Introduction
Geriatric emergency departments (Geriatric EDs) have rapidly evolved as a significant care model for responding to the unique emergency care needs of older people. Advancements and insights addressing older emergency department (ED) patients’ screening, assessment, care processes, disposition, and discharge appear in clinical practice and across the peer-reviewed literature. This article provides an overview of emerging themes and future directions published in the recent Geriatric ED literature.
Overview of Geriatric Emergency Departments
Within and beyond emergency medicine, the term Geriatric ED is frequently used interchangeably with the broader term geriatric emergency medicine (GEM) as well as with senior ED, senior friendly ED among other related terms. In other cases, Geriatric ED is used to refer to a distinct, purpose built separate space where the dedicated treatment of older adult ED patients occurs in a hospital. For clarity, this article will use the term Geriatric ED to simply refer to any emergency department “that has made the decision to intentionally implement changes in its people, processes, and place in order to improve the quality of care it providers to older patients – regardless of the physical space or resources [1••].”
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History of Geriatric Emergency Departments
It is well established that emergency departments have treated older patients since their very inception. Furthermore, focused attention to geriatric issues in emergency departments can be traced back at least 40 years to the publication of Schwartz et al. [2] Geriatric Emergencies. A current concise history of Geriatric EDs can be found in Hogan et al. [3], as well as a timeline in Magidson and Carpenter [4••]. The first recognized Geriatric EDs began emerging about 2008 is the U.S. as well as in Australia and Canada. The next decade saw increasing activity in the number of new Geriatric EDs, Geriatric ED Guideline [5] publication in 2014, and the creation of the Geriatric ED Accreditation [6] standards in 2018 by the American College of Emergency Physicians. More than 465 Geriatric EDs have met these accreditation standards to date [7].
Geriatric ED Guidelines and Accreditation
Two seminal events spurred the development of Geriatric EDs including the 2014 Geriatric ED Guidelines [5] publication and the 2018 Geriatric ED Accreditation [6] program of the American College of Emergency Physicians (ACEP). First, the Geriatric ED Guidelines are a set of principles developed and endorsed by 4 major emergency medicine professional organizations including the: American College of Emergency Physicians (ACEP), Society for Academic Emergency Medicine (SAEM), Emergency Medicine Nurses Association (ENA), and the American Geriatrics Society (AGS). Second, the Geriatric ED Accreditation (GEDA) program evaluates emergency departments (EDs) on their ability to provide high-quality care tailored to the unique needs of geriatric patients. To obtain GEDA accreditation, EDs must meet specific criteria that encompass a broad range of standards, including staff education and training in geriatric care, adequate facility resources, and patient-centered policies and procedures. By adhering to these standards, accredited EDs demonstrate a heightened level of care for older adult patients, potentially leading to reduced hospital admissions, shorter stays, and improved coordination of care post-discharge. ACEP provides detailed guidelines and a checklist outlining the necessary steps and standards for accreditation. Additionally, there are educational resources and toolkits designed to assist EDs in meeting these criteria. These resources include best practice protocols, staff training modules, and case studies, all aimed at guiding departments through the accreditation process.
Geriatric EDs Emerging Themes and Directions
Building on the above overview, the focus of this Geriatric ED review is focused on the period 2018–2023. It represents a growth period where many Geriatric EDs gained multiple years of experience and researchers were collecting systematic data at single and multiple sites. Overall, the scholarly literature has matured with more well designed empirical studies sharing results. Earlier Geriatric ED literature was frequently conceptually based, aspirational, and consisted of commentaries describing the opportunities and need for improved care models and processes. The recent literature reviewed for this article revealed a growing number of empirically based studies reporting findings informing the field of Geriatric EM. These findings are giving the first glimpses of an evidence-based approach to Geriatric EM. The research and literature in Geriatric EM is decidedly international with well-designed and executed studies providing quality data notably from researchers and clinicians in Canada, Australia, the United Kingdom, the United States among other contributors [8‐10]. Complementing the empirically based research, a host of well-designed, insightful qualitative studies is contributing to the knowledge base and suggesting specific new directions for research [11].
Geriatric EDs “calls for action”
Turning to emerging directions in the recent Geriatric ED literature, a set of four distinct “calls for action” regarding Geriatric EDs include 1) health system level integration; 2) developing care processes; 3) implementing minimum Geriatric ED standards; and, 4) setting future research agendas.
