Improving Emergency Department Care for Aging Missourians: Guidelines, Accreditation, and Collaboration

Abstract

Aging baby-boomers present significant challenges to accessible, affordable emergency care in America for patients of all ages. St. Louis physicians served as early innovators in the field of geriatric emergency medicine. This manuscript summarizes a multi-institutional November 2016 symposium reviewing the Missouri history of geriatric emergency care. In addition, this manuscript describes multispecialty organizations’ guidelines, healthcare outcomes research, contemporary medical education paradigms, and evolving efforts to disseminate guideline-based geriatric emergency care using a “Boot Camp” approach and implementation science. This manuscript also reviews local adaptations to emergency medical services and palliative care, as well as the perspectives of emergency department leaders exploring the balance between infrastructure and personnel required to promote guideline-based geriatric emergency care with the anticipated benefits. This discussion is framed within the context of the American College of Emergency Physician’s planned geriatric emergency department accreditation process scheduled to begin in 2018.

Background

Adults over the age of 65 will have increased from 4% of the population in 1900 to over 20% by 2050, largely reflecting the triumphs of medicine to overcome cancer, cardiovascular disease, and infections that were previously fatal. With medical advances prolonging life, innovative healthcare leaders launched the American Geriatrics Society (AGS) in 1942.¹ Residency and fellowship programs trained generations of primary care and specialty physicians that increasing numbers of elderly Baby Boomers would be able to access geriatricians when frailty ensued. Patient care needs for geriatricians were projected to increase by threefold between 2000 and 2030,² but few of the nation’s medical schools had a division or department of geriatrics or any geriatric course requirements. Caring for an aging nation would be the responsibility of all physicians, not just geriatricians, but the country was woefully unprepared for the “silver tsunami.”

Using John A. Hartford Foundation funding in the 1990’s, emergency medicine (EM) answered these geriatric challenges with research exploring falls prevention³ and detection of cognitive impairment,⁴ as well as geriatric-focused resident curricula and a series of increasingly detailed textbooks. EM researchers quickly realized that an increasing focus on older patients opened a Pandora’s Box of previously unrecognized issues and threats to recovery from acute illness or injury – such as delirium, dementia, depression, frailty, and unmet social needs. The traditional model of EM care is a linear one-problem, one-diagnosis approach (Figure 1a). In contrast, older adults frequently present atypically with both the chief complaint and the likelihood of recovery clouded by multiple other functional, cognitive, medication, and social factors (Figure 1b).⁵ Despite quality indicators⁶ and EM resident core competencies⁷ that emphasize the importance of identifying age-related functional and cognitive frailties, attention to geriatric syndromes such as injurious fall prevention,⁸ functional decline, dementia, and delirium⁹ was often lacking. Suboptimal emergency care for older adults was associated with patient dissatisfaction,¹⁰ preventable ED returns,¹¹ and loss of independence after minor injuries. St. Louis physicians were historic innovators in the field of geriatric EM. Cognizant of this history the SLU and Washington University Departments of EM co-hosted a multidisciplinary half-day symposium on November 8, 2016 to highlight ongoing local innovation including opportunities for trans-hospital networking to improve older adult emergency care. This manuscript summarizes that symposium.

Figure 1a.

Traditional EM Management Pathway

Source: Adapted from [11] with permission.

Figure 1b.

Geriatric Emergency Care Model

Source: Adapted from [11] with permission.

St. Louis and the Silver Tsunami

St. Louis was very involved in those early years, exploring some of the unique problems inherent to older adults, and determining if screening and preventative services in seniors being evaluated in the ED might decrease healthcare utilization and improve outcomes. In 1990, Drs. Douglas Miller and John Morley at St. Louis University (SLU) demonstrated that the use of formal geriatric assessment instruments in outpatient departments significantly improved identification of problems relating to cognition, gait, affect, and nutrition in an outpatient setting.¹²

Drs. Morley and Miller subsequently collaborated with early leaders in the nascent field of geriatric EM.¹³ They forged local collaborations between geriatrics and EM at SLU highlighting the need for a formal assessment of functional status in these patients.^4,11 These findings fueled efforts to fund research exploring the unique challenges providing emergency care to elders. This funding supported the development of leaders in the nascent field of geriatric EM via the Jahnigen Scholarship¹⁴ and promoted best practices. A geriatric specific curriculum in EM and the publication of the first comprehensive textbook on geriatric emergency care followed.¹⁵

Momentum slowed locally and during much of the first decade of the new millennium, Missouri was less involved in innovative geriatric EM, even as national efforts accelerated. Early geriatric EM leaders and those attempting to implement best practices today have identified three essential lessons:

• Targeting the right patients (as opposed to targeting all patients);

• Extending care - effective geriatric interventions almost always need sustained care to achieve best outcomes;

• Delivering required care – mandates that referring providers retain significant influence over the care delivered because referrals without control generally do not work.

