The Geriatric ED and Clinical Protocols for the Emergency Care of Older Adults
Our protocols have yielded early promising results, but further research is underway to determine their specific impact. The goal is to create a protocol that is feasible and effective for the specific institution and department to which it is applied. By ensuring all members of the healthcare team are involved in the development and design of a protocol, there is ownership of its implementation and use, with the overarching goal of improving patient care.
Geriatric ED Guidelines
In the beginning of 2014, new consensus-based Geriatric Emergency Department (GED) guidelines were published in order to “provide a standardized set of guidelines that can effectively improve the care of the geriatric population and are feasible to implement in the ED.”12 These guidelines are the result of a 2-year effort by representatives from ACEP, the American Geriatrics Society, the Society of Academic Emergency Medicine, and the Emergency Nurses Association, who were committed to optimizing the emergency-care delivery model for geriatrics. The participants encompassed both academic and community providers and included clinicians and researchers. These guidelines were formulated based on an 80% consensus among the representatives and, when possible, validated using existing literature at the time.
The genesis of the GED guidelines was multifactorial. In addition to the formation and rapid growth of geriatric interest groups and sections within EM academic organizations over the last 14 years, as well as the development of geriatric core competencies for EM residents in training, the 2010 Census Data results sharply outlined the details of the rapidly growing population of older adults in the United States. This acted as an alarm highlighting the need for a structured document containing best practice recommendations from geriatric emergency healthcare providers, researchers, and advocates. “The subsequent increased need for healthcare for this burgeoning geriatric population represents an unprecedented and overwhelming challenge to the American healthcare system as a whole and to emergency departments specifically,” the authors of the GED guidelines noted.
In response to a growing national interest in geriatric ED patients and an ever-increasing competition to attract patients from this demographic by EDs across the country, there has been a surge of self-designated GEDs during the last few years. Currently, more than 70 hospitals claim to have GEDs, raising the question of what sort of geriatric patient care is actually being delivered in these EDs. The question is of increased importance because very few of these “GEDs” are in academic centers or are associated with thought leaders in EM. In fact, when 30 self-designated GEDs that were snowball sampled in 2013 by researchers who asked what specific changes they had made toward the goal of improving care for the elderly, several rescinded this self-designation.
Because of heightened concerns for the needs of the increasing geriatric population overall, and the rise in the proportion of ED visits by this demographic, the authors of the GED guidelines state that “the contemporary emergency medicine management model may not be adequate for geriatric adults,” and offer the new GED guidelines as a basis on which EDs can consider ways to improve care for older adults while addressing the unique needs of this population. The GED guidelines propose specific methods and processes by which ED care of the elderly can be optimized. The authors note that “similar programs designed for other age groups (pediatrics) or directed towards specific diseases (STEMI, stroke, and trauma) have improved the care both in individual EDs and system-wide, resulting in better, more cost-effective care and ultimately better patient outcomes.”
The GED guidelines consist of 40 specific recommendations in six general categories: (1) staffing/administration; (2) equipment/supplies; (3) education; (4) policies/procedures/protocols; (5) follow-up/transitions of care; and (6) quality-improvement measures. This template outlines how to construct an effective GED program. The following highlights recommendations for each of these categories:
Staffing/Administration. Set qualifications and responsibilities for the medical director, nurse manager, staff physicians, nurses, and specialists, as well as accessibility to specialist ancillary services, with the goal of establishing hospital site-specific staff and coordination of local resources.
Equipment/Supplies. Develop potential physical and structural enhancements that address issues of mobility, comfort, safety, and behavioral needs (including memory cues and sensorial perception) while decreasing iatrogenic complications, such as the development of pressure ulcers (eg, the use of reclining chairs and pressure-redistributing foam mattresses).
Education. Provide nurse and clinical provider education and specialty-specific training focusing on contemporary, research-based geriatric-specific material, with regular assessment for interdisciplinary core competencies.
Policies/Procedures/Protocols. Implement a directed, comprehensive approach to facilitate screening and assessment of geriatric patients for added needs/post-ED adverse outcomes, as well as validated, ED-feasible screening tools/instruments for delirium and dementia, medication management, falls, use of urinary catheters, and the provision of palliative care.
