The Geriatric ED and Clinical Protocols for the Emergency Care of Older Adults

Follow-up/Transitions of Care. Design discharge processes best suited for older patients (eg, large-font instructions), as well as collaborate with community resources to provide home-health services and home safety assessment in order to facilitate care following discharge.

Quality Improvement. Implement a system to collect and monitor pertinent and prevalent geriatric emergency care indicators (eg, incidence of injurious falls and documentation of fall risk assessment) designed to increase staff education and program success.

The authors clearly state that the GED guidelines represent recommendations. They are not a mandate for every ED, nor are they a list that requires 100% compliance. Instead, the document provides the potential steps to be taken, the rationale for these recommendations, and an outline of the resources available to aid in the transition from theory to implementation in any ED. The goal is to ensure better, safer, and age-appropriate treatment. In summary, these guidelines represent an effort to improve and even transform emergency care for older adults on the brink of one of the most significant challenges facing our healthcare system both in and beyond the ED.

Moving forward, the authors of the GED guidelines have defined a plan that “includes dissemination, implementation, adaptation, and refinement.” In addition to approval by each of the organization’s board of directors and the copyright of the material in 2013, the ED guidelines have now been widely disseminated through publication in numerous news articles (including international publications) and discussions on satellite radio. Tracking of new GEDs is planned. In addition, the prioritization of the guidelines is underway using a modified Delphi method, with the express purpose of assessing the relative potential benefits and harms associated with each recommendation by providing a weighted list from most important to least important.

A “Geriatric Emergency Department Boot Camp” is being developed to bring the recommendations to hospitals interested in “geriatricizing” their EDs. Geriatric EM leaders will act as consultants, providing training and a toolbox of resources. Specific reviews and revisions of the GED guidelines will take place in a 4- to 5-year cycle. Clearly, a next important step is the development of a GED certification system based on outcome studies of the individual components.

Criticisms of the GED guidelines have already been voiced among some EM providers. Specific concerns include a fear of partitioning the ED (as has occurred with pediatrics); an increase in cost and decreased efficiency; the need to maintain general expertise among EM physicians; the lack of evidence-based data upon which the recommendations were made; the fact that some guidelines were extrapolated from other clinical settings; and the belief that these changes will be too logistically difficult and take too much time.

The fact remains that the wave of geriatric patients (the “silver tsunami”) is already beginning to hit the shores of our hospitals. And GEDs are already here to help absorb the impact. The lack of iron-clad evidence for many of the recommendations should not be an absolute obstacle, but rather part of the natural evolution and improvement of similar endeavors. Nor should GEDs contain empty beds while younger adults sit in the waiting room, or conversely, force the elderly to wait for space in the GED when there are empty beds in the main ED. Ideally, the GED should be the location where the ED staff can implement these guidelines, which they can afterwards utilize in any part of the ED. These guidelines are designed to provide the best available expert opinion on how to deliver better geriatric care in the ED. The imperative for this goal is clear and necessitates this educated “leap-of-faith.” Change is never easy and often comes with an upfront cost of time, resources, and money. Moreover, there is nothing in a well-designed GED that may not also benefit, or at least will not adversely affect care of a younger adult as well. Therefore, flexibility and optimal utilization of space in a busy ED need not be sacrificed.

Conclusion

To improve diagnostic evaluation and care of the increasing number of geriatric patients presenting to the ED, reliable tools, protocols, and guidelines must be developed and implemented to ensure diagnostic accuracy, decrease adverse events, and improve patient outcomes. Fortunately, the new GED consensus guidelines are flexible and do not need to be wholly embraced—lending themselves to modifications and institution-specific adoptions. The “protocolization” and implementation of the guidelines may improve patient flow, operational efficiency, and, most importantly, the quality of care delivered. And likely, these guidelines will provide the foundation for future education and research into the improved emergency care of older adults.