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1.
Health System Level Integration
Tejada et al. [12], make the case for Geriatric EDs’ health system level integration by listing eight “critical actions” needed to make a meaningful difference in the emergency care of older adults. These actions are policy oriented and address upstream system-level factors designed to place Geriatric ED care as part of a total care system in order to effectively manage the emergency care needs of worldwide rapidly growing older adult populations. The eight actions are listed in Table 1.
Table 1
Eight critical actions to make a meaningful difference in the emergency care of older adults
Critical Action | |
|---|---|
1 | Train and educate caregivers in the ED to effectively screen and assess the unique needs of older adults in the Emergency Department. |
2 | Work “upstream” from the Emergency Department to guide the care for older persons to avoid the need for emergency care, e.g., primary care, urgent care center, and EMS. |
3 | Develop care systems to support patients and families in crisis. For example, enhance primary care strategies to assist patients with multimorbidity early in their course of illness. |
4 | Enhance systems to support vulnerable older adults at risk for self-neglect and elder mistreatment. |
5 | Enhance community-wide public health approaches for fall prevention. |
6 | Develop safe and effective alternatives to hospitalization which can be integrated into emergency department care, e.g., hospital at home, advanced home health. |
7 | Develop systems to support and integrate family caregivers in the emergency department, particularly for those who have cognitive impairment. |
8 | Expand healthcare literacy that addresses the needs of older adults and family caregivers to prevent non-urgent visits to the emergency department. |
These proposed Geriatric ED care integration actions require a coordinated response both within and across health systems in conjunction with efforts of the care service providers and government agencies that comprise the aging network. It is through these combined and collaborative efforts that desired improvements in the outcomes of the emergency medical care of older adults will be realized.
2.
Developing Care Processes
Turning to Geriatric ED care processes, a more concrete “call to action” is offered by Shih et al. [13], focusing on three high impact Geriatric ED clinical conditions of delirium, falls, and polypharmacy. They note the related screening, assessment, and care practices supported by the Geriatric ED guidelines [5] and that they are pragmatically achievable for all EDs regardless of whether or not they are seeking Geriatric ED accreditation from ACEP. The authors recognize that while the full “GED guidelines currently remain aspirational for the vast majority of U.S. EDs”, a focus on the three high impact conditions of delirium, falls, and polypharmacy would be a step forward in the care of older people in all the nation’s EDs [13]. The significance of their message is evident in the article’s simultaneous publication in both the Journal of American Geriatrics Society and the Journal of Emergency Medicine.
3.
Implementing Minimum Geriatric ED Standards
The global contribution and leadership advancing Geriatric EDs is seen in the “call to action” in the publication of a Belgian set of Geriatric EDs’ Minimum Operating Standards outlined in a consensus statement for hospitals operating in Belgium [14]. These proposed standards extend Belgium’s current federal legislation that established “minimal operational standards for in-hospital geriatric care”, yet it did not explicitly extend to ED care. Heeren et al. [14], describes the modified Delphi process that lead to the consensus statement specifically on Geriatric ED care in Belgium. The stated objectives of the Geriatric ED minimum care standards were to 1) assess the risk of atypical presentations of a serious condition; 2) orient the patient to the most appropriate location in the care system; and, 3) ensure the continuity of geriatric aspects of care. At the end of the consensus meeting the minimal Geriatric ED care standard included 10 statements with a larger set of up to 57 specific elements separated for Belgium’s 1) conventional EDs (intended length of stay < 4 h); and, 2) their EDs with dedicated observational ED capacity (intended length of stay up to 24 h). The set of elements included: specific clinical protocols and guidelines, specific materials and equipment, specific accommodation criteria, the availability of a geriatrician, and quality control perspectives. Furthermore, there was the requirement for EDs to ensure the availability of an inpatient geriatric team within the hospital network to be available for consultations.
A particularly innovative aspect of these proposed Belgian Geriatric ED minimum care standards and their federal legislation is that they are not strictly chronically age-based (e.g., age 65 and up) rather that the care is to be provisioned to anyone based on “a profile similar to that of geriatric patients in the Belgian federal legislation of the hospital-based care programme [14].” In this way, the standards recognize the increasing heterogeneity of older populations and the decreasing utility of simply applying crude chronological age criteria.
