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CreatingaGeriatric EmergencyDepartment CreatingaGeriatric EmergencyDepartment APracticalGuide JohnG.Schumacher
UniversityofMaryland,BaltimoreCounty
DonMelady
UniversityofToronto
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Informationonthistitle: www.cambridge.org/9781009017701
DOI: 10.1017/9781009039253
©JohnG.SchumacherandDonMelady2022
Thispublicationisincopyright.Subjecttostatutoryexception andtotheprovisionsofrelevantcollectivelicensingagreements, noreproductionofanypartmaytakeplacewithoutthewritten permissionofCambridgeUniversityPress.
Firstpublished2022
PrintedinGreatBritainbyAshfordColourPressLtd.
AcataloguerecordforthispublicationisavailablefromtheBritishLibrary.
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Names:Schumacher,John(Gerontology),author.|Melady,Don,author.
Title:Creatingageriatricemergencydepartment/JohnSchumacher,AssociateProfessorandCo-Director, DoctoralPrograminGerontology,UniversityofMaryland,BaltimoreCounty,MD,DonMelady,Associate Professor,DepartmentofFamilyandCommunityMedicineoftheFacultyofMedicine,Universityof Toronto,Ontario,Canada.
Description:Cambridge,UnitedKingdom;NewYork,NY :CambridgeUniversityPress,[2022]|Includesindex. Identifiers:LCCN2021024564(print)|LCCN2021024565(ebook)|ISBN9781009017701(paperback)| ISBN9781009039253(ebook)
Subjects:LCSH:Geriatrics.|Emergencymedicine.
Classification:LCCRC952.5.S382022(print)|LCCRC952.5(ebook)|DDC618.97/025–dc23
LCrecordavailableat https://lccn.loc.gov/2021024564
LCebookrecordavailableat https://lccn.loc.gov/2021024565
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CambridgeUniversityPresshasnoresponsibilityforthepersistenceoraccuracyof URLsforexternalorthird-partyinternetwebsitesreferredtointhispublication anddoesnotguaranteethatanycontentonsuchwebsitesis,orwillremain, accurateorappropriate.
Everyefforthasbeenmadeinpreparingthisbooktoprovideaccurateandup-to-dateinformationthatisin accordwithacceptedstandardsandpracticeatthetimeofpublication.Althoughcasehistoriesaredrawn fromactualcases,everyefforthasbeenmadetodisguisetheidentitiesoftheindividualsinvolved. Nevertheless,theauthors,editors,andpublisherscanmakenowarrantiesthattheinformationcontained hereinistotallyfreefromerror,notleastbecauseclinicalstandardsareconstantlychangingthrough researchandregulation.Theauthors,editors,andpublishersthereforedisclaimallliabilityfordirector consequentialdamagesresultingfromtheuseofmaterialcontainedinthisbook.Readersarestrongly advisedtopaycarefulattentiontoinformationprovidedbythemanufacturerofanydrugsorequipment thattheyplantouse.
Thisbookisdedicatedtomymanyfriendsover90fromwhomIhavelearnedso much – MomandDad,Rod,Helen,Glen,Betty,Rosabel,Jim,Bob.Andtomymuch youngerhusband,Rowley!
DonMelady
Thisbookisdedicatedtomywifeandpartner,Sarah,whomadespaceforthisworkto happen.Also,tomyintergenerationalteachers,mom,dadandgrandmotherNana, teachinggentlelessonsingraceandpatientadvocacy.
JohnG.Schumacher
Place:AddressingthePhysical Environment
QualityImprovementintheGeriatric EmergencyDepartment:Getting Started 100 DonMelady,JohnG.Schumacher,and AdrianeLesser
LaunchingYourGeriatricEmergency Department:FromFirstStepsto Accreditation 111 Appendix:PracticalResourcesand Links 117 Index 137
Acknowledgments Wewouldliketothankallofourcolleaguesfromseveraldisciplinesandmanycountries aroundtheworld.Theirvaluableandgenerouscontributionsaddedalottothisbook.They areallactivelyinvolvedinimprovingthecareofolderpeopleintheworld’sEDs.We couldn’thaveproducedthisguidewithouttheirhelp.
NematAlsaba,MD,GoldCoastUniversityHospital,Australia
NanaAsomaning,RN,MScN,Toronto,Canada
JayBanerjee,MD,UniversityofLeicester,UK
FernandaBellolio,MD,MayoClinic,USA
MaryBennie,RN,MSc,BelmontHospital,Newcastle,Australia
KevinBiese,MD,UniversityofNorthCarolina,USA
NickBott,PsyD,DepartmentofMedicine,StanfordUniversitySchoolofMedicine,USA
Audrey-AnneBrousseau,MD,UniversitédeSherbrooke,Canada
ChrisCarpenter,MD,WashingtonUniversity,USA
SimonConroy,MD,UniversityofLeicester,UK
ElizabethGoldberg,MD,BrownUniversity,USA
PaulHo,MD,QueenElizabethHospital,HongKong
TessHogan,MD,UniversityofChicago,USA
CarolynHullick,MD,UniversityofNewcastle,Australia
RanjeevKumar,MD,KhooTeckPuatHospital,Singapore
OsamaLoubani,MD,DalhousieUniversity,Canada
AaronMalsch,RN,Wisconsin,USA
PamMartin,RN,YaleUniversity,USA
StephenMeldon,MD,ClevelandClinic,USA
MichelleMoccia,RN,DNP,Livonia,Michigan,USA
SimonMooijaart,MD,UniversityofLeiden,TheNetherlands
ColinOng,MD,NgTengFongGeneralHospital,Singapore
AnnOsborne,RN,GoldCoastUniversityHospital,Australia
AdamPerry,MD,Pennsylvania,USA
ThomRinger,MD,UniversityofToronto,Canada
TonyRosen,MD,CornellUniversity,USA
CaroleSargent,PhD,GeorgetownUniversity,USA
LaurenSoutherland,MD,OhioStateUniversity,USA
JirapornSri-On,MD,NavamindradhirajUniversity,Thailand
WeextendaspecialthankyoutoPaulWebsterforhiseditorialsuggestionsand guidanceasthebookdeveloped.
DonMeladyreceivesanannualstipendfromtheGeriatricEDCollaborative.Oneofhis jobrequirementsinthatroleistopromotethedisseminationandimplementationof GeriatricEDmodelsofcare.Healsosits,onavoluntarybasis,ontheBoardofGovernors oftheGeriatricEDAccreditationProgram,whichisanot-for-profitofferingofthe AmericanCollegeofEmergencyPhysicians.
JohnG.Schumacherhasnodisclosuresofpotentialconflictsofinterest.
Introduction Doyousometimeshavetheuneasysensethatsomethingintheemergencydepartment whereyouworkneedstochange?Doesthisfeelingstemfromthetreatmentofolder patients?Doyouhearcommentslike, “Isitmyimagination,oraretherelotsmoreold peoplearound?” or “therearesomanycomplaintsfromolderpatients” or “whyisitthat lookingafterolderpeopleintheEDissohard?”
Ifanyofthosecommentsechowhatyou’rethinkingandhearinginyourED,thisbook’ s foryou.WespeakdirectlytoyouandotherEDclinicians,administrators,andhospital leaderswhowantpracticalguidanceabouthowtoimprovetheirED’scareofolderpeople. Wewanttoprovideyouwithimmediatelyapplicableinformationandevenaroadmapto startimprovingcareofyourolderpatients.Inthisbookweofferaguidethat’sboth evidence-basedandexperience-based.We’vepackeditwithactionableinformationto giveyouideasabouthowtochangeyourED’sstructures,processes,andoutcomes.And we ’veorganizedittoprovideastep-by-stepframeworkforanyED,largeorsmall,toassess andaddressitsreadiness,staffing,processes,equipment,resources,andspaceasitseeksto improvetheEDcareofolderpeople.
