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

The IUC was removed, and the patient was started on IV antibiotics for a urinary tract infection (UTI) secondary to IUC placement. The inpatient stay was prolonged for an additional 3 days until his delirium cleared and he could be continued on oral antibiotics as an outpatient.

Discussion

There is nothing extraordinary about these two cases. Every day elderly adults present to EDs throughout the country with confusion caused by pneumonia and dehydration that is sometimes initially attributed to worsening dementia and then complicated or prolonged by overuse of powerful sedating medications. Also, complications resulting from IUCs inserted in the ED all too often prolong hospitalizations. But by using protocols designed for better, more efficient emergency care of elderly patients, their ED care can be substantially improved and any subsequent inpatient care shortened.

The older adult population (ages 65 years and older) often presents to the ED with similar complaints to their younger counterparts—eg, chest pain, abdominal pain, dyspnea. However, the history, physical examination, and social assessment of elderly patients usually lead to a more comprehensive work-up, as older adults tend to present in an atypical fashion for both illness and trauma, thus necessitating a broader differential. In addition, they are more susceptible to adverse reactions from medications and procedures.

Regardless of the ultimate diagnosis, simply presenting to an ED as a patient (and sometimes spending many hours there) places older adults at elevated risk of morbidity and mortality. The challenge is to develop reliable tools to streamline the management of this population in order to increase diagnostic accuracy, decrease adverse events, and improve patient outcomes.

Clinical Protocols
Clinical protocols are one way in which we can educate and standardize the practice of multiple levels of provider, including nurses, midlevel providers, and physicians. Adopting protocols is natural for EPs—the key is to make sure the clinical protocol to be implemented is designed or modified for the ED setting in which it will be implemented.

In our ED, we have recently implemented the following two protocols for common scenarios in older adults: (1) assessment and management of delirium; and (2) decreased use of IUCs. These protocols employ the following stepwise project plan:

1. Focus groups involving nurses, midlevels, residents, and attendings to assess ED provider knowledge, attitudes, and practice patterns regarding the clinical issue  in older adult patients, and to guide development of the clinical protocol by understanding needs and constraints of the current ED environment;
2. An extensive literature review of the clinical topic;
3. Development of the clinical protocol by the workgroup;
4. Implementation of protocol after multiple educational sessions using a scripted slide presentation to ensure all providers receive the same information; and
5. Subsequent data analysis from the electronic medical record to assess the impact (ie, outcome) of the protocol.

Delirium
Delirium is a common syndrome in older adults, but is often unrecognized despite its clinical importance. Although 7% to 17% of older adults who present to the ED suffer from delirium,^1-6 emergency physicians (EPs) miss 64% to 83% of cases, and 12% to 38% of patients with unrecognized delirium are actually discharged from the ED.^1,6-8 Unfortunately, patients discharged from the ED with undetected delirium are three times more likely to die within 3 months than those whose delirium was recognized.

Life-threatening causes are more apt to be recognized early on in the ED. With this in mind, we developed a new, comprehensive, evidence-based protocol for recognition, diagnosis, management, and disposition of agitated delirium in older adults in the ED, with a focus on identifying and treating the commonly missed contributing causes: analgesia, bladder-urine retention, constipation, dehydration, environment, and medications.⁹

IUC Placement in the ED
The second protocol implemented at our institution is a new, evidence-based protocol for the placement, management, and reassessment of IUCs. As emphasized by the National American College of Emergency Physicians (ACEP) 2013 Choosing Wisely Campaign,¹⁰ inserting an IUC is a procedure that should be undertaken judiciously as it is associated with an elevated risk of infection, delirium, falls, and other adverse events. As of 2008, the Centers for Medicare and Medicaid Services no longer reimburses for hospital-acquired catheter-associated UTIs.¹¹

After conducting focus groups of our ED providers, we learned that IUCs are placed more frequently than needed—often for reasons of convenience—and are rarely reassessed or removed if the patient is admitted to the hospital. Thus, our protocol highlights appropriate, possibly appropriate, and inappropriate indications for IUC placement, with an emphasis on trying alternative modes of urine collection, communicating among healthcare providers regarding the necessity of an IUC, and reassessment of the patient for IUC removal.