Older people who present in the emergency department (ED) are often dealing with multiple chronic conditions, polypharmacy and complex physical and social challenges that require geriatric-focused care.
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“Though geriatric protocols have been in place in inpatient and outpatient environments for years, it is difficult to provide such care in a fast moving ED environment, even though the ED is a major point of contact for older adults with the health system,” says Saket Saxena, MD, of Cleveland Clinic’s Center for Geriatric Medicine.
As part of a system-wide focus on the medical and psychosocial needs of older individuals, geriatric specialists and emergency department physicians at Cleveland Clinic have joined forces in the development of a geriatric-focused ED at its main campus. Led by Dr. Saxena and Stephen Meldon, MD, Vice Chair of the Emergency Services Institute, the geriatric ED brings appropriately tailored observation, assessment and referrals to complex older patients.
The service consists of a dedicated four-bed geriatric care unit (GCU) in the ED’s existing observation unit for patients who need a more comprehensive evaluation.
The service was launched in September 2019 following the favorable outcome of a pilot study in 2018 at the main campus looking at the use of an integrated geriatric evaluation service in the ED. The goal was to facilitate smooth transitions for older patients to skilled nursing facilities or home.
“It’s hard to drill down to some of the nuances with these patients in the fast-paced ED where the focus is on getting tests as quickly as possible to determine if a patient needs to be admitted,” says Dr. Meldon. “If I see a geriatric patient is not functioning well, that’s very different from dealing with a broken arm. That’s where the geriatric expertise comes in. The typical emergency provider doesn’t always have the training or time to address these needs.”
The GCU reflects a growing awareness nationally among healthcare providers and emergency department physicians of the importance of expanding ED services to address geriatric patients’ unique presentations and outcomes.
The American College of Emergency Room Physicians (ACEP) has developed a Geriatric ED accreditation program in which hospitals integrate best practices for older adults into existing ED services or create a designated ED space for older adults.
A fall leading to a wrist fracture, for example, is often more than just a wrist fracture for an older person, Dr. Saxena explains. That person may be having problems with balance because the medications they’re taking are causing precipitous drops in blood pressure. “If the adverse reaction is left unaddressed, that patient will return home with a very high probability of returning to the ED with a similar presentation,” he says.
Other older adults often end up in the ED because they lack the right type of social support, and the ED functions as a sort of safety-net for them.
In an ideal world, they would have access to the kind of comprehensive, geriatric-focused primary care that can in many cases help prevent the need for ED care in the first place. But since many older adults don’t have this care, “we need to focus on the available resources and use those resources where we can make the most difference,” Dr. Saxena says. Since the ED is chief among those resources, “ED physicians are now expected to make a more detailed evaluation of older patients, especially when the condition is not a clear-cut emergency.”
The front porch approach
The geriatric ED provides resources to emergency department physicians using the “front porch approach” as opposed to the “front door approach.” The front porch approach focuses on a closer examination because the older patient’s needs are not always black and white and the emergency situation not as well defined. “For the patient who comes to the emergency department repeatedly for dehydration, the question is ‘what is causing that dehydration?’” Dr. Saxena explains.
Patients with cognition issues, mobility issues, lack of social support and adverse drug reactions are among those the geriatric ED works to identify as soon as possible. “Whether they’re discharged home or admitted to the hospital, the goal is to identify these problems on day one,” says Dr. Saxena.
When it’s not immediately clear whether or where a patient needs to be admitted, they can be placed in the GCU and examined by a geriatrician and a care management specialist or receive a physical therapy consult to determine whether they need to be admitted to the hospital, transitioned to a rehabilitation or skilled nursing facility, or prescribed home services.
Says Dr. Meldon, “that kind of in-depth evaluation simply isn’t possible in a busy ED where we’re focused on turning over beds because more patients are coming in. The geriatric ED can help fill that need.”