Nurses Help Deliver Tailored Geriatric Care in ED

Cleveland Clinic nurses play a vital role in a recently developed program that improves the quality of care and outcomes for geriatric patients in the Emergency Department.

The geriatric care unit (GCU) connects older patients to a geriatric specialist and allows them to be observed for up to 23 hours in the ED. Since opening in 2019, the Cleveland Clinic GCU has streamlined geriatric patients’ access to appropriate post-emergency care, which in turn has helped reduce unnecessary admissions to the hospital. And nurses say their training has benefits that extend beyond the elderly.

Adverse medication response, polypharmacy, balance, mental health issues and cognitive impairment are among common contributors to problems that send the elderly to the ED. These conditions often require special expertise and more digging than has traditionally been supported by the fast pace of emergency medicine.

In the GCU, however, nurses conduct screenings for those conditions and are members of a medical team that includes a geriatrician. Medication adjustments, referral for fall-prevention therapy, and transfers to skilled nursing facilities might well be more appropriate than admitting the patient to the hospital.

Cleveland Clinic ED nurses have fully embraced the GCU, says Karen Guzi, MSN, RN, ACNS-BC, BCEN, a clinical nurse specialist in the department. They see its benefits both in the quality of care to patients and in the expansion of their professional expertise. “It isn’t just a matter of identifying another patient group,” Guzi says. “The nurses have expanded, and will continue to develop, their geriatric education.”

The program was developed by Stephen Meldon, MD, Senior Vice Chair of the Emergency Services Institute, and Saket Saxena, MD, of the Center for Geriatric Medicine. Nurses have been “absolutely integral” partners in the development of the GCU, Dr. Meldon says. They perform, for example, screenings for fall risk, delirium, depression and suicide risk – all critical for helping to identify underlying conditions.

Dr. Meldon explains that not all older patients in the ED require the GCU. “There’s the obvious group of patients who are sick and need to come into the hospital,” Dr. Meldon says. “But there’s also a big gray area, where I’m just uncomfortable sending this patient home. They may not have the support structure or the functional status I would like. I’m not quite sure why they’re dizzy, but I don’t think they need to be admitted. It’s that middle group where it’s helpful to have a geriatric expert weigh in on the case.”

That help, along with the breathing room afforded by extended observation time, eases nurses’ concerns, Guzi says. “Nurses used to be frustrated by limitations that kept them from extending more resources to elderly patients, and now they have those resources,” she says.

Elderly patients often worry that if they are admitted to the hospital, they will never go home, but the availability of a 23-hour observation unit allays some of those fears, Guzi adds. “They’re very much more comfortable coming into this environment.

Barbara Morgan, MSN, RN, NE-BC, Associate Chief Nursing Officer, Emergency Services and Nursing Director at the main campus, says the expertise nurses develop for the GCU sharpens their awareness of issues that may arise among non-elderly populations as well.

“In the Emergency Department, we see all age ranges and the full scope of all medical and surgical conditions. The knowledge that we gain from starting the geriatric care unit has helped across the board,” Morgan says. “For example, delirium screening has elevated our awareness for delirium among all of our patients. And not just here at the main campus. We standardized delirium screening at all of our Emergency Departments. We are always seeking knowledge to enhance our practice and patient care.”

A commitment to the program

As the nurse specialist for the unit, Guzi is a go-to resource for her nursing colleagues. “I am there Monday through Friday, and I’m also available by phone during off hours,” she says. “I’m the person who is coordinating the education and checking in with the nurses to ask how they’re doing and what we need, as well as to look at what else we can be providing to our nurses to level them up. How do we grow this?”

She also will help with administrative tasks as the team develops research.

“I have the time to support the nursing staff so they are able to participate without the burden of having to do some of the administrative components of research,” she says.

How to replicate the approach

Cleveland Clinic’s GCU model cannot be replicated by every hospital or emergency department, but Dr. Meldon believes it has useful implications for those that aim to do better by their elderly patients.

“Not everybody can station a geriatrician in the ED, but you can look and say, What’s the most good I could do within this set of resources?” he says. “Some geriatric EDs can do fall screenings and screenings at the bedside with standardized tools. Nurses can do that, and then they can help arrange follow-up with PCPs or outpatient physical therapy appointments.”

Guzi agrees, and notes that improvements can be made simply by ensuring that team members share a common understanding of the available tools and protocols with geriatric patients. “In an emergency room, things happen very quickly, and time seems to be the most coveted resource,” she says. “We’ve demonstrated that it can be done in an expeditious manner effectively.”

Morgan says that better ED care for a rapidly growing patient population benefits everyone — including family members and caregivers. “It’s just been so hopeful and more optimistic when they bring a loved one into the Emergency Department.”