Académique Documents
Professionnel Documents
Culture Documents
Abstract
Background: The aging of America poses a challenge to emergency departments (EDs). Studies show
that elderly patients have poor outcomes despite increased testing, prolonged periods of observation,
and higher admission rates. In response, emergency medicine (EM) leaders have implemented strategies
for improved ED elder care, enhancing expertise, equipment, policies, and protocols. One example is the
development of geriatric EDs gaining in popularity nationwide. To the authors knowledge, this is the
rst research to systematically identify and qualitatively characterize the existence, locations, and features
of geriatric EDs across the United States.
Objectives: The primary objective was to determine the number, distribution, and characteristics of
geriatric EDs in the United States in 2013.
Methods: This was a survey with potential respondents identied via a snowball sampling of known
geriatric EDs, EM professional organizations geriatric interest groups, and a structured search of the
Internet using multiple search engines. Sites were contacted by telephone, and those conrming geriatric
EDs presence received the survey via e-mail. Category questions included date of opening, location,
volumes, stafng, physical plant changes, screening tools, policies, and protocols. Categories were
reported based on general interest to those seeking to understand components of a geriatric ED.
Results: Thirty-six hospitals conrmed geriatric ED existence and received surveys. Thirty (83%)
responded to the survey and conrmed presence or plans for geriatric EDs: 24 (80%) had existing
geriatric EDs, and six (20%) were planning to open geriatric EDs by 2014. The majority of geriatric EDs
are located in the Midwest (46%) and Northeast (30%) regions of the United States. Eighty percent serve
from 5,000 to 20,000 elder patients annually. Seventy percent of geriatric EDs are attached to the main
ED, and 66% have from one to 10 geriatric beds. Physical plant changes include modications to beds
(96%), lighting (90%), ooring (83%), visual aids (73%), and sound level (70%). Seventy-seven percent
have staff overlapping with the nongeriatric portion of their ED, and 80% require geriatric staff
didactics. Sixty-seven percent of geriatric EDs report discharge planning for geriatric ED patients, and
90% of geriatric EDs had direct follow-up through patient callbacks.
Conclusions: The snowball sample identication of U.S. geriatric EDs resulted in 30 conrmed
respondents. There is signicant variation in the components constituting a geriatric ED. The United
States should consider external validation of self-identied geriatric EDs to standardize the quality and
type of care patients can expect from an institution with an identied geriatric ED.
ACADEMIC EMERGENCY MEDICINE 2014; 21:337346 2014 by the Society for Academic Emergency
Medicine
From the Section of Emergency Medicine, Department of Medicine, University of Chicago School of Medicine (TMH), Chicago, IL;
the University of Chicago (TOO), Chicago, IL; and the Division of Emergency Medicine, Washington University in St. Louis School
of Medicine (CRC), St. Louis, MO.
Received August 5, 2013; revision received September 6, 2013; accepted September 7, 2013.
Dr. Carpenter, an associate editor for this journal, had no role in the peer review or publication decision for this paper. The
authors have no relevant nancial information or potential conicts of interest to disclose.
Supervising Editor: Lowell Gerson, PhD.
Address for correspondence: Christopher R. Carpenter, MD, MS; e-mail: carpenterc@wusm.wustl.edu. Reprints are not available
from the authors.
ISSN 1069-6563
PII ISSN 1069-6563583
337
337
338
urrent (and soon to be) older adults pose a signicant challenge to the specialty of emergency
medicine (EM).14 Despite a trend favoring
increased testing, prolonged periods of observation,
and higher admission rates, studies have shown worse
emergency department (ED) outcomes in this population.57 In response to the geriatric demographic imperative, leaders from the Society for Academic Emergency
Medicine (SAEM) and the American College of Emergency Physicians (ACEP) recommend modifying the
model of emergency health care delivery to better care
for older adults.1,810 Strategies for improved ED elder
care range from the education and attitude change of
emergency providers to the redesign of ED physical
plants and departmental operational changes.1116
One recent and evolving response to the aging demographic imperative is the development of geriatric EDs.
