Health care systems worldwide are grappling with a 21st-century reality for emergency medicine: While we thought EM was primarily resuscitation, trauma, and procedures, it turns out that an increasing amount of our time is spent providing complex care to frail older people.¹

Following the lead of ACEP, the Society for Academic Emergency Medicine, the Emergency Nurses Association, and the American Geriatrics Society, European leaders recently published a geriatric EM core curricula, and emergency nurses are acknowledging the need for a unique approach for the senior citizen in the emergency department.^2–4 Seniors generally visit an ED more frequently than their younger counterparts, and they often present with more urgent and emergent conditions once in the ED. Both the number and nature of aging baby-boomer presentations to the ED could threaten access to care for patients of all ages unless leaders across disciplines devise more efficient strategies to integrate acute care during and following an ED visit.

Fortunately, innovations increasingly exist to overcome these challenges.⁵ ACEP Now reported on geriatric emergency department (GED) guidelines in 2014, endorsed by the ACEP Board of Directors, designed to inform staffing, education, protocols, and quality improvement initiatives to ED leaders.⁶ However, publishing alone isn’t enough to alter clinical practice across health care settings.

Thankfully, a diverse group of international stakeholders and funders is now providing innovative approaches to implement change. Could one of these approaches be the key to improving older-adult ED efficiency, patient-centric outcomes, and value-based purchasing for you?

United States: The Geriatric Emergency Department Boot Camp

All health care is local, as the saying goes; adapting the GED guidelines to fit local populations and available resources for a hospital and region is no exception.

Supported by grants from the John A. Hartford Foundation and the Gary and Mary West Health Institute, the Geriatric ED Boot Camp (led by Ula Hwang, MSc, MD, Kevin Biese, MD, MAT, Teresita Hogan, MD, Michael Malone, MD, and two authors of this article) has taken ED geriatric training to two health care systems over the last 18 months: Aurora Health Care in Wisconsin and the Magee-Womens Hospital of University of Pittsburgh Medical Center. Boot camp faculty worked intensively for six months with frontline ED nurses and physicians, hospital executives, and home health services to identify quality improvement (QI) opportunities across their EDs. The GED Boot Camp culminated in a two-day site visit to provide mentoring and coaching for the local teams, followed by six months of teleconference follow-up as the sites implemented individually selected QI projects to measure improved older-adult emergency care. The boot camp team is currently scaling up this approach to include at least nine hospital systems across the United States.

Canada: The Senior-Friendly Emergency Department Course

The Senior-Friendly ED (SFED) course has now been offered twice, in Toronto and Winnipeg, with attendance from 40 hospital teams across six provinces and four U.S. border states. In preparing for the SFED, individual hospitals send interdisciplinary teams of multiple individuals for a one-day intensive interactive learning program. This approach allows teams to identify challenges within their own institutions and realistic opportunities for improving older-adult patient outcomes and staff satisfaction. These courses not only focus teams on actionable problems but on interacting with other hospitals. This approach often reveals new opportunities for real-world solutions while simultaneously creating a team committed to achieving meaningful change at its own site.

Australia: Integrated Emergency Care for Older Persons Symposium

Because of professional silos, reimbursement issues, and the fast pace of an ED, linking vulnerable older patients with outpatient resources to reduce falls, address functional decline, and prevent unnecessary ED returns is challenging. EM alone cannot overcome these barriers. Clinicians, community providers, funders, and policy makers across the care continuum will converge in Melbourne, Australia, in October 2016 for a two-day scientific program aimed at identifying internationally relevant solutions for providing more integrated ED care. (You can find registration and program information at alfredetc-professional-development.cvent.com/IECOP.) The Integrated Emergency Care for Older Persons Symposium includes interactive roundtable debates, simulations, and original research presentations to alter practice in an innovative marketplace.

^* Emergency department, hospitalists, primary care, geriatricians
^† Home health services, Meals on Wheels, transportation services, Alzheimer’s Association
^‡ Emergency department and geriatricians
^§ ED Administration Conference, Western ED Operations Conference

As summarized in the above table, each approach has advantages and disadvantages, but each awaits definitive proof-of-concept.⁷

The expansion of geriatric care in EDs will continue, and we as EM providers have the opportunity to either define best practices or have best practices defined for it by others.⁸ Delivering high-quality, patient-centric emergency care for an aging population will remain a challenge and will require a team-based approach. A one-size-fits-all solution to bridge disciplines and create comprehensive ED geriatric care is unlikely, so the best strategy is to link innovation and providers in a multipronged approach similar to that seen in the growth of cardiac, stroke, trauma, and pediatric care.

Dr. Melady is employed at Mount Sinai Hospital in Toronto. Follow him on Twitter at @geri_EM.

Dr. Lowthian is employed at Monash University in Melbourne, Australia. Follow her on Twitter at @Emergedu.

Dr. Carpenter is employed at Washington University in St. Louis. Follow him on Twitter at @GeriatricEDNews.

References

1. Lowthian JA, Curtis AJ, Cameron PA, et al. Systematic review of trends in emergency department attendances: an Australian perspective. Emerg Med J. 2011;28(5):373-377.
2. Hogan TM, Losman ED, Carpenter CR, et al. Development of geriatric competencies for emergency medicine residents using an expert consensus process. Acad Emerg Med. 2010;17(3):316-324.
3. Conroy S, Nickel CH, Jónsdóttir AB, et al. The development of a European curriculum in geriatric emergency medicine [published online ahead of print April 25, 2016]. Eur Geriatr Med. doi:10.1016/j.eurger.2016.03.011.
4. McClelland M, Sorrell JM. Enhancing care of older adults in the emergency department: old problems and new solutions. J Psychosoc Nurs Ment Health Serv. 2015;53(3):18-21.
5. Hwang U, Rosenberg MS, Dresden SM. Geriatrics Emergency Department – The GEDI WISE Program. In: Malone ML, Capezuti E, Palmer RM, eds. Geriatrics Models of Care: Bringing ‘Best Practice’ to an Aging America. Switzerland: Springer International Publishing; 2015:201-209.
6. Carpenter CR, Hwang U, Rosenberg M. New Guidelines Enhance Care Standards for Elderly Patients in the ED. ACEP Now. March 6, 2014.
7. Platts-Mills TF, Glickman SW. Measuring the value of a senior emergency department: making sense of health outcomes and health costs. Ann Emerg Med. 2014;63(5):525-527.
8. Hogan TM, Olade TO, Carpenter CR. A profile of acute care in an aging America: snowball sample identification and characterization of United States geriatric emergency departments in 2013. Acad Emerg Med. 2014;21(3):337-346.