Geriatric emergency department: coordinated & tailored care

A new article by Nagurney et al. in press in the Annals of Emergency Medicine examined association between emergency department (ED) visits and functional decline in the community-living geriatric population. The study found that although not as debilitating as an acute hospitalization, ED visits that do not result in hospitalization are still associated with clinically significant decline in functional status within 6-months of the visit.

From a cohort of 754 community-living older persons across up to a 14-year span, the team matched 813 ED visits without hospitalization (ED-only) to 813 observations without an ED visit (control). The mean participant age was 84 years. Disability was measured by data collected on demographic characteristics, chronic conditions, body mass index, cognitive impairment, depressive symptoms, and physical frailty. After a 6-month follow-up period, the ED-only group had a significantly higher disability score than the control (adjusted risk ratio: 1.14). Furthermore, both nursing home admissions and mortality rates were higher between the two groups (3.11 and 1.93, respectively). Considering that even a relatively minor issue may be a flag for functional decline and additional resources on both preventive and corrective fronts, effective screening and demographic-specific acute care is crucial.

As a nexus between inpatient and outpatient care, the ED has a major role in improving care coordination and allocation of resources to the geriatric population. The American College of Emergency Physicians (ACEP) recognizes the heterogeneity of this demographic, and one solution to Nagurney et al.’s findings is proper dissemination and implementation of the Geriatric Emergency Department (GED). GED’s are designed to address specific needs of the older population with associated benefits such as improved healthcare outcomes and a reduction of unwarranted hospitalizations/readmissions. One effective pillar is the utilization of an interdisciplinary team to address symptoms that are typical of and unique to geriatric patients. A holistic approach through advanced care coordination between a medical team, social workers, pharmacists, and physical therapists allows various metrics of care to be addressed (e.g., home health services, assessment of patient gait, and pharma-compliance).

In a podcast with Urgent Matters, Drs. Ula Hwang & Kevin Biese of the Geriatric Emergency Department Collaborative (GEDC) describe in detail the opportunity for GED development in terms of care coordination and safely preventing avoidable hospitalizations.  Dr. Hwang describes the ability for “[GED] on-site assessments to screen for delirium, cognitive dysfunction, depression, and check what their needs are in the home.” All patients are given follow-up calls starting at 24-48 hours and subsequent regular intervals to assure a successful transition to the outpatient setting (regardless of hospitalization status). The team-driven, simple screening approach to prevent poor outcomes and improve ED experience for the geriatric patient is evidence-based (e.g., Karam et al., McCusker et al.). Looking forward, the future should focus on prevention of reducing functional decline, iatrogenic problems, and improving effective care throughout the healthcare continuum.

The US Census shows that over 40 million Americans are 65+, and that the population of 85+ are now the fastest growing. Dr. Terry Filmer, president of the John A. Hartford Foundation (a major supporter of initiatives to improve healthcare for older adults), states that there are currently over 100 GED’s in the United States - a rapidly increasing number to meet the demand.

St. Joseph’s Regional Medical Center designed a GED program – click here to learn more about their implementation and protocol-specific information from the Urgent Matters Toolkit.

Ameer Khalek is a MPH Candidate of the GWU Milken Institute School of Public Health