The geriatric ED theoretically provides selected
improvements in patient care through specialized services and environmental enhancements. The rationale in
support of geriatric EDs includes inadequate EM graduate medical education in essential geriatric principles,17
as well as insufcient recognition of geriatric syndromes such as dementia and delirium.1822 In addition,
over the next two decades, the U.S. health care system
will expend a signicant and increasing proportion of
medical capital on aging adults, so developing scally
responsible alternatives to the status quo will become
increasingly urgent.23,24
The impetus to develop geriatric EDs varies.25
Although little empiric evidence exists, some reasons
include:
1. Patient benets such as establishment of more accurate diagnoses, improved therapies and health outcomes, better customer service, best practice
protocols, improved safety, and enhanced satisfaction.26
2. Hospital benets such as marketing to attract higher
reimbursement populations; growing a referral base
for higher reimbursing hospital-based programs
such as cardiac, neurologic, and orthopedic care;
physical therapy services; otolaryngology; and falls
centers.27 The onus to prevent never events or iatrogenic complications such as urinary tract infection
and decubitus ulcers begins in geriatric EDs or those
caring for geriatric adults in emergency situations.28
Additional benets could include optimization of
admission rates and length of stay and decreased
readmissions.29 More effective collaboration with
nursing homes, skilled nursing facilities, emergency
medical services, home services, and community
resources are goals of geriatric EDs.30 The expectation from cooperation of these institutions is for
improved transitions of care, health care maintenance, injury prevention, and improved patient satisfaction.31
3. Staff benets including effective and efcient practices of care; increased satisfaction; focused education to enhance competence and clinical skills; and
provision of resources such as equipment, tools, and
effective protocols and policies to facilitate the work
process.27
339
Figure 1. Snowball sampling and survey distribution. ACEP = American College of Emergency Physicians; GED = geriatric ED;
SAEM = Society for Academic Emergency Medicine.
hospitals. We contacted these sites or individuals by telephone to conrm geriatric ED existence and to identify at
each a correspondent knowledgeable in the specics of
that geriatric EDs operations. Four hospitals stated that
they did not operate geriatric EDs and were removed
from the sample. No ED or administrative personnel for
geriatric ED conrmation or sampling could be identied
in six hospitals.
Survey Content and Administration
The methodology of survey-based research has been
described recently.37 When possible, previously validated
survey instruments are preferable,38 but for our objectives, no such instrument exists. Therefore, our survey
instrument was developed by a detailed review of existing research focused on ED interventions to improve
geriatric adult emergency care,5,6,13,15,20,25,26,32,34,35,3946
as well as discussions with a multidisciplinary collaboration of representatives from SAEM, ACEP, the American
Geriatrics Society, and the Emergency Nurses Association. This collaboration continues to develop geriatric ED
infrastructure, personnel, protocol, and educational
340
Three did not respond, and three stated they did not
operate geriatric EDs. The entire survey is available in
Data Supplement S1 (available as supporting information
in the online version of this paper).
Data Analysis
Primary data analysis was performed using SPSS Statistics version 21 (IBM SPSS, Armonk, NY). We summarized survey respondents and nonrespondents using a
ow diagram.37,47 Frequency tables were created to
characterize responses.48 Categories were reported
based on general interest to those seeking to understand components of a geriatric ED or as most applicable to hospitals planning future geriatric EDs.
Categories include date of opening and location, geriatric patient volumes, number of general ED and geriatric
ED beds, physical plant changes, patient selection, staffing qualications and education, policies and protocols,
screening and assessment tools, linkage to community
services, and referral to clinical programs or services.
RESULTS
We surveyed 36 hospitals as detailed in Figure 1. Thirty
hospitals responded and conrmed geriatric ED existence. Respondents consisted of 43% physicians, 50%
Table 1
Physical Plant Changes
Change
Beds/mattresses
Lighting
Flooring skid/shine
Visual aids
Sound level
Corridor safety
Handrails
Hearing aids
Recliners
Nourishment
Other
Percentage of Geriatric
EDs Making Change
97
90
83
73
70
60
60
60
53
43
47
341
Table 2
Number of GED Physician Staff
All physicians cover both GEDandgeneralED
patients
Departments with ED physician assigned to
cover only the GED
One
1.5
l-2 dependingontimeof day
1-3 dependingontime of day
2
4
No report
6.5%
36.7%
3.3%
3.3%
3.3%
20%
6.6%
20.3%
342
DISCUSSION
The U.S. geriatric demographic imperative,64 in conjunction with a deteriorating primary care infrastructure65 and unprecedented scal challenges, places
increasing demands on the ED. Some of the immediately measurable results of these pressures are a
constellation of elder care improvement strategies. One
such approach is the development of geriatric EDs. To
date, geriatric EDs have resulted from efforts of individual institutions or have been established by owners of
multiple hospital corporations. The preponderance of
geriatric EDs in the Midwest is attributable to one multihospital system, Trinity Health, which has developed
geriatric EDs throughout its member institutions. The
preponderance of geriatric EDs in the Northeast was
not addressed by our survey.
The constellation of geriatric EDs will vary with time,
and identication of relevant informants is complex.
Therefore, the snowball sample technique was used for
gathering data from groups that are hidden or difcult
to access. Even with this technique, identication
proved problematic. Internet searches yielded four selfidentied geriatric EDs with which conrmatory contact
could not be established. Leads from professional organizations produced three sites that denied or, upon
reection, felt that they did not operate a geriatric ED
and one with which no contact was established. It is
likely that this methodology did identify the majority of
present and planned geriatric EDs. However, any number could begin operations in the near future.