Another lesson learned pertains to the required resources for implementing “best practices.” The learning phase typically involves decreases in efficiency that characteristically revert to equal or superior levels of throughput with the added benefit of improved care and better outcomes once the intended intervention becomes standard care. When appropriately implemented the investment is worth the time and effort. These investments imply the crucial need for long-term committed collaboration across domains of care (pre-hospital, ED, inpatient, and outpatient including home health services). Long-term success requires getting all stakeholders to the table to adapt healthcare delivery in a patient-centered, cost-effective way.¹⁶

Overcoming Inertia: The Evolution of Geriatric Emergency Medicine

The “diffusion of innovation” across the country was slow despite opinion leaders’ endorsements to refine pre-hospital, ED, and post-acute care. The pace of adaptation quickened when the first self-defined “Geriatric Emergency Department” opened in 2008 followed in rapid succession by 29 more by 2014.¹⁷ The American College of Emergency Physicians (ACEP), Society for Academic Emergency Medicine (SAEM), Emergency Nurses Association (ENA), and AGS worked collaboratively to develop “Geriatric Emergency Department Guidelines”¹⁸ that provide evidence- and consensus-based recommendations about the education, staffing, protocols, quality improvement metrics, and infrastructure modifications that are most likely to improve the experience of care and outcomes for older adults. In January 2017, ACEP established a three-tiered accreditation program for EDs based upon these guidelines (Figure 2).¹⁹

Figure 2.

Historical Timeline of Geriatric Emergency Medicine

Abbreviations: EM (emergency medicine), GSI (geriatrics for specialty initiative), SAEM (Society for Academic Emergency Medicine), ACEP (American College of Emergency Physicians), ED (emergency department), AGS (American Geriatrics Society), ENA (Emergency Nurses Association)

Educating Clinicians – Relevant Geriatric Free Online Access Medical Education (FOAMed)

Historically EM training has prioritized the “guts and glory” of ED work – trauma, procedural resuscitation, and acute critical illness – while reinforcing the “one patient-one problem” approach. In contrast, current ED practice involves predominantly assessment and care of frail adults with multiple co-morbidities transitioning through a complex health care system.

EM educators strive to fill this education gap. Six months prior to the citywide symposium, symposium organizers encouraged SLU and Washington University EM residents to complete six online modules (www.geri-EM.com). This FOAMed resource is a peer-reviewed and accredited resource that provides free CME and an interactive case-based approach with the opportunity for self-assessment in each of the core competency domains of Geriatric EM: cognitive impairment; trauma and falls; medication management; atypical presentations; functional assessment; and end-of-life care.⁷

Implementing Palliative Care in the ED

Patients seeking care solely to alleviate distress often find the ED ill equipped. Discrepancies between patient goals and those of the ED (rapid assessment and initiation of interventions targeting life threatening conditions) are common.²⁰ Families identify a focus on disease modifying interventions rather than distress modifying actions for patients approaching end of life as a source of preventable distress. Incorporating palliative care into an ED requires assessing physical, emotional, spiritual, and social domains. A simple ED screen to assess palliative care appropriateness is the clinician query “Would I be surprised if this patient were to die in the next year?”²¹

Overcoming these barriers does not require extensive financial or time commitments from an institution. Identifying an ED palliative care champion dramatically increases access to palliative care for ED patients. Obstacles to ED palliative care include:

• inadequate palliative care education²²

• insufficient protocols to identify palliative care patients

• poorly developed ED-palliative care hospital collaborations

• inappropriate privacy and space for discussions about goals of care in the ED

• lack of access to advanced care planning documents that have been completed, or lack of access to forms available for patients to complete.

Adapting Emergency Medical Services for Geriatric Care

The Community Health Access Program (CHAP) coordinates transitions of care (Figure 3) focusing on patients using emergency medical services (EMS) for non-emergency or chronic care. CHAP works one-on-one with patients to identify individual medical, social and mental health needs. CHAP staffing includes three community paramedics and an “access coordinator” working with inpatient and outpatient providers and resources. Individuals with more than two ED visits within a 20-day period trigger an alert. Since 2015 CHAP decreased ED visits by 56% and inpatient admissions by 65% for these “High Utilizers”. The current EMS financial structure does not reimburse for these non-traditional efforts, so hospital finances, charitable donations, and grants currently fund this program.

Figure 3.

CHAP team member evaluates a patient at home including vital signs and signs/ symptoms of congestive heart failure decompensation in the immediate post-ED period.

CHAP is collaborating with Memory Care Home Solutions to train paramedics to provide nonpharmacological interventions that improve outcomes in older adults with cognitive impairment. The goal of the partnership is to decrease preventable ED and EMS utilization for patients with dementia, while helping these patients to remain in their homes. Providers from both agencies are able to identify patients who might benefit from the others’ services in order to link families to appropriate resources.

