1. What is known about creating an effective ED care environment for elder care? (from first responders, through discharge) in terms of obtaining adequate data, maximizing communication, supporting sensory deficits, configuring the physical environment to optimize functioning, incorporating safety features, enabling efficient care for providers, and providing transitional data to discharge environment?

Submitted by Harvey Meislin, MD

Response by Carol Howe, MD, MLS

Despite the fact that “based on demographic changes alone, older patients will increase from 15% to 25% of ED visits in the next 30 years. These patients take more time, require more testing, and are the most frequently admitted demographic group, both to the hospital and to the intensive care unit” (Wilber et al., 2006, p. 1345), there is surprisingly little information or research being done (or, more accurately, reported to date) on how best to meet the unique needs of older patients within the emergency department. Reflecting on recently published Institute of Medicine reports on hospital-based emergency care, Wilber et al. (2006) note that “emergency care of seniors…is given only two paragraphs as an appendix to the IOM main report and passing mention in several other areas. In contrast, the emergency care of children is given a similar mention in the appendix and its own 360 page report” (p.1345). In their article, Wilber et al. spell out some of the major problems with present systems, primarily “with the intent to provide information that will help shape discussions on this issue” (abstract).

Not surprisingly, Wilber is also the author of the monograph “Geriatric Emergency Medicine,” which is part of the American Geriatrics Society’s New Frontiers in Geriatrics Research: An Agenda for Surgical and Related Medical Specialties (available on line at: http://www.frycomm.com/ags/rasp/chapter.asp?ch=3), and coauthor of the 2003 article in Academic Emergency Medicine. “A Research Agenda for Geriatric Emergency Medicine,” on which the final web-based version is based.   The documents are almost identical and report, based on a comprehensive review of the literature, “Research agenda items [which] were defined for multiple topics within geriatric emergency medicine and trauma” (Wilber et all, 2003, abstract). Studies and results are divided into three broad categories: General Geriatric Emergency Care; Screening and Comprehensive Geriatric Assessment in the ED; and Specific Clinical Syndromes such as abdominal pain, falls, cardiopulmonary arrest and trauma. Three highest priorities are identified for research. The first falls within the general category and the last two within the specific clinical syndrome category. The wording of the first order of priority closely resembles the wording in the constellation of questions being asked by Dr. Meislin:

Highest-priority Research in Emergency Medicine

1. Can alterations in the process of ED care, such as those found to be beneficial elsewhere (i.e., geriatric specialty inpatient units), improve the outcomes of older ED patients? Hypothesis-generating studies related to this key research question include the following: evaluation of the micro-environment of the ED to determine the characteristics (communication, physical environment) that affect outcomes in elder patients, development of brief instruments to detect cognitive and functional impairment in older ED patients, and study of the effect of interventions (educational models, protocols, computer support systems) in improving physician documentation and medication prescribing.

Hypothesis-testing studies related to this key research question include the study of specific elements of care (i.e., improved environment, communication, recognition of delirium, linkage with geriatric teams) on outcomes in older ED patients. This should lead to the study of a multifaceted approach to geriatric ED care on patient outcomes. (Wilber et al., 2003 p.256)

I quote the above at length to indicate that the very questions being asked by Dr. Meislin, are the same questions identified as being of the highest priority in The Research Agenda Setting Process (RASP) of the American Geriatric Society’s project described above. These are the key questions around which new research needs to be oriented because there is so little available data.  Schumaker (2004) similarly notes that:

The work of Sanders [7] provided a solid foundation for the development of geriatric EM. Unfortunately, since this work of more than a decade ago, there has been only modest evidence of geriatric EM research or new scholarly literature. Aminzadeh and Dalziel [12] recently provided a useful literature review on older adults in the ED. Their review reiterates the distinct pattern of service use and care needs required by older adults. They also note the inadequacy of current approaches to serving this population and call for more research and intervention projects targeting at-risk older adults.