4.
Setting Future Research Agendas
A final “call to action” to note in recent literature is the publication of the European Research Agenda for Geriatric Emergency Medicine [15•]. Respondents in the two stages of data collection represented 25 countries and 176 respondents in stage 2 of the modified Delphi study. The final proposed research agenda included 10 research questions falling broadly into three GEM domains 1) screening & assessment; 2) interventions; 3) personnel & education/training. The top 3 research questions included 1) Is implementation of elements of comprehensive geriatric assessment, such as screening for frailty and geriatric interventions, effective in improving outcomes for older patients?; 2) Which interventions in older ED patients are effective in reducing ED or hospital length of stay?; and, 3) Is ‘hospital at home’ effective and cost-effective in improving outcomes in older ED patients? This prioritized list of research questions can guide researchers, funders, and policy maker to collect systematic evidence to inform the practice of GEM and continuously improving older patient outcomes.
Assessing Geriatric ED Financial Sustainability
The “calls to action” in the recent Geriatric ED literature serve as a crucial guide for the near future, however, they also hint at the broader implications of specialized Geriatric ED practices, including issues of financial sustainability. Such considerations are becoming increasingly relevant as the healthcare industry grapples with the costs and benefits of specialized emergency care for older patients. Researcher are beginning to publish accumulating evidence suggesting financial sustainability for the return on investment in Geriatric EDs. While the data is modest, research by Hwang et al. [16••], reports Geriatric ED care resulted in cost savings ranging from $1,200 to $3,200 per patient at one Geriatric ED. Additional recent studies support the findings of Geriatric ED savings from ED settings that vary in terms of hospital size and health systems suggesting the stability of these findings [17‐19]. Future studies should build on these findings and strive to include multiple hospital sites and using meta-analyses to extend the generalizability of the findings. As an additional note, reimbursement models remain complex and continue to evolve, particularly, cross-nationally. Continued focus on the return on investment and overall efficacy of Geriatric ED models will assist advocates and policy makers as they consider ways to create sustainable reimbursement models that can support the continued development of Geriatric ED care.
Assessing Geriatric EDs’ Efficacy of Care
Complementing the focus on Geriatric EDs’ financial sustainability are investigations looking at the overall “efficacy” of the care provided by the Geriatric ED model. The remarkable heterogeneity of existing Geriatric EDs makes this assessment process challenging. Nonetheless, several promising studies are beginning to yield finding that suggest Geriatric EDs are having a positive impact on outcomes of interest and efficacy [20‐22]. While the majority of studies to date have been single site studies, Gettel et al. [23], and colleagues published a larger study looking at 38 Geriatric EDs and 152 matched nongeriatric EDs and found support for superior outcomes on multiple measures including urinary tract infections, diagnoses delirium/dementia, ED discharge, ED length of stay; and 30 day readmissions.
In addition to Geriatric ED patient outcomes, evidence is accumulating regarding the impact of specific professionals in a Geriatric ED on key outcomes. Dresden et al. [24], noted how transitional care nurses (TCNs) are associated with lower risk of readmissions and fewer readmissions. The positive results were at two of three hospitals in the study suggesting variability in the findings, yet the preponderance of the findings are in a direction supporting the efficacy of Geriatric ED care. Furthermore, Hwang [25] concluded “Targeted evaluation by specific geriatric ED transitions of care staff may be an effective delivery innovation to reduce risk of inpatient admission” Additionally there is also evidence specific Geriatric ED processes appear to be foundational to the model and include “having a targeted approach to assessment, a patient-centered approach to care, and staff with inter-facility, intra-facility and inter-personal communication skills [26].
Multiple investigators report encouraging findings on the outcome of reduced readmissions. For example “URGENT is a comprehensive geriatric assessment (CGA) based nurse-led care model in the ED with geriatric follow-up after ED discharge aiming to prevent unplanned ED readmissions [26]. The URGENT care model shortened ED LOS and increased the hospitalization rate, but did not prevent unplanned ED readmissions. Other approaches like the Geriatric and Palliative (GAP)-ED partnership project has yielded inconclusive outcome results, however, the project did demonstrate that “patient and family satisfaction with the presence of the GAP-ED specialist was high [27].” Hughes et al. [28], conducted a systematic review of ED interventions with older adults with 17 articles meeting eligibility criteria and found a mixed pattern of effects. Overall, they concluded, “there was a small positive effect of ED interventions on functional status but no effects on QOL, patient experience, hospitalization at or after the initial ED index visit, or ED return visit.” Investment in well-designed additional Geriatric ED efficacy research is clearly needed.
