The Geriatric Emergency Department

Background/Foundations

The current model of care delivery in the Emergency Department (ED) is designed for rapid evaluation, treatment, and turnover of patients. The layout is designed to maximize resources while improving throughput at the expense of privacy and comfort (e.g., hallway beds, lack of space for family and/or caregivers). Choices in materials favor cost savings and space conservation (e.g., fluorescent lighting, narrow mattresses, and vinyl flooring). The triage system is designed to rapidly identify patients needing immediate intervention and is guided by the principle that clinicians target a primary acute medical problem using an optimal treatment algorithm. A traditional ED visit ends with admission for necessary medical care or discharge because the acute needs of the patient have been met. Too often, little emphasis is placed on arranging post-ED follow-up care or ensuring patient comprehension of discharge instructions. Although this approach may work for younger patients, the current ED model presents a challenge in the management of elders. Moreover, the model undermines the ability of the ED to care optimally for older adults and complicates their transition to follow-up care and access to community-based resources.

Unlike younger patients, older adults have atypical and complex presentations of disease and trauma. They often present with vague complaints, polypharmacy, age-specific multifactorial geriatric syndromes (e.g., falls and delirium), comorbid disease burdens, and functional and cognitive impairments. Older adults are more likely to receive a greater number of diagnostic tests and treatment regimens, have longer lengths of stay, and often have multiple hospital admissions. Finally, after an ED visit, elders are more likely to suffer from health and functional decline and worsened quality of life. Adverse outcomes after ED visits have patient care and cost ramifications, suggesting that improved models of integrated care may facilitate good outcomes and decrease costs.

Advances in health education, pharmacotherapy, and health-related technology, have resulted in an increase in life expectancy. Accordingly, 20% of the US population, totaling more than 77 million people, will be aged 65 years and older in 2030, outnumbering the number of children for the first time in US history. Of particular significance, the most rapidly growing segment of the population is 85 years and older, which is projected to increase by 129%, from 6.4 million in 2016 to 14.6 million in 2040.

The 2013 RAND Report ( https://www.rand.org/pubs/research_reports/RR280.html ), evaluated the evolving role of hospital EDs in the US health care system. It found that EDs are increasingly used for complex evaluations. Emergency clinicians are the primary decision makers for half of all hospital admissions. ED admissions of Medicare patients are growing faster than any other US patient group, with 6 of 10 patients admitted through the ED. Furthermore, recent estimates indicate there is more than 1 ED visit for every 2 older adults in the US annually. EDs increasingly see older patients with multiple health care needs due to convenience, perception of increased quality of care, and lack of rapid access to primary care providers. Because of the increasing number of elders and the outsized role EDs play in their medical care, it is necessary for ED design and structure to evolve and meet the challenge.

Geriatric Emergency Department Guidelines

In response to this growing need, an interdisciplinary group of professional specialties, societies, and organizations developed the Geriatric ED (GED) Guidelines, which were published in 2014. The guidelines consist of 40 specific recommendations in 6 general categories: (1) staffing and administration; (2) equipment and supplies; (3) education; (4) policies, procedures, and protocols; (5) follow-up and transitions of care; and (6) quality improvement measures.