Overall, it appears that clinical and scholarly work in geriatric EM appears to have lost momentum since the efforts of Sanders [7], [8] and [9]. The early work characterized the population and provided a model, however, the pace of work has diminished despite rapidly increasing older adults ED populations. The research has been dominated by descriptive studies of use rates and issues such as acuity levels, repeat visits, and 6-month mortality rates [4] and [12]. Research considering the impact that the older adult population has on the practice of EM is much more limited in scope. (p.557)

Some small progress appears to have been made in the few years since the release of the Research Agenda.  The February 2005 issue of Academic Emergency Medicine has three articles and a commentary germane to the above questions.  One of the themes that arises consistently in the literature is the absence of communication and the great compromise of care which this engenders. Geriatric patients often cannot serve as their own spokespeople because of underlying cognitive issues or because of their acute illness.  They are nonetheless often sent to the ED by an extended care facility (ECF), for example, without good accompanying records. Conversely, these same patients are often returned to the ECF without good documentation. Terrell et al (2005) devised a “one page, standard ECF- to –ED transfer sheet with 11 essential data elements on a single form” and found that “Although included in only one third of transfers, when used, the form resulted in successful documentation” (p.117). In his commentary, Fernandes (2005) notes that

A simple data form that is used by everyone ensures that one does not need to search many documents for important information, especially when time is of the essence. As we move to a paperless environment, this communication will be easier electronically if the necessary first steps have occurred, i.e., common use of a simple form that captures necessary data elements. This paper highlights two concerns. First, reciprocal communication by the ED to the ECF was not addressed. Second, the majority of postintervention transfers did not include the transfer form, suggesting an avenue for improvement. In the end, however, this study is an important step in a continuing effort at seamless communication regarding the needs of the geriatric patient. (p.158)

Similarly, some uniformity and consistency in advance directive paperwork would be very helpful. Again, Fernandes, commenting on Siebens’ paper in the same 2/2005 issue of Academic Emergency Medicine:

Siebens' paper demonstrates how a better focus on advance directives and on paramedic and primary care provider communication, as an example, can reduce the number of ED visits and hospital admissions that might otherwise be considered inappropriate. While most communities have adopted advance directives, the significant variance can ultimately obstruct patient care. (p. 158)

(For a very recent patient’s perspective see a 2/21/07 Opinion piece in the Arizona Daily Star written by Marietta Luce (http://www.azstarnet.com/allheadlines/170114.php).

A second commonly expressed theme in the literature about the work that needs to be done—is the importance of considering the environment.  There is much written about the Acute Care for Elders (ACE) model in hospital units including ACE stroke units, ACE oncology units and ACE rehab units. Briefly,

ACE includes a specially designed environment (with, for example, carpeting and uncluttered hallways); patient-centered care, including nursing care plans for prevention of disability and rehabilitation; planning for patient discharge to home; and review of medical care to prevent iatrogenic illness. (Counsell et al, 2000, abstract)

I did not find any references to the ACE model being specifically applied to the design of an emergency department. As reported by Adams and Gerson, “some institutions have devised a geriatric ED. Nassau University Medical Center on Long Island developed a unit that is staffed not by emergency physicians but by geriatricians. Mount Sinai Hospital in New York City has introduced geriatric nurse practitioners in the ED” (p.272). Even doing a very generalized Internet search, I was able to find almost no other examples, nor did I read about specific environmental adaptations to make emergency departments more comfortable for the elderly.  “The ambient environment, the noisy waiting room, the hard gurneys, the crowded department, the lack of pillows, the rushed history and physical examination, the harried caregivers, the separation from friends and family…”(Adams & Gerson, p 272), remain the norm. The most substantive experimental research on the effects of environment (which I was able to find) was in a paper by Wilber in the February 2005 Academic Emergency Medicine issue. Wilber and his colleagues studied the effect substituting a reclining chair for the typical hard gurney. They found that “The chair patients had less pain and greater satisfaction than did the gurney patients” (p.121). In his commentary on this article, Fernandes sates that