Thisbookgrowsoutoftheauthors’ experience – 60yearsbetweenthetwoofus – of workinginthe fieldofGeriatricEmergencyMedicine(EM).DonMeladyhasbeenan emergencyphysicianfor30years.Duringhiswholecareerasaclinicianandeducator,he’ s takenanactiveinterestinhowhecanimprovehisowncareofolderpeopleandhowsystems ofcarecanbechangedtodothesame.BasedatMountSinaiHospital,Universityof Toronto,Canada,heisthefoundingchairoftheGeriatricEMCommitteeatthe InternationalFederationofEmergencyMedicine.JohnSchumacherhasbeenabioethicist andmedicalsociologistfor30years,focusingonEDsandresearchingthecareprovidedto olderpeople.Hiscareerhasconcentratedonimprovingtheinteractionsbetweenphysicians,olderpatients,andthesettingsinwhichtheytakeplace.Hehasconsultedonthe creationandoperationofnumerousGeriatricEDsasafacultymemberbasedatthe UniversityofMaryland,BaltimoreCounty(UMBC),USA.
Ourbookhasalsobenefittedfromcontributions,suggestions,comments,andgoodadvice fromourcolleaguesaroundtheworld,aninternationallistofGeriatricEDauthorities –nurses,doctors,andacademicswhofocustheirpracticeonimprovingcareoftheolderED patient.
It’snosecretthatinalmosteverycountryoftheworld,thepopulationofolderadultsis risingsteeply[1].Notsurprisingly,thesedemographicslinktoanincreaseinthenumberof olderpeopleinEDsacrosstheworld.WeknowthatEDshavetreatedolderpatientssince theirinception,accumulatingextensiveexperiencewiththispatientpopulation.However, whilewehaveseensignificantpracticeadvancesintheareaofGeriatricEmergency
Medicineoverthepast30years,manyofthemhavenotbeenintegratedintomainstream EDpractice.Infact,relativelyfewEDshavemadeanyofthesystematicchangesdescribed heretoprepareforthegrowingnumberofolderEDpatients.Empiricalresearchisslowly emerging.AndexperiencesuggeststhatEDsimplementingchangeslikethosein The GeriatricEDGuidelines [2]ortheEuropeanGeriatricEmergencyMedicineCurriculum [3]reportconsistentimprovementsinoutcomes,betterfunctioning,reducedcosts,and higherstaff satisfaction.
ThisbookisaimedathelpingpracticingEDinterdisciplinaryclinicians,EDleaders,and hospitaladministratorswhoareresponsibleforprovidingacutecaretoolderadults. Colleagueswhoareinvolvedinqualityimprovementandcontinuingeducationprograms maybenefitfrommuchofitsfocusedcontentandsuggestions.Hospitalsinvolvedin graduatemedicaleducationforemergencymedicineandemergencynursingmay find thisbookavaluableresourceforprogramming.Finally,hospitalsconsideringaccreditation bytheAmericanCollegeofEmergencyPhysician’sGeriatricEDAccreditation(GEDA) body(www.acep.org/geda/)may findthisbookahelpfulresource.
WerecognizethatEDsarehighlyvaried,bothnationallyandinternationally.Wehave organizedtheninechaptersofthisbooktotranscendthestructureofanysingleEDor medicalsystemwithaneyetoprovidingguidancethatcanbetailoredtoanyED.Wewantto provideabriefevidence-andexperience-informedpracticalguidetogetyoustartedon improvingyourED’scareofolderpeople.
Westartwiththe firstchaptertitled “MakingtheCaseforaGeriatricEmergency Department.” Firstofall,weclarifythataGeriatricEDreferstoany generalEDthatis makingchangestoimprovethecareitprovidesitsolderpatients. Wegiveyousome rationaleformakingthischangetoconvinceyourhospital’sleadershipandprovideyou withsomeevidenceandscriptstousewhenpitchingtheidea.Chapter2, “Starting aGeriatricEmergencyDepartment,” getsintothenutsandboltsofthe firststepsof assessingyourcurrentED,identifyingyourallies,andexploringdifferentmodelsof GeriatricEDs.InChapter3, “OvercomingResistance:WhattoDoWith ‘Yeah,But ... ” wesharepracticalstrategiesforaddressingthepush-backyoumaygetfrompioneering aGeriatricED.
Chapters4,5,6,and7arethecoreofthebook’ s “practicalguide,” withlotsof informationandsuggestionsabouthowthingscanbedifferentinaGeriatricED. Chapter4, “You:AnApproachtoYourOlderEmergencyDepartmentPatients,” describes somekeychangesthatcliniciansmaywanttoadoptoradaptintheirapproachtoolder people.
Chapters5,6,and7introducetheGeriatricED’s3Psofpeople,processes,andplace. Chapter5, “People:AddingStaffingandTraining,” examinesthestaff rolesnecessaryto implementaGeriatricEDincludingthecentralGeriatricEDnursecarecoordinatorrole. ThenChapter6, “Processes:ImplementingProtocolsandPolicies,” presentsthewiderange ofprocesschangesthatcouldbemadeaspartofaGeriatricED.ThefocusofChapter7, “Place:AddressingthePhysicalEnvironment,” isthesmalladditionsandchangesyoucan maketogeriatricizeyourED,aswellasthelargereconfigurationsofthephysicalspace.
Chapter8,entitled “QualityImprovementintheGeriatricEmergencyDepartment: GettingStarted,” providesanintroductiontointegratingqualityimprovementeffortsinto theGeriatricED.Ourconclusion,Chapter9, “LaunchingYourGeriatricEmergency Department:FromFirstStepstoAccreditation,” encouragesyoutotakeactionandbegin youreffortstoimprovingcareforolderadultsintheED.TheAppendixincludesreferences
tocommonlyusedassessmenttools,modelpolicies,andalistofadaptationstothephysical environmentusedbyGeriatricEDsaroundtheworld.
Throughoutthebook,we’veprovidedpersonalaccountsfrommanydifferentEDs internationallytoputahumanfaceonGeriatricEDchange.Theyarestoriesfrompeople workinginbigcities,smalltowns,andacademicandcommunityhospitalsaroundtheglobe abouthowandwhytheygotstartedonthisjourneyandabouttheoutcomestheyhaveseen.
Overall,thisbookisdesignedasapracticalguideforinterestedEDpeoplewhowanttips, tricks,ideas,andsuggestionsbasedonevidenceandexperienceforbetterwaystoorganize theirEDstomeasurablyimprovecareoftherapidlygrowingpopulationofolderED patients.
Ourardenthopeisthattheinsightsweofferwillmakeyourlifeasaclinicianbetter,and that,asaconsequence,yourolderpatientswillgetevenbettercarethantheyalreadydo.
References 1.UnitedNationsPopulationDivision.World populationprospects:The2017revision –key findingsandadvancetables.Working PaperNo.ESA/P/WP/248;2017.
2.CarpenterCR,BromleyM,CaterinoJ,etal. Optimalolderadultemergencycare: introducingmultidisciplinarygeriatric emergencydepartmentguidelinesfromthe AmericanCollegeofEmergencyPhysicians, AmericanGeriatricsSociety,Emergency
NursesAssociation,andSocietyfor AcademicEmergencyMedicine. AnnEmerg Med.2014;63(5):1–3.
3.BellouA,NickelC,Martín-SánchezFJ, etal.TheEuropeanCurriculumof GeriatricEmergencyMedicine: acollaborationbetweentheEuropean SocietyforEmergencyMedicine (EuSEM)andtheEuropeanUnion ofGeriatricMedicineSociety (EUGMS). Emergencias.2016;28(5):295–7.
1 MakingtheCaseforaGeriatric EmergencyDepartment “ Ms.HospitalCEO,I’veGotaProposalandIt’sGoingtoSolve SomeofYourProblems!” Itstartedasasomewhatzanyidea. “AGeriatricED?You’vegottobekidding?”
Thenitsuddenlybecameatrend. “Really?Thereare250GeriatricEDsintheUSA alone?”
Now,it’sshapinguptobeasstandardapartofEDpracticeasthe “GoldenHour” and the “door-to-balloon.”
Yes,hundredsofhospitalsaroundtheworldhavecreatedGeriatricEDsinthepast decadetobetterserveolderpeople.Eachoneisuniqueandwascreatedforuniquereasons. Buteachhospital’sdecisiontocreateaGeriatricEDwas,inalllikelihood,simplyasensible andoftenoverdueresponsetothegrowingneedsofitsolderEDpatients,families,staff,and hospital.
