia, mental health disorders, cancer diagnosis, and comorbidity index. The study cohort consisted of 21,393 frequent geriatric ED users. Four groups of frequent geriatric ED users were identified: people with low comorbidity (39.0%), comprising the individuals with the lowest number of physical and mental health conditions; people with cancer (32.7%); people with pulmonaryand cardiac diseases (18.1%); and people with dementia or mental health disorders (10.2%), composed of individuals with the highest proportion of common and severe mental health disease, as well as dementia. This group accounts for the highest use of overall healthcare services. These profiles will be useful in developing customized interventions addressing the needs of each subgroup of frequent geriatric ED users. More research is needed to bridge the remaining gaps, especially regarding the healthiest frequent geriatric users of EDs.

249 The Impact of an Electronic Medical Record Alert on Recognition and Referral of High-Risk Elders in the Emergency Department Setting

Older patients frequently utilize Emergency Departments (ED). Multiple comorbidities, polypharmacy, impaired mobility (falls), changes in mentation (delirium, dementia) and poor social support often contribute to ED visits. Traditional assessment tools, such as ISAR, to identify high-risk geriatric patients can be difficult to implement in a high volume, high acuity ED setting. We examined the impact of an electronic medical record (EMR) best-practice alert (BPA), on recognition and referral of high-risk older patients in the Emergency Department (ED) who could potentially benefit from geriatric evaluation. Retrospective case control study in a busy academic ED with 67,000 total annual visits, and 24% geriatric (age ≥ 65 y) visits, from October 1, 2019 to May 31, 2020. In the initial program (10/1/19-3/30/20), ED providers were educated about high-risk geriatric conditions and an EMR BPA alerted ED providers to a positive (+) triage delirium screen. Starting 3/31/20, an enhanced BPA used EMR-automated recognition that also included age ≥80y, fall complaint, documented dementia history, polypharmacy (≥ 10 medications recorded), or high ED utilization (>5 visits in 1 year) in addition to the (+) delirium screen. A modified Delphi method was used to select these additional high-risk geriatric characteristics. Frequency of BPA notification and ED or ED-observation unit geriatric consultation (summed as comprehensive geriatric assessment, CGA) are reported for initial and enhanced BPA cohorts. Data was abstracted from the electronic medical record. The difference between initial and enhanced BPA encounters is reported. Analysis used SAS studio (v9.4, Cary, NC). 95% CI and p-values are reported. 7,718 geriatric patients were seen during the initial program; 1,836 were seen during the enhanced BPA program. Mean age in the initial cohort was 74.9 years (95% CI, 74.7, 75.0) and 75.6 years (95% CI, 75.1, 76.0) in the enhanced BPA cohort (p=0.002). % Female was 53.0% and 52.9%, respectively (p= 0.95). Unenhanced BPA alerts in the initial program averaged 53/month (range 45-67). BPA alerts in the enhanced program averaged 699/month. In the initial cohort, 318 (4.1%) BPA alerts led to 30 CGA. 303 (4.1%) patients for whom the initial BPA did not fire were also referred for CGA. Overall, during the initial period, 333 (4.3%) patients had CGA. The enhanced BPA resulted in 1398 (76.1%) alerts and 82 (5.9%) CGA. 14 (3.2%) BPA-negative patients were also referred for CGA. Overall, during the enhanced-BPA, 96 (5.2%) patients had a CGA. After the BPA enhancement, the proportion of geriatric evaluations increased a relative 21% (4.3% to 5.2%, p=0.09). Overall CGA referrals averaged 56/month during initial BPA and 48/month in the enhanced period. Of note, due to COVID-19 impact, overall ED volume declined 29% and geriatric ED visits declined 30% during the enhanced BPA period. This single-site study demonstrates that the EMR can be used to identify high-risk elders. An enhanced automated EMR BPA increased both ED provider alerts and, more importantly, geriatric evaluations in high-risk older ED patients. An EMR-based automated alert can be a useful adjunct to increase referrals and geriatric evaluations in the ED setting for this at-risk population.

What We Can Do To Justify Hospital Investment in Geriatric Emergency Departments.

What We Can Do To Justify Hospital Investment in Geriatric Emergency Departments.

Concepts in Practice: Geriatric Emergency Departments

In 2018, the American College of Emergency Physicians (ACEP) began accrediting facilities as "geriatric emergency departments" (EDs) according to adherence to the multiorganizational guidelines published in 2014. The guidelines were developed to help every ED improve its care of older adults. The geriatric ED guideline recommendations span the care continuum from out-of-hospital care, ED staffing, protocols, infrastructure, and transitions to outpatient care. Hospitals interested in making their EDs more geriatric friendly thus face the challenge of adopting, adapting, and implementing extensive guideline recommendations in a cost-effective manner and within the capabilities of their facilities and staff. Because all innovation is at heart local and must function within the constraints of local resources, different hospital systems have developed implementation processes for the geriatric ED guidelines according to their differing institutional capabilities and resources. This article describes 4 geriatric ED models of care to provide practical examples and guidance for institutions considering developing geriatric EDs: a geriatric ED-specific unit, geriatrics practitioner models, geriatric champions, and geriatric-focused observation units. The advantages and limitations of each model are compared and examples of specific institutions and their operational metrics are provided.

INNOVATIONS IN EMERGENCY MEDICAL CARE: EARLY ADOPTERS OF GERIATRIC EMERGENCY DEPARTMENTS

Hospital emergency departments (EDs) treat more than 20 million older adults each year making it a remarkably significant site of healthcare delivery. To date, the nation’s nearly 5,000 EDs have been slow to modify their staffing, ED training, procedures, or physical environment to better serve the unique needs our heterogeneous older adult population. Nonetheless, nationwide a small set of innovative EDs have redesigned their care and now promote themselves as Geriatric Emergency Departments (GEDs) which specifically tailor care to older adults and their families. Using a systematic, nationwide search process of U.S. hospitals, this research identified n=83 EDs which clearly self-identified as GEDs. All eligible GEDs were contacted with n=54 (65%) responding to our self-administered survey regarding their organization, delivery of care, and adherence to national guidelines on the emergency medical care of older adults. Results document a wide variety of care models, staffing patterns, screening procedures, clinical care modifications, quality improvement efforts, physical environment enhancements, referral patterns, and tracking of older patient outcomes. Analysis of open-ended responses demonstrated widely divergent interpretations of the national guidelines on emergency care for older adults including the definition of a GED. Based on the findings, research recommendations are made to researchers regarding the conceptualization and specific wording of future survey items in order to increase the reliability and validity of research into GEDs.