Wilber et al. have elegantly demonstrated that simple alternatives can be provided that affirm patient dignity…. One other piece of information further supports the authors’ efforts. A 1997 paper suggests that for every day of deconditioning, significant physiologic effects may result, including loss of muscle mass and bone density, with higher subsequent risk for injury. Pain reduction, as shown by Wilber et al., is an important first step to reduce the need for longer hospital stays as a result of deconditioning. (p. 158)

It is interesting that the lead author of the American Geriatric Society’s RASP project for Emergency Medicine chose to tackle the almost overwhelming scope of the proposed research agenda with this seemingly simple research study whose only experimental intervention is a chair. As indicated by Fernandes, however, even seemingly small interventions can have very widespread effects.

2. Are there specialty elder ED programs? If so, describe program and provide contact info.

a. Department of Emergency medicine, Nassau University Medical Center

http://www.numc.edu/htms/emservices.htm

NUMC is proud to announce the opening of the first emergency room exclusively devoted to taking care of the people who took care of us.

People in their 60s, 70s and 80s have more complex medical needs than younger people. At NUMC's new Geriatric Emergency Room - the first of its kind on Long Island - we have board-certified doctors who are specially trained in geriatric medicine. Not only do they treat emergency illness, they also carefully assess each patient for symptoms of illnesses that are common among the elderly.

Also on hand are psychiatrists, nurses and social workers, who make sure patients can manage the activities of daily living.

If you or an elderly loved one or friend need emergency care, come to the Emergency Department and you will be directed to the Geriatric Emergency Room. We're happy to be there for the people who were there for us.

East Meadow, New York
GERIATRIC EMERGENCY ROOM
(516) 572-6406

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b. First-of-its-kind geriatric emergency medicine fellowship created at New York-Presbyterian/Weill Cornell

http://www.news.cornell.edu/releases/Feb05/geriatric.html

Mt. Sinai Hospital in New York has a Geriatric Emergency Medicine Division, which is part of its Emergency Department, but the page was in the process of being reconstructed. The Geriatric Emergency Medicine Division, according to Adams and Gerson, is staffed by geriatric nurse practitioners who “attempt to improve communication, assist with coordination across practice sites, reduce unnecessary utilization, assist with patient care, expedite admission, or assist with discharge planning. (2003, p. 272).

http://www.mountsinai.org/msh/msh_frame.jsp?url=clinical_services/emergency_ms.

3. Are there known processes than can be initiated in the ED to assist the elderly post ED discharge?

To some extent this question is covered in the responses to 1 and 2 above.  Although it is important to note Adams and Gerson’s caveat re a and c above that “…we know of no scientific data available to show the effect of such approaches,” (p. 272) they do, however, concede that “perhaps the rest of us should still take note” (p. 272).

Hastings and Heflin (2005) have summarized much of the available data on this question in their article “A Systematic Review of Interventions to Improve Outcomes for Elders Discharged from the Emergency Department.” This article is worth reading in its entirety and includes a very helpful table (Table 3, pp.982-3) outlining all the “Clinical Trials to Improve Outcomes for Elders Discharged from the emergency Department (ED).”

Some of the high points of their discussion:

Although we identified relatively few trials with a controlled experimental design and rigorous evaluation of outcomes, important conclusions may be drawn from the available data. Three of four RCTs designed to measure functional outcomes showed improvements in the functional status of elders enrolled in the intervention.32,34,36 The three positive trials included 1) use of a specially trained nurse to perform geriatric assessment and 2) a component of home-based care (p.954)

Another notable feature of the trials showing improvement in functional status was their selection of patients at high risk of adverse outcomes….

Targeting a high-risk group appears to be more effective than applying these intensive interventions more broadly. It is not known whether this high-risk group should be the "older old" group, or a group identified with a screening instrument. Keeping the identification of at-risk elders in the ED brief and moving more of the intervention to the patient's home have tremendous appeal as an effective strategy for future study.

