Table 1:
Geriatric Emergency Department care can be provided in a range of situations, from large volume academic centers to smaller community hospitals.
| GED Unit | Geriatrics Practitioner Model | Geriatrics Champion | Geriatric-Focused Observation Unit | |
|---|---|---|---|---|
| Examples of U.S. institutions: | • Mt Sinai Medical Center, NY • St. Joseph’s Hospital, NJ |
• Northwestern University, IL • Bridgeport Hospital, CT |
University of North Carolina Hillsborough, NC | Ohio State University, OH |
| Annual ED volume | • MSMC: Total: 109,258; ≥65 years: 18,574 (17%) • SJRMC: Total: 157, 413; ≥65 years: 16, 218 (10%) |
• NW: Total 86,998; ≥65 years: 16,530 (19%) • BH: Total: 94,240; ≥65 years: 16,746 (18%) |
Total: 17,000; ≥65 years: 2,250 (15%) | Total: 80,350; ≥65 years: 15,145 (18.8%) |
| Proportion older adults receiving specialized care* | • MSMC 10% • SJRMC 9% |
• NW: 12% • BH: 10% |
50% screened by nurses | 11.4% of patients ≥65 years are placed in ED Observation Unit |
| Criteria for specialized care | • MSMC: ISAR ≥ 4, ESI ≥ 3, hospital discharge last 30 days, or ED clinician request • SJRMC: age ≥ 65 years |
• NW: ISAR ≥ 3, or ED clinician request • BH: TRST ≥ 2, ED clinician request, BPA for advanced dementia & critical illness |
Age ≥ 65 years | Meets observation status criteria |
| Hours/days specialized care available | • MSMC: 9 hours/day; 7 days/week • SJRMC: 8 hours/day; weekdays |
• NW: 11 hrs/day, weekdays • BH: 10 hrs/day, weekdays; 8 hrs/day, weekends |
24hrs/day, 7days/week | • Observation Unit is open 24/7. • Geriatricians: weekdays. • PT, OT, Pharmacy & CM team: Monday-Saturday |
| Specialized care providers: | Interdisciplinary team of care providers with specialized training in geriatric patient care: ED physician, ED nurse, social worker or case manager, PT, OT, pharmacist & geriatrics consultants (physician or APP) | • NW: specialized ED nurse-led program, with interdisciplinary team of SW, PT, OT or pharmacist, as needed. • BH: Specialized Geriatric APRNs supported by Geriatric & Palliative Care team and GENE trained RN. Interdisciplinary team of SW, chaplains, PT, OT, CM, & pharmacist, as needed |
Interdisciplinary team of social workers, PT, OT or pharmacist available. Dedicated nurse champion and nurse team help develop protocols and lead nursing education, but are not present in the ED at all times. | Interdisciplinary team of ED care providers with specialized training in geriatric patient care: ED physician, ED nurse, social worker or case manager, PT, OT, pharmacist & geriatrics consultants (physician or APP) |
| Strengths: | • Cohorting of patients, resources, medical supplies and care specialists for better care • Better management of delirious patients due to structural improvements • Education can be focused on nurses and staff in the unit. |
• Identifying high risk patients, early intervention • Safe discharge from ED to appropriate level of care • Focused geriatric assessments with specialist level of training • Lower cost & increased flexibility than dedicated GED unit • Can improve ED wait times & length of stay for patients being discharged |
• Repurpose existing case management and nursing roles. • Lower cost and increased flexibility than dedicated GED unit |
• Preserves ED flow and length of stay. • Consultants can keep normal business hours and bill professional fees for their evaluations, similar to inpatient care. • Prevents unnecessary admissions |
| Limitations: | • Sustainability in hospitals with boarding or difficulties with patient flow • Requires dedicated space in the ED. • Staffing costs if geriatric specialists are assigned to the unit. |
• ED nurse screening may be not be fully implemented and deferred to geriatrics practitioner. • Geriatric assessments may increase length of stay • Staffing and training costs. • Staff turnover can lead to periods of reorientation and cultural adaptation |
• No dedicated geriatric emergency care provider in the ED setting • Geriatric assessments increase length of stay • Coordinating care with outpatient resources. |
• Requires an ED Observation Unit and a geriatric champion • Need consultant buy-in from hospital inpatient services to prioritize the Observation Unit. • Observation status does not count towards the qualifying inpatient stay for skilled nursing facility placement, which could increase hospital length of stay for patients requiring placement. |
*
Proportion of total ED encounters for patients ≥65 years in age who are either: treated in the GED Unit, evaluated by the Geriatric Practitioner, are screened for geriatric syndromes by ED nurses (Geriatrics Champion model), or placed in the Geriatric-Focused Observation Unit.
Abbreviations: GED – Geriatric emergency department; MSMC: Mt. Sinai Medical Center (New York, NY); SJRMC: St. Joseph’s Regional Medical Center (Patterson, NJ); NMH: Northwestern Memorial Hospital (Chicago, IL); UNC: University of North Carolina at Chapel Hill Medical Center (Chapel Hill, NC); NYWC – Weill Cornell Medical Center (New York, NY); PT: physical therapy; OT: occupational therapy; CM: case management; SW: social work; APRN: advanced practice registered nurse; APP: advanced practice provide; ISAR: Identifying Seniors at Risk Tool;53 TRST: Triage Risk Screen Tool.54