Now,whenwesay, “GeriatricED,” wedon’ tmeanwhatyouprobablythinkwe mean:ItisNOTaseparatespace,downthehall,custom-built,exclusivelyforolder patients – althoughafeware.Rather,whenweusetheterm “GeriatricED, ” everywhereinthisbook,itmeans aregulargeneralEDthathasmadethedecisionto intentionallyimplementchangesinitspeople,processes,andplaceinorderto improvethequalityofcareitprovidestoolderpatients – regardlessofphysical spaceorresources.
Webelievethat every EDhasthecapacitytoadoptadifferent culture ofcareinorderto becomea Geriatric ED.Youdon’tneedmillionsofdollarsofrebuildandhalfadozennew employeestomakeithappeninyourED.Thechangeswe’reguidingyoutoareavailableto everyED,large,small,urban,rural,community,oracademic.
Inthousandsofhospitalsworldwide,thesamescenarioisunfoldingwithincreasingintensity:OlderpatientsandtheircaregiversshowuptotheEDingreater numberseveryday,oneveryshift,withcomplex,multifacetedneedsdemanding attention.BusinessasusualisnotanoptionforEDsinrespondingtothesepatients. ByjoiningtheGeriatricEDmovement,manyhospitalstransformtheircareforolder adultsandsatisfytheir fi nancialandfundingneedswhileincreasingtheirsta ff satisfaction.
WhyCreateaGeriatricED? ThedecisiontocommittoaGeriatricEDmodelofcareisasignificantone.Itrequires aclearandconvincinganswertothebasicquestion:Whydoit?
Here’stheanswer:demographicsand finances.
Inanutshell:Peoplearoundtheworld – especiallyinwealthynationslikeAustralia, Canada,Europe,Japan,Singapore,theUK,andtheUSA – arelivinglongerwithcomplicationsofchronicdiseases,andwithaconcomitantincreaseinratesofdementia,alongwith often-frayingsocialsupportnetworks.Meanwhile,justabouteverywhereintheworld growingnumbersofolderadultsarevisitingEDswithever-increasingfrequency.Once they’reatanED,there’sstrongevidencethattheyusemoreresourcespervisit,aremore likelytogetexpensivetestswithadvancedimaging,aremorelikelytobeadmitted,andare morelikelytosufferhealthcare-relatedharms.Adoptinganewapproachtotheircare – with sometimessmallchangesinstructureandprocesses – canhaveabigimpactintermsof improvedoutcomesforpatients while savingmoneyforyourhospital[1–3].Asthe demographicSilverBoomcontinuesoverthenexttwodecades,thechangespresentedin thisbookareessentialbothonmoralgroundsandifyouwanttoachieve financial sustainabilityandongoingqualityofcareinyourED.
Foramoredetailedanswer,readon.
Todate,hospitalEDsaroundtheworldhaverespondedtothequestion, “Why?” by reimaginingallorpartsoftheirEDsinaformthatisbroadlydescribedasaGeriatricED [4,5].Notsurprisingly,theseearlyadoptersvarywidelyintheirGeriatricEDstaffing, policiesandphysicalenvironments.Butwhenwetakeaquicklookacrossthem,three commonreasonsstandout(Table1.1).
Table1.1 Commonreasons:WhycreateaGeriatricED?
1.Thecompellingbusinesscase
2.IncreasingnumberofEDvisitsbyolderpatients
3.The “groundtruth” ofimprovingcareforolderEDpatients
Box1.1 SampleElevatorPitchforYourCEO You: HelloNatalia!It’stimeourEDcaughtupwithalotofotherhospitalstostartaGeriatric ED.We’regettingleftbehind.
Honestly,ifyouaskmostoftheEDstaff,they’lltellyouthatwedon’tdoaverygoodjob witholderpeople.TheystaytoolongintheED;they’retheoneswhoalwaysendupbouncing back;we’readmittingwaymoreofthemthanweneedto;they’reclogginguptheEDand hospitalneedlesslybothforthemandforus.
WecouldbedoingbetterandIdon’tthinkitneedstocostalotofmoney.Wealreadyhave someofthepeopleweneed.Oneofourdocswouldlovetotakethisonasaproject.We alreadyhaveasocialworkerandaphysiotherapist.Buttheycouldbebetterusedifwe focusedthemontheolderpatients.However,wedoneedaspecificgeriatricnursecare coordinatortopulltheteamtogether.That’sgoingtocostmoney – probably$120,000ayear. Nevertheless,resultselsewheresuggestthatbyputtingthatteamtogether,youcanmake ahugedifferenceinoutcomes.I’msurewecanavoidatleastoneadmissionperday.That wouldwaymorethanbalancetheexpense.Otherplacesthathavedonethiskindofthingare savingupto$3000perpatient.Andweseealotofthesepatients!Plus,itcouldmakeahuge differenceonED flowandonincreasinginpatientcapacityandyourbottomline.It’salsothe kindofthingthatgetsalotofpositiveattentioninthepress.Patientsandfamiliesloveit.Can Iputtogetheraproposalforyou?
TheCompellingBusinessCase We’llgettothedemographicsand “truthontheground” argumentsshortly.Butsurelythe mostcompellingargumenttothequestion, “whydoit?” residesinthebusinesscase.This needstobearticulatedclearlyforyourhospitalleadershiptoacceptthatchangeisneeded. YourjobistoremindthemorconvincethemthatnotonlydoesaGeriatricEDprovide better-qualitycaretoalargepartofyourpatientbase,itcanalsosavethehospitalmoney andputitonasurer financialfooting.
Tomakethiscase,youneedtothinkaboutwhatkeepsahospitalexecutiveawakeat night.Thosethingsinclude “howdoweensurewe’reprovidingthebestcarepossible?” They alsoinclude “howdoweensurethehospitalis financiallyviableandthatwehavethemoney weneedtoprovidethebestcarepossible?” Bereadytoframeyourproposalinthoseterms.
Here’soneexample:
Dr.GoodpersonsawthevalueofcreatingaGeriatricEDatGoodIntentionsMemorialHospital. Butsheknewthatupfrontcapitalandsomeoperationalspending,evenifjustasmallamount, wouldbeahardselltothecash-strappedboard.ShestartedbyspeakingwithherEDchiefto betterunderstandhowthedepartmentwasfunded,andwhatchallengesitfaced.Shelearned thattheMinistryofWellness,itsprincipalfunder,penalizeddepartmentsthathadlonglengths ofstay(LOS)andexcessiveadmissions.Theirdepartment’sLOShadbeenincreasingoverthe lastdecade.Andmuchofthatincreasewasforolderpeoplewhoendedupbeingadmittedfor “socialissues.” Manyofthoseissueswerethingslikemobility,functionaldecline,caregiver burnout,safetyissuesathome,whichwerenoteasilyaddressedbyinpatienttreatmentandled toprolongedadmissionswithassociatedbedblock.
Herchiefwaswillingtosharethefundingandpenaltyformula.Basedonthat, Dr.Goodpersonstartedwithasimple “Whatif?” WhatifwecouldreducetheLOSforsuch patientsbyjustonehour?Whatifadmissioncouldbeavoidedforjust1outofevery20patients whowouldotherwisebeadmitted?Shegathereddataaboutthenumberofadmissionsanddid aquickback-of-the-envelopecalculation,discoveringthatbyreducingLOSbyonehouron averageandavoiding5%ofsocialadmissions,thedepartmentcouldavoid$250,000eachyear inLOSpenaltiesfromitsfunder!Foraprojectthatmightcostjust$100,000,thatwasabigreturn oninvestmentthatanyCEOcouldappreciate!
Thefollowingargumentishighlypersuasivetoyourexecutiveleaders.Unscheduled acuteadmissionstohospital,likeDr.Goodperson’sso-calledsocialadmissions,arerarely “financiallydesirable” admissionsforyourhospital[6,7].Thisappliesparticularlytoolder patientswhoconsumelargeamountsofresources,especiallynursing,eventhoughthey haverelatively “low-paying” admissionsdiagnoses.Theysometimesendupwith aprolongedlengthofstaythroughpoorlymanagedpainfulconditions,lackofattention tofrailty,andincidentdelirium.Hospitalswouldusuallypreferto findmoreappropriate alternativestoprovidingthecarethosepatientsneed,whileensuringthatpatientsreceive excellentcare.Thehigh-payingdesirableadmissionsarethehigh-intensitysurgeryand complexmedicalinterventions(cancerandtransplantsurgery,cardiaccatheterizations, interventionalradiology,etc.).Buthospitalscannotwelcomethosepatientsifallthebeds arefullofolderpeople,justwaitingfortheirphysicaltherapyassessment(thatcouldhave beendoneintheED)whilesimultaneouslyencounteringallthehazardsofhospitalization –confusion,deconditioning,poornutrition,andsleepdeprivation! ThesearethegrimrealitiesofhospitalfundingthatwerarelyconsiderintheED.But yourexecutivesknowthemwell,andthat’swhatkeepsthemupatnight.Fortunately,you
cantellthemthatyoucansolvealotofthoseproblemsbyimprovingtheuseofscarce inpatientbeds.Withasmallinvestmentandexecutivesupport,youareproposingan efficient,relativelylow-costinterdisciplinaryEDteam,andadepartmentarmedwith olderperson-focusedprotocolsandpolicies.YourmovetowardaGeriatricEDwillensure thatolderpeoplearethoroughlyassessed,linkedwithappropriateresources, flawlessly transitionedtoappropriatecare,and,ifadmissionisnecessary,aremorecompletely assessedsothatatargetedtime-limitedadmissionispossible.Thisistheclassicwin-win ofgametheory:olderpeoplecomingtoyourEDgetenhancedqualitycare;staff intheED areabletoperformmoreeffectively; and thehospitaladdressessomeofitsbiggestfunding challenges.
Healthcaresystemsaroundtheworldaremovingawayfromafee-for-servicemodel (“youdosomething;wepayyou”)toavalue-basedmodel(“youdosomethingwell;wepay youmore ”)andprogressivelytoarisk-basedmodel(“youdosomethingbadly;wetake moneyawayfromyou”).Inthisnewworld,payorsystems,privateorgovernmentmanaged,emphasize value:maximumqualityforreducedcost.Fortunately,youcan demonstratethatyourproposedGeriatricEDtransformationwilldeliverthatequation. ByenhancingthestructuresandprocessesofyourED,whatwecouldcallGeriatricED interventions,tobetterassessandmanageolderpatients,thereisevermoreemphasison providingincreasedvalue.Ateamapproachandstandardizedprotocolsgivethepatient whattheyneed.Theygetnotjustasplintforabrokenwristandapatonthebackasthey leave.Theyalsogetanassessmentoftheirfallthatconsiderstheirmedicationlist;provides PTassessmentforstrengthconditioningtopreventthenextfall;andcoordinateslinksto necessarysocialservices.Thisapproachensuresthattheydowellathomeandthehospitalis not financiallypenalizedforanavoidableEDrevisit.Thehospitalisalsonotpenalizedforan unnecessaryadmissionofthisfrailolderpersonwhoisadmitted “forfurtherassessment” justbecausetheyarenot “safefordischarge” andtheemergencydoctorhasnoalternatives available.
Fortunately,basedonalargestudypublishedinJAMAOpen,youcannowtellyour hospitalexecutivethatthereisstrongevidencethatGeriatricEDinterventionsareassociatedwithcostsavingstoMedicareofupto$3000perpatient[1,8].Goingbackto Dr.Goodperson’sback-of-the-envelope,if20%ofyour60000visitsperyeararepeople over65,andyourhealthcaresystemsaves$3000perpatient,thatcouldbeaverylarge numberofcostsavings!Clearly,notallofthatsavingaccruestoyourEDbutassystems movetowardvalue-basedmethodsofpayment,improvementsinoutcomeswilllikely translatesoontoincentivepaymentstoyourinstitution.
Yourargumentwillalsoneedtoreinforcethatprovidinghigh-qualitycaretoyour largestsingle-usergroup,olderpeople,isconsistentwithyourhospital’smission,values, and financialgoals.Probablyitsmissionstatementincludessomethingalongthelinesof “deliveringexcellentcare,withoptimaloutcomes,whileaddressingpatients’ values,and doingsoinacost-effectivemanner.”
ButcanyoutellyourCEOabouttheladyyousawlastweek?Sheistheonewhowaited fourhourstohaveheranklefracturediagnosedandthenwenthomewithoutanyone consideringwhyshehadfallen(becausenoonehadbeenpromptedtoinvestigate).Her dementia(thatnoonehadidentified)hadcausedhertotripleuponheranti-hypertensives (thatnoonehadassessed)leavingherpersistentlypresyncopal.Oncedischargedhome, withnocommunityfollow-up(thatnoonehadarranged),shecouldn’tmanagewithout agaitaid(thatnoonehadoffered),andcontinuedtakinghermedsinthesameway.
Predictably,shehadanotherfalltwodayslater,thistimewithabrokenhip.Onherreturnto yourED,herdeliriumwasnotidentifiedintheED(becausenoonescreenedforachangein mentalstatus).Asaresultofthedelirium,shehashadamarkedlyprolongedhospitalstay, forwhichthehospitalisstillpaying.Oh,anddidyoumentionthatsheisthemotherofthe town’smayor?
Inwhatwaydoesthisstory fitwiththehospital’smissionofexcellentcare,optimal outcomes,respectforpatientvalues,andcost-effectiveness?Unfortunately,youknowthatif youauditjustonemonthofolderpatientsinmostEDs,it’squiteprobableyou’ll findmore thanonestorythatfailsonsomeofthosefronts.Howexpensive – measuredin financial, reputational,andmoralcosts – iseachofthosestories?HowmuchwouldyourCEOinvest topreventevenone?Oneamonth?Oneeveryday?Makesureyouknowyourhospital’ s strategicprioritiesandrefertothemoften.They’reimportant!
Targetingimprovedcareforyourprincipalusergroupscanalsohaveastrongimpacton “marketshare.” Hospitalsarenotabusinesslikeallothers.Buttheydoneedtohave “customers” comingthroughthedooriftheyaregoingtobeseenasvaluableandcontributorypartsoftheircommunitiesandtoremain financiallyviable.Whenolderpeopleare attractedtoyourEDandnottothe “other” hospital,theyalsobringtherestofthefamily.So, becauseMomgetsexcellentEDcareforherfallandheadinjury,itismorelikelythatDad willbecomingtoyouforhishipreplacementanddaughterforherobstetricalcareandson forhiscomplexcancersurgery.WhileprovidinggoodcaretoMomisnotahigh-revenue activity,theotherthreeare.Asanexample,thereissomeemergingevidencethathospitals withGeriatricEDsshowedlessofadrop-off inusage,visits,andthereforerevenueduring theCOVIDpandemicthanthosewithout.
Tosomeextent,thesechangesrequireavisionaryeye.Butmostexecutiveshopetobe visionaries.Theyeitherwantto lead oratleastnot tobeleftbehind!Itshouldnotbedifficult toconvinceanexecutivethatprovidingbettercaretoalargernumberofolderpatientsby makingsomeintuitivechangesatthefrontdoorwillpayqualitydividendstothepatientand financialdividendstotheinstitution.
NowLet’sCrunchSomeOtherNumbers! Yourexecutiveleaderwillwantmorethanjustaspirationsinordertosupportchange. Quantifyingthebusinesscasebeginswithananalysisofcurrentdemographicsandprocesses.Assemblethedatathatarespecifictoyoursite.Theyshouldinclude:
• numberofpeopleofage ≥65inyourcatchmentareaincluding,gender,race/ethnicity, socioeconomicstatus
• numberofpeopleofage>85(typicallythehigher-intensityEDusers)
• numberofpeopleofage55–64groupsinceitincludesthegroupofpeopleagingintothe age>65by2030 – theBabyBoomturningintotheSilverBoom Lookforpatternswithinthosepopulations:
1.Theproportionofpeopleofage>65withinyourEDpopulation(thisisatellingnumber thatEDstaff oftenoverestimate – it’susually much lowerthantheythink.Learningthat itwilllikelydoubleoverthenext10yearscanbeagreatspurtoaction!)
2.CurrentEDprocessmeasuressuchas:
• EDlengthofstayforpatients>65,>75,and>85
• EDtohospitaladmissionrateforpatients>65,>75,and>85
• EDreadmissionratesforpatients>65,>75,and>85
• EDrevisitsat3daysand28daysforpatients>65,>75,and>85
• Patientsatisfactionscores
LearnabouthowyourEDgetsitsrevenue:Howisitpaid?Howisitpenalized?Whatareits main “moneymakers”?Whatareits financialproblems?Whataretherealitiesaroundstaff remuneration?You’reproposingchangestobothstructure(IT,educationandtraining,staff hires,infrastructure)andprocess(newprotocols,newworkflows).Whataretherelated costs?Canyouimagineincreasedrevenueassociatedwithanyofyourchanges?Whatabout savings?
You’llbeassistedinthesecalculationsbyanonlineGeriatricEDReturn-on-Investment Calculatorthatallowsyoutopluginmanyvariablesandcomeupwithsomenumbers-based argumentstopresenttoyourleadership: https://surfcovid19.shinyapps.io/ged_calc/.
Box1.2 SampleElevatorPitchforYourCEO You: HelloFreeman!Goodtoseeyou. Freeman,I’dliketosharewhatI’mworkingonatthemoment – it’screatingaGeriatricEDin ourED.Wearedesigningittobothimprovecareandhelpthehospital.Yousee,inthepast fiveyears,our65+patientvolumehasincreased30%andnowisthelargestsinglecohortwe see.Olderpatientsare30%ofourEDbounce-backsandthat’sknockingabigholeinrevenue andstaff morale.Ourprocessesarenotagood fit,whichisslowingusdown.Often,ourolder patientsendupadmittedjustbecauseeveryonegetsfrustratedthatthere’snogoodoptions.
Toaddressthesituation,Iwanttomodifythejobdescriptionofsomeofourstaff,probably addanewperson,changealotofprocesses,andaddsomebasicstotheplace,including someITchanges.I’vegotanEDphysicianchampionandweplantohiretwooverlapping geriatricemergencynursecarecoordinators.They’lldoalotoftheneededservicecoordinationandtraintherestofourstaff.It’sallgoingtotakesomemoney – probably$200,000 ayear.There’sadefinitereturnonthatinvestment – decreasedavoidableadmissionsand shorterlengthofstay.Iknowpatientswillloveitandboostourpatientsatisfactionscores. Probablyfewercomplaints.DefinitelyfewerreturnEDvisits.Itcouldeasilysaveusmorethan $200,000ayearandputuswayaheadofthemarketinthiscitybycreatingourGeriatricED. WhatI’dlikefromyouareyoursupportandsomeonefromyourexecutiveteamtowork withusasachampion.
WhatelsecanIputintoaproposalforyou?
GeriatricEDsHaveanImpactonCoreFinancialMetrics Complementingthesecoredemographicand financialconsiderationsyou’venowgathered, you ’llalsoneedtoaddressothermetricsforthebusinesscase.Ifyoucankeepinitialcosts revenue-neutral,itwillbeeasiertopitchtheexpectedvaluefromthefollowing:
1. GeriatricEDsReduceEDReadmissions. ImplementingaGeriatricEDmodelofcareis associatedwithreducingthenumberofreadmissionsofolderadultEDpatients. Reducingreadmissionsisanenormouspositiveforolderpatientsandtheirfamilies. Gettingitrightthe firsttimedecreasestheillnessexperience,lowerspain,anxiety,and time,andincreasespatientconfidenceinyourhospitalsystem.ItalsobenefitstheED sincevalue-basedreimbursementpoliciesincreasinglyinclude financialpenaltiestoEDs forreadmissions[9,10].
2. GeriatricEDsIncreaseLevelsofEDPatientSatisfaction. Givingpatientsandfamilies asenseofthoroughness,completeness,andpatient-centerednessdefinitelyimproves patientsatisfaction.Thisimprovementmaybedifficulttoquantify financiallyalthough somesystemsincentivizeimprovingsatisfactionscoresbyremunerationtostaff or fundingtoasite[11].
3. GeriatricEDsIncreaseEDBrandRecognitionandDiff erentiation. Althoughthey areagrowingtrend,inmostlocations,GeriatricEDsarerelativelyrare.Beingthe “ fi rst onyourblock ” tohaveonecanactasabranddi ff erentiatorforboththeEDandthe hospital.YoumaybetheonlyhospitalaroundwithanEDthatprioritizesgeriatric care,perhapsevenanaccreditedone,therebyincreasingyouroverallhealthsystem’ s visibilityandreputation.YourGeriatricEDcanattractpatientsfromoutsideyour catchmentareawhointentionallyseekcareinyourEDtherebyincreasingthe fl owof patientsintoyourhealthsystem’spatientpopulation.Enhancedreputationalso increasesyourED’ssocialcapital,whichallowsyoutoaccrueotherlesstangible bene fi ts.
4. GeriatricEDsIncreaseEmployeeMoraleandRetention. Everymanagerknowsthat recruitmentcostsandpoorstaff retentionareamajordragon financialwell-being.The introductionofaGeriatricEDtypicallyincreasesEDemployeemorale.Itintroduces asystematicapproachtocarethat fitsbetterwiththeneedsofolderpatients,andstaff feelempoweredtoprovidehigher-qualitycaretotheirolderpatients.Cliniciansliketo workinasettingwheretheyfeeltheyaredoingtherightthingbytheirpatients;where thenumberofcrisiscaseswitholderpatientsisreducedbecauseofhavingaccessto ateamapproachandenhancedprocessesofcare.Employeemoraleriseswithafeelingof increasedcompetenceattreatingolderpatientsandofdecreasedwork-relatedstress, evenofmoraldistress.Higheremployeemoraleisassociatedwithlowerlevelsof employeeturnover[12].
Table1.2 listsasummaryofquestionsthatmayinformsomeissuesrelatedtomaking abusinesscaseforGeriatricEDs.
Table1.2 QuestionsforGeriatricEDbusinesscasediscussion
1.HowmightaGeriatricEDimpactourEDreadmissionrate?
2.HowmightaGeriatricEDimpactourEDpatientsatisfactionscores?
3.HowmightaGeriatricEDdifferentiateusfromcompetinghospitalEDs?
4.HowmightaGeriatricEDincreaseEDstaff moraleandretention?
Box1.3 MountSinaiHospitalToronto JosephMapa,thenCEOofMountSinaiHospitalinToronto,Canada,oncesaid, “TheEDisnot justthefrontdoortothehospital,it’salsothehospital’sdoorintothecommunity.” The hospitalwasawarethattheircommunitywaschangingandin2010theBoardofDirectors madeexcellenceinthecareofolderpeopleoneofitsstrategicpriorities.TheCEOfeltthat geriatricimprovementsintheEDwere “notgoingtobeanexpensivechallenge.Itisnotlike creatinganewneurosurgicaloperationroom.It’saboutcreatingtalent,systems,programs.
Withsomesupport,it’spossibletomakeithappen.” Dr.HowardOvens,theEDchief,always identifiedolderpatientsas “ourcoreusers” andmadetheircareapriority.Overhis20years, manysmallgradualchangeswereadded,mostofthemledbythegeriatricemergency management(GEM)nurseswhowerethefrontlinechampionsofchange.OneGEM,Nana Asomaning,rememberstheslowimplementationofsmallimprovements – acquiringasupply ofwalkersandnonslipsocks,writingordersetsforcommonpresentations,addinggeriatric modulestothenursingeducation.Buthermainaccomplishmentwassolidifyingtheinterdisciplinaryteamapproach – nursing,doctors,PT,OT,socialworkallworkingtogetheron complexcare: “Collaborativeworkwiththeteamisactuallythethingthatwillgetyoutothe finishline.”
The “GroundTruth” ofImprovingCareforOlderEDPatients Hospitalsarenotbattlefields,butmilitaryjargonsometimesproduceshelpfulpeace-time insights.Withrootsintacticaldecision-making, “groundtruth” isatermfortheinfluential descriptionsbyindividualswhodirectlyobserveandexperienceasituation.IntheED,the frontlinenurses,technicians,andphysiciansarethestaff whoreportthegroundtruthneeded toimprovethecareofolderEDpatients.Thesehonestnarrativesprovidethemotivationfor EDstoexplorehowtoaddresstheneedsofbothpatientsandstaff tocreateaGeriatricED. TheEDleadershipcanhelpaccessthatgroundtruthbydirectlyaskingstaff abouttheir “pain points” incaringforolderEDpatients.Whereintheprocessoftreatingolderpatientsdothings breakdowninbothpatientcareand flow?Triage?Diagnostictesting?Disposition?Admission versusdischargetocommunity?Orsomeotherpoint? Table1.3 listssomesamplequestionsfor EDstaff
Figure1.1 NanaAsomaning,MountSinaiHospital,Toronto
Table1.3 QuestionsforEDstaff onchallengeswitholderEDpatients
1.WhataresomeofyourbiggestchallengestreatingolderadultsinyourED?
2.WhataresomeofyourdailystrugglesincaringforolderadultsinyourED?
3.WhatthingsmightmakeiteasiertodoyourjobwithyourolderEDpatients?
ProvidinganopportunityforEDstaff tosharetheirpainpointswhencaringforolder patientsisapowerfulwaytogainspecific,localknowledgeasabasisforchangeandtofoster buy-in.
ThecollectedgroundtruthofanEDcan beusedtoinformqualityimprovement initiatives.Forexample,EDsta ff mayidentifydi ffi cultiesassessingolderpatients withcognitiveimpairmentasach allenge.Aqualityimprovemente ff ortmightstart byasking, “ HowmightweimproveourassessmentofolderEDpatientswith cognitiveimpairment? ” Thiscanleadtoasetofpossibl esolutionsthatcouldbe testedaspartofaqualityimprovementproject.Forexample,ifasked,thenursing sta ff maybringuphowdi ffi cultitistoknowwhetheranolderpersoniscognitively impairedornot – andwhetherthatimpairmentisne worlong-standing.Puttingthis problemintheforegroundmakesiteasiertoinitiateaprocess – whetheritbe deliriumscreeningattriageorlater,ort heintroductionofdementiascreening,or aprocessforcontactingcaregiversofpatients – thatwouldaddressbothsta ff needs andimprovepatientcare.
TheIncreasingNumberofEDVisitsbyOlderPatients Toservetheneedsofapopulation,it ’simportanttoknowthatpopulation ’svital statistics.Anawarenessofbasicdemographictrendsprovidesimportantcontextual insightsforhospitalsconsideringthecreationofaGeriatricED.TheUScensusreports thattherewereabout49millionolderadultsin2016.By2030,injust10years,the numberofUSolderadultswillriseto72millionrepresentinga50%increaseinthe population.Onapercentagebasis,theUSpopulationwillmovefrom13%olderadultin 2010toover20%olderadultby2030[ 13].Althoughallareasofthecountrywillsee increasingnumbersofolderadults,thesedemographictrendsobviouslyvary.Some states,likeVermont,Maine,NewMexico,andNevada,areagingmuchmorerapidly thanothers[ 14 ].
Internationally,thedemographicshiftsofagingpopulationsareacceleratinginmany countries,ledbyJapan,Germany,andItalywhereolderadultsalreadyexceed20%oftheir totalpopulations.TheUnitedNationshasdesignatedsuchnations(age65+>20%)as “superagingsocieties” [15].Ascanbeseenin Table1.4,theissueofpopulationagingis robustin2019,andby2030itshowsthesesamecountriesasoverwhelmingly “superaging.” Theseoveralldemographictrendsprovideacontextfortheincreasingnumberofolder adultsprojectedtopresenttoEDsworldwide[16].
IncreasedNumberofOlderEDPatients Aspopulationsage,EDstreatanincreasingnumberofolderpatients.Onanationallevelin theUSA,thenumberofolderadultEDvisitsincreasedfrom19.4millionto23.1million
Table1.4 Percentofpopulationaged ≥65(2019)andprojectedageaged ≥65(2030) Country
Source:WorldBank, https://data.worldbank.org/indicator/SP.POP.65UP.TO.ZS?locations=AU/ WorldBankestimatesbasedonage/sexdistributionsofUnitedNationsPopulationDivision’sWorldPopulation Prospects:2019and2021Revision.HealthNutritionandPopulationStatistics:Populationestimatesand projections.
between2010and2016.Thischangerepresentsa20%increasethatmirrorstheincreasein theUSpopulationofolderadultsduringthisperiod[17,18].Asnotedabove,theolderadult USpopulationisprojectedtoincreaseby50%inthenext10years.ThissuggeststhatEDs couldexperienceasimilar50%increaseinthenumberofolderpatientstoatotalof 35millionvisitsage65+[19].
IncreasingProportionofOlderPatients BasedontheseprojectedincreasesinthenumberofolderEDpatients,EDsareexpected toexperienceacorrespondingchangeintheproportionoftheirpatientpopulationage 65andolder.Currently,olderadultsmakeup15.9%ofEDvisitsnationally[ 17]. However,asthedemographyoftheUSAchangeswithmoreolderpeopleandfewer peopleundertheageof18,theproportionofolderEDpatientsisexpectedtoincrease. Mooreetal.[ 20]reportthattheproportionofEDpatientsage65+increasedbetween 2006and2014andincreaseswerealsoseeninthepercentageof45– 64-year-oldED patients.Atthesametime,EDvisitsforthoseaged0 – 44decreased.TheseshiftingED patientproportionstowardolderadultshaveimplicationsforthetypesofEDservices o ff eredandsta ff neededintheED.
TheseEDdemographicshiftspromoteEDstorespondinhighlysensitiveways. Table1.5 listssamplequestionsforEDsta ff astheEDleadershipplansforthecoming increasesinnumberandproportionofolderEDpatients.Thehospitalleadershipmay alsowanttoconsiderthesesamequestionsfromawork fl owandworkforceperspective.
Table1.5 QuestionsforEDstaff aboutprojectedincreasesinolderEDpatients
1.Asastaff member,ifyourEDexperiencedarapid,20%increaseinvisitsbyolderadults,what specificchangesmightyourEDneedtomake?
2.Asastaff member,ifolderadultsbecomethelargestoverallpercentageofyourED’spatient population,whataretheimplicationsforyourEDoperations?
3.Asastaff member,thinkingaboutyourEDoverthepast fiveyears,howwouldyoudescribeyour impressionofthepatternsofolderadultEDvisits(e.g.,increase/decreaseofnumberofvisits, lengthofvisits,chiefcomplaints,disposition)?
TectonicDriftorSeismicShift? Typically,themovetowardaGeriatricEDhappensinoneoftwoways.Toborrowlanguage fromgeology,thechangecaneitherbeatectonicdriftoraseismicshift.
The tectonicdrift towardaGeriatricEDistheslowincrementaladditionofchangesover aperiodoftime.Maybeforyears,yourEDhashadaphysicaltherapistonstaff who graduallyhasbuiltinanapproachtoassessingallpatientswithfallsandcoordinating outpatientplans.Andmaybe,yearsago,yourequiredmodulesongeriatrictopicsinyour yearlynursingeducation.Thenafewyearsback,therewasthatqualityimprovementproject tobuildadeliriumscreenwhenyougotthenewelectronicrecord.And, “Well,we’vealways hadfoodanddrinkavailableandweusuallyhavewalkersandcanesaroundtogiveorsellto patientsatdischarge.” Littlebylittle,byslowincrements,youarechangingbothstructure andprocessesofcare.Now,whenyoulookatyourpeople,processes,andplace,it’sstarting toresembleaGeriatricEDquiteclosely!
Box1.4
SampleElevatorPitchforYourCEO You: HelloAltaf!
Weneedtodosomethingwiththewaywe’redoingthingsdownintheEDforolderpeople. Asyouknow,thissmalltownhasbecomeamajorretirementdestination:OurEDcensusis now40%overage65.Butwedon’thaveeventhebasicstomanagethisdiversegroup.We’re stillstuck20yearsagowhenitwasallkidsandfactoryworkers.We’renotservingour communityandIthinkalotofpeoplegotothehospitalinHappyHillswhoseEDisfocusing oncaringforolderpatients.Wecoulddojustsomebasicthingsinourplacetogetstarted.I’d liketogetsomeextratrainingforafewofournursestobegeriatricsuperusers,toknowmore aboutourcommunitylinkages.WecouldbuildinabasicscreeningtooltotheEDchartto identifypeoplewithfrailty.They’retheonesmostlikelytobounceback.Addingafewbasics –likewalkers,foodanddrink(whichwedon’thave),acomfortcart – wouldmakeadifferencein patientexperience(andlikelyourratings).Andourvolunteerdepartmentsaystheycould trainsomeoftheirfolkstohelpoutwithourpatientswithdementia.It’sgoingtocostabit, butwouldlikelygetusalotofattentioninthecommunity.Somepositiveattentioninthe localnewspaperwouldbeawelcomechange!
The seismicshift toaGeriatricEDisnowhappeninginmoreandmoreplaces.Perhaps theCEOofthehospitalgetsthewordthatthehospitalboardhasdeclaredexcellentcareof olderpatientsastheneweststrategicpriorityforthehospital. “Folks,we’vegottomake thingshappen!” Orperhapsamajordonorexpressesaninterestinmakingalargebequestto
aninnovativeprojectthatfavorsolderpatients. “WhataboutanamedGeriatricED?” Or, whoknows,maybethere’sanewinfectiousdiseasethatspecificallytargetsolderpeople,and yourEDrealizesitneedstoradicallyrethinkhowitprovidescareforthem – andfast.In someplaces,thereisanintensepressuretomakeachangeinthewayyourEDprovidescare toolderpeople – togofromzerotoahundredinayearortwo.Youneedtobereadyto respondtothatpressuretomakeaseismicshifttoaGeriatricED.
Conclusions Thischapterexaminedthequestion, “WhycreateaGeriatricEmergencyDepartment?” Compellingreasonsabound.Thesechangeswilllikelycometoyourdepartmentsooneror later.Ifyou’rereadingthisbook,likelyyou’vealreadystartedthinkingabouthowyoucan startmakingchanges.
BusinessasusualisnotanoptionforEDsgiventhechangestheyareexperiencing onadailybasisintheirEDpatientpopulation.Patientdataanalysisalmostalways showsthatEDsareexperiencingarapidlyincreasingnumberandproportionofED visitsbyolderpatients.Beyondthedataanalysis,frontlineEDclinicalsta ff report groundtruthsregardingtheneedtoimproveEDprocessesforolderEDpatients.It’ s cleartoEDstaff thatthereisaneedtoimprovetheircareofolderadultsintheirED andthataqualityimprovemente ff ortintheformofaGeriatricEDmaybeawayto gainmomentum.
Fortunately,theconceptforaGeriatricEDalsohasastrongbusinesscaseforthe hospital.Someofthemoreintangibleimpactsareanincreaseinmarketshare,reinforced brandrecognition,enhancedreputation,andadditionalphilanthropicsupport.Butinterms ofdirectfunding,itislikelytodecreaseavoidableadmissions,decreaseearlyEDrevisitsand hospitalreadmissions,improvepatientsatisfactionscores,andhaveanimpactonstaff moraleandthereforerecruitmentandretention.
Nowthatyou’vegotyourCEO’sattentionfor why theyneedaGeriatricED,Chapter2 willexplore how youcangoaboutbuildingtheproposal.
References 1.HwangU,DresdenSM,Vargas-TorresC, etal.Associationofageriatricemergency departmentinnovationprogramwith costoutcomesamongMedicare bene fi ciaries. JAMANetwOpen. 2021Mar1;4(3):e2037334 – e2037334.
2.ParejaT,MadrigalM,MauleonC, HornillosM,JimenezP.Geriatricevaluation unitintheemergency room:clinicalbenefitsandcost effectiveness. JAmGeriatrSoc.2007Apr;55 (S1):S122.
3.PinesJM,EdgintonS,AldeenAZ.Whatwe candotojustifyhospitalinvestmentin geriatricemergencydepartments. Acad EmergMed.2020/05/18ed.2020Oct;27 (10):1074–6.
4.HwangU,MorrisonS.Thegeriatric emergencydepartment. JAmGeriatrSoc. 2007;55(11):1873–6.
5.SchumacherJG,HirshonJM,MagidsonP, ChrismanM,HoganT.Trackingtheriseof geriatricemergencydepartmentsinthe UnitedStates. JApplGerontol.2018/11/ 18ed.2020Aug;39(8):871–9.
6.PearlR.Whymajorhospitalsarelosing moneybythemillions[Internet]. Forbes; 2017[cited2021Mar1].Availablefrom: www.forbes.com/sites/robertpearl/2017/11/ 07/hospitals-losing-millions/? sh=e11dd7b7b50
7.GrudzenC,RichardsonLD,BaumlinKM, etal.Redesignedgeriatricemergencycare mayhavehelpedreduceadmissionsofolder adultstointensivecareunits. HealthAff. 2015;34(5):788–95.
8.KennedyM,OuchiK,BieseK.Geriatric emergencycarereduceshealthcarecosts –whatarethenextsteps? JAMANetwOpen 2021Mar1;4(3):e210147–e210147.
9.McCuskerJ,Ionescu-IttuR,CiampiA, etal.Geriatricservicesreduceemergency department(ED)returnvisits. JAmGeriatr Soc.2005Apr;53(4):79.
10.McCuskerJ,Ionescu-IttuR,CiampiA, etal.Hospitalcharacteristicsand emergencydepartmentcareofolder patientsareassociatedwithreturn visits. AcadEmergMed.2007May;14 (5):426–33.
11.RichterJP,MuhlesteinDB.Patient experienceandhospitalprofitability:isthere alink? HealthCareManageRev [Internet]. 2017;42(3).Availablefrom: https://journals .lww.com/hcmrjournal/Fulltext/2017/07000 /Patient_experience_and_hospital_profitab ility__Is.7.aspx
12.ZaheerS,GinsburgL,WongHJ, ThomsonK,BainL,WulffhartZ.Turnover intentionofhospitalstaff inOntario, Canada:exploringtheroleoffrontline supervisors,teamwork,andmindful organizing. HumResourHealth.2019 Aug14;17(1):66.
13.OrtmanJ,Velkoff V,HoganH.Anaging nation:theolderpopulationintheUnited States,CurrentPopulationReports.US CensusBureau;2014.
14.DemographicsResearchGroup[Internet]. [cited2020Apr24].Availablefrom: https:// demographics.coopercenter.org/nationalpopulation-projections
15.UnitedNationsPopulationDivision. Worldpopulationprospects:the2017 revision – key findingsandadvancetables. WorkingPaperNo.ESA/P/WP/248;2017.
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17.RuiP,KangK.Nationalhospital ambulatorymedicalcaresurvey:2015 emergencydepartmentsummarytables [Internet].CentersforDiseaseControl NationalCenterforHealthStatistics;2016. Availablefrom: www.cdc.gov/nchs/data/a hcd/nhamcs_emergency/2015_ed_web_t ables.pdf
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2 StartingaGeriatricEmergency Department WhereDoIStart? AfteryourbrilliantpitchtotheCEO(seeChapter1),theygaveyouthego-aheadtomake somepreliminaryplansandprepareaproposalforconsiderationatnextmonth’sexecutive reporttotheboard.Nowwhat?Thischapterprovidesaguideincluding:
1.You’renotstartingfromzero
2.Articulatingwhat’simportanttoyourEDandyourhospital
3.MappingtruthsaboutyourEDandolderadults
4.Howmightwecreateit:assessEDwith3Ps – people,processes,place
You’reNotStartingfromZero You’renotthe fi rstEDintheworldtoconsidermakingsomechangestothewayyou providecareforolderEDpatients.So,you ’llprobablydowhatmostofusdowhenwe haveanewproject – phoneafriend!WhileeveryEDisdi fferent,youalmostcertainly willbenefi tfromreachingouttootherGeriatricEDs,ofwhichthereareaneverincreasingnumber.Inwhatevercountryyouwork,therearelikelyafewEDsthatare leadingthesechangesandwillbehappytosharetheirexperiencesofwhatworkedand whatdidn ’tattheirplace.AnorganizationliketheGeriatricEmergencyDepartment Collaborative(GEDC),basedintheUSA,hasthemissionofdisseminationandimplementationofolder-person-focusedmodelsofEDcare(https://gedcollaborative.com). International[1],European[2],andAustralianEmergencyMedicine[3]organizations havealldevelopedguidancefordepartmentswantingtomakechangeintheir GeriatricEDs.
Yournewfriendwilllikelytellyouthatthereareafewcoredocumentsyoushould masterbeforeyougomuchfurther.Backin2012,whenthe fieldofGeriatricEmergency Medicinewasstilldeveloping,agroupofAmericancollaboratorsgottogethertoestablish general,experience-andevidence-informedguidelinesaboutthecharacteristicsof aGeriatricED.Theresultingdocument, TheGeriatricEDGuidelines,wascodeveloped andadoptedbyaninterdisciplinarygroupoftheAmericanCollegeofEmergency Physicians(ACEP),theSocietyofAcademicEmergencyMedicine,theEmergencyNurses Association,andtheAmericanGeriatricsSociety[4].Thatdocumenthasinformedthe creationofmostGeriatricEDstoday,whethertheybetherelativelyrareapproachofafreestandingseparateEDorthemorecommonmodelofageneralEDthathasbeen “geriatricized.” ItremainsessentialreadingforanyEDthatisstartingdownthisroad.Manyofthe suggestionsinthispracticalguidearebasedonit.
AsGeriatricEDsstartedtoproliferate,in2018ACEPcreatedaprogramtoaccreditEDs, atthreedifferentlevels,thathavetransformedtheircaresufficientlytobecalledaGeriatric ED(seeChapter9formoredetail).EvenifaccreditationisnotagoalforyourED,theACEP criteriaarealsoessentialreadingtohelpyouunderstandtherangeofchangesthatare availabletoyouasyouimproveyourED’sapproach[5].Theyalsogiveguidanceaboutan approachtoqualityimprovementeffortsinyourEDandthemetricsyouneedtomeasure.
Finally,twobriefresourceswillroundoutyourintroductiontoGeriatricEDs.Firstis aguidebyWestHealth,afoundationcommittedtoimprovingcareofolderpeople,that producedanimplementationguidetohelpyougetstarted: www.westhealth.org/wp-content /uploads/2018/09/GED-Implementation-Guide.pdf.Thesecondisarobusttoolkitcalled theGeriatricEmergencyDepartmentIntervention(GEDI)ToolkitcreatedbytheHealth CareImprovementUnitinQueensland,Australia: https://clinicalexcellence.qld.gov.au/res ources/gedi-toolkit.WiththesefewresourcesyouwillhaveasolidfoundationinGeriatric EDdevelopment.
Evenwithinyourowndepartmentandhospital.Theremaybeopportunitiesthatyou canexploittogetstarted.OneEDmanagernoticedthatshehadaccesstoaphysical therapistbutthePTwasoftendoingrelativelylow-impactactivitieslikecrutch-teaching anddemonstratingstretchingexercisesforpeoplewithbackpain.Shere-focusedthePT rolespecificallyonassessingolderpeoplewithfallstodeterminefunctionalabilityandhow tooptimizeitfordischarge.Shewasabletoprovidemorevaluetothepatientandproduce amuchmoresatisfiedPT,andimprovethequalityofcarewithfewerbounce-backsbecause offailingfunctionathome[6].Similarly,itmaybepossibletorefocusyourpharmacy servicesmorespecificallyonolderpatients – notcreatinganewrolebutgettingmorevalue outofwhatresourcesyoualreadyhave[7].
What’sImportanttoYourED?What’sImportanttoYour Hospital? FollowingtherecognitionthatyourEDalreadytreatsolderEDpatients,andconducting somepreliminaryanalysisofyourcensusofolderEDpatients,wehavefoundthenextstep isfortheEDstaff towritedowntheiranswertotwoquestions: (1)Whatisimportantto yourED?(2)Whatisimportanttoyourhospital?
Whilethesemayseemsimplistic –“Ofcourseweknowwhatisimportant!”– wehave foundthattheEDteamneedtodiscussandwritedownwhattheythinkisimportantinthe EDsincetheanswersmayormaynotbeconsistentacrosstheEDleadership,EDstaff,and thehospitaladministration.Analternativewaytothinkaboutthisistoask:Whatarethe indicatorsthatyourEDisdoingwell?SomeEDshavea “dashboard” ofindicatorsthatthey monitor.Eventhechoiceofwhatindicatorsareonthatdashboardcanrevealalotabout whatisimportant.Theseindicatorsmayinclude:numberofEDpatientstreated;EDpatient satisfaction;EDrevenue;numberofED48-hourreadmissions;andnumberof30-day hospitalreadmissions.It’ssurprisinghowoftentheseindicatorsare not segmentedbyage andthatmaybeyour firsttask.Thekeyistoknowandwritedownthemetricsthatare explicitlyusedbytheEDandhospitaltomeasuresuccess.
Atthesametime,thehospitalmayhaveaspecificsetofhospital-wideindicatorsthatit trackstomeasure “ success ” initsownhospital-widedashboard.Onceagain,itisimportant todocumentthesehospital-levelindicatorsofsuccess,ideallyoverbothaone-yearand a five-yearperiodtoestablishpatternsovertime,andyourinterpretationofthem.
Next,comparedashboarditemsimportanttotheEDtodashboarditemsthatare importanttothehospital.Towhatdegreearethedashboardlistsconsistent?Isthere agapbetweenwhatisimportanttotheEDandwhatisimportanttothehospital?For example,isitimportantfortheEDtoavoidhospitaladmissions/readmissions(avoidable hospitalizations)comparedtothehospitalasawholewherehospitaladmissionsmaybe somethingthatisimportanttothe financialhealthofthehospital?Itisnotuncommonfor theretobeconflictinareasofimportancethatmayimpacttheorganizationandfunctioning ofyourGeriatricED.
Next,explicitlyconsiderhowolderEDpatients(age>65)maydrivetheindicatorsyou listedasimportanttotheEDandtothehospital.Whatmightbetherelationshipbetween olderpatientsandtheindicatorsyoulist?Spendsometimehypothesizingaboutthese potentialrelationshipsandpathways.Whatrolecanyousuggestolderpatientsplayinyour ED’sandyourhospital’smeasuresofsuccess?Asyoudothis,remember,donotmake “perfecttheenemyofthegood” asnotedbyJimCollinsin GoodtoGreat (quotingVoltaire!). Theseanswersmaybealittletrickyandalittlemessyandthatisokay.Youwillgaininsight bycomparingtheseareasofimportanceasseenfromtheperspectiveoftheEDandthe hospital.
Truth-MappingExercise:What’sTrueaboutOlderAdults inYourED? Withaninitialunderstandingofwhat’simportanttoyourEDandhospital,youcandeepen yourunderstandingbydoinga “truth-mappingexercise.” Truthmappingisasimpleand powerfultechniquethatisinspiredbytheworkofPatrickLencioni[8].Theexercise involvesateamlistingonawhiteboardeverythingthattheyknowis “true” abouttheir organization.Thiscouldbedonewithanonlinesurveywithallyourstaff.Or,asyouare assemblingacoreteam,youmaywanttopullthemtogetherforthisexercise.Getoneortwo nurses,adoctor,perhapsaclericalorservicestaff person,someonefromadministration together.Thenaskthemtolistwhattheyknowis “true” abouthowtheycareforolderadults intheirED.
Thegoalistodeveloparobust,redundant,chaotic,perhapsmessylistofeverythingthey canthinkofrelatedtoolderadultsandtheirED.Thingsonthelistcanbepositive,negative, orneutral.Makethelistaslongasyoucaninthetimeallotted.Lencioninotesyourlistmay include “apples,oranges,monkey,andCadillacs.”
OneED’slistmightlooklikethis:
• Wedon’tdifferentiateolderfromyoungerEDpatients
• Ourexamroomsareuncomfortablycrowdedwhenanolderpatienthasmorethanone familymember
• Onenurse,Nancy,isextremelypatientwitholderpatientswhoareconfused
• Olderpatientshavereallylongcharts
• Triageisadisasterforoldpeople – theycan’thear,Ican’thear,I’mgettingstoriesfrom paramedics/thepatient/thefamily
• Wehavegrahamcrackers,icechips,andgingeraleforourpatients
• Somestaff hateseeingolderpatients
• Ambulancestaff don’tliketransportingolderpatients
• Ourlocalnursinghomesendsusmanyoldpatientswithnoinformation