The above failures of geriatric ED identication by
EM professional organizations highlight the probability
that emergency physicians may not have a clear picture
of what constitutes a geriatric ED. Additionally, patients
searching for improved geriatric emergency care may
never identify the quality institutions they seek. Development of a clear denition of geriatric EDs is imperative to both the EM leaders shaping provision of this
care and the patients seeking care. Our results clearly
show that the denition of a geriatric ED remains
elusive. Various components and models of geriatric
EDs exist seemingly based on individual or expert opinion. No published best practices exist and no geriatric
ED offers proven outcome benets. Many geriatric EDs
share operational features, personnel, policies, and
protocols similar enough that outcome data could be
collected and analyzed. One additional long-term goal
of this research is to improve the efciency and reliability of high-quality emergency services for older adults
by dening the essential attributes of an effective geriatric ED, as well as delineating the key components likely
to improve individual targeted outcomes.
A research consortium to analyze the outcomes generated by various geriatric ED interventions may be the
most efcient manner to identify successful geriatric ED
models of care. A regional, national, or international
geriatric ED research consortium could expedite the
incorporation of key components into existing and
future geriatric EDs. The advantages of establishing a
geriatric ED research consortium include ease of
access between pertinent stakeholders to assess awareness,66 practice patterns,67 and regional variation in
343
344
to their institutions, and the exact number of observations is unknown. This description reects the state of
geriatric EDs in this country at a particular point in
time; geriatric EDs can rapidly implement new processes or eliminate others, and new geriatric EDs can
be created at any point.
CONCLUSIONS
The snowball sample identication of U.S. geriatric EDs
resulted in 30 conrmed respondents. It is likely this
technique identied the majority of existing geriatric
EDs. There is signicant variation in the components
constituting a geriatric ED. The United States should
consider external validation of self-identied geriatric
EDs to standardize the quality and type of care patients
can expect from an institution with an identied geriatric ED.
References
1. Sanders AB. Care of the elderly in emergency
departments: conclusions and recommendations.
Ann Emerg Med 1992;21:8304.
2. Roberts DC, McKay MP, Shaffer A. Increasing rates
of emergency department visits for elderly patients
in the United States, 1993 to 2003. Ann Emerg Med
2008;51:76974.
3. Pines JM, Mullins PM, Cooper JK, Feng LB, Roth
KE. National trends in emergency department use,
care patterns, and quality of care of older adults in
the United States. J Am Geriatr Soc 2013;61:1217.
4. Gruneir A, Silver MJ, Rochon PA. Emergency
department use by older adults: a literature review
on trends, appropriateness, and consequences of
unmet health care needs. Med Care Res Rev
2011;68:13155.
5. Schnitker L, Martin-Khan M, Beattie E, Gray L. Negative health outcomes and adverse events in older
people attending emergency departments: a systematic review. Australasian Emerg Nurs J 2011;14:141
62.
6. Aminzadeh F, Dalziel WB. Older adults in the emergency department: a systematic review of patterns
of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med 2002;39:2387.
7. Hastings SN, Barrett A, Weinberger M, et al. Older
patients understanding of emergency department
discharge information and its relationship with
adverse outcomes. J Patient Saf 2011;7:1925.
8. Wilber ST, Gerson LW, Terrell KM, et al. Geriatric
emergency medicine and the 2006 Institute of Medicine reports from the Committee on the Future of
Emergency Care in the U.S. Health System. Acad
Emerg Med 2006;13:134551.
9. Fitzgerald RT. White Paper: The Future of Geriatric
Care in Our Nations Emergency Departments:
Impact and Implications. Dallas TX: American College of Emergency Physicians, Oct 27, 2008.
10. Adams JG, Gerson LW. A new model for emergency care of geriatric patients. Acad Emerg Med
2003;10:2714.
345
346
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
hospitalized patients without a specic medical indication for catheterization. J Patient Saf 2006;1:2017.
Carpenter CR. Evidence based emergency medicine/Rational Clinical Examination Abstract: Will
my patient fall? Ann Emerg Med 2009;53:398400.
Carpenter CR, Scheatzle MD, DAntonio JA, Ricci
PT, Coben JH. Identication of fall risk factors in
older adult emergency department patients. Acad
Emerg Med 2009;16:2119.
Sherman FT. The good news: its our 60th birthday.
The bad news: a giant, geriatric tsunami! Geriatrics
2006;61:1011.
Bodenheimer T. Primary carewill it survive? N
Engl J Med 2006;355:8614.
Roush RE, Tyson SK. Geriatric emergency preparedness and response workshops: an evaluation
of knowledge, attitudes, intentions, and self-efcacy
of participants. Disaster Med Public Health Prep
2012;6:38592.
Imamura T, Brown CA, Ofuchi H, et al. Emergency
airway management in geriatric and younger
patients: analysis of a multicenter prospective observational study. Am J Emerg Med 2013;31:1906.
Wang HE, Devlin SM, Sears GK, et al. Regional
variations in early and late survival after out-of-hospital cardiac arrest. Resuscitation 2012;83:13438.
Cairns CB, Maier RV, Adeoye O, et al. NIH roundtable on emergency trauma research. Ann Emerg
Med 2010;56:53850.
Wolinsky FD, Liu L, Miller TR, et al. Emergency
department utilization patterns among older adults.
J Geront Med Sci 2008;63A:2049.
Caplan GA, Williams AJ, Daly B, Abraham K. A
randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention
after discharge of elderly from the emergency
departmentThe DEED II study. J Am Geriatr Soc
2004;52:141723.
Pena ME, Snyder BL. Pediatric emergency medicine. The history of a growing discipline. Emerg
Med Clin North Am 1995;13:23553.
Cales RH, Trunkey DD. Preventable trauma deaths.
A review of trauma care systems development.
JAMA 1985;254:105963.
Institute of Medicine. Committee on the Future of
Emergency Care in the United States Health System. Future of Emergency Care: Emergency Care
for Children Growing Pains. Washington DC:
National Academies Press, 2007.
Editorial. Who cares for the elderly? Lancet
2008;371:959.
Ward RC, Mainiero MB. Graduate medical education in the era of health care reform. J Am Coll
Radiol 2013;10:70812.
The Joint Commission. Advanced Certication for
Primary Stroke Centers. Available at: http://www.
jointcommission.org/certication/
primary_stroke_centers.aspx. Accessed Dec 7, 2013.
Society of Cardiovascular Patient Care. Chest
Pain Accreditation. Available at: http://www.scpcp.
org/index.php/services/accreditation/chestpain.
Accessed Dec 7, 2013.
79. Adams R, Acker J, Alberts M, et al. Recommendations for improving the quality of care through
stroke centers and systems: an examination of
stroke center identication options: multidisciplinary consensus recommendations from the Advisory
Working Group on Stroke Center Identication
Options of the American Stroke Association. Stroke
2002;33:e17.
80. The Joint Commission reports high interest in new
certication program for comprehensive stroke centers. ED Manag 2012;24:1279.
81. Topol EJ, Kereiakes DJ. Regionalization of care for
acute ischemic heart disease: a call for specialized
centers. Circulation 2003;107:14636.
82. Jacobs AK, Antman EM, Faxon DP, Gregory T, Solis P. Development of systems of care for ST-elevation myocardial infarction patients: executive
summary. Circulation 2007;116:21730.
83. Graham K, Strauss C, Boland L, et al. Has the time
come for a national cardiovascular emergency care
system? Circulation 2012;125:203544.
84. Saver JL, Fonarow GC, Smith EE, et al. Time to
treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke.
JAMA 2013;309:24808.
85. Prabhakaran S, ONeill K, Stein-Spencer L, Walter
J, Alberts MJ. Prehospital triage to primary stroke
centers and rate of stroke thrombolysis. JAMA Neurol 2013;70:112632.
86. Rajamani K, Millis S, Watson S, et al. Thrombolysis
for acute ischemic stroke in Joint Commission-certied and -noncertied hospitals in Michigan. J
Stroke Cerebrovasc Dis 2013;22:4954.
87. Sampalis JS, Denis R, Lavoie A, et al. Trauma care
regionalization: a process-outcome evaluation. J
Trauma 1999;46:56579.
88. Haas B, Stukel TA, Gomez D, et al. The mortality
benet of direct trauma center transport in a regional trauma system: a population-based analysis. J
Trauma Acute Care Surg 2012;72: 15105.
89. Cudnik MT, Newgard CD, Sayre MR, Steinberg SM.
Level I versus Level II trauma centers: an outcomesbased assessment. J Trauma 2009;66:13216.
90. Lang ES, Wyer PC, Haynes RB. Knowledge translation: closing the evidence-to-practice gap. Ann
Emerg Med 2007;49:35563.
91. Watters JK, Biernacki P. Targeted sampling: options
for the study of hidden populations. Social Problems
1989;36:41630.
92. Heckathorn DD. Respondent driven sampling: a
new approach to the study of hidden populations.
Social Problems 1997;44:17499.
Supporting Information
The following supporting information is available in the
online version of this paper:
Data Supplement S1. The geriatric emergency
department survey instrument.
Data Supplement S2. Hospitals with conrmed
geriatric EDs.