Is it possible to improve clinical outcomes for seniors discharged from the ED, and decrease service utilization rates? Clinical trial results available to date have been mixed. The DEED II trial demonstrated reductions in hospital admissions at 30 days and emergency hospital admissions at 18 months… The recent nonrandomized trial by Guttman and colleagues found that unscheduled ED visits could be reduced at 14 days.30 Conversely, ED return visits were actually increased in the intervention groups described by McCusker et al.34 and Gagnon et al.,35 and there was a nonsignificant trend toward increased visits to the ED and other outpatient providers in the DEED II study.32 The potential for increased rates of service utilization in health services intervention trials has been previously documented.41 Providing additional care to relatively underserved populations is likely to uncover more needs that require additional services…

[F]urther work needs to be done to investigate the current process of care for elders discharged from the ED. High-quality studies are needed to evaluate communication between the ED and primary physician, rate and length of time until follow-up, and appropriateness of prescription medication. A more complete understanding of all of the factors that impact clinical outcomes and health service utilization is critical to building effective interventions.  (excerpted from “Discussion” section, pp.984-5)

This response unfortunately ends where it began—with all available studies and commentary pointing to the overwhelming need for further research and definitely with far more questions than answers.

References

Adams, J. G., & Gerson, L. W. (2003). A new model for emergency care of geriatric patients. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 10(3), 271-274.

Aminzadeh, F., & Dalziel, W. B. (2002). Older adults in the emergency department: A systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Annals of Emergency Medicine, 39(3), 238-247.

Counsell, S. R., Holder, C. M., Liebenauer, L. L., Palmer, R. M., Fortinsky, R. H., & Kresevic, D. M., et al. (2000). Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: A randomized controlled trial of acute care for elders (ACE) in a community hospital. Journal of the American Geriatrics Society, 48(12), 1572-1581. 

Fernandes, C. M. (2005). Geriatric care in the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 12(2), 158-159.

Gillick, M. R. (2002). Do we need to create geriatric hospitals? Journal of the American Geriatrics Society, 50(1), 174-177.

Hastings, S. N., & Heflin, M. T. (2005). A systematic review of interventions to improve outcomes for elders discharged from the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 12(10), 978-986.

Luce, M.D. 2007, Feburary 21. The do-not-resuscitate bracelet law’s a mystery. Arizona Daily Star (166) 52, A9.

Meldon, S., Ma, O., & Woolard, R. (Eds.). (2004). Geriatric emergency medicine. New York: McGraw Hill.

Meldon, S. W., Mion, L. C., Palmer, R. M., Drew, B. L., Connor, J. T., & Lewicki, L. J., et al. (2003). A brief risk-stratification tool to predict repeat emergency department visits and hospitalizations in older patients discharged from the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 10(3), 224-232.

Schumacher, J. G., Deimling, G. T., Meldon, S., & Woolard, B. (2006). Older adults in the emergency department: Predicting physicians' burden levels. The Journal of emergency medicine, 30(4), 455-460.

Siebens, H. (2005). The domain management model--a tool for teaching and management of older adults in emergency departments. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 12(2), 162-168. 

Terrell, K. M., Brizendine, E. J., Bean, W. F., Giles, B. K., Davidson, J. R., & Evers, S., et al. (2005). An extended care facility-to-emergency department transfer form improves communication. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 12(2), 114-118.

Wilber, S. T. Geriatric emergency medicine, chapter 3 of new frontiers in geriatrics research: An agenda for surgical and related medical specialties, created and maintained by the american geriatrics society. Retrieved February 20, 2007, from http://www.frycomm.com/ags/rasp/chapter.asp?ch=3

Wilber, S. T., Burger, B., Gerson, L. W., & Blanda, M. (2005). Reclining chairs reduce pain from gurneys in older emergency department patients: A randomized controlled trial. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 12(2), 119-123.

Wilber, S. T., & Gerson, L. W. (2003). A research agenda for geriatric emergency medicine. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 10(3), 251-260.

Wilber, S. T., Gerson, L. W., Terrell, K. M., Carpenter, C. R., Shah, M. N., & Heard, K., et al. (2006). 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. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 13(12), 1345-1351.