ED Leadership Perspectives on Engaging Hospital Administrators with Geriatrics

In 2009 the ED was the site for 75% of non-elective hospital admissions in those 85 years old and above.²³ Age is an independent predictor of hospital admission so an aging America will directly impact access to ED and hospital care for patients of all ages for several decades.²⁴ Medical centers already struggle to provide timely and cost-effective healthcare for the increasing number of patients over age 65. Aging “baby boomers” will add three million new seniors to the US population annually for another decade, and with greater longevity, the number of patients over age 85 is rapidly expanding. EDs will become more busy with complex older patients, some of whom will be injured but most of whom will visit with acute complaints associated with chronic medical issues.^25,26 Without an appropriate focus on feasible and efficient geriatric emergency care quality, timely access to emergency care could be negatively influenced for every age group in every ED.²⁷ As hospitals continue to improve the quality of care through core measures and evidence-based practice, creative solutions and innovations will be necessary to ensure cost-effective, accessible emergency care for older adults. In comparison with the investments already made in pre-hospital care, ED operations, interventional resources, and post-hospitalization rehabilitation for cardiac, stroke, sepsis, and trauma care, investments to “geriatricize” the general ED for an aging population have been trivial. Hospital administrators require the advice and assistance of ED leaders to determine how to best care for this population in a fiscal environment that is providing less reimbursement layered with penalties for both poor patient satisfaction and preventable return visits.^16,28,29 ACEP’s recent decision to begin accrediting EDs on a three-tiered platform similar to trauma centers may resonate with key decision-makers and payers to provide the financial stability required to foster disruptive innovation and sustained progress.^19,30,31 Early research exploring the value of the “Geriatric ED” have been inconclusive.^32,33 However, these results are not justification to stop innovating since these findings may reflect inadequate or incomplete implementation strategies^34,35 or assessment of the wrong outcomes.³⁶

The financial resources required to better align the ED physical environment with aging populations are relatively modest, but require expertise.^30,37 The most valuable resource for the busy ED is a content expert in geriatric care to lead revisions of the physical plant, structuring of patient protocols, and general staff education. Additional resources helpful to avoid preventable ED returns include trained geriatric emergency nurses, home health caregivers, social workers and case managers, as well as access to transportation, prescription assistance, and physiotherapy.^38,39

The GED Boot Camp Implementing System-Level Change and Collaborative Learning

As previously noted, despite the existence of published and professional society endorsed geriatric EM quality indicators⁶ and resident core competencies⁷ for a decade, older adults in the ED usually do not receive guideline-directed fall prevention⁸ or cognitive assessment.⁹ These deficiencies are associated with patient dissatisfaction,¹⁰ preventable ED returns,¹¹ and functional decline. How is this gap between published guidelines and bedside healthcare delivery possible? The Institute of Medicine estimates a 17-year delay for just 14% of practice-ready healthcare research and guidelines to reach the bedside.⁴⁰ As a pertinent example of an implementation science intervention designed to accelerate knowledge uptake in medicine, organizers introduced symposium attendees to the “GED Boot Camp” initiative, which links innovators with healthcare systems primed to adapt effective interventions into multidisciplinary local practice. The Boot Camp promotes and accelerates knowledge transfer by incorporating prior sites’ local leaders’ lessons learned into regular teleconferences with other past and future Boot Camp sites so that avoidable mistakes or barriers can be more efficiently anticipated and overcome. The “GED Boot Camp” preparations include several months of preparatory teleconferences between the Boot Camp organizers and the local sites, as well as quarterly teleconferences with prior sites for at least a year to assist with the implementation and assessment of quality improvement projects.

Conclusions

Innovation and expertise likely exist in every community for reformulating the longitudinal processes of geriatric emergency care from the pre-hospital setting, through the ED to the inpatient services, and post-hospitalization recovery. Geriatrics is a team sport and requires multidisciplinary engagement as well as support of hospital administration, payers, and home health services. Medical advances in the 20th Century rendered previously unimaginable relief of suffering and early mortality. Now it is incumbent upon 21st Century providers to wisely invest in system-level resources and educational products that best align patient care experiences with costs and attainable patient-centered outcomes for geriatric patients.

Biography

Christopher R. Carpenter, MD, MSc, MSMA member since 2016, is Associate Professor; Jason Wagner, MD, Brian Froelke, MD, are Assistant Professors; Brent E. Ruoff, MD, MSMA member since 2003, is Associate Professor, and Lawrence Lewis, MD, is Professor; Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO. Don Melady, MD, Msc(Ed) is Assistant Professor, Department of Emergency Medicine, University of Toronto. Craig Krausz, MD, is Associate Professor of Surgery, Saint Louis University School of Medicine. Jennifer Cordia, RN, BSN, MBA, is Chief Nursing Officer; and Derrick Lowery, MD, Director, Palliative Care Services, are at Christian Northeast Hospital, St. Louis, MO. Laurie E. Byrne, MD, is Emergency Medicine Division Chief, Saint Louis University School of Medicine. Douglas K. Miller, MD, is in the Division of Geriatric Medicine, Department of Internal Medicine, Saint University School of Medicine and Indiana University Center for Aging Research Regenstrief Institute Indianapolis, IN.

Contact: carpenterc@wustl.edu