Assessment of Geriatric ED Quality
A related point to the issue of Geriatric ED efficacy is the overall question of Geriatric ED quality. Schuster et al. [29], reports on a novel quality measure for Geriatric EDs called the GeriQ-ED© that evaluates a settings’: screening for delirium, taking of a full medications history including an assessment of the indications, education of geriatric knowledge and skills to emergency staff, screening for patients with geriatric needs, and identification of patients with risk of falls/ recurrent falls. Example questions include: In the past 12 months, did your ED review performance outcomes amongst its elder patient population? Does your ED have written protocols and/or established standards of care for the following (e.g., delirium management, use of restraints, etc.? Does your ED use a standardized screening tool in order to identify elders who are at risk of functional decline or otherwise vulnerable (e.g., ISAR, PRISMA-7). In the last 12 months, has your ED offered clinicians and staff any of the following educational activities related to the assessment or care of elders?
Another source for assessing Geriatric ED quality may come through the voice of older ED patients. Graham [30] and other researchers are directly asking older ED patients about their ED care. Graham describes involving patients and caregivers to develop items for a new patient-reported experience measure for older adults attending the emergency department and he notes “PREM-ED 65 represents the first instrument to attempt to measure older peoples' experiences of ED care.” Such efforts are consistent with practices advocated by the Patient-Centered Outcomes Research Institute (PCORI).
Practical Geriatric ED Introduction, Design, and Resource Materials
Underlying the substantive Geriatric ED themes articulated above and serving as a foundation for people new to the Geriatric ED area, the recent Geriatric ED literature includes numerous resources simply providing a practical introduction to the area. Melady and Perry’s [31] list of the ten best practices in the Geriatric ED. The proposed practices represent their synthesis of international Geriatric ED works and focus on 1) using geriatric principles & recognizing complexity; 2) educating ED staff on Geriatric EM; 3) geriatric specific rapid assessment and risk stratification; 4) awareness of atypical presentation of disease; 5) systems for medication management; 6) variability in “normal” investigations & test results; 7) systems to assess cognitive impairment/delirium; 8) assessing acute presentation in context of patient’s psychosocial needs; 9) using palliative care principles; 10) use of interdisciplinary team for acute assessment and transition planning. In the same volume, Perry, Tejada, and Melady [32] outline an approach to older patients in the emergency department (ED) where they note that “the ED clinicians must simultaneously evaluate and treat older adults along multiple domains: cognitive impairment, atypical presentations, functional impairment, medication management, trauma and falls, and end-of-life care.” Clearly listing these domains helps busy ED providers to frame their care processes and approach more broadly than they might with patients in other age groups.
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Another resource focused on high-value Geriatric ED practices and approaches is offered by Magidson & Carpenter [4••] with their set of practices designed to “inform and prioritize decision-making for this unique patient population.” They provide a table of Geriatric ED screening instruments for falls, delirium, and elder abuse including analysis of their “pearls and/or pitfalls.” They include a discussion of education/workforce preparation particularly advocating for a multidisciplinary approach to Geriatric EM. In terms of a comprehensive GEM resource, the updated 2021 Silver Book II is a well-written resource focused on the urgent care of older adults from an international perspective [33]. The volume is focused on assessing frailty and applying comprehensive geriatric assessment as part of the process of care. Stated goals of this guide include 1) decreasing variation in practice; 2) influencing the development of appropriate services; 3) identifying and disseminating best practice; 4) influencing policy development.
The area of Geriatric ED planning and design has received attention with Southerland et al. [34], describing 4 models in including 1) Geriatric ED-specific unit; 2) Geriatrics practitioner models; 3) Geriatric champions; and, 4) Geriatric-focused observation units. In their book titled Creating a Geriatric Emergency Department: A Practical Guide, Schumacher and Melady [1••] conceptualize the design of geriatric EDs into two categories of 1) separate space approach; or, 2) an integrated space approach. This accessible book serves as a blueprint for emergency physicians, emergency nurses, and hospital administrators exploring how to start their journey. Their simple advice is to “start anywhere” and they introduce the “concept of the 3Ps” regarding creating a Geriatric ED to focus on the People, Processes, and Place.
Seminal Geriatric ED Resources
Two seminal resources providing the latest information as well as a space for collaboration among the leading researcher and clinicians dedicated to advancing GEM are:
1)
The Geriatric Emergency Department Collaborative (GEDC) https://gedcollaborative.com/ that is a one-stop hub for education, training, and dissemination. Funded by John A. Hartford Foundation and the Gary & Mary West Health Institute, GEDC resources include a robust set of online learning programs with companion continuing education credits. It produces an ongoing series of timely Geriatric EM focused webinars that are archived and freely available as well as supporting a podcast titled GEMcast. Additional dissemination efforts includes GEDC’s publication of the open-access, peer-reviewed Journal of Geriatric Emergency Medicine.
2)
The Geriatric Emergency Care Applied Research (GEAR) network https://gearnetwork.org/ is dedicated to “generating evidence to improve the emergency care of older adults and those with dementia and other cognitive impairments.” GEAR has general resources including educational videos as well as specific resources for scholars and researchers. GEAR published a series of systematic literature “scoping reviews” with titles including “Emergency Department Care Transitions for Patients with Cognitive Impairment [35]”, “Optimal Emergency Department Care Practices for Persons Living with Dementia [36]”, as well as other topics. The GEAR network is also a source of funding opportunities for researchers through its requests for proposals.
Geriatric ED Workforce Education and Training
As the Geriatric ED field has developed, recent literature is beginning to systematically examine and evaluate the required education and training of the ED workforce including assessing learning gains. Small studies are beginning to provide insight into the efficacy of education and training programs. Hesselink et al. [11] reports on a Dutch program that trained emergency physicians on geriatric knowledge and the respondents self-reported more ability and attentiveness to recognizing frailty and geriatric syndromes. It also improved the emergency physicians’ attention to social history.
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Cetin-Sahin et al. [37], surveyed front-line ED nurses and physicians, to assess and compare: 1) ratings of elder-friendly ED care process quality indicators; 2) variability in ratings; and, 3) concurrent validity of ratings against perceived overall quality of geriatric care. Subscales included Screening, Protocols, Geriatric Team, Multidisciplinary Staff, Discharge Planning, Family-Centered Discharge, Physical Environment, Furniture/ Equipment, Staff Education, Data Monitoring, and Quality Improvement. Results indicated subscale scores were positively associated with overall quality of care. Research by Sir et al. [38], revealed emergency physicians reported insufficient GEM training and an overwhelming percentage reported no GEM education programs in their hospitals [38]. The research also revealed while the administrators of the EDs recognize care of older adults is important, they identify finances and time are key obstacles to providing GEM education. Hesselink et al. [39], also reports, “Various geriatric education programs improve the geriatric knowledge of ED professionals and seem to positively impact their clinical practice. However, more program evaluations with larger study samples, and use of valid and reliable outcome measures, are needed to provide robust evidence on the effectiveness of such programs.”
Analysis of Geriatric ED Processes and Protocols
Central to operation of all Geriatric EDs are the specific care processes and protocol used to deliver care to the older adult patient population. Fortunately, the empirical evidence for Geriatric ED processes and protocols continues to be collected and reported in the literature. Recent focal areas include studies examining core areas of 1) screening & assessment; 2) cognitive dysfunction; and, 3) falls. In the area of screening and assessment, Blomaard et al. [9] reports on a risk stratification tool used on more than half of their eligible older patients and found its feasibility and acceptability promising. A study examining the feasibility of combining triage screening with geriatric screening showed potential to improve triage decisions and assist clinicians in providing more appropriate care to patients earlier in the process [40].
In the domain of cognitive dysfunction, Carpenter et al. [41], examined the prevention and detection of delirium, altered mental status and confusion. Findings suggest, “Transdisciplinary stakeholders prioritize ED delirium prevention studies that are not reliant on health care worker tasks instead of alternative research directions such as defining etiologic delirium phenotypes to target prevention or intervention strategies.” Challenges to evaluating cognitive dysfunction in the ED were articulated by Chary et al. [42] and included 1) availability of caregivers; 2) reliability of sources; 3) language barriers; 4) time constraints; and, 5) incomplete transfer documentation.
Specific approaches involving cognitive impairment in the ED include Bosetti’s [43] findings from the CogMUPA study finding that “After adjusting for confounding factors, the 30-day readmission rate was significantly associated with the MUPA unit intervention. Comprehensive Geriatric Assessment in a GEMU improved health outcomes in elderly patients with NCD in the ED.” Similarly, Oliveira et al. [44] found utility with the REEDEEM risk stratification score to identify delirium that relied on triage information and early history taking. Shenevi et al. [45] reported on the ADEPT tool used to assess, diagnose, evaluate, prevent and treat delirium and agitation in the ED. Overall, it appears that delirium and associated decline can be significantly addressed through protocolized delirium care in the ED [46].
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In the area of dementia and ED care, Dresden et al. [36] published a scoping review on dementia listing research priorities including 1) training and dementia care competencies; 2) patient-centric and care partner-centric evaluation interventions; 3) the impact of community- and identity-based factors on ED care for PLWDs; 4) economic or other implementation science measures to address viability; and, 5) environmental, operational, personnel, system, or policy changes to improve ED care for PLWDs.
The EDs’ process for assessing and treating falls is an area added by Shih et al. [47], who reported a remarkable lack of follow up care with only 60% of ED patients with fall related injury receiving follow up. Jacobsohn et al. [48] noted the lack of workflow integration into the ED as a limiting factor for falls risk identification. Hammouda et al. [49] reported the need for “harmonizing definitions, research methods, and outcomes is needed for direct comparison of studies” related to falls. Related to falls, GEAR researchers prioritized five research priorities 1) EMS role in improving fall-related outcomes; 2) identifying optimal ED fall assessment tools; 3) clarifying patient-prioritized fall interventions and outcomes; 4) standardizing uniform fall ascertainment and measured outcomes; and, 5) exploring ideal intervention components [49]. Davenport et al. [50] examined provider attitudes and reports “the majority of providers felt that all geriatric patients should undergo screening for fall risk factors, and most answered that all geriatric patients screened and at risk for falls should have an intervention performed.” Surprisingly, few ED providers were willing to spend 2–5 min on fall risk assessment or prevention activities [50].
A systematic review of ED mobility assessment by Eagles et al. [51], found assessments included the “Timed Up and Go (TUG), Get Up and Go, tandem walk, and a gait assessment. However, the quality of studies was moderate to poor, findings were uneven, and no meta-analysis was possible.
Conclusions
This review documents Geriatric EDs and their implementation is receiving increasing attention in clinical practice and in the research literature. While the implementation of Geriatric ED model is relatively new and has been spreading relatively slowly, a reasonable question asks, “Can the Geriatric ED model be replicated successfully?” Several research studies suggest replication is possible and desirable for health systems. Two examples include 1) The Veterans Administration (VA) hospital system that has expanded Geriatric EDs throughout its large federal health system with positive results [52]; and, 2) Marsden et al. [53], describes the successful implementation of the Geriatric ED model into two different EDs which demonstrated “an increased likelihood of discharge, decreased ED length of stay, decreased hospital costs for those who were admitted, with an associated reduction in risk of mortality, for adults aged 70 years and over.” Other examples exist as well as important studies supporting Geriatric EDs’ financial sustainability and efficacy suggesting the replication of Geriatric ED care models will continue into the future.
Overall, the Geriatric ED field is maturing and health care facilities and systems no longer need “to invent everything they are doing” to improve their emergency care of older adults. Interested organizations can use existing published Geriatric ED tools and care protocols modifying them for their own use rather than starting from scratch. They can participate in the GEDC to gain access to resources and collaborate on larger research projects. Empirical research findings continue to accumulate with the preponderance of the data pointing to better outcomes experienced by older patients receiving care through Geriatric EDs.
Acknowledgements
Thank you to Adeola Ojomo, UMBC SMaRT Scholar, who assisted in the bibliography preparation for this manuscript and the College of Arts Humanities and Social Sciences Dean’s Office support of this undergraduate research program.
Compliance with Ethical Standards
Conflict Interest
The authors declare no